Therapeutic and ethical practice: a participatory action research project in old age mental health

Research and review

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AbstractDespite the contemporary emphasis on evidence-based practice, there remains a dearth ofknowledge about how professional philosophy and expertise influence clinical practice. Theseissues are magnified when caring for people for whom ‘good’ care is hard to define (for example, older people with mental health needs) owing to the dual demands of physical care(in this study for example, continence care) and psychological care (for example, patientautonomy). The aim of the present study was to analyse ethical tensions of developing andmanaging continence care in an assessment unit for older people with mental health needs. A participatory action research approach was used, seeking to engage the unit staff in devel-oping their practice. Data were collected by focus group and individual interview, observationand secondary data analysis. The study demonstrated the complexity of decision-making in thisfield, not least when there was tension between the duty to provide good clinical care and theduty to respect the autonomy of the patient. Despite the relative stability of the external evidence base in continence care, the clinical decisions fluctuated in time, place and person (situated decision-making).

Key words: ethics, evidence-based practice, mental illness, older people, participatoryaction research

IntroductionNurses are beginning to debate just how appropriate and effective is the introductionof practices based on quantitative research evidence from elsewhere into individualclinical settings (Blomfield and Hardy 2000; Rolfe 1996). Blomfield and Hardy (2000)argue that the tacit, experiential sources of knowledge that nurses use to inform theirpractice need to be promoted as equally important and valid contributors to effective

Practice Development in Health Care, 1(1) 39–53, 2002 © Whurr Publishers Ltd

Therapeutic and ethicalpractice: a participatoryaction research project inold age mental health

Charlotte Clarke — Professor of Nursing Practice Development ResearchUniversity of Northumbria at Newcastle

Andrew Gardner — Staff Nurse, Newcastle, Northumberland and NorthTyneside Mental Health NHS Trust, Royal Victoria Infirmary, Newcastle uponTyne

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40 Clarke and Gardner

clinical practice. This rather polarized debate is not restricted to nursing practicealone, with Greenhalgh (1999) arguing that clinical decisions in medicine result fromaccumulated case expertise (the stories of patients and clinical anecdotes).

Viewing decision-making as only a series of cognitive steps has also receivedcriticism from Martin (1999), with Sleep and Clark (1999) referring to the ‘tyranny ofexternal evidence’. Indeed, French (2000) highlights the individual and organization-al risks associated with implementing evidence-based practice that result from researchfindings being generated in a place that is different to the place of implementation.

Despite the contemporary emphasis on evidence-based practice, there remainsa dearth of knowledge about how professional philosophy and expertise influence clin-ical practice. These issues are magnified when caring for people for whom ‘good’ careis hard to define owing to the dual demands of physical care and psychological care.The nature of evidence-based practice is complex, with Sackett et al. (1996) high-lighting that research-based knowledge must be applied to the clinical environmentand individual patients, and that clinical decision-making must accommodate patientpreference. One central feature of an evidence-based practice approach is that it is alogical decision-making process in which as much of the proposed intervention isinformed by good quality research as is possible.

However complex in its implementation, evidence-based practice underpinsthe UK government’s drive for quality care, or ‘clinical governance’. The study report-ed in the present paper arose from the desire of one NHS Trust to introduce more evi-dence-based practices as part of ongoing development of its nursing services. The unitchosen by the Trust consisted of an 18-bedded inpatient ward and day care assessmentunit for older people with mental health problems.

From early discussions between researchers and managers at unit and ward level,continence care was identified as one area of practice with potential for development.On average, one-third of the patients admitted to the ward experienced continence dif-ficulties and the predominant way of dealing with these problems was to use contain-ment methods, such as incontinence pads. Continence care was felt to present a partic-ularly suitable focus for nursing practice development as it is an area of care in whichassessment, planning, delivery and evaluation is predominantly the responsibility ofnurses and one in which nurses have considerable autonomy to act in care delivery. Thestaff had considerable commitment to continence care and they felt it was an area ofmental health care for older people that was often overlooked and needed further devel-opment. These three features made it particularly suitable for practice developmentactivity (Waterman et al. 1995). The general goal of continence care for any patientgroup is for continence promotion rather than incontinence management (DoH 2000).

