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Introduction Beginnings Making sense of the information Deciding what to do Reviewing the plan
 
     
     

Stage 4 - Reviewing the plan

Case Information

  • The dementia care mapping led to decisions that Ahmed needs progressively more support, as the onset of his dementia is rapid. Kawthar also has needs for support as carer. Practitioners need to work with Kawthar and Ahmed with sensitivity to their culture, employing interpreters to facilitate good communication.
  • The implementation of the plan is evaluated critically in the light of responses and views from all those involved, with particular regard to maintaining the involvement of Kawthar,
  • Ahmed and Neeta are collaborators in this process. Staff in BestCare introduce some ideas on how important it is to evaluate the evaluation, in an effort to maintain their self-criticality. They draw on some of the issues crossing global and cultural boundaries, in a rich source of critical discussion in a book written about critical practice development in New Zealand (Opie, 1992).
  • The care package is working. Occasional support has been provided through Ahmed attending the day centre. Kawthar cares for him the rest of the time, with support from the Carers Centre and Age Concern who run a self-help network for partners of people with Alzheimer's Disease.
  • Ahmed's condition is deteriorating rapidly. He has been wandering and becoming subject to wild mood swings and is often aggressive towards Kawthar.
  • The social worker tries to speak with Ahmed with the interpreter. He has lost most of his language skills and barely acknowledges her.
  • Kawthar does not know how to cope but does not want to reject her husband.
  • The manager of the day centre for frail elderly clients has contacted the social worker to say the day centre can no longer cope with Ahmed's needs. The manager suggests a specialist day centre take over.
  • The social worker has been reflecting self-critically on practice to date. The social worker is uncomfortable about the implicit ageism and deficient person-centred practice of arranging a day centre for Ahmed largely to give Kawthar relief. The social worker realises this could be construed as an ageist response which would not be contemplated if Ahmed was a young man suffering from dementia. The social worker seeks to empower Ahmed and Kawthar. This entails trying to
  • build on the strengths of the situation
  • create Win-Win situations for both of them.
  • The social worker has been busily networking in the multi-disciplinary team. He receives additional advice from the psycho-geriatrician on working with Ahmed, in view of his rapidly progressing dementia.

Key Questions

Values-based questions:

  • What help is available on Kawthar managing the ethical and practical dilemma about doing the best for Ahmed without feeling she is rejecting him?
  • What ethical and value guidelines are available to guide practitioners' considerations of the next stage of implementation of the plan?

Practice-led questions:

  • Is there sufficient, relevant evidence to enable practitioners to judge how effective the plan is to date?
  • What does the person-centred assessment offer, regarding possible explanations for Ahmed's aggression? It should be possible to obtain a non-medical response to this by understanding his frustrations at losing some faculties. The social worker and colleagues are working on the basis that non-medication is the goal at this stage.
  • How can the social worker find out what are Ahmed's wishes?
  • How can the social worker take Kawthar's wishes into account?
  • To what extent does the plan need to be changed to meet Ahmed's changed circumstances?
  • How can Kawthar's dilemma be reconciled with the need for action on Ahmed's condition?
  • If the plan needs to be changed, will resources be sufficient?
  • In that event, will the appropriate services be available?


Research Focused Questions

Knowledge-based questions:

  • What can be done to care for Ahmed, in the face of his rapid decline as the dementia progresses?
  • Should the overall coordinator of care for the family ensure that the health authorities and social services determine which agency should be responsible for providing services for Ahmed: residential or nursing care?


Skills-related questions:

  • How should health and social services professionals be working together to sustain the community care package?
  • How can practice skills best advance practice at the next stage of implementing the plan?
  • How can the goal of empowering Kawthar and Ahmed be realised in the situation where Ahmed's condition is deteriorating so rapidly?

Relevant Knowledge

Understandings of Dementia: The Bio-medical model versus Personhood

It is inevitable that most of the literature around dementia and Alzheimer's disease is dominated by the medical model. Medical understandings, including attempts to treat, ameliorate and even cure the disease, predominate in discussions of how professionals diagnose and respond to dementia.
Alternative understandings are necessary, as in hospice work, if the principle is to respect the person rather than to act on the body of the person to try to arrest the disease.
Jonathan Parker (2001) proposes one based on the concept of personhood, following Kitwood (1997). Whereas the bio-medical model leads to a focus on the disease rather than the person, the concept of personhood puts the experience of the dementing person in the foreground. It is possible now to give meaning to the sense of self of the person, the person's rights and the recognition and respect for that person as a person.
The emphasis of work with Ahmed, for instance, now shifts from the vain attempt to treat and cure him to attending to his wants and empowering him as far as possible to maximise the quality of his life as his capacities fail.
Parker, J. (2001) 'Interrogating Person-Centred Dementia Care in Social Work and Social Care practice' Journal of Social Work, 1(3) pp. 329-45

Loss and Change

Living with a person who is deteriorating rapidly into dementia is akin to living through bereavement. Traditionally, research into bereavement conceived the process of losing and grieving in stages. A more flexible approach is the dual process model of coping with loss (Stroebe and Schut, 1999). Kawthar, like a bereaved person, has to cope with the loss of the husband she knew. She also has to adjust to the changes in her life this implies. This leads to two orientations, the loss orientation and the restoration orientation. In the former, she will remember how they once were, as a couple. In the latter, she will be trying to face up with the new demands of the situation, without Ahmed as the person he was. Both orientations involve positive and negative emotions. She is likely to oscillate between the two. Caroline Currer, in her book on responding to dying and bereavement in social care work, examines these models (Currer, 2001, pp. 101-4).
Currer, Caroline (2001) Responding to Grief: Dying, Bereavement and Social Care, Basingstoke, Palgrave
Stroebe, M. and Schut, H. (1999) 'The Dual Process Model of Coping with Bereavement: Rationale and Description' Death Studies, Vol. 23 pp. 197-224

