The aim of this assignment is to offer a reflective and critical discussion on promoting self-empowerment to children and young people within the Child and Adolescent Mental Health Team (C.A.M.H.S) where my practice placement is based and to reflect on how this impinges on my practice as a Nurse. In reviewing the relevant literature and research, together with the relevant health and social, requirements of legislation and codes of nursing practice I will identify what is needed in my role as a nurse to promote self-empowerment for children and young people within C.A.M.H.S.
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In order to help me with the reflective process I have used Driscoll`s (2007) model of reflective learning. This Model has 3 stages 1) What? A description of the event 2) So What? An analysis of the event 3) Now What? The benefit of using a reflective model is it “turns experience into learning and empowers nurses to demonstrate accountability and self-regulation” (McKinnon 2016:39). Critical reflection is an integral part of our professional practice. The Nursing Midwifery Council (N.M.C 2018 Code of Professional Practice sets out a framework of standards that nurses must uphold in order to safeguard the patient and the wider public. These standards are Prioritise People, Practise Effectively, Preserve Safety, Promote Professionalism and Trust. My reflective account will focus around the N.M.C code “Prioritise People” however it must be said that during this assignment there are occasions when all parts of the code are applicable.
For the purpose of confidentially (N.M.C Code 2018) any references to the client’s name and location of the C.A.M.H.S team can in no way be identified and are purely co incidental.
- Unlike the Black Report (1980) that focussed purely on the inequalities in health, a central theme of N.H.S modernization today looks towards prevention of ill health and empowerment of positive mental health. In terms of children and young people’s mental health, recent Government reports are promoting Health Care Professionals to actively encourage person centered care and partnerships in care by fostering good relationships and empowering the younger generation to make informed choices and decisions about their mental health care and treatment (D.O.H. 2004, D.O.H 2010, D.O.H 2015, D.O.H. 2018, NHS England 2018). Such recommendations include the C.A.M.H.S service. Whilst these recommendations are well received. I am however left wondering how they did their research into listening into the needs of children and young people, for example, who was their target audience? From my literature searches and the findings of the Care Quality Commission (2018) it seems that except for a few independent studies, there has never been, since the history of C.A.M.H.S a national study conducted soliciting children and young people opinions on what they think of C.A.M.H.S service. Corry et al (2001 in Moore (2016) study found 66 per cent of young people indicated that they feel they had little or no involvement in decision making about their healthcare. Edwards et al (2018) study found that whilst adolescents were keen to have shared participation in care, they felt unable to ask to ask the correct questions about their care as they lacked insufficient knowledge about their condition. Contrast this to Moore and Kirk (2010) that found that children and young people are keen to participate in their care if they believe that they will be listened to and respected by health care professionals.
The United Nations Convention on the Rights of the Child (1989 part 12) gives clear guidelines on the rights of children and young people to have a voice in their care and well-being. If this is to be achieved, then health care professionals such as nurses must recognise and respect the contribution that children and young people make to their own health and well-being (N.M.C 1.5, 2.2). If care is to be delivered effectively it is essential nurses work in partnership with the child and young person (N.M.C 2.1). However, we cannot just assume user participation is just as straightforward. There may be barriers to the child’s refusal to participation (2.3 NMC 2018). For example, for user participation to happen the child or young person must be able to demonstrate they have sufficient emotional, intellectual maturity and demonstrate an understanding of any healthcare interventions being offered (Cornock 2011). This is called the Gillick competence (Gillick v West Norfolk and Wisbech Area Health Authority 1986) and is used as the benchmark for determining a child or young person ability to consent to treatment if they are under the age of 16.
Encouraging empowerment enhances the child and young person’s confidence, as they feel they have a voice and are being heard. This motivates them to ask questions which ultimately leads to a willingness to be more involved in their health care and treatment plans (Chen 2016).
Pender (2002) identifies the skills needed to facilitate empowerment as being:
- Advocacy: to support the patient in their decision making
- Negotiation: to confer and discuss healthcare considering the options from the patient’s perspective
- Networking: to link with other disciplines and sources of support to ensure a collaborative approach to health care.
- Facilitation: to ensure that the patients have all the available information to enable them in decision making, and to assist their progression though the care pathway”
- Listening: to actively make an effort to hear what the patient is saying, and not what you may presume they mean.”