The aim of the present study was to analyse ethical tensions of developing andmanaging continence care in an assessment unit for older people with mental healthneeds. The objectives were three-fold:

� To appraise the relevance of information on continence care derived from anumber of sources: research, professional guidelines, service users and providersand family carers.

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41Therapeutic and ethical practice

� To problem solve the implementation of each source of evidence for a specificcare environment.

� To promote continence care which is preventative and which promotes thewell-being of service users.

MethodAchieving the study aims required a research design that engaged the nursing staffon the unit, allowing them to understand and articulate their current practice andengage in a process which potentially required them to reconceptualize their care ofolder people with mental health needs. Therefore the project used an actionresearch methodology, which Street (1995) and Hart and Bond (1995) describe as:recognizing the relevance of specific care environments; challenging prevailing atti-tudes towards care; responding to changing evidence and service and user demands;emphasizing theory development from specific clinical issues. Participatory actionresearch methodologies require a high degree of close collaboration between theresearchers and the clinical practitioners with the research team taking a lead ingathering data, whereas the ward staff lead the implementation and evaluation ofchanges to practice.

The project design involved three concurrent strands of activity in whicheach step informed the subsequent step, creating a helical project design (Figure 1):

� The collection of ‘evidence’ from different sources: published research andpolicy, carer perspectives, practitioner perspectives.

� Collaborative appraisal of this ‘evidence’ and discussion about its implicationsfor patient care in the local context.

� Periodic data collection that described the nature of continence managementon the unit.

Participatory action research methodologies require a highdegree of close collaboration between the researchers andthe clinical practitioners with the research team taking alead in gathering data, whereas the ward staff lead the imple-mentation and evaluation of changes to practice.

Data sources and collection methods

The ‘evidence’

Evidence about continence care for older people with mental health needs was inter-preted in an inclusive way: not only published research but also the perspectives ofpractitioners and family carers. Data were collected from a number of sources. First,

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research- and policy-based evidence was derived from local documents and publishedliterature and guidelines. This included an interview held with the continence advisorfor the Trust. Second, data were collected about the experiences of continence care offamily carers. The intention had been to interview family carers of current patients onthe unit. However, the clinical staff were concerned about the effect of such an inter-vention on the fragile relationships between patients, their carers and the unit staff.Consequently, three carers of people with continence problems were interviewed whowere not associated with the unit, and who were identified through the carer’s supportnurse at the Trust. Third, evidence about the nature of professional practice withpeople with continence problems on the unit was collected from some of the unit staffin a series of monthly group meetings. These meetings were also central to the secondstrand of the research design.

Collaborative appraisal

To promote collaborative enquiry, a joint collaborative learning/project managementgroup (CL/PMG) was established. This included the two members of the research teamand members of the clinical staff (two staff nurses and one support worker participatedconsistently and others more occasionally). The CL/PMG met four times during a six-month period and acted as a problem-solving group to assess the relevance of differingsources of evidence and its implementation. Moreover, the CL/PMG was a forum forclinical staff to explore and describe the complexities of managing continence care for

Figure 1. Helical project structure.

Time

Evidence source 1

Description of continence

management 1


management 2


management 3

Evidence source 2 Evidence source 3

Collaborative appraisal

Action planning �

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older people with mental health needs. These meetings also acted as a source of datafor the project and were tape-recorded, with the exception of the first meeting, whichwas used to introduce the project.

The nature of continence management

To identify any change in the continence management of service users during the timeof the project, a set of data was collected at the start, middle and end of the project. Thiscontinence assessment and management (CAM) data included case note abstractionand participant observation. The CAM data were collected over one eight-hour shift oneach of the three occasions, including observation over a night shift on one occasion.

Data management and analysis

The project received approval from the local Medical Ethics Committee. Anyresearch with older people with mental health needs is ethically challenging(Wilkinson 2002) and in the present study information about the work was commu-nicated by posters placed on noticeboards in the unit and information sheets that werediscussed with the family carers before interview. Observation on the unit was limitedto public areas, such as living areas and corridors, to minimize the intrusiveness of thestudy and to ensure that privacy was maintained. Had anyone indicated unwillingnessor unease about the presence of the observer, the observer would have withdrawn.That this was not necessary may have reflected the participant nature of the observa-tions, although the observer was not a member of unit staff and so would have beenrelatively unfamiliar to the patients. The staff were involved in the study as colleaguesrather than interviewees and so voluntary participation was accepted as an expressionof consent to data collection. The qualitative data from the interviews and CL/PMGmeetings were audio-taped and transcribed. Analysis followed standard methods ofopen coding and constant comparison. The CAM data were approached as qualitativedata and subjected to a similar process. The present paper focuses on the perspectivesof the staff, in which they explore some of the tensions in their professional practicewhen managing continence care.

