Care Program Approach as a Tool for User Empowerment
Introduction
Providing effective care is the major challenge facing mental healthcare services ( 1994, 1992). The decrease in the number of institutional beds available continues to place additional pressure on mental health professionals to expand their professional boundaries and expertise ( 1994). The care reforms throughout the 1980s, culminating in the document Working For Patients ( 1989), have accelerated this process, specifically in the development of effective medication management techniques ( 1994) and the influence of user groups demanding ever more flexible forms of care ( 1991).
This paper examines stances that are being adopted in relation to the current and future direction of mental health nursing practice. The argument is made that mental health nursing is being pushed into a direction that is essentially positivistic and narrow in its focus, stating that the current hegemony of thinking which dictates that our primary focus of concern should be with individuals suffering from severe or recurring mental illness, allied with the drive towards ‘evidence based practice’ is symptomatic of wider issues that should be of concern to all parties interested in the issue of mental health care (1998). This paper would also like to critically examine contemporary mental health practices and development strategies to implement professional development of self and others, highlighting that their logical outcome is the inclusion of individuals from the right to health care and question the motives underpinning what could be considered a fundamental shift in the provision of mental health services. The argument is then advanced that caution should be adopted by mental health nursing services before abandoning what (1994) described as ‘redundant ideologies’ and that a broader view of mental health nursing action should be accommodated.
The Care Program Approach
Since removed the chains from 12 patients in Bicetre Hospital in 1792 that began the move towards humane care and kindness to the patients, mental health services have evolved through time. Humane treatments became more common. Due to advances in medicine, mental illness was tolerated more and more accepted.
The history of mental health care goes a long way up to the dawn of civilization. But modern health care program only began by the 1930’s when the Mental Treatment Act was acted upon. Man has always been very curios of himself. Later, he found out that not all man act, think and do the same. And those who do not act like what the “common people would do were driven out of the society. People believed that such illness was caused by evil spirits who enter the body and take over it. The so called evil spirits were driven out by medicine men through magic and reincarnation. The belief that mental illness was caused by evil spirits was carried up to the time of great change, The Renaissance. The mentally ill were thought to be a menace were put in prison with common criminals or locked up in asylums where no professionals were to take care of them. They were subject to cruel torture and are often locked up in cages for being disobedient. Mental illness was still considered to be irreversible.
In the Eighteenth Century, a certain pioneered a therapeutic approach to behavior. Although many people still believe that mental illness was caused by evil spirits, science was starting to catch up with the paradigm and therapies was being recommended. Mesmer suggested that he could cure mental illness by letting them hold rods filled with iron fillings in water, he thought that this would give people balance in the universe. A far cry from today’s methods of therapy.
In the Nineteenth Century, mental illness was more beginning to be tolerated and accepted in the society. The asylums were converted into mental hospitals run by the National Asylum Workers Union which was formed right after the 1930 Mental Health Act. Later the union was known as Mental Health and Institutional Workers Union. The majority of the mental hospitals was owned by this Union, the workers were known and portrayed to be hardworking, dedicated, lowly paid and identifying strongly with working class ideology. The Nursing Mirror, the organization of nurses in England, thought that mental nursing was in need of reform and that it should take general nursing as its model. And so in 1923, a preliminary year of training ended with the same examination for all grades of nurses regardless of the field of nursing they wished to enter. Mental nurses opted for Medico-Psychological Associations training sensing that the examination for all grades of nurses did not meet their standards. But the professional status which are aspirations to some nurses was not enough. The working conditions, the pay and the number of hours they worked were appalling. Their request for pay increase and less hours work was refused. A report by in 1922 changed the dread condition. Lomax observed that training only transmitted knowledge and knowledge alone would not produce a good character. He concluded that nurses should be carefully selected for their personalities and dispositions, and training should be such as to help them be of assistance to the patients. He also considered that when nurses were accused of providing low standard of patient care, this was because nurses were treating patients in the same way as they themselves are being treated (1922). Since it was unusual then for a doctor to criticize publicly his hospital superior, he lost his job. Another report was published in 1924 which sought to improve mental health nursing made a number of recommendations; institutions were overcrowded and inappropriate for training purposes, a system of thoroughly classifying patients had to be in operation and infirmary for nurses would be advantageous. Finally the report strongly recommended building of schools specifically suited to the training of nurses. In the 1930’s, an influx of men into mental health nursing from depressed areas. Entry requirements involved candidates being able to take part in organized games, play musical instrument and being physically fit (1960). The nurses were instructed to show kindness and forbearance. The rules were strict and regimental with a little scope for nurses to show initiative. Their duties include washing and feeding of patients and maintenance of wards. The Mental Health Act of 1959 enabled the professionals to regain control on the entire system of management of patients, admission and implementation of patient’s legal rights from the magistrates. However the treatment of patients changed a little. The regimental and segmental approach was still being used. The role of the nurses also remained the same with little or no emphasis on equipping patients to return to the society (1960).