If I am to promote the concept of self-empowerment to my patients I must “practise effectively” and “prioritise people” (NMC 1, 6, 2018). By listening to what they truly want, understanding their core values and beliefs I can work alongside the child and young person to develop a care plan that is developmentally appropriate and personally relevant, to them (Day 2007). When patients participate in the decision-making process, better outcomes are achieved, and they feel more in control of their care (Kravitz and (Melnikow (2001 in Pender 2002, Agner 2018)
If I am to empower children and young people to become more involved in their care, I need to make their care plan more “young person centred “. If I am to engage them in the participation of care, I need to make sure need to ensure the core values match what is going on for the children in their lives at the present time. Hindley and Whittaker (2017) It has been found that children are keen to be included in discussions and those who were asked directly about their treatment felt more valued and less anxious about what was happening (Kelsey et al. 2007) whereas some children and young people felt those healthcare professionals overuse of medical terminology confused them or who spoke over them to the parents causing barriers to effective participation . (Day 2007,Coyne 2006) .
So far, I have spoken about what the young person needs from the nurse to enable empowerment. I was however curious about any potential barriers that might prevent the nurse from effectively engagingly with the child or young person in preventing empowerment. My own personal thoughts would be that there may be a danger that the nurse adopts a traditionally held belief that “she knows best” or “we have always done it this way”. Ironically by her having to “let go” may in some way make her feel disempowered? Old fashioned attitudes such as these would of course go against the N.M.C Code (2018) and the nurse would be in breach of the code. Bucknall (2018) study found some nurses were reluctant to engage in patient participation and motivation as they felt that they did not have the skills in either not knowing how to motivate or how to promote patient participation. Others were reluctant to encourage user participation as they felt time constraints got in the way whilst others were resistant to change their current practice. In terms of promoting patient empowerment a criticism of The Future in Mind (2015) and Five Year Forward View (2018) Indeed some practitioners do not seem to have been given guidelines on helps or hinders the process of participation (Moore 2018).
Examples of child and young person patient empowerment can be drawn from my placement experience at the C.A.M.H.S outpatient clinic. The team engage with the children, young person and their families by encouraging them to actively contribute towards the decision-making processes about their treatment options and follow up care. Within the C.A.M.H.S placement where I am based is the implementation of care pathways. (N.M.C 2018:6) These are psychological and treatment-based therapies which are evidence based and formulated by the local Trust (2018) and are recommended by National Institute for Health and Clinical Excellence (N.I.C.E) and the Care Quality Commission (C.Q.C). Each pathway is specifically focussed around a patient diagnosis and operates a flow chart outlining which specific team get involved, at what level and what intervention is needed and at what time. For example, primary care, secondary care, tertiary care. Using depression as an example under the N.I.C.E guidelines for “Clinical Depression in Children and Young People” [CG28 2017] the child who has mild symptoms of depression is monitored at primary care level under “Watchful Waiting”. If they show no improvement or their symptoms worsen, they are referred to C.A.M.H.S Core Team for Cognitive Behavioural Therapy or group therapy. If they do not improve then further assessment by the Psychiatrist for medication or in-patient treatment is considered. The child or young person is actively involved in every step of the care pathway and in all the decision making and treatment options alongside the parents and depending on age.
There are some who believe that using standardised clinical care pathways removes “the person centredness” of patient care and are seen to be paternalistic. Davies (2011 in Barker 2013) suggested the shift in focusing purely on evidence-based practice removed the “individualisation” of care away from the nurse. Barker (2013) says that being able to use your clinical judgement and make decisions about patient care is essential to clinical effectiveness and competence.
One thing I have learnt during my placement is that whilst it is essential to work with evidence-based practice and develop my theoretical knowledge base, without my skills of learning how to engage with the child and the young person the process of the therapeutic engagement is completely lost. If I am to successfully implement a care pathway that it is essential, I effectively engage with the child or young person. In order to do this, I must actively demonstrate the 6 core values of care, compassion, competence, communication, courage and commitment DOH (2012). I realised during my placement was when I reviewed my learning contract was a specific area of the 6Cs was lacking. I was lacking “Competence” in my understanding of “diversity” and the young person. (1.3 N.M.C, Driscoll 2007). I realised if I was to gain meaningful and trusting relationships with young people, I needed to gain a deeper understanding and greater insight into what diversity meant and how it related to children and young people’s mental health. I achieved my learning goal by spending time with a peer support worker meeting young people who had gender identity issues and listening to them about what they need from C.A.M.H.S
There will be occasions when barriers to empowerment may arise when on one hand I am wanting to try and promote empowerment to the child or young person but on the other hand I have a duty to act in their best interest of health and medical safety (N.M.C 2018:4.3). Examples might include when they are experiencing an episode of severe mental illness (Mental Health Act 1998) or they are at serious risk to either themselves or others (Children Act (2004). If they lack the mental capacity to make accurate and safe decisions for their level of treatment and care (Mental Capacity Act 2005). When occasions such as these arise, I am accountable for my actions and have a duty to keep the patient safe from harm and protect the wider public. I have a duty of care to Practise effectively, preserve safety, promote professionalism and trust and prioritise people (N.M.C 2018). I must report my concerns immediately to my line manager in conjunction with the Trusts Safeguarding procedure, when liaising with other health care professionals about my client. I need to make sure I have accurate record keeping of my conversations and that my referrals are timely. I write down all patient observations and discussions as they happen and record judgments, any actions and decisions taken. I ensure that my referrals to the appropriate agencies are timely and I follow the Trusts safeguarding Policy and Procedure (N.M.C 2018, The Victoria Climbié Inquiry, (2003).