Limitations of the project

The project attempted to implement an innovative research design that has the poten-tial to be transferred to a wide number of clinical settings and clinical issues. The pro-ject collected a small amount of data from any single source, but the credibility of thatdata is sound — data sources were triangulated and in many instances data resultedfrom extensive discussion. In particular, the views of the unit staff were accessed repeat-edly over a six-month period, during which time the essence of their perspectiveremained stable. The secondary data, collected by abstraction from case records, like any secondary data, can only be as sound as the data that is recorded by the prac-titioners. For the present study, written information about continence assessment andmanagement is as significant in its absence as in its presence. For example, the infre-

Therapeutic and ethical practice

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quent references to continence issues indicated the low priority given to them by staff.The quality of observational data is hard to assess. In the study data were collected byan experienced practitioner — this may lead us to have confidence in the observation-al skills deployed but also leads us to consider that familiarity with a clinical situationmay result in detail being ‘not seen’ as of significance (Reed and Procter 1995). It wasdisappointing to have been unable to interview family carers of patients on the unit,and consequently data collected from the three carers who were not associated with theunit does not comment directly about the unit and its management of continence.

From the inaugural meeting to establish the CL/PMG and to implement theproject it was apparent that some radical changes had taken place since the initial dis-cussions that had established continence care as the research focus and identified theassessment unit as the research site. These changes were to alter markedly the natureand progress of the whole project. Unfortunately, such effects of organizational changeoccur all too often in collaborative research (LeGris et al. 2000).

The one factor that had the most immense effect on the project was the changeof clinical personnel involved, and this happened in a number of ways. At a Trust man-agement level, the initial commissioner of the project moved into another post, and lackof clear responsibility for the project within the Trust resulted in a prolonged period ofestablishing the project and a lack of ‘championing’ of the work at a directorate level.At a ward management level, the ward manager had had a crucial role in identifying theissue of continence care as an area for the project to address. However, before data col-lection started, this manager was moved to another clinical area, together with the othermost senior nurse. There was also a complete change of medical consultants associatedwith the unit at the time that the project was starting. Although the project did notdirectly involve the medical staff, their effect was great. The new consultants appearedto use different admission criteria and, as a result, the nature of the ward populationchanged. Previously, the ward had admitted a large number of very dependent and oftenincontinent patients with substantial behavioural problems. Subsequent to medical staffchanges, the patient group consisted largely of self-caring, independently mobile, conti-nent patients, typically suffering from anxiety, depression or in the early stages of demen-tia and who required rapid assessment and treatment of acute mental health problemsbefore moving on to other care settings. Levels of incontinence amongst the patientsdecreased from one in three patients experiencing difficulties to around one in every ten.The opening of a new residential home in the area resulted in more rapid discharge ofpatients. Where the unit once worked to maximum capacity, the majority of whom hadcontinence problems, within months the bed occupancy level fell to around 40%, ofwhom very few had continence problems.

Findings

Conflicts in care

The staff described their work in managing continence care as complex and filled withtensions about the nature of their professional practice. Repeatedly, at CL/PMG

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meetings, they expressed conflict between building trusting relationships with theirclients and the need for immediate care interventions. This was compounded by per-ceived conflicts between the right of the client to make autonomous decisions aboutcare received versus the nurses’ duty to provide care both to the client and to others.Nurses accepted that a point would be reached when intervention was necessary eitherfor the patient or the others in the social environment, but making the choice betweenintervention and respecting the patient’s autonomy often proved difficult.

