A critical analysis of patient-centred assessment including a reflective analysis simulated problem focused assessment.
Richard and Whyte (2011), report that patient-centred practice is acknowledged to be a fundamental component of individual sessions between patients and healthcare professionals. This assignment will evaluate patient-centred literature and address the main components related to this idea, with specific emphasis on “sharing power and responsibility” and the “therapeutic alliance”. This essay will critically analyse what the term ‘patient-centred’ means and the factors involved with patient-centred assessments to ensure its success. As Psychological wellbeing practitioners (PWPs) it is important to demonstrate the key competencies required for an effective and collaborative assessment such as attitude, knowledge and skills. I will critique my performance of my clinical simulation carried in a patient-centred context. To conclude, I will create a summary of what I learned from the reflective practice.
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The UK currently is going through significant changes with regards to mental health. According to the Five Year Forward View in Mental Health (2018) one in four individuals experience mental health difficulties each year experience mental health difficulties each year. The Department of Health, (2008) make it clear that when Psychological wellbeing practitioners carry out assessments, the assessments must be patient-centred. DoH though fail to mention how the patient centred assessment must be delivered. Richards and Whyte (2011) mention in the Reach out Manual that in order for an assessment to be collaborative and share understanding between the client and the practitioner, the assessment must take a patient-centred approach demonstrating key common and specific factors to reach a collaborative decision when exploring treatment options. Mead and Bower (2000, 2002) describe the importance of patient-centred care more clearly in the five-dimensional framework to identify the ingredients needed to ensure an assessment is patient centred which will now be explored in greater detail.
A patient-centred approach is considered to be a vital factor in high quality care. A Biopsychosocial approach is the first dimension of patient-centred consultations identified by Mead and Bower (2002). Engel (1977) first introduced the concept of biological factors and their importance in fully understanding patient’s issues and to explore these in greater detail, in relation to shared planning/outcomes. Stewart et al (1995) report that the biopsychosocial approach is the key theme for patient-centeredness and the readiness to become fully involved in patients problems regardless of what these maybe and to fully explore issues and not just their biomedical problems.
To further understand the patient experience the second dimension is based on viewing the patient as a person. In order to understand a patient’s primary presenting issue, as a practitioner we must view this in an individual view of the patient’s problem (Bower, 1998). The first dimension looks at a broader biopsychosocial framework, however the second dimension looks at both the symptoms of the patient and the way in which it affects the patient in which these symptoms appear (Lipkin et al, 1984).
Sharing power and responsibility is the third dimension which was first introduced by Bryne and Long (1976). In patient-centred interviewing, practitioners have a use of a variety of questions such as open and closed which allows the client to take direction in relation to the questions asked. Bryne and Long (1976) further emphasise the importance of involving the patients in their care. De silva (2012) report on their findings that shared decision making can have improvements for patient care, however sharing power and responsibility has to be supported with collaborative care.
Therapeutic alliance is an important factor in relation to the patient-centred approach and this refers to the therapeutic relationship between the professional and patient (Mead and Bower, 2000). Therapeutic alliance has an importance of element in therapy in patient centred contact Brenner (1979). Collaboration between the patient and the practitioner is an important foundation which is demonstrated throughput which must be a respectful, mutual and cooperative (Kazantiz, 2012). A therapeutic relationship encourages positive outcomes for the patient, resulting in better treatment options that provide the best support and care (Hovarth et al, 2011).
Practitioner as a person is the last dimension within the framework. This discusses the significance of knowing that practitioners are also viewed as human beings and their personal qualities can have an impact on the patient-centred relationship (Kissil, 2017). All five dimensions are supported within patient centred interviewing and are necessary for PWPs to carry out adequate assessment to best support patients suffering from common mental health problems. PWP’s are required to demonstrate the appropriate skills and knowledge to carry out an assessment and therefore providing the best collaborative support to the patient (Stewart et al, 2000).
National Institute for Health and Care Excellence (NICE, 2011) report patient-centred care should be at the forefront when carrying out assessments with individuals experiencing common mental health problems such as anxiety and depression. Mcwhinney (1995) argues that the patient centred approach is purely a foundation and mentions ‘some things are just good in themselves’. Similarly, Epstein et al (2005) argue that when considering outcome measures as PWPs, often the outcome measures do not necessarily justify to that of the patients presenting problem. The effects of this is the difficulty in measuring patient-centred care whereby outcome measures do not reflect the patient problem descriptor (Epstein et al, 2005).