Working in C.A.M.H.S can present highly emotive situations between the nurse and the patient. I need to be aware of my own personal prejudices and beliefs as this can cloud my judgment and interfere with the therapeutic relationship when delivering patient care because there is a danger, I may deliver care that I think the patient needs and not necessarily what they need (Rungapadiachy 1999). If we are not aware of our reactions the nurse client relationship may be endangered.With these thoughts in mind, I would like to reflect on an episode of care that happened to me during my placement at C.A.M.H.S. It was during an assessment of a 13-year boy who had been taken into care. He had presented to the team with moderate depression. During the assessment session he spoke very little except to speak of his sense of hopelessness. He was tearful and felt he had been abandoned by his parents. He was being bullied at school. I came away from the session feeling overwhelmed with sadness and feeling very hopeless myself (like the boy), because I could not make it better for him. My mothering instincts were in overdrive and I just wanted to give him a hug. I spoke about my experience during supervision with my mentor. My need to want to rescue the boy would only disempower him further and this would not help. If I was to help this boy, I needed to put my personal feelings aside. The clinic had evidence-based practice tools such as the C.B.T and care pathways that could help empower him with skills and confidence to increase his self-esteem and then if need be, he could move onto another care pathway and undertake peer group work. It was a useful learning exercise for me and I learned that only when nurses can begin to understand their own emotional limitations and the effect it has on others can they begin to create an effective environment for healing others (Kirsten and Eula 2008).
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In addition to reflective frameworks such as Driscoll (2007) I found The Johari Window (Luft 1969) a useful framework, commonly used in mental health to understand the concept to improve self-awareness. Whilst it is not within the confines of this assignment to explore it in greater depth in essence this model has four quadrants;
Open area: What is known about me to myself and others?
Blind: This is how others see you such as certain mannerisms characteristics of which you are not conscious
Hidden What is known to us but not to others
Unknown Not known to self or others to decrease the hidden and unknown quadrant requires self-disclosure, feedback, readiness to change, exposure (which can be painful) develop self-awareness and to change some behaviours and characteristics.
This assignment has discussed empowering children and young people when using the services in C.A.M.H.S. It has identified current polices relevant to child and adolescent mental health which recommends person centred approaches and patient empowerment to take control over their mental health with the hope that they can prevent illness in the future.
The key theme that has emerged in this assignment is that children and young people want to take control in decisions about their mental health and become autonomous. However, in order for that to happen their core values must be met. They must be listened to, respected, spoken to age appropriately and have their individual needs met. From the research evidenced in what the children are saying, it appears Health Care Professionals have limited or no formal training in identifying the barriers and enablers to patient participation. Whilst patient participation is recommended in the documents mentioned in the main body, it is concerning it seems to be no official guidelines for the Health Care Professional. This must be investigated as soon as possible. Furthermore, the nurse is reminded that the purpose of clinical governance is to ensure that patient care is carried out using evidence‐based guidelines (if there are any?). This places significant responsibility onto the Nurse as it ensures her practice is always evidence based and sensitive to the needs of the patient. By doing this it continuously improves the quality of health care so that the patient always remains central to the care process. (Scally & Donaldson 1998 Royal College Nursing 2003).
By using Driscoll`s (2007) reflective framework as a guide I gained a deeper understanding of linking national, local policies, my code of practice (N.M.C 2018) together with relevant research to link it with the emotional needs of the child and young person during my placement in C.A.M.H.S. I saw the reflective process as two-fold. Firstly, how the recommendations in the report contribute towards patient centred care and the promotion of self-empowerment. Secondly how my own professional development has grown by doing this assignment and being on placement.
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