The move away from institutional approach of care for mentally ill to within the community begin in 1960. it was assumed at that time that funds would be available for this transition and it was envisaged that the care for mental patients would be shared equally between community agencies and psychiatric units of hospitals. This prediction did not materialize until the next decade, the 70’s where it saw the setting up of community nursing services with mental health nurses working with clients in their own homes. The 1980’s saw mental health nurses adopting amore systematic approach which was client centered and holistic. The decade also heralded the dominance of institutional care and treatments with many nurses working in residential homes and client’s homes. This process has continued into the 1990’s with an expansion of educational opportunities for nurses’ training which seeks to prepare nurses for a professional, practitioner role.
People centered approach to mental health care “users” was emphasized as a revolutionary approach in helping people with mental or learning disabilities. The “user” of this approach is recognize to have more power and control over what happens to their lives. Person centered approach, as a plan in helping “users” achieve best results in mental health program was also emphasized and recommended through the Department of Health () publication, The Valuing People, (2001) as the main means of planning with the people involve in the program and all its services should adopt a person centered approach.
The Mental Health National Service Framework (MHNSF) sets out the way modern mental health services will be delivered. Services will be much more accessible, intervene more quickly to offer help and support, seek out those who are difficult to engage, involve service “users” and carers in planning developments, use effective care processes; and be delivered in partnership across health and social care as well as other key agencies
All mental health service users have a range of needs which no one treatment service or agency can meet. Therefore it is important to have a system which allows a service user access to the most relevant response that is needed. The principle that applies here is getting people to the right place for the right intervention at the right time. This principle is the guiding light of the Care Program Approach (CPA).
The CPA was introduced in April 1991 in response to concerns about the Health Sector delivery of mental health services. This approach was developed in response to serious incidents involving people with mental disorders and therefore has a particular focus on issues relating to risks.
The care program approach with its principle of user involvement is generally considered to be a good thing. With the rise of consumerism, and mental health care viewed as a program or service that needs to be purchased, it increased the confidence and the ability of the people recipient of mental health services to vocalize their dissatisfaction with those services and their desire and ideas for improving the mental health system (2004).
The apparent willingness of the government and mental health workers to enable the people using the program gives a big impact and a bigger role in determining how the mental health system works. The government, in show of its support for user involvement in creating a health care program established the Commission for Patient and Public Involvement in Health to ensure that the public is actively involved.
We cannot talk of the CPA’s user involvement approach without any reference to the concept of “empowerment”. The concept of empowerment reflects the belief that genuine, meaningful involvement would, as a process and in its outcome, would bring about positive change and improvement for service users, both individually and collectively and to the entire mental health system as well (2004).
Since the advent of community care policies in the 1980s and the development of the Care Program Approach (CPA) considerable emphasis has been placed on ensuring that individual users are fully involved in the planning, delivery and review of the care and treatment they receive (2004). Describing the CPA assessment process, Department of Health guidance states that it will involve the user and the “carer” where appropriate, as central participants in the process (1999a). Phrases such as ‘user-centered’, ‘client-driven’, or even ‘user-led’ are often used by service providers in describing both the value base and process of care that individual users should be experiencing in their contact with services. This would make it appear that the person who is a recipient and an active participant of the service is recognized to as far as possible as respecting the person’s needs and wishes with the program.
Role of the Nurse in the CPA
The shift from the hospital to the community care of people with mental illness and the growing involvement of the independent sector have left many nurses concerned about their role in future mental health provisions (1990). They believe that this confusion has been exacerbated by the fact that the knowledge base of mental health nursing is still a contentious issue. For example, should training for mental health nurses be centered on the biological sciences, the social sciences or the acquisition of interpersonal skills? A clear definition for mental health nursing was provided by (1994) which states that mental health nursing and psychiatry are branches of their respective professions, nursing and medicine. Each has separate features of responsibility, and the role of mental health nurse is to voluntarily assist in the work of the psychiatrist, to give medications, monitor for reactions, record effects and recommend adjustments in drug dosages. They are also instructed to discuss, share data and plan together so that the patient’s total program makes sense and is as constructive as possible ( 1994). However such definition seemed too technical and to robotic that it seemed to ignore the many invisible skills that (1994) describes as a great value. These invisible skills were the technical aspects of nursing and the interpersonal aspect which was later found out in earlier studies of (1979). The technical aspects include works such as giving injections and medication. These are the functions that are valued by the management since they are tangible and quantifiable. The interpersonal skill talks about building warmth and empathy with the patients. These are not tangible and usually receive attention only when complaints arise. A number of studies have attempted to define the role of the mental health nurse by examining aspects of the mental health nurse’s work. Early descriptions of the psychiatric nurse could only be drawn from the records of doctors and the Journal of Mental Science. The role of the nurse seems to shift from different paradigms of treatment time to time. A nurse’s role has many facets, from the ability to assess, educate and provide therapy to managing people and information, and personal development. In a busy environment, it is also important that nurses are able to apply knowledge to practice through their developing skills. With the care program approach, the main role of the “carer” is to facilitate and organize a program with the “user”. Since empowering the patient is the main thrust of this program, the nurse should as much as possible take a less active role in the program other than to asses and evaluate the user’s progress.
