Factors that Affect Person-Centred Care and Inter-professional Working

Person Centred Care within inter-professional workings will be discussed, critically assessed and evaluated within this essay. The incident used is one of a nine year old male, diagnosed on the Autistic Spectrum Disorder, with Aspergers Syndrome (AS), admitted into general hospital for a circumcision. For reasons of confidentiality the child will be referred to as James.

AS is a form of autism, which is a lifelong disability that affects how a person makes sense of the world, processes information and relates to other people, can be very literal in what they say and can have difficulty understanding jokes, metaphor and sarcasm.

For example, a person with Asperger syndrome may be confused by the phrase 'That's cool' when people use it to say something is good. (Brasic 2001) James arrived at hospital with both parents and had already been sick due to nerves and worry. James was shown to the children's ward by a Child Nurse and shown to his bed; there were five other children on the ward.

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It had already been discussed at an earlier meeting that James would be the first child to go down for the operation; his parents had explained that if he saw any child coming back from their operation in any distress, then it would be almost impossible that James would go down for his operation. All the Child Nurses on the ward were aware of James's condition. It was explained to the parents that as James had been sick and looking very pale, that he would have to wait until he had calmed down and feeling better before he could have the operation.

Therefore it was agreed that he would not be able to first, but could go second. The parents and Child Nurse discussed this with James and suggested that when the first child came back it would be better if James was not on the ward - this was agreed and arrangements were made. After a short while the Anaesthetist came to explain to James what was going to happen when he went up to theatre. However this caused confusion for James as he did not understand what the anaesthetist had meant by "theatre".

It became apparent that the anaesthetists had not been made aware of James's condition, and the parents had to explain that the theatre was the name given to the room where the operation took place and he was not going somewhere to see a show. The anaesthetist went to talk to the Child Nurse, and came back to apologise for not knowing about James's condition. James was shown to another room where an Operating Department Practitioner (ODP) was waiting to take James to the theatre; she informed the parents that all the theatre staff was aware of the fact that James had AS and had special needs.

The father then went with the ODP, porter and James to the theatre and stayed with him until he was under general anaesthetic. After an hour the Child Nurse took the father to the recovery room where the ODP explained that everything had gone well, and escorted James back to the ward with the farther, porter and Child nurse. Once James had something to eat and drink and had passed urine he was allowed home. The incident took place in a busy city hospital with surrounding rural areas.

Admission to hospital was a referral from the child's General Practitioner (GP) to the Consultant. This would fall in line with the Standard 7: Children and Young People in Hospital of the National Service Framework (NSF) and Standard 8: Children and young people who are disabled or who have complex health. The policies within the NSF would include that, children have access to child-specific services, access to care, local to where they live and services that are staffed by appropriate levels of trained staff with child-specific training.

In addition Parents and children with specific needs such as disabled children and children with learning difficulties have their needs identified early and are provided with effective multi-agency support. At the heart of the Children's NSF is a deep-seated change in the workings of health and social care services. It is intended to lead to a cultural shift, resulting in services which are designed and delivered around the needs of children and families using those services, not around the needs of organisations (DOH 2004).

On April 5th 1995 the Bristol Royal infirmary (BRI), released a statement admitting it had halted a pioneering technique for open heart surgery for infants after nine of 13 babies operated on died over an 18-month period prior to 1993. An inquiry found that there was no paediatric trained anaesthetist to look after the children or paediatric nurses and that organs and hearts from the deceased had been removed without parental consent. The report of the public inquiry into children's heart surgery at the BRI, found that the procedures for caring for sick children in hospital were not safe (The Kennedy Report 2001).

The Bristol inquiry led to the early publication, in 2003, of the hospital standard of the NSF for Children (NSFC). The publication of the DOH: Getting the right start: NSFC Standard for Hospital Services Chapter 3: Hospital Standard Part One, section 2. 5 focuses on Child-Centred Hospital Services (CCHS). The purpose is to amalgamate CCHS so that they; Consider the whole child, not simply the illness being treated; treat children as children; that all staff are concerned with the overall experience for the child and family; to make sure that children and parents are partners in their care, not just patients. DOH 2003)

There are many health professionals involved in the case study, all with their own responsibilities and roles. Child Nursing is not just a question of caring for a child. A Child Nurse has to understand how a healthy child develops towards adulthood and know how to reduce the impact of illness or hospital admission on the child, hospital admissions that last a significant period of time can affect the Childs 'attachment' to its main caregiver, thus affecting this important developmental relationship at such a crucial age.

