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Evidence based practice (EBP) refers to integrating professional expertise with the best available external research, and incorporating the views of service users (Beresford, 1996). Evidence based practice has received its reputation by examining the reasons why interventions are necessary (Duffy, Fisher and Munroe, 2008). Within my placement EBP was important for refining my practice so the service user was provided with appropriate support for her individual needs. I used my EBP to carry out research to determine what evidence supported or rejected the use of a specific intervention; within this case I used a counseling approach.
The principle of social work intervention is to provide good practice and should be based on a decision-making framework (Preston-Shoot and Braye, 2009). This framework operates on four concepts:-
- The legislation that informs a decision;
- Social work ethics and NISCC codes of conduct;
- Information to ensure a well-informed decision;
- Knowledge drawn from research, theory, practice and other professionals.
In addition to powers and duties of social workers, legislation embeds notions of partnership, respect, rights and anti-discriminatory practice, which are key elements in social work practice (Preston-Shoot and Braye, 2009).
My practice learning opportunity involved working with adults with a learning disability in a day care setting. The benefits of the day centre were to provide a service for local people to access support in living with, or caring for someone, with a learning disability. Northern Ireland statistics show that in 2008 there were 9,460 people with a learning disability in contact with Trusts (www.northernireland.gov.uk). From the 9,460 people with a learning disability there were 2,574 benefiting from care management, 42% (1,086) of whom were being supported in their own homes and 35% (898) being cared for in residential homes solely for the use of people with learning disabilities (www.northernireland.gov.uk).
This evidence based case study is based on Miss A, a 35 year old woman, who has a learning disability and Spina Bifida resulting in her using a wheel chair for mobility. Within the past few years Miss A’s family life has changed dramatically. In previous years Miss A had lived in the community with her elderly parents, who cared for her. She is one of three children and has two older brothers. Miss A’s mother, after being diagnosed with Dementia, was admitted to a residential care home. Her father after having been moved to residential care himself passed away in November 2008 due to his physical health. Miss A now resides in a private nursing home and attends day care three days per week. In March 2008, there were 75 residential homes in Northern Ireland solely for people with a learning disability providing 898 places (www.northernireland.gov.uk).
Miss A has been previously diagnosed with MRSA; it is currently located in her toe, having been previously present in her urine. Treatments from the residential care staff have the infection under control, however the infection still remains.
The recent death of her father plays a significant role in Miss A’s life and continues to affect her socially and emotionally.
Some of the stereotypical assumptions I had before meeting Miss A were that because she had a physical and learning disability that she would be hard to communicate with, that she would have limited understanding and limited verbal skills. I have challenged this opinion and realised that Miss A is a very competent individual with good communication skills, and can express her likes and dislikes proficiently. As for her physical disability this does not affect her cognitive or cerebral functions. I had also made the assumption that as Miss A had MRSA that it could easily be cross-contracted due to a lack of knowledge and education. After researching the issue and contacting infection control within the Trust I deducted that MRSA is a problem within clinical settings but can be easily controlled with proper preventative procedures. This can be identified as a risk, but should not be a reason to oppress or discriminate Miss A.
After having initially met Miss A, liaised with her social worker, accessed her case file and Tuned In to her life issues, I met with Miss A to prepare for the initial assessment and gather information into how best to support her. My role with Miss A was to provide a reassessment since the changes in her circumstances and the death of her father. My role was to determine what support she may need, and to include her wishes and feelings.
History has shown that there has always been an importance to assessment in social work, but since the 1990’s there has been specific importance to a new form assessment to include risk. The National Health Service and Community Care Act 1990 stresses the importance of inter-agency collaboration and a multi-disciplinary assessment process (Trevithick, 2000). The purpose of an assessment may seem evident; that is, to assess the needs of individuals who may need help and/or support. In recent history however assessment seems to mean a relationship between need and available resources (Whittington, 2007, p23) leading to a question if this is ethical or effective practice?
