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Bridging
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Bridging – talking meaningfully about the care of people at risk ©Phil Barker and Poppy Buchanan-Barker 2004 From Relationships to Partnerships Within
less than a decade, the concept of ‘risk’ has become a central focus of
mental health policy and practice. Various processes of ‘risk
assessment’ and ‘risk management’ are employed as a form of
contemporary governance, attempting to control the actions of both
service users and practitioners to best meet the fiscal needs of the
organisation (Crowe and Carlyle, 2003). This suggests that the
organisation – rather than the ‘patient’ – is most ‘at risk’ (of
litigation). Crowe
and Carlyle (2003) saw a need for nurses to re-examine carefully their
socially mandated role as ‘guardians’ of people at risk, if they were
to continue to fulfil their espoused ‘therapeutic’ role. The
‘nurse-patient relationship,’ first described over fifty years ago, is
a major ‘given’ of nursing practice: nurses spend time with patients
and this (of itself) is therapeutic (Jackson & Stevenson, 1998).
However, in Moyle’s view, such ‘close relating’ did not come
instinctively to all nurses. Instead, she found a clear dichotomy
between the close relationship expected by patients and the distant
relationship often provided by nurses (Moyle, 2003). In
the 1990’s, the ‘therapeutic relationship’ was reframed by the business
culture of healthcare as a ‘partnership’. In her study of acute
psychiatric care Cleary (2003) noted that the ‘partnerships’ concept
was commonly cited as the ‘cornerstone of integrated patient care’ and
even had been hailed as ‘the nursing hallmark of this decade’ (Cotroneo
et al,1997). However, “when patients are denied the right to pursue a
choice contrary to what the clinician considers best, the possibility
of real partnership is precluded” (Cleary, 2003: 143). A
major problem with recent developments in mental health care involves
the careless borrowing of concepts (like partnership or consumer) from
business and commerce; re-applying them, with little critical
consideration, to wholly different contexts. Given its in-built power
imbalance, the ‘partnership’ between providers and recipients of mental
health services could hardly be more different from the free-market of
commerce. This suggests the need to ‘unpack’ the language of care and,
perhaps, the need to generate more meaningful terminology. The Emergence of the Observation Culture At
least within residential care, the commonest way that nurses have
exercised their ‘guardian’ role has been through the practice of
‘observation’ (SNMAC, 1999). Although a longstanding aspect of nursing
care (Davidhizar & Vance ,1993; Rogers, 1993),
over the last 15 years ‘observation’ has been defined specifically in
documented procedures, and mandated generally through policy directives
(Duffy, 1995; Bowers et al, 2000; Clinical Resource and Audit Group,
2002). In too many setting, ‘obs’ (as it is euphemistically known) has become the raison d’ętre
of acute care nursing. However, there is widespread consensus that
observation fails to meet the needs of either users or professionals
(Barker and Cutcliffe, 1999; Barker and Cutcliffe, 2000; Bowles et al,
2002), and there have been strong appeals to review the approach to
supporting people at risk (O’Brien and Cole, 2003; Langham &
Lindow, 2004; Meiklejohn et al, 2003). To
the layperson ‘observation’ must represent a curiously illogical
response to a human crisis. If we thought that an electric plug was
faulty and might catch fire, we would not ‘put it on observation’.
Similarly, if we though that someone might haemorrhage, we would not
simply ‘observe’ the person. Observation would merely be a minor part
of more complex process of examination and investigation, hopefully
leading to decision-making as to ‘what to do next’. However,
in Horsfall and Cleary’s (2000) view the ineffectiveness of observation
is linked to its reinforcement of the traditional medical hierarchy of
power relations. The ‘observation policies’ that dominate practice, may
emphasise succinctness and clarity. However, this is invariably at the
expense of any consideration of patient rights, therapeutic processes
and inherent ethical dilemmas. ‘Observation’ becomes something that is
done ‘to’ people and, much research illustrates how unsatisfactory this
is for service users. Langham and Lindow (2004) acknowledged how organisational cultures made many professionals ‘practice defensively rather than defensibly’. However, they urged professionals to ‘take appropriate risks’ and ‘talk
about risk’, looking holistically at a person's life, including other
harms they may be experiencing, such as racism and trauma. Updating Observation In
Scotland, the Clinical Resource and Audit Group (CRAG) published a
review, which attempted to address many of the accepted weaknesses of
observation. Although CRAG (2002), proposed that ‘engagement’ should be
an integral aspect of ‘observation’, they ignored most of the original
work on this concept, especially the philosophical and ethical
arguments. In particular, Barker and Cutcliffe (1999; 2000) had argued
that observation was a dimension of engagement – not vice versa. Professionals cannot fail to observe if actively engaged
with the person in their care. However, as countless studies
illustrate, professionals can (and frequently do) conduct
‘observations’ without any human engagement. Regrettably,
CRAG’s report, although a useful update on policy and process,
conserved the use of the term ‘observation’, which has long outlived
its usefulness. The
names we give to things denote the nature of the thing itself, how it
‘works’ and perhaps also our relationship to it (Wittgenstein, 1965).