Bowlby (1957) argued that "the mother-child attachment has an evolutionary basis, promoting the child's survival by increasing mother-child proximity, particularly when the child is stressed or fearful. The mother thus serves as a secure base for the young child's exploration of the world". Thus working in partnership with the parents, or whoever looks after the child at home is essential. Communication is another factor that can be complex in the treatment of a young child. (Holmes, J 1993)

It is the responsibility of the Child Nurse to make sure that the medical file of the child has been read and understood, before admission, so all the needs of the child can be met. It is also the responsibility of the person in charge of the ward to make sure that all staff are aware of any requirements. In the case of a child with AS, the communication with the child has to be precise and clear, keeping sentences short and understandable. This is where person centred care comes into play with the child's needs taken into account. (Wollin, S)

Not all of James's person centred care was met in this incident, which was clear when the anaesthetist had no information of the child's needs. Anaesthetists are generally understood as the doctors who put patients to sleep for surgery. Although this is an important part of their work, anaesthetists are highly trained medical doctors, and have a range of practice which extends beyond anaesthesia for surgery to include pain management and intensive care. Anaesthetists have a medical background to deal with many emergency situations.

In these situations they provide vital care of breathing, resuscitation of the heart and lungs and advanced life support. It is not clear where the line of communication broke down so that the anaesthetist had no information on James's condition. If the Child Nurse failed to inform the anaesthetist for the needs of the child then the responsibility falls on the anaesthetist themselves to read the medical file before engaging with the child, and to be aware of any needs that should be taken into consideration, this was clearly not the case and caused confusion for James. (Gothard,1996)

ODPs are an important part of the operating department team who work with surgeons, anaesthetists and theatre nurses to help ensure every operation is as safe and successful as possible. ODPs provide high standards of patient care and skilled support alongside medical and nursing colleagues during peri-operative care. The ODP's role involves the application of theory to practice in a variety of clinical settings. The ODP therefore needs a broad knowledge and skill base including management and communication skills and will be involved with the assessment, delivery and evaluation of peri-operative care.

The ODP showed a clear understanding of Person Centred Care by informing the parents of James's needs and informing them that all staff had been made aware, thus showing appropriate skills and knowledge in the role of an ODP. (Timmons,S Tanner,J) The purpose of Person Centred Care is to certify that the service user has a positive role and is an equal partner with Health and Social Care professionals in assessing, identifying options, and delivering the most suitable package of care for that individual within organisational boundaries.

This will involve the provision of full information on all aspects of the service user's needs and available services that facilitate the patient to be treated with respect, courtesy and dignity at all times. In addition, the service user should be at the centre of any plans made, and the assessment should take into account the complete person's needs, whether these are social or medical. The service user should be at the core of the plan, be onsulted and have their views taken into account. It should include all aspects of care, including; Social Services, Health, family and voluntary sector. (http://www. cpa. org. uk) An example of Person Centred Care was evident when the Child Nurse discussed with James about being the second patient to theatre for the operation. Rather than just talking to the parents the child was included into the discussion and his feelings, needs and opinions were taken into account and acted on.

Until The Children's Act of 1989, children didn't really have individual rights, and any decisions or action taken were made by discussion with their parents, completely bypassing the child's feelings and thoughts, which meant that decisions could be made about what was best for the child without having to consider the wishes or opinions of the child. Children were seen as the property of their parents and the overriding philosophy was one of parental rights and responsibility, instead of the rights of the child (Kay 2001).

The Children Act 1989 was updated and replaced with The Children Act 2004. The Act also shapes the policies and procedures of any organisation or individual who works with children. It was introduced because previously the laws relating to children were often disjointed, out of date and particularly difficult to put into practice (Mullally, 1994). The Children Act 1989 was brought in to consolidate the law for the definitive benefit of children and this is compatible with the concept of Person Centred Care.

The Act recognises the right of children to contribute to decisions about their own welfare, depending on age and understanding, and gives children a voice when decisions are made about them. When involving a child in decisions about their welfare and health, age and understanding have to be taken into consideration. The term Gillick competent is used to describe a child under the age of 16 who has "Sufficient understanding and intelligence to be capable of making up their own mind on the matter requiring decision" (Smith, 1996).

The practice implication for this is that when taking into account the opinions and wishes of the child, it must first be established what the wishes and views are, and then whether they can be considered or acted on, based on whether the child is deemed to have a full enough understanding of the implications of their decisions. However, the courts cannot make a Doctor forcefully give medical treatment, they can only authorise the treatment, and it is for the doctor to decide whether or not an individual child is Gillick competent.

The courts are usually disinclined to do so. (http://confidential. oxfordradcliffe. net) To understand the use and meaning of Person Centred Care it is necessary to explore what a person is. The Concise Oxford English Dictionary (11th edition) describes a person as: "A human being regarded as an individual". However, this is a very narrow meaning; perhaps greater emphasis can be explained by human behaviour and the unique complexity of human cognition. Client Centred Therapy is seen as the forefather of Person Centred Care.