The issue of whether or not to intervene with patients who were refusing carewas often seen by staff as an ethical dilemma, balancing patients’ rights against effectson health and effects on others in the immediate environment. BMA/RCN (1995)guidelines suggest that it is acceptable to force basic care on patients who are cogni-tively incapacitated and refusing basic care if that care is deemed necessary to preservetheir health and the nurses in this study expressed a similar point of view. However, thedecision about when to intervene assertively was difficult to make as it required bal-ancing the need for care against the need to build trusting therapeutic relationships:

We have a duty of care which means that we, for their own interests,

where it eventually gets to the point where it’s so bad that the skin is start-

ing to break down ecertera, ecertera, you will have to be forcible or use the

minimum amount of force required to remove very badly stained wet cloth-

ing for their benefit. (CL/PMG)

The need to build trusting relationships with the patients was seen as being ofprimary importance in this care setting and a driving force behind care delivery. Nurseswould be unlikely to be able to have any beneficial interactions with their patients inthis setting if they were not able to gain the patient’s trust. In contrast to the problemof patients refusing continence care that was reported by staff in the CL/PMG meet-ings, no incidents of patients refusing care or nurses having to make a decision onwhether or not to intervene were observed. In all cases of nurse-initiated activity thepatient co-operated fully with the care offered by the nurse.

Conflicting expectations of care

Conflicting viewpoints and expectations of patients’ family carers further complicateddecisions about intervention. For example, active intervention to assess and promotecontinence could provoke complaints, as could not intervening through respect forpatient autonomy:

And then you’ve got the relatives coming on your back, you know ‘mum’s

sitting on the whole thing’, and you go and try and change them and when

we try she won’t comply, and we can’t force her. They don’t see why we

can’t force her and they think we’re in the wrong. (CL/PMG)

Conflict between a relative’s expectations of care and the care objectives of thenurses was a source of great frustration for the staff. Ward staff needed to be able to jus-


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tify their actions effectively to relatives and to do this they needed support from man-agement. In the following quote the effect of complaints on the morale of ward staff isnoted:

We aren’t super beings. We can’t offer magic, you know, that’s why staff

get so cheesed off because to have this, these complaints, it doesn’t hap-

pen very often but it’s amazing how much power one complaint [has], the

effect on staff morale. If [out of ten people] one person complains, that’s all

you hear about. (CL/PMG)

Engaging with continence care

Environmental constraints could also lead to difficulties in providing other care inter-ventions to patients with continence problems, such as taking patients on day trips, asin the quote below. There is a risk that patients requiring a high level of continencecare could be deprived of other therapeutic activities, such as day trips.

We were going on a trip one afternoon and patients had to carry around

huge night pads … public toilets with heavy immobile patients … you’ve got

to be realistic. If you’ve got a 20-stone patient out in the wild world (day trip

to coast) then you’re not going to find somewhere to change her easily.

(CL/PMG)

The ward staff also spoke of their motivations about continence care.Motivating staff towards good continence care was clearly difficult and staff wereunable to identify any positive incentives for promoting good continence care:

Can’t think of any decent carrots unfortunately. (CL/PMG).

It’s very, very difficult to get people to do continence courses. It’s not

something people want to do. (CL/PMG)

There was a prevalent feeling that continence assessments have been imposedfrom ‘higher up’. The staff felt little involvement or ownership regarding them and alsofelt there was a lack of guidance and support in how to carry them out. Consequentlythey tended not to be maintained:

We were told to assess patients, oh we had to assess them but we were

never told how to assess them. So how did we know? (CL/PMG)

Nonetheless, the staff did discuss how they managed preventative continencecare, referring to their assessment of ‘toilet signs’ — patient behaviours, such asincreased agitation, wandering or fiddling with clothing, that indicated that he or shewas aware of a need to use the toilet. No examples of patient behaviours indicating aneed to use the toilet were found in the documents studied and staff appeared to under-estimate the value of such observations and the need to document them.

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In summary, some of the key issues in promoting evidence-based continencecare in this care setting were identified as:

� There was a lack of positive incentives for staff to provide care that actively pro-moted continence.

� There was a lack of ownership of continence care by the staff on the ward.� Conflict could occur between building trusting relationships between staff and

patients and imposing care interventions on the patients if the patient did notwant that care.

� Conflict could occur between relatives’ expectations and nurses’ expectationsof care and could result in relatives making complaints about the nursing care.