There is a world of difference between ‘observing’ and ‘engaging’. If
we wish to emphasise and value the kind of activities associated with
engagement, logic would determine that we begin by not calling it
observation. Given
that observation has acquired (rightly or wrongly) such a bad name, the
need to reframe it is not a linguistic luxury. A decade ago, nurses in
the UK acknowledged that their old ‘psychiatric’ title either was ‘bad’
or inadequate for describing their work. So, they renamed themselves
‘mental health’ nurses. It is ironic that nurses have not felt
similarly motivated to jettison the terminology of ‘observation’. To be is to do In
the early development of the Tidal Model (Barker, 1997) attempts were
made to represent more precisely ‘what’ nurses did in the name of
caring – especially for people at risk, who often retreat from human
contact. It was obvious, therefore, that professionals needed to ‘reach
out’ in some way, to make contact with the person. Such contact was the
necessary first step to gain access to the person’s ‘lived experience’,
from which might develop an appreciation of the appropriate caring
response. This process was called ‘engagement’ (Barker, 1998; 2000; Barker and Buchanan-Barker, 2004). Through
workshops and ongoing discussion with colleagues in various Tidal Model
evaluation projects, we have had an opportunity to revisit the ‘naming’
of the caring process we described for supporting people at risk.
Although ‘engagement’ was useful originally in distinguishing it from
the limited scope of mainstream ‘observation’, it is not without its
problems. ‘Engagement’
now features in both policy documents and the published literature, and
this has led to a blurring of meaning. ‘Engagement’ can mean a ‘moral
commitment’, which fits neatly with the value base of the Tidal Model.
However, ‘engagement’ can also mean ‘an encounter between hostile
forces’. As fewer people become ‘engaged’
to be married, and the media report more and more ‘engagements’ on
battlefields around the world, the hostile connotation of the word is
reinforced. Over
the past year we have reviewed alternative names for the supportive
human process necessary to reach out to people in distress, in an
effort to connect with them, meeting them – at the very least - halfway. We have re-named this process – bridging. Bridging – it means what it says Bridging provides an apposite metaphor for the necessary work of supporting people in distress, or otherwise ‘at risk’.
In
mental health care, we need to ‘cross’ the threatening waters of
madness; to ‘reach’ the person in distress. The bridging metaphor aptly suggests
the necessary creativity and effort involved in building a bridge to
connect with a person who may be alienated, isolated, threatened and
fearful. It acknowledges that the activity of ‘bridging’ has inherent
dangers. Bridge builders need to act skillfully and carefully,
acknowledging all the risks that might be involved. They also need to
ensure that the ‘basic building blocks’ are in place, before any
further develop takes place. Again, in mental health care, these
‘building blocks’ are human – not bureaucratic - processes. These
powerful metaphors communicates a desire to depart radically from the
bureaucratic system that has overtaken the mental health system; one
which has dehumanized both professionals and the people in their care. Most significantly, unlike ‘observation’, which is a thing (noun), ‘bridging’ is indicative, denoting the activity
involved in caring. ‘Bridging’ cannot exist outside of the
interpersonal relationship between professional and person in care.
‘Bridging’ can only develop as the two people begin to make contact. We can only know how bridging
‘works’ by examining the shared outcomes of ‘bridging’ as a human
encounter. Much like playing a musical instrument or riding a bicycle,
we can only learn to do ‘bridging’ by doing it. The Personal Security Plan: Archie’s story A
Tidal Model assumption is that risk (to self or others) is related to
the human state of ‘emotional insecurity’ (Barker and Buchanan-Barker,
2004). Mainstream ‘risk management’ aims to keep the person ‘safe’.