Implications and Suggestions for Improvement
Good theoretical reviews of the Care Program Approach make it the best alternative for mental health nurses to follow as the new paradigm in treatment for mental health. The review identifies five main benefits of user involvement that emerge from the literatures. First, it gives the first hand experience or the expertise of the user in respect to their own mental distress or mental health system. The user of the program is the one person who knows what kind of treatment is best suited to him. Second, because of the knowledge of the users own mental health it ensures that the “carer” is well informed of what kind of service or coping mechanism to be utilized by the user. This often emphasizes self help, mutual support and individual strength. Third, since the program is dynamic and personal because it caters to the needs of the users, the carer can use many different alternatives, other than rigid instructions coming from the mental health system. The carer can evaluate and re asses immediately the progress of the program and suggest changes if the user needs to. Fourth, the program itself contributes alternative models or approaches to mental health which could compliment existing services. The dynamic of the program is that along the way the user and the carer also learns many things that do not only develop and “cure” the user but as well as the carer personally. The entire mental health system also benefits from the program since it opens new ideas and alternatives that are previously overlooked. Lastly, it enables the user to develop new skills and increase their confidence and self esteem which is primarily the main trust of this program aside from helping the user get back to the society successfully. The empowerment mechanism of the program is definitely used to perfection.
But underneath the glib assertion of user involvement being a good and almost a perfect thing, the somewhat broad definition of it that has just been given, both the concept and the reality are significantly more complex. The terminology alone can complicate things, many people who have had contact with mental health services as well as many who provide services are not comfortable with the term ‘user’ for a number of reasons. ‘Survivor’, ‘consumer’, ‘client’ and ‘patient’ are still preferred by many, denoting how they choose to define themselves, or the person, in relation to their mental health and/or the mental health system (2004). The processes and the objectives of involvement mean that it is not straightforward. Examination of these in more detail gives a good sense of the complex and diverse array of activities that can be included, and also where potential or actual difficulties with user involvement may lie.
Yet at the same time it appears that despite all these positive developments and apparent commitment to user involvement, things are still falling short of the mark. Looking at the experience of individual service users in relation to their involvement in the care and treatment that is provided to them, there is good evidence to show that considerable difficulties continue to exist. An extensive study of service users’ perspectives on community and hospital care found that the majority of users in the study did not know the purpose of the CPA, who their CPA key worker was (now known as care coordinator), or whether they had a care plan, and less than a third said they were involved in actually drawing it up or reviewing it ( 2001). Lack of involvement at an individual level was mirrored at a service level where the study found low levels of user involvement in the running of services, little awareness of user involvement groups and, even where there was awareness, little belief that such groups had an influence. The conclusion was drawn that ‘users still do not feel involved in making decisions about their care at any level. It is clear that the government’s intention of putting the patient “at the centre” has not filtered down to all those who provide mental health services – be they organizations or individual mental health professionals.
(2003) study also goes into considerable depth in looking at user involvement, with a particular focus on involvement at the service-planning level. Looking at the experience of users who were involved in designing the NSF, the study describes a poorly planned and poorly managed process that even resulted in some users resigning from the consultation group. Black and minority ethnic service users felt particularly marginalized (an experience repeated elsewhere in user involvement initiatives), and many people felt unhappy with the final version of the program, not considering it to be a true reflection of the work that they had contributed.
Number of barriers to greater involvement of user appears consistently in the literature. Some of observations were as follows. Lack of information for users, the meaningful involvement being expensive and time consuming. User groups that support user involvement lack resources and expertise to conduct the program and the still on going resistance from mental health professionals about the value of user involvement.
Suggestions for Improvement
Mental health professionals should try to willingly accept that user involvement is the norm and the new paradigm in the mental health service. On the part of the user it is important to ensure that users have a base of support and accountability from which they can work. In this way the user would stick to the program.
Credit:ivythesis.typepad.com
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