� Issues relating to continence care tended to be viewed by the nurses from with-in a moral and ethical decision-making frame.

DiscussionEthical practice

The present study has shown that in this clinical setting, practice based on the expec-tations of distant sources such as that in guidelines and family members, could causeconflict with the experiential and philosophical knowledge underpinning the practicesof the nurses. These are practices that are driven by the need to build trusting thera-peutic relationships and to respect patients’ rights to make autonomous decisions abouttheir nursing care. This raises questions about what is the best possible continence carein this clinical setting, and how it could be identified and implemented. Thrown intosharp relief are the tensions between basing practice on academically reviewed and val-idated research and the experience of the nurses themselves so that the nature of ‘best’knowledge available to inform future practice is unclear.

There are two basic principles of ethics for nursing. The first is the universalduty of good clinical care — the use of expertise to protect the life and health of thepatient to an acceptable standard. The second is the universal duty to respect theautonomy of the patient. Clearly, these are the two issues that, at times, conflict witheach other when caring for older people with mental health needs. Furthermore, defin-ing ‘good clinical care’ is problematic when the ‘correct’ management of continencecompromises the need for a therapeutic relationship to be nurtured and when that rela-tionship is itself perceived to be the means of achieving the objectives of care. This iswhat Raines (2000, p. 30) describes as an ethical dilemma: ‘when two or more ethicalprinciples apply in a situation, that support mutually inconsistent courses of action’.

In the case of continence care, such ethical tensions result in a whole series ofquestions to which the answers are complex if, indeed, there can be any answer. Forexample, how can nurses make the decision whether or not to intervene; how can theyweigh the consequences of non-intervention against the consequences of intervention;does intervening or not intervening increase or decrease patients’ distress; and is therea point at which coercion and force become acceptable? Although BMA/RCN (1995)


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guidelines indicate the primacy of preserving health even if that is contrary to the wish-es of the patient, the immediacy of the care situation presents multiple and sometimesconflicting avenues of action.

The answers to such questions are not morally neutral, although the technicalrationality of evidence-based practice seduces one into assuming a false neutrality(Trinder 2000), but are loaded by the values placed on the autonomy of the patient.Older people with mental health needs are not traditionally afforded the regard thatwould allow society to value their autonomy (Kitwood and Bredin 1992).

Nurses in the present study were conscious of a duty of care to prevent harm tothe patient (for example, preventing skin breakdown) but also felt they had a duty torespect the right to autonomous decision-making of the individual. They also had tobalance the rights of an individual against the feelings (and rights) of other patients inthe individual’s immediate environment, and to manage the sometimes differing expectations of relatives. Conflict easily occurred between these ‘duties of care’, leav-ing nurses in a dilemma about the correct approach to take.

Knowledge and optimal nursing practice

The dominance of external evidence to legitimate practice has four major consequences:

� It stifles the creation of knowledge by practitioners.� It compromises the accountability of practitioners to service users, imposing

professionally defined evidence.� It silences the knowledge base of the service user so that care may fail to build

on self-management strategies.� It fails to match the pace of change in practice so that practices often operate

beyond a known evidence base.

In the small study reported here, the clinical decisions of practitioners were abalance between the known ‘best practice’ (of continence care) and the expressedwishes of the service users (older people with mental ill-health). In many situations, thepractitioners expressed professional discomfort with having to compromise ‘best prac-tice’ and/or service user autonomy. The decisions made were located in the context ofthe care situation and were therefore inconsistent in time, place and person. Thisprocess of situated decision-making is illustrated in Figure 2 as a model of how varyingsources of information are filtered through ethical principles of professional practice.These demand an articulation of the value base of practice so that there is a clear andshared understanding of ‘best’ practice. The creation by the practitioner of situatedknowledge may result in optimal practice for a particular patient in a particular set ofcircumstances, which is quite distinct from the global nature of evidence-based prac-tice. For example, service user resistance to intervention for incontinence was accom-modated if the service user was in a private room, but refuted if they were in a publicroom, say at a mealtime with other service users. Situated decision-making embracesthe plurality of knowledge within moral and ethical frameworks of practice so that opti-

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mal practice does not necessarily equate with evidence-based best practice. From otherwork as well, it is recognized that the knowledge base of practitioners is very differentin its origin and orientation to the knowledge base of service users and carers (Clarkeand Heyman 1998).