Usually, this involves carefully managing the social and
physical environment, so preventing the person from acting harmfully
towards self or others. Often little or no attention is paid to the
private, intrapersonal, world of the person’s ‘lived
experience’. However, If people can become more ‘emotionally secure’,
within themselves, they will by consequence be ‘safer’ within the
interpersonal and physical environment. The
Tidal Model employs a specific ‘care plan’ to address emotional
insecurity. Archie was seriously suicidal person with a long experience
of ‘being on obs’. However, he believed that observation was a ‘waste
of time’ because ‘the problem isn’t out there (pointing to his body) but in here
(pointing to his head)’. Although he had no idea how nurses could ‘get
inside’ his head, Archie gave his time over several months to help
explore ways that nurses might understand better the ‘private world of
experience’. The outcome was the original ‘Security Plan’. On the
advice of a wide range of people who have since experienced the
process, it was renamed the Personal Security Plan, emphasizing
ownership by the person in care. The
Personal Security Plan is a single sheet of paper, on which the nurse
and the person in care, co-construct a provisional plan, which aims to
help the person feel more secure within him/herself and the wider
social environment. It is written in the person’s own voice, and
revised at least once a day, in an effort to become part of the
person’s lived experience of risk. This collaborative form of ‘risk
assessment’ and ‘ collaborative care planning, has been practiced
within Tidal Model projects at home and abroad for over five years. It
is worth noting that Langham and Lindow (2004) called for just this
kind of this kind of collaboration, focused on accessing the person at
risk’s ‘lived experience’. However,
writing words on paper is easy. The real challenge lies in the process
necessary to find those all-important words. ‘Bridging’ exemplifies the
way nurses might use themselves to reach out, connect and begin to
share the reality of living with risk. Meaning in the Metaphor Policies,
procedures and protocols now securely underpin the bureaucratic culture
of Western health and social care. However, ethical practitioners need
to continue questioning the philosophical and ethical underpinnings of
these processes. What are they for? On what ideas (or evidence) are
they based? Who is the intended beneficiary? Although
we framed the concept of ‘bridging’ specifically for the ‘risk’
context, experience tells us that this is the key building block of all
therapeutic encounters – in bridge-building terms it is the ‘keystone’.
Although we have psychotherapy and counseling backgrounds, we believe
that ‘bridging’ – like many other human encounters necessary within the
Tidal Model – is not psychotherapy or counseling. It is more important than that: it is conversation. The very ordinariness of these ‘bridging’ conversations can render them quite extraordinary, for both parties. In
supervision, we have been privileged to watch and listen to lots of
nurses attempt to ‘bridge’ with people in deep distress. We hear them
address issues such as: · How to bridge when trust appears to be absent? · How to bridge when very differing points of view exist? · How to bridge when the two parties are beginning from very different starting points? · How to bridge when reaching understanding appears impossible? · How to bridge when the nurse and the person in care, clearly have very different beliefs? Critics
will argue that using metaphor is too subtle or complex for care-face
staff to understand. We could not disagree more strongly. The support
that people at risk need must be sensitive, compassionate and creative.
We cannot afford to offer less. More importantly, since the experience
is invariably ‘beyond words’, metaphor fulfils a key role in expressing
the inexpressible. Indeed, the rigid template of most ‘observation
guidelines’ may have led many practitioners to simply follow the
‘letter of the law’, giving up thinking and feeling their way towards
the person in distress. Over
the last few years we have been conducting experiential workshops in
different countries. We usually begin by asking the group: “what would
you want for one of your loved ones, were they to experience ‘a
breakdown’, and become a risk to themselves or others?” So far, none of the 2,500 participants has ever said - ‘put on observation’. Instead, we have been struck by the way professionals demand compassionate, sensitive and creative caring
for their loved ones. In the real world of professional practice there
is little support, for ‘caring by guidelines’, at least where real
people at risk is concerned. Although CRAG (2002) stated that anyone
could be called upon to conduct observation, in our experience the
nurse is, almost always, the ‘care face’ practitioner, to whom this
onerous responsibility falls. It seems appropriate, therefore, for
nurses – and the discipline of nursing - to begin to develop its own
language for the discrete processes necessary to care for people at
risk, rather than – as so often has been the case – have the story of
care written for them, by others. References Barker P (1997) Towards a meta theory of psychiatric nursing. Mental Health Practice, 1(4) 18-21 Barker P (1998) Its time to turn the tide. Nursing Times 94(46) 70-72 Barker P (2000) The Tidal Model: The lived experience in person-centred mental health care. Nursing Philosophy 2 (3) 213-223 Barker P and Buchanan-Barker P (2004) The Tidal Model: A guide for mental health professionals London: Brunner Routledge Barker P and Cutcliffe J (1999) Clinical risk: A need for engagement not observation. Mental Health Practice 2(8) 8-12 Barker P and Cutcliffe JR (2000) Creating a hopeline for suicidal people: A new model for acute sector mental health nursing. Mental Health Care 3(6_ 190-92 Bowers
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