There are many purposes of an assessment, for example to assess risk, to assess need, to act as an advocate for someone and also to implement agency and government policy (Whittington, 2007, p25-26). Coulshed and Orme (2006) explain that assessment is an ongoing process where the purpose is to understand people in relation to their environment; it is a basis for planning what needs to be done to maintain, improve or bring about change with the service user’s participation.
The initial preparation for the assessment with Miss A included visiting her social worker and studying her case file. This enabled me to gather information to dispel any preconceptions I had about meeting this service user. The social worker passed on her knowledge of Miss A, such as medical conditions, family circumstances and finances, and also any previous problems that had occurred. I felt it was important to work in partnership with Miss A’s social worker so I could keep her up to date with events, and also contact her if I required advice about Miss A. The purpose of Miss A’s individual assessment was to gather information by interacting and communicating with Miss A and others involved in her care, this was also to gain a holistic perspective to her needs. Her assessment was guided by legislation such as, the Chronically Sick and Disabled Persons Act (NI) 1978, which places a duty on health and social services to investigate a level of need, and also the Health and Personal Social Services (NI) Order 1972 which stipulates a responsibility to provide personal social services for the promotion of social welfare for the general public (http://www.understandingindividualneeds.com).
As a model of assessment I used Smale’s (1993) Models of Professional Care which were useful in gathering important information about Miss A. I used the procedural and questioning model to gather information into how Miss A felt about certain issues in her life, such as the bereavement of her father, contact with her other family, and other issues she felt were working or not working. I used these methods of assessment as this followed Trust guidelines. I used The Model of Professional Care to gain a holistic understanding of information. I also included the Exchange model in the assessment as I considered Miss A to be the expert of her own life. I feel the use of the Procedural model was useful in certain aspects of the assessment as it worked in collaboration with the Trust’s format of assessment and worked as a form of gathering information, but feel I could have used more of an Exchange model to communicate effectively with Miss A rather than just form filling. I feel Smale’s method of assessment provided me with tools to help Miss A identify factors that were important for her to maintain, but also issues she would like to change. By working in partnership with her I felt we would have an open and trusting working relationship.
I also focused on Person Centred Planning (PCP) in regards to the assessment with Miss A. Person Centred Planning, which evolved from the White Paper; a government policy known as Valuing People, suggested four key principles; Rights, Independence, Choice and Inclusion as a proposal of changing services (Thompson, Kilbane and Sanderson, 2008, p9). This policy also helped inform guidelines for Northern Ireland’s Equal Lives Policy (2005). Person Centred Planning focused on finding out what is important to and what is important for (health and safety) Miss A. I found PCP a continual process of listening and learning, by focusing on what’s important to Miss A now and in the future (Thompson, Kilbane and Sanderson, 2008, p27). By using person centred tools, such as a one page profile, I gained knowledge of what was important to Miss A including her family, her boyfriend and her independence, as well as knowing what was important to keep her safe and healthy. I used a person centred approach to make others aware of Miss A’s great personality characteristics as well as the help and support she would like. I feel this was fundamental to demonstrate that Miss A is a person behind her disability. I found by using this approach was an essential skill in understanding Miss A and helped me to be anti oppressive and actively support her needs
One particular piece of legislation which I found to be significant in the assessment of Miss A was the Human Rights Act (1998), which identifies Miss A’s right to family life. Since the death of her father and the institutionalisation of her mother due to her mental health, Miss A has been experiencing disintegration of her family and has lost the support connected to it. The Human Rights Act could have a great significance as Miss A needs emotional and physical support to visit her mother and has not been receiving it; therefore her right to family life is being impeded. The assessment identified that contact with her family and friends are imperative for this right to be upheld. Therefore as a result my role was to facilitate this right, and help to support Miss A in retaining family contact.
The main objectives we (Miss A and I) identified within the assessment were;
- That Miss A had limited support to help discuss the death of her father.
- That Miss A was not receiving contact with her mother or other family and would like to.