May and Mead (1999) argue that patient centred care signifies a ‘moral imperative’ whereas Epstein and Street (2011) patient centred relationship must serve better outcomes as well as a shared therapeutic relationship to promote improved outcomes. PWP’s are also expected to have a sound understanding of the ‘IAPT minimum data set’ and the importance of confidently reflecting these to the patient’s (British Psychological Society, 2016). Patients themselves are able to identify their symptoms and can identify these within the IAPT measures; this then classifies the difficulties from a biopsychosocial perspective (Mead and Bower, 2002).
Lambert and Barley (2001) and the British Psychological Society (2016) report that a PWP must demonstrate the necessary common factors which result in a mutual trusting relationship. These common factors ensures that a clear introduction is demonstrated, followed by information gathering and then information giving which results in a mutual decision making whereby both the patient and practitioner understand what is required of them. Common factors are necessary skills required that are present in a problem focused assessment and without these common factors it can have a negative impact on the therapeutic relationship. In order to gather and provide the vital information to the patient, common factors must be demonstrated such as delivering an empathic approach to show the patient that as a practitioner you are understanding what they are trying to portray (Lambert and Barley, 2001). This is then followed by non-verbal communication such as body language and eye contact, clearly showing the patient that as a practitioner you are fully engaged with the patient and actively listening to their problems (Richard and Whyte, 2011).
The main challenge in achieving efficiency with patient-centered care is the attitudes of clinicians. Patient-centered care requires practitioners to pay careful attention to patients’ needs, beliefs, and values. Many clinicians already believe that they pay attention to patients as is and hence do not need to go the extra mile. Cushing (2015) argues that many practitioners are of the opinion that patient-oriented care could blur the boundaries of the professional relationship or make it harder for them to administer care. Also, practitioners may argue that their experience in the field gives them the credibility to decide the best course of treatment for a patient. However, Baker et al. (2008) demonstrate that the assessment by practitioners or person-centredness is not always accurate especially since they may not know everything about a specific patient. Besides, practitioners often battle against conflicting values such as risk management and organisational targets, which could hinder their ability to completely indulge in the glorified patient-centred care. In particular, there are concerns that despite improvement in the quality of care provided, some level of paternalism exists. It means that some structural changes may be necessary to ensure that patient-centred care is administered efficiently.
According to Kinsella (2010), reflective practice is important in order to improve and develop skills, knowledge and understanding. The essay will now explore a critical reflective analysis of my problem focused assessment, identifying competencies used, what was done well and what areas need improvement in order to demonstrate the required skills for a problem focused assessment.
The problem focused assessment was based around a patient named Joe, who was experiencing anxiety symptoms and referred by his GP. The first part of the assessment was the introduction, where I introduced my role (figure 1) and my language was collaborative. However, before the introduction, it was important to check Joe understood the role and the purpose of the session (see figure 1).
tPWP “Ok, so my role as a Psychological Wellbeing Practitioner would be to work with someone with common mental health problems. This could include stress, anxiety and depression. we work together to try and overcome any difficulties you are going through at the moment and decide an identified treatment option together. Treatment options are up to 6 sessions lasting 30 minutes each.”
Figure 1: failed to explain the importance of guided self help
I felt nervous starting my problem focused assessment. As I looked over the recording, I was still unsure whether the video was recording so this doubt remained in my unconscious mind. . Due to the nerves, I continued to feel anxious, therefore missed the opportunity to clearly explain what guided-self-help consist of. If I had mentioned this, the patient perhaps could have clearly seen this in a more positive way. Cuijpers, et al, 2010 report that guided self-help have effective and positive results when explained and carried out appropriately. Considering this, I clearly explained guided self-help in both role plays at university and in service, “tools and strategies to try and overcome any difficulties.” Neenan (2008) reports giving examples of coaching can really help patients look at what is expected from both the patient and the practitioner. By giving an example such as “guided self-help is more of a coaching support, we can give you the relevant materials but there is also a responsibility and you completing relevant tasks.” The patient may never have come across therapy before, using such an example allows the patient to understand what is expected of them as a patient and what support the practitioner can provide. PWP is a fairly new role, therefore a clear explanation of the role and what is expected which results in a solid therapeutic alliance, which is key in patient-centred interviewing (Mead and Bower, 1999).
tPWP: It is just a chance for you to tell me what is going on for you. I will ask quite a couple of questions at any stage, so if you would like to grab a glass of water take a break then that’s absolutely fine. We are a confidential service, which means everything you tell me will be kept confidential throughout, unless you tell me there’s risk to yourself or anyone else. This would mean that this is shared with other agencies. This is to ensure we keep you safe and keep everyone around you safe. I will be taking notes throughout the session and these will be shared with my line manager which is just for supervision purposes. I am providing the best care and support to you. Do you have any questions before we start?