Situated decision-making embraces the plurality of knowledgewithin moral and ethical frameworks of practice so that optimalpractice does not necessarily equate with evidence-based bestpractice.

Three ‘knowledge chains’ are described by Clarke and Wilcockson (2002): thatof practitioners that is derived from sources other than their immediate practice envi-ronment (for example, research); that of the practitioners derived from their practice;and that of the service user. The knowledge for practice results in the drivers for devel-opments in practice being derived from outside any specific care environment — ‘dis-tal knowledge’. Distal knowledge is relatively prescriptive and is not owned by practi-

49Therapeutic and ethical practice

Figure 2. Situated knowledge and optimal practice.

Distal knowledge‘Evidence-’ based stable, generalizable technical

rationality

Proximal knowledgeTacit, dependent on social

systems and professional andorganizational cultures

experimental

Service user knowledgeIndividual, personalized,

relatively stable

Situated knowledgeUnstable in place, time

and person not generalizable

Situated decision-makingOptimal and critical practice

Moral and ethical frameworksPhilosophy of care

Corruption of care

Universal duties of‘good’ clinical care

and respect forpatient autonomy

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tioners themselves. Knowledge from practice is that which is derived from within a spe-cific care environment. It is, therefore, dependent on the contextual issues within thatenvironment such as staffing levels, the nature of the service and the process of engag-ing service users in care provision. Consequently, knowledge from practice does notmeet many of the criteria used to judge the quality of knowledge, such as its ability tobe generalizable (Clarke and Procter 1999). Practitioners have a very strong sense ofownership of ‘proximal knowledge’ and it allows them to be sensitive to service users atan individual and local level. However, one of the more major concerns about evi-dence-based practice is that the dominance of quantitative science may devalue, oreven exclude, other sources of knowledge, such as proximal knowledge (Trinder 2000).The knowledge of service users is that which is derived from their own experiences ofself-management and the acquisition of information from family, friends and lay sourcesof information.

Clarke and Wilcockson (2001) argue that whilst a great deal is expected of evi-dence-based practice, it is no panacea. Distal knowledge may be a tool (Trinder 2000)but it is the proximal knowledge that allows practitioners in health and social care toknow whether it is the right tool for the job or the right knowledge for the needs oftheir patients. As a result, there is relative stability of distal knowledge but instabilityin decision-making based on the rapidly fluctuating proximal knowledge — situateddecision-making as demonstrated in the present study. Similarly, Martin (1999) high-lights how ‘clinical judgements made by mental health nurses are time- and situation-dependent and consequently are unique’.

The context of decision-making

The social system in which individual practitioners in the present study made decisionswas very important. The staff had experienced changes in ward and unit managementduring the study period. It was a ward with a high profile of medical research but thiswas one of the first nurse-led studies to be undertaken in the unit. The consequencesof these changes and profile were to somewhat disempower the ward nursing staff. Theyexperienced a lack of clinical nursing leadership, a lack of support in decision-making,and at times, a lack of confidence in the decisions made given the multiple stakehold-ers with an interest in differing outcomes of a decision. For example, the staff felt pun-ished for complaints but not rewarded for praise from relatives and patients, and theylacked the strategic direction that would help them manage the expectations of rela-tives. Furthermore, continence care was framed as the responsibility of ward nursingstaff only even to the extent that the continence advisor for the Trust was somewhatmarginalized from influencing care in the ward. Indeed, during the time of the studythe ward developed its own continence assessment documentation despite the concur-rent implementation of ‘Trust-wide’ documentation.

The complexity of making clinical decisions was illustrated by Martin (1999)who advocates a model of clinical judgement as a matrix of interlocking concepts thatinclude the concepts of self, client and social system, with those of professional rela-tionships, nurse–patient relationship and healthcare roles.

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Proximal knowledge is generated through the critical examination of care andservice provision in relation to the needs of the service users. In a wider context,Brechin et al. (2000, p. xi) argue that ‘critical practice draws on an awareness of widerethical dilemmas, strategic issues, policy frameworks and socio-political contexts’. Onthe whole, though, debates about advanced practice do not appear to concern them-selves with ‘seeing’ patient need and subsequently reconceptualizing care provision andthe role of professionals (Clarke and Wilcockson 2002).