From the identification of objectives Miss A and I decided to work towards solutions by preparing a work plan.
After the initial assessment was carried out with Miss A we proceeded to work towards formulating a care plan and targeting her objectives. A care plan provided clear information for everyone involved with Miss A and helped work in partnership with her and the Trust. For a person centred care plan the word ‘support’ is used in preference to ‘care’ because the verb implies that support is there to help people achieve their goals and ambitions” (Thompson, Sanderson and Kilbane, 2008). “A support plan is developed by the person with help where necessary, and it describes how the person intends to be supported in order to live their own life” (Thompson, Sanderson and Kilbane, 2008). I feel the use of a support plan with Miss A, rather than a care plan is an anti-oppressive method, as it incorporates Miss A’s feelings and opinions into how she wishes to be supported.
I used the formulation of a support plan with Miss A to record the objectives she would like to meet and used these to formulate an intervention. It was clear from the assessment and one page profile that limited contact with her mother was an issue, and that the death of her father had a significant impact on her life.
I then proceeded to investigate theory of loss and grief as I had never experienced a loss of Miss A’s magnitude before. I found the Kubler-Ross Model and the 5 responses to grief to be particularly informative. (Goldsworthy, 2005). This theory helped inform my knowledge and in turn helped me be empathetic to Miss A. I was able to identify that Miss A can experience the 5 stages of grief and that they are not necessarily in a specific order. I felt Miss A was at two stages of grief, some days she experiences anger at her father leaving, and other times she has deep feelings of depression of losing him. I was able to use Kubler-Ross’s model to identify these stages in Miss A, and also to advise her that these feelings were part of the normal process of grief.
The assessment also identified that Miss A had a lack of support in discussing her feelings of grief. Research suggests that people with learning disabilities experience many of the emotions of bereavement but are limited in the opportunities they have to resolve their feelings of grief (Cathcart, 1995; Elliot, 1995; Read, 1996). There are many reasons for this and Murray et al explains that historically, professionals, parents or carers of individuals with learning disabilities believed that those in their care did not understand the concept of death and thus were unable to grieve for the loss of a loved one (McLoughlin, 1986; Elliot, 1995; Read, 1996 cited in Murray et al. 2000). Kitching (1987) and Bradford (1984) highlight that the capacity to grieve is not dependent on a person’s intellectual ability, but that a person with learning disability may experience grief in the same way as a child. Therefore research shows that people with a learning disability experience grief and loss but have a limited support network to discuss it with. I used this research to formulate a plan for the intervention with Miss A and we concluded that I could be support for discussing her grief.
From the assessment and care plan with Miss A, and following discussions my practice teacher, I discussed that I would use counselling skills to help support Miss A with her feelings of grief. I felt Miss A needed her emotional needs met since the feelings of the death of her father were so dominant. Miss A and I also decided that I would facilitate visits to her mother for emotional and physical support, as her mother was in the latter stages of dementia and Miss A found it hard to communicate with her.
Rationale for Counselling Intervention:
After having conducted an assessment and care plan with Miss A, and building a rapport over numerous meetings, it was decided that a counselling intervention would be the most appropriate form of support for grief. My practice teacher and I felt that if Miss A had the opportunity to discuss her feelings this would help her grieve more effectively and perhaps help her cope better.
The two models of counselling that are prominent in social work are the work of Carl Rogers and Gerard Egan, who base their counselling approaches from psychodynamic work around inner thoughts and feelings. Both counselling theories “reflect the social work values of accepting the individual, using skills in listening to the information that is given, and work towards a joint understanding and decision making about ways forward” (Coulshed and Orme, 2006). I focused on researching counselling theory to help me understand how I could help Miss A through her grief. Trevithick explains that within social work, humanistic approaches to counselling have been particularly influential, specifically with the work of Egan (1990) and Rogers (1961), mainly because they promote personal freedom and are consistent with anti-discriminatory practice and anti-oppressive perspectives” (Trevithick, 2000). I found that the Roger’s (1961) Person Centred counselling informed me that I could show unconditional positive regard for Miss A and understand that she is the expert of her own grief.
