Person-Centred Care Planning

Outline  Review current care planning practices in the different branches of nursing  Examples from practice  Consider care planning within models of nursing and care philosophies  Person-centred approaches  Reflection

Exercise A  List the types of care plans you have used in practice:  Name them  Write down any known theory or philosophy behind them  Describe them

Exercise B  List the elements you think are important for a ‘good’ care plan (explain why)

Discussion Issues  Different client groups within the health service and voluntary sectors  Can one model fit all?  Who should be involved in the care planning process?  Care collaboration – the way forward or a case of too many cooks? (consistency v multi- perspective)

Care Planning Philosophy  Why worry about models of nursing and philosophies of care when care planning?

Care Planning Philosophy  Philosophies of care and nursing models provide:  structure and an evidence base for the care planning process  context within contemporary mental health care so that care practices match current trends in theory and philosophy  consistency between care providers

Philosophies of Care  Name some philosophies of care that drive nursing (past and present)  What models of nursing have influenced care for people with mental health problems and learning disabilities?

Nursing Process  Assessment (of patient's needs)  Diagnosis (of human response needs that nursing can assist with)  Planning (of patient's care)  Implementation (of care)  Evaluation (of the success of the implemented care)

Models of Nursing  Roper, Logan & Tierney (1980) Activities of Daily Living (Holistic)  Roy’s Adaptation Model

Roper, Logan & Tierney (1980): Activities of Daily Living  Maintaining a safe environment  Communication  Breathing  Eating and drinking  Elimination  Washing and dressing  Thermoregulation  Mobilisation  Work and play  Expressing Sexuality  Sleeping  Death and dying

Roper, Logan & Tierney (1998): Activities of Daily Living  Bio-psychosocial model of medicine  Useful for assessing older people, people with mental health problems and chronic diseases  Focuses on the functional status of the person

Roy’s Adaptation Model Biological Psychological Social Sees individual as a set of interrelated systems:

Roy’s Adaptation Model  Individual tries to maintain balance between the 3 systems and the outside world  Because there is no absolute balance we adapt to a level we find acceptable

Roy’s Model in Practice  Patton (2004) examined use of the model in acute psychiatric nursing:  Acknowledges the potential (has clear scientific & philosophical basis)  Needs more research-based evidence as to it’s efficacy

 Focuses on the continuous process of change inherent in people  Aims to empower people to reclaim control of their lives using 3 domains of self, world and others

 Self domain – where person feels their world of experience  World domain – where people hold their story  Others domain – relationships (past, present & future)

 Have to believe the following:  that recovery is possible  that change is inevitable - nothing lasts  that ultimately, people know what is best for them  that the person possesses all the resources they need to begin the recovery journey  that the person is the teacher and the helpers are the pupils  that the helper needs to be creatively curious, to learn what needs to be done to help the person, now!

 The Ten Commitments 1.Value the voice - the person's story is paramount 2.Respect the language - allow people to use their own language 3.Develop genuine curiosity - show interest in the person's story 4.Become the apprentice - learn from the person you are helping 5.Reveal personal wisdom - people are experts in their own story 6.Be transparent - both the person and the helper 7.Use the available toolkit - the person's story contains valuable information as to what works and what doesn't 8.Craft the step beyond - the helper and the person work together to construct an appreciation of what needs to be done 'now' 9.Give the gift of time - time is the midwife of change 10.Know that change is constant - this is a common experience for all people

Comparisons  All these models take an holistic approach  Activities of Daily Living is generally more medically orientated  Roy’s & Tidal models see the uniqueness of the person  Roy’s is more scientifically based but less applicable than the Tidal model

Recovery Orientated Planning  Individual and collaboratively developed  Identifying hopes, goals and ambitions  May consider triggers and coping strategies  Identifies resources, may include within and outside of services.  Resources may be personal and environmental

 Move beyond focus of treating illness to promoting health & wellbeing But …. Could be frightening process, thinking about traumatic experiences and taking back responsibility

Application to practice 1)Think about your own recovery orientated plan. What would you want to include? 2)In pairs identify someone you worked with on your last placement. What would you include in a recovery orientated care plan?

Key elements  The trusting relationship between the named person and the service user.  Allowing and facilitating the service user to contribute their own feelings and views to the care they are receiving.

Strengths Model (Rapp, 1984) – Emphasis is on the client’s strengths, interests and abilities NOT upon weaknesses, deficits and pathology. – People with mental health problems can learn, grow and change. – The client is viewed as the director of the helping process. – The client/care co-ordinator relationship becomes the foundation for the mutual collaboration. – The community is viewed as a potential resource rather than an obstacle.

Care Pathways Current trend in healthcare and used in both residential and acute/treatment settings. Pathways form the central part of multi-disciplinary healthcare records. Can be used as guides to what interventions/work you may want to implement with service users. It should be used in partnership with service users.

Risk Management  Risk assessment and risk management are a key consideration in working with individuals experiencing mental health problems.  You will see a range of care plans used in clinical settings based around risk management e.g. CPA level 2 risks assessments and ‘zoning’.

Current Practice  Personal Plans:  Emphasis on client involvement  Helps build therapeutic relationship  What happens if you identify an area you feel should be documented. Is this your own personal view on what the client should be working towards or is this a risk issue?

Current Practice  Risk Assessment Plans:  Essential for addressing areas not highlighted by service user  Still discuss the risk management plan with the service user even if they don’t agree  Therapeutic risk taking – important to be care planned and owned by the whole multi- disciplinary team

Evaluation of Care Plans Evaluation of care plans is completed according to the time frame of the care plan and in collaboration with service user (this is often reviewed in individual clinical supervision)

Acute/Treatment Ward Settings  Care pathway documentation  You will find some variation in care planning documentation used.  Standardised care plans around observation levels (high, intermittent and low.)  Standard Trust care plan which can be used through either a personal plan or risk management approach