Figure 2: Introduction mostly collaborative
I introduced myself and introduced my role as a PWP. Beck (1976) outlines the importance of having the collaborative approach between patient and therapist which enables a shared understanding in working together to achieve the desired objective. Clear introduction and its rationale is likely to achieve growth and results in patients having a greater understanding of low intense treatments. This then allows to build positive therapeutic relationship (Dattilio et al, 2012).
The Information gathering section began with a lovely warm open question where the tPWP asked “in your own words what kind of brings you to the session today”. This question was extremely effective because it gave me as a practitioner a better understanding of the patient’s concerns. Joe was experiencing anxiety symptoms and allowed me to look at the psychological, biological and social factors that influenced Joe in a patient centred way as well as building the therapeutic alliance (Mead and Bower, 2000).
Richard and Whyte, 2011 state the importance of funnelling and these funnelling skills come soon after the 4W’s. Funnelling involves process of asking further specific questions to elaborate what exactly the patient’s problem is. There were times where I could have funnelled further but instead moved on too early. (Figure 3, below)
Joe: I believe things have changed a little at work , I’m struggling to make decisions. I will decide something and then I feel unsure if it is the right choice. However, previously I would have just done it , I’m now checking with my line manager before I make a decision.
tPWP: So just talking about work that you mention you are seeking reassurance a lot more than usual. Is that correct?
Joe: Yes that a fair summary
tPWP: So when the situation that you are going through what sort of thoughts are you thinking what is going on in your head?
Joe: It’s difficult to say because lots of these things are going on it is when I think about these things afterwards when I’m lying in bed whatever I’ll be thinking about what I’ve done or said that day, I think ahead of how things may go wrong in the future.
Figure 3 – failure to funnel
This was a missed opportunity to funnel further about Joe’s experiences around work (fig 3). The information gathering section is a key element of the problem focused assessment Finnet al, (1997). This causes a barrier in communication (Roth and Pilling, 2007) and therefore Joe himself voluntarily informed me that he was a Community Nurse. If Joe voluntarily did not mention his occupation later in the information giving, this increases his vulnerability towards risk. Joe mentioned he had access to means, working as a community nurse, increases the likelihood of Joe wanting to harm himself (Daigle, 2005). This could also improve the risk assessment, if the funnelling of process was done earlier. This poses the idea of the patient as a person especially when feeling vulnerable (Mead and Bower, 2000). The impact of not funnelling here resulted in me moving into what thoughts the patient was having. Even though questions were asked about his thoughts, more focus could have been centred towards Joe’s work life. This would have given Joe the opportunity to give me specific examples of any difficulties he may be facing.
When conceptualising the ABCE model of CBT, I again failed to funnel Joe’s emotions (see figure 4 below).
tPWP : these thoughts , how does this impact your behaviours?
Joe: So that’s probably with the promotion, one of the consequence is not taking the initiative and passing decisions to the line management
tPWP: also you mentioned reassurance can you see how that is impacting you What about physically what do you notice changing?
Joe: I suppose appetite is poor and sleep issue is there anything else that you feel physically is changing
tPWP : Ok we have the behaviours, physical and thoughts, can you think about anything that triggers it off?
Joe: Work and home
Figure 4 – not exploring Emotions
The majority of Joe’s ABC symptoms were elicited well. When I drew out the ABC cycle, a key factor which affected this assessment was my ability to fully explore Joe’s emotions as a tPWP. Instead I asked Joe how he felt about various different situations. I could have collaboratively encouraged Joe to verbalise some of his emotions he had been feeling along with other symptoms. If Joe cannot understand his emotions, then this makes it difficult for him to understand or even make sense of how the physical, behaviours and cognitions are making him feel. Funnelling is a key competency required to achieve a better outcome and creates a therapeutic alliance on the patient centred assessments (Mead and Bower, 2002). This reduces the power imbalance between the patient and practitioner (Roth and Pilling, 2007) because the patient builds the trust and provides the practitioner the power to support the patient by making changes to their lives and overcome the difficulties they are experiencing. Although I provided feedback and reflected what Joe had been experiencing. I asked a many open questions that were particularly useful. On the other hand, funnelling would have enhanced my questioning skills (Richard and Whyte, 2011).