I also analysed Egan’s (1990) Skilled Helper Model and found it to be an effective theory for an approach to counselling. I found that the structure and framework of the model and the three stages were useful as a guide to follow. I found that although this method of counselling may not be as person centred as Roger’s it could be more effective in helping Miss A understand her own grief as it followed a certain framework, could empower her and could be evaluated over time. This theory helped inform my practice by helping me realise that I do not need to be a qualified counsellor to support someone; I just need to be able to actively listen, to use empathy and be reassuring knowing that Miss A’s agenda is paramount. I consider this in itself to be a person centred way of counselling.
I decided to follow a combination of Rogerian method and Egan’s approach to help support Miss A as an intervention. I decided I would use the structure of Egan’s model to help build a logical, consistent framework to the intervention, while using the core principles of the Rogerian approach to demonstrate my skills and values, such as working with respect, empathy, genuineness and good active listening (Coulshed and Orme, 2006).
Egan’s Skilled Helper Model form of counselling provides a structured and solution focus basis. It is a three stage model in which each stage consists of specific skills that the helper uses to support the service user move forward (Nelson, 2007). Egan’s model is described as a three-stage process: identification of the service user’s current issue(s); identification of the service user’s desired situation; and the formulation of an action plan to achieve this. This process is facilitated by the “skilled helper” using the skills outlines by Egan (Nelson, 2007).
The goal of using Egan’s model with Miss A was to help her manage her grief and better understand the “norms” associated with it, such as anger or depression according to the Kubler-Ross Model. Egan (1998) claims his model is to ‘help people become better at helping themselves in their everyday lives’. To provide Miss A with the empowerment to help herself grieve.
The use of Egan’s Skilled Helper Model was to explore how Miss A felt about her bereavement. I used it to ask open questions about how Miss A felt about her father. We explored her past and discussed her relationship with her father before his death. I also used this stage to focus on aspects of her father before he died and what she missed about him, this was to explore and gather information about what her relationship was like with her dad. I was able to use a range of skills to gather information about Miss A’s grief. Trevithick (2000) explains that social work skills are “the degree of knowledge, expertise, judgement and experience that is brought into play within any given situation, course of action or intervention” (Trevithick, 2000).
Some of the skills I incorporated into Egan’s counselling were active listening, I used this skill with a range of non verbal cue’s to indicate to Miss A that I was interested in what she was saying. I concentrated on active listening as Miss A was portraying feelings and knowledge of the death of her father which was a sensitive subject and needed my full concentration. I portrayed active listening by nodding, giving eye contact and facing Miss A which were successful in helping build a rapport with Miss A, thus helping her open up. Another skill I feel I used well with Miss A was empathy. I feel I portrayed my feelings of empathy by responding appropriately to her answers and reassuring her that her thoughts and feelings around grief were normal. I found myself using Empathy a great deal with Miss A as I had never experienced bereavement before and she helped me understand how it felt. It’s easy to imagine how someone feels, but when you’re faced with helping them I felt I really needed to place myself in “her shoes”.
I also found I made good use of silences with Miss A, I used these to give her time to reflect on her thoughts and answers. I have found by doing this that the meetings were paced better, and showed that she was the expert of her own grief and I was just there to listen and to reassure her. I found that by using Rogerian person centred skills like genuineness, empathy, communication and active listening I was able to understand Miss A and show her that I was there to support with her agenda. Throughout the discussions of grief I feel Miss A was able to vent a lot of her feelings that she had since her father’s funeral. I feel I was able to support her understand those feelings and help her recognise that anger, depression, or denial are normal feelings that many people in her situation suffer.
Throughout Egan’s Skilled Helper Model and each of the sessions with Miss A I found that she responded well to being able to discuss her feelings with someone. The Rogerian influence on the intervention enabled me to build trust, partnership and a good rapport with her facilitating an open working relationship and providing her with support.