Crucially, proximal knowledge involves understanding how one’s practices andcare interventions are reflective of little more than the philosophy to which we ascribe.For example, in dementia care, the biomedical model leads to care interventions suchas pharmaceutical and behavioural management, whereas a socio-critical model leadsto interventions such as family nursing and systemic practice (Clarke 1999). Similarly,for older people the need for a safe environment could be emphasized, reflecting pater-nalistic and warehousing assumptions about the roles of practitioners and services, orthe need for freedom to make risky decisions could be emphasized, reflecting moreemancipatory assumptions about care provision. The apparent difficulties faced bypractitioners in the present study in making complex decisions may have been reflec-tive of an uncertain philosophy of care. However, it must be acknowledged that no suchcomplex decisions were observed during period of observational data collection soalthough a challenge to practitioners they are perhaps not frequent events.

Distal knowledge is unable to help us make choices between such philosophi-cal underpinnings of our professional practice. Indeed, the more the shift towards thereductionalist approach and technical rationality of evidence-based practice, the lesspractice becomes theoretically explicit (Im and Meleis 1999). Philosophical guidanceis more likely to be derived from policy developments and here it may not concur withthe assumptions about practice held by individual practitioners or teams.

However, proximal knowledge is not necessarily ‘better’ than distal knowledgeor policy. Indeed, the assumptions that underpin the practices of some people are quiteharmful to the people they care for. For example, the personal beliefs of some practi-tioners may actively promote discriminatory care, and Wardhaugh and Wilding (1993)refer to the lack of appreciation of the essential humanity of all service users as under-pinning the ‘corruption of care’, initiating a cascade of events and processes that resultin organizations delivering care that betrays the standards espoused by caring institu-tions. Raines (2000) describes how some of the coping strategies used by nurses whofind themselves confronted with ethical dilemmas and ‘moral anguish’ lead them to dis-tance themselves from their patients. They fail to even recognize the ethical conflictspresent and report emotional exhaustion, depersonalization and negative coping styles— some of the very factors that Wardhaugh and Wilding (1993) warn of as precursorsto corrupt care practices. The role of effective leadership, and in particular a visionand purpose in patient care, is essential to the appropriate use of knowledge to deter-mine patient care. Although situation-specific theories such as that tentatively pro-posed in the present study, have the ability to inform nursing knowledge, the primevalue is in generating theory that is grounded in practice and that clarifies current prac-tice, acting to improve future practice in a specific area (Im and Meleis 1999).


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ConclusionThe project did not achieve its original goal of engaging a group of practitioners toexamine critically and develop the continence care of older people with mental healthneeds. This resulted from a number of factors, not least the movement of many staff andthe subsequent reduction of ownership and relevance of the study for the staff. It isundoubtedly a very modest study in terms of the amount of data collected, and the datamust therefore be approached with considerable caution. It is offered here for its abili-ty to stimulate debate, that is, for its catalytic validity (Reed and Biott 1995).

The present study does, however, have the potential to open a debate on issuesthat are central to the understanding of the nature, purpose and future of nursing itself.These issues concern the basis on which decisions are made in practice and expose thetheories-in-action of those practitioners. What the present study does demonstrate isthe considerable complexity of day-to-day decisions when two ethical principles arecaused to conflict with each other: the duty of good clinical care and the duty of respectfor patient autonomy. Furthermore, the ability to define good clinical care breaks downwhen ‘good’ continence care (as an outcome) is at odds with the need to have a rela-tionship of trust between the nurse and the patient in order to deliver ‘good’ care (as aprocess).

In the context of healthcare systems that require defendable (if not defensive)practice, the stability of distal knowledge is promoted through evidence-based practice.The proximal knowledge of practitioners, together with the knowledge of service usersand relatives, must be filtered through the philosophies of care and ethical frameworksthat ensure care is not corrupted from the values held by society. The product of theseprocesses is the generation of situated knowledge, which is unstable in place, time andperson. This knowledge does, however, have the ability to inform care beyond evi-dence-based practice into the creativity and reflexivity of optimal and critical practices.

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Therapeutic and ethical practice: a participatory action research project in old age mental health

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