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Reflecting back on my video simulation, I felt I did not funnel enough. One example of this is Joe’s line of work, because I felt as though I did not want to distress Joe too early on in the assessment. Sanders et al, (2009) argue that by asking further questions when the client does not feel ready to answer may have adverse consequences such as; a negative effect on the therapeutic relationship. Although, I did not want to affect the therapeutic relationship, Joe voluntarily offered to share his occupation with the tPWP. As Joe shared this information it showed he acknowledged the importance of his symptoms of anxiety, especially when Joe’s job was an identified symptom.
In my experience from above, I have learned the importance of funnelling and going beneath the depth of what is being asked. I did ask relevant questions and picked up on some real life feelings and symptoms required for a problem focused assessment. Moreover, I did not adequately explore the issues further by using the process of funnelling. Going forward, I would like to improve my funnelling ability and to become more competent at doing this. Over the next few weeks, I will continue shadowing qualified staff, observe how each staff carries out their problem focused assessment but most importantly learn how the process of funnelling is demonstrated. I will then discuss with the practitioner, what I observed and how I will implement the knowledge and skills learned in my own assessments. It would also be beneficial, if qualified staff observed me when conducting a problem focused assessment. Reflecting back and discussing what was done well and what areas need developing would be useful, as well as identifying whether the key competencies (Roth and pilling, 2007) were present when conducting a problem focused assessment but most importantly paying particular focus on the funnelling process. This will become apparent whether I have achieved my reflection.
As a trainee, watching back the video simulation, the common factors skills that were evident were interpersonal skills such as empathy, non-judgmental approach and showing warmth and compassion. Thwaites and Bennet-Levy (2007) report in order to demonstrate empathic communication skills, it is vital to portray the full range of empathy skills in order to come across as being genuine and the real urge to have a collaborative relationship between the patient and practitioner.
I used normalising and non-judgemental approach when asking Joe about his lifestyle questions and how and whether this impacts his mental health (see figure 6)
tPWP: Do you drink alcohol?
tPWP: How often do you drink alcohol?
Joe: when I am I might have about 2 glasses of wine or 2 beers but just recently when I’ve been going out socially, a bottle of wine
tPWP: That sounds like a big change from what you were drinking before.
tPWP: Is that because the way you have been feeling?
Joe: I’m not sure, I’m not worried about it, don’t feel like anything
tPWP: Do you feel like it’s affecting your mental health?
Figure 6 : Non-judgmental approach
Asking Joe “Do you feel like it’s affecting your mental health” was the tPWP’s approach in having a non-judgmental stance. As a PWP it is vital to be able to identify any obstacles that may get in the way of treatment (Hague et al, 2016) Alcohol can have a significant effect on someones mental health, especially when gathering information on the amount of units an individual is drinking. This then in turn had a positive effect on building a helpful relationship between both the practitioner and patient (Pinto et al, 2012). Checking Joe’s attitudes to alcohol demonstrated a normalising and non-judgmental stance. This was then explored with links between alcohol and his mental health. This helped both the tPWP and Joe to move into the next session of the assessment which was conceptualising Joe’s symptoms. If Joe felt judged with regards to the amount of alcohol he was consuming, then may become hesitant. Therefore, he might not be open and honest about his symptoms. Briddon et al, (2008) argue the importance of remaining optimistic and encouraging Joe’s motivation for change (Mitchie et al, 2011). When we feel judged, we are likely to remain within the vicious cycle, especially if the judgement is derived from a practitioner who aims to understand the patient as a person and if judged, this has adverse consequences on the patient’s motivation in wanting to change their behaviour.
The above example shows my ability to normalise and take a non-judgmental stance to build the therapeutic alliance. Throughout the assessment, the tPWP put his pen down to actively listen and provide appropriate eye contact to demonstrate compassion and warmth towards Joe. This allowed the problem focused assessment to develop positively as we progressed through each stage and both the tPWP and Joe to share power and reasonability to collaboratively identify suitable treatment options.
After watching the video simulation, empathic verbal statements, good use of reflections for clarification and regularly use of collaboration language was demonstrated throughout the problem focused assessment. Moving forwards as a tPWP , I shall record my assessment sessions in order to monitor whether my engagement and interpersonal skills are still present. This will happen more at University, where we will be looking at treatment interventions and demonstrating further competencies.
To conclude, there are many factors that are relevant for a patient centred assessment which is providing the specific needs for patients. Taking into account my video simulation, it demonstrated that I am component as a tPWP to carry out problem focused assessments. There are some areas of development required but a particular area that stood out was the skill of funnelling. The questions and areas which were done well and relevant actions to follow. Schon's (1983) emphasises the importance of reflective practice that which is an ongoing process by organising service needs, as well as shadowing qualified practitioners in order to meet the patients needs.
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