Stage 4 - Reviewing the plan
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
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
- What help is available on Kawthar managing the ethical and practical
dilemma about doing the best for Ahmed without feeling she is rejecting
- What ethical and value guidelines are available to guide practitioners'
considerations of the next stage of implementation of the plan?
- 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
- 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
- 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?
- 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?
Understandings of Dementia: The Bio-medical model
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.
proposes one based on the concept of personhood, following
. 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
J. (2001) 'Interrogating Person-Centred Dementia Care in Social Work
and Social Care practice' Journal of Social Work, 1(3) pp.
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
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).
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
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
Payne, M. (2000) Teamwork in Multiprofessional Care, Basingstoke,
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
- maintaining evidence-based practice
- not becoming isolated but teamworking with colleagues in the multi-disciplinary
- 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
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
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
J. et al., (1998) Community Care: A Reader, Buckingham, Open
The practicalities of community care:
Sharkey, P. (2000) The Essentials of Community
Care: a guide for practitioners, Basingstoke, Palgrave
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.
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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.