Flexibility and Multi-disciplinary Teamwork

In situations where change is rapid, the care package needs to be kept under constant review. It is crucial for different practitioners in health and social services to work closely together. Sometimes problems arise because of health and social services practitioners separately gate-keeping resources. National Service Frameworks go some way to alleviate these. There is a need to improve the effectiveness of collaboration between agencies and teamwork.
Malcolm Payne examines in detail the issues involved in developing such joint work (Payne, 2000). In Chapter 3, (pp. 46-67) he examines how to review the work of the team and put the team itself under critical scrutiny.
Payne, M. (2000) Teamwork in Multiprofessional Care, Basingstoke, Palgrave
Also see Audit Commission (2002) Integrated Services for Older People, Building a Whole System Approach in England, Audit Commission.

Sustaining Critically Reflective Practice

The social worker is developing critically reflective practice. This entails balancing several elements in a continually self-critical way and, specifically:
  • maintaining evidence-based practice
  • not becoming isolated but teamworking with colleagues in the multi-disciplinary team
  • not working in a service-led but in a person-centred way.
Social work takes place in constantly changing and often uncertain circumstances. This makes it even more important to keep plans and decisions under review.
Theories and evidence arising from research are not built up in a straight line from ignorance to full knowledge. Many findings generate debates and controversies. Knowledge accumulates in a patchy way. Its diversity reflects the diversity of perspectives on research and research evidence. Knowledge is multi-dimensional. This mirrors the diversity of people's (service users, carers, practitioners, managers, members of the public) perceptions and experiences.

Social workers are responsible for sustaining their own critical awareness. The personal and professional development of the social worker depends on the ability to keep one's practice under critical review. This implies being able to admit that some decisions and actions were not ideal and to be prepared to act differently next time.

It is important not to try to hold onto the view that evidence based practice is a simple formula which will reduce the uncertainties and complexities of social work to a straightforward formula. In the last chapter of their book, Critical Practice in Social Work, Adams, Dominelli and Payne point out that being a critical practitioner does create dilemmas but it also opens up opportunities for fresh ways to practice (Adams, Dominelli and Payne, 2002, p. 310). Chapter 31 of their book (pp. 304-11) examines what is involved in further development as a critical practitioner.
Adams, Robert, Dominelli, Lena and Payne, Malcolm (eds) (2002) Critical Practice in Social Work, Basingstoke, Palgrave

Other relevant sources of further knowledge

General aspects of community care are covered in:

Bornat, J. et al., (1998) Community Care: A Reader, Buckingham, Open University Press

The practicalities of community care:

Sharkey, P. (2000) The Essentials of Community Care: a guide for practitioners, Basingstoke, Palgrave

Summary

The key features of this case have been:

  • Developing a self-critical, evidence-based practice,
  • the actions of the practitioner, engaging purposefully with Ahmed and Kawthar in an empowering, person-centred way,
  • working with them to establish the explanations for their difficulties and assess their circumstances and needs,
  • working with them to manage Ahmed's dementia so as to empower him and Kawthar as his carer,
  • reviewing with Ahmed and Kawthar the work done,
    self-critically evaluating the practice.

Bibliography

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Ahmad, W. (ed) (2000) Ethnicity, Disability and Chronic Illness, Open University Press.
Ahmad, W. and Atkin, K. (eds) (1996) ‘Race’ and Community Care, Open University Press.
Audit Commission (2000) Forget Me Not, Mental Health Services for Older People, Audit Commission.
Audit Commission (2002) Forget Me Not, Mental Health Services for Older People (Update 2002), Audit Commission.
Audit Commission (2002) Integrated Services for Older People, Building a Whole System Approach in England, Audit Commission.
Barnes, M., et al (1999) Unequal Partners: User Groups and Community Care, Bristol, Policy Press
Barnett, E. (2000) Including the Person with Dementia in Designing and Delivering Care, Jessica Kingsley.
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Dalley, Gillian M. (1996) Ideologies of Caring: Rethinking Community and Collectivism, Basingstoke, Macmillan
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Tibbs, M.A. (2001) Social Work and Dementia, Good Practice and Care Management, Jessica Kingsley.
Trotman, F. and Brody, C. (2002) Psychotherapy and Counselling with Older Women, Cross-Cultural, Family and End of Life Issues, New York: Springer.
Ware, T., Matosevic, T., Hardy, B., Knapp, M., Kendall, J. and Forder, J. (2003) ‘Commissioning care services for older people in England: the view from care managers, users and carers’, Ageing and Society, 23/4:411-428.

Robert Adams
Professor of Social Work
University of Teesside

My thanks to Lindy Conway and Craig Wilson, Staff Development and Training Unit, Northumberland NHS Care Trust, for critically reviewing and commenting in detail on an earlier draft of this case study. My thanks also to Dr Sally Richards, University of Southampton, for many helpful suggestions, including additional reading. Responsibility for any mistakes remains mine.

     
       
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