Some of the values I tried to incorporate into my counselling and indeed my relationship with Miss A were empowerment and self-advocacy, by letting her know that her agenda was central. I wanted to create a balance of power and to provide a supporting role rather than a dictator role, which I feel I achieved by being able to listen to her views and incorporating PCP. Social work has a distinctive value base with beliefs and principles playing an important role in practice (Thompson, 2005). Challenging my values has helped me to treat Miss A with unconditional positive regard, and with the respect and dignity she deserves. I have challenged my values anti-oppressively by researching MRSA and not making assumptions about the condition; I have challenged my stereotypical attitude around learning disability demonstrating that Miss A is first and foremost a person with feelings and issues before recognising she has a disability.
On evaluation of the Egan’s Skilled Helper Model and my intervention with Miss A have shown that her agenda was central to the sessions, a balance of power was necessary to achieve the trust and respect of one another and that listening is paramount to providing effective counselling. I entered the sessions with Miss A being unaware of what to expect, I was troubled that I would not have enough knowledge about grief to help support her. After the initial session I soon realised that I didn’t need to be a qualified counsellor to make a difference to her understanding of grief, I just needed to be able to explain her feelings to her and reassure her that they were normal and not as she phrased it “being mental”. I found that by working with Miss A using the Skilled Helper Model I was able to apply my skills of listening, communication and empathy to help her understand her feelings. I have never personally had a bereavement of Miss A’s scale before but feel as a direct result of working with Miss A I have learned that grief is a powerful emotion for anyone to experience and it can take a significant amount of time to recover from. The only regret I have of using the Skilled Helper Model was that I feel I did not have enough time to fully help support Miss A, I feel as I had a placement of only eighty-five days I did not have enough time to fully counsel her for the best outcome.
I feel throughout the intervention process I tried to maintain person centred principles with Miss A by providing her with the opportunity to discuss what was important to her. Research shows that the use of Egan’s model is not person centred as it incorporates the counsellor to ask all the questions, and therefore have the control; but I feel by working in partnership with Miss A to discuss the death of her father was important for her emotional well being and empowered her to help resolve her grief. I also incorporated Roger’s core skills of genuineness, respect and trust to achieve this
Through working with Miss A I have found the experience to be invaluable learning. I have discovered that there is a spectrum of ability with adults and their learning disability. I have found that each person is an individual, and that group care is not necessarily recognising of this. In regards to Miss A I have learned not to make assumptions or stereotypes before meeting the person, as this can lead to oppression and even discrimination. Miss A is an individual, with individual needs, and at this assessment and intervention her emotional needs were prominent.
I feel I completed the aims I had intended to by supporting Miss a through her grief using Egan’s Skilled Helper Model. I incorporated Roger’s core skills into this model to help facilitate person centred sessions, and create an understanding that she was the expert, and I was there to listen and support her. If I was to repeat the intervention I would use Egan’s model again as it provided me with a structured, logical framework to work with and provided me with the identification of the skills I needed to make the sessions successful and effectively counsel Miss A.
I feel my future learning needs from working with Miss A are to use more formal language as I identified I talked to her informally using words such as “wee”. I feel I did this to appear more friendly rather than her social worker, but realise this is not a professional manner to work. Other learning needs I identified were to pace the sessions more appropriately and ensure that Miss A understands the conversation. I feel during the initial sessions with Miss A I spoke more to engage her in the discussion, and feel this was more of a nervous reaction to having to counsel Miss A. During later sessions I was able to take this skill into consideration and settle quicker into sessions to give Miss A the opportunity to discuss what she wished.
Overall I feel my relationship with Miss A was good, I feel the assessment and intervention were successful, and I feel I worked in a person centred way incorporating knowledge, skills and values to inform my practice. I feel Miss A felt positively about our work together as her feedback from sessions indicated that she was satisfied with the support I provided.
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