Psychologist Carl Rogers based his theory, in the 1930s and 1940s, Rogers believed that three core conditions were necessary and significant if change were to occur, these were Empathy, Congruence, and Unconditional positive regard, he based his works on human behaviour and how this is interpreted, These interpretations are that people can be understood only from the vantage point of their own perceptions and feelings; 'confluence'. People are aware of their behaviour, inherently good and effective; are purposeful and goal directed; and that the therapists should not attempt to manipulate events for the individual (Rogers,1951).

What Rogers had seen in these interpretations was that the client knows best, that the answers lie within him to successfully change and grow; 'self-actualization'. It is the client who knows what is hurting them most, psychologically and physically. The client knows the way forward. From this Rogers concluded that it was the counsellor's task to empower the client to make choices and decisions for themselves, rather than to guide, advice or to sway the course of action the client should take. (Mearns and Thorne 1996)

Person Centred care is all about making sure the patient has a greater say in how they are treated, offering more health and social care choices, and providing the implements and information needed to satisfactorily make those choices. As in Client Centred Therapy, it is not up to the health professional to make those choices for the patient, but to make the patient feel that they have been; informed and had time to consider choices; listened to and understood and had been involved with their care from the start with a sense of achievement and empowerment.

Inter-professional collaboration is widely advocated in health and social care policies and has become a commanding force, spear-headed by the Government's modernisation programme to improve partnership. However, existing research provides a relatively poor understanding of how professionals collaborate or the meanings they attach to their collaborative work (Donald and Menmuir 2005). The recent Green Paper entitled Every Child Matters and the preceding Children Act 2004 propose that within each local authority in England and Wales all children's services should be integrated under a Director of Children's Services.

Nursing is an applied professional and studious discipline that is often practised in a variety of complex situations across health and social care. A key feature of nurses' work is to work with other professionals and in a facilitative manner with support workers. After the death of Victoria Climbie in February 2000, a public enquiry was held; one of the key features to come out of the enquiry was the complete failure of communication and lack of understanding between inter-professional bodies. It is believed that if there was better collaboration between professionals then her death may have been avoided (Laming, 2003).

The death of Victoria is not a day to day occurrence, however in relation to Person Centred Care there was clearly there was simply none. The case study used does not compare with Victoria's case, but the values of the client are. Each person has the right to be treated as an individual and by good inter-professional collaboration this can be achieved with each professional talking to each other and sharing notes. If the Child Nurse, OTP, and other health staff do not collaborate with each other than you have a complete breakdown in communication and the patient is left feeling lost and uncared for as no one knows what to do.

Inter-professional Collaboration highlights the benefits and factors' arising from working together for patients, service users and carers through a review of theoretical models, the success being dependent on many factors including co-operation replacing competition. Leathard (2003) notes that in the early 1990s an Occupational Therapist stated that; while the health professionals where endeavoring to work together the underlying challenge was to become "top dog".

The competition to become "top dog" over rides the real issue of inter-professional collaboration and can be explained by using Maslow's Hierarchy of Needs Theory (Rogers, 1967). Maslow developed the Hierarchy of Needs model in 1940-50's, and the Hierarchy of Needs theory remains valid today for understanding human motivation, management training, and personal development. Maslow's ideas concern the responsibility of employers to provide a workplace environment that encourages and enables employees to fulfil their own unique potential.

With this in mind, there is always the danger of competition for hierarchy out weighing the true purpose of inter-professional collaboration. It should also be noted that working in partnership with other agencies can raise ethical and moral issues; it may be the case that all agencies do not share the same agenda and do not have the same professional approach to their work. (www. openlearn. open. ac. uk 2008) The Government has introduced several initiatives to promote and support inter-agency and inter-professional working.

The publication of National Service Frameworks (NSFs) by the government outlines their long-term strategies to improve specific areas of care. National standards and goals are set by multi-professional teams including service users, carers and agents and agencies related to the area of care. (Dr Tope & Dr Thomas 2007) In conclusion, as a student social worker it is important to see everyone as an individual and not stereotype people. Person Centred Care is about listening to patients/service users and finding out what their needs are; what is important to them while they go through the journey of care they are receiving.

Assumptions should not be made on what they are feeling or what they require, and that the care they are given is holistic and centres on the whole person. Importance should also be centered on who they are, their life before they came into care, covering all the needs of the individual; not just the physical or medical, but also their spiritual, emotional, and social needs; so any arrangements and decisions can be made with the patient being involved. There should also be an awareness of issues of diversity which is essential in finding out about the patient's history, culture, beliefs and identity.

Inter-professional collaboration is an important factor in Personal Centred Care, if all health care and social professionals share information and talk to one another; in a context that all can understand, and then the care and protection of patients will be improved. Unfortunately this was not the case with Victoria Climbie. The over ridding factor of Person Centred Care is always to emphasise on what the individual can do. What they want and where they are going; not on what they cannot do. It is paramount to work 'with' patients/service users, not for or against them.