Introduction
This assignment attempts to explore the integration of core concepts and frameworks in health studies. The purpose of the assignment is to analyse the writer’s current professional practice, focusing on the outcomes of reflection, models of health, focus for learning, methods of enquiry and occupational mode of practice. Where reflective accounts are used to demonstrate a relationship to current practice, the author will make these entries in the first person (Webb, 1992, Hamill, 1999).
The author is a senior staff nurse within an acute and emergency care facility in the North West of England. To ensure anonymity and confidentiality no reference is made to either patients or staff (NMC, 2004).
During the last three decades, many professional groups have taken up reflective practice. Bulman & Schutz (2004) argue that this enhances learning and promotes best practice within nursing. It is seen as an appropriate form of learning and a desirable quality amongst nursing staff (NMC, 2002).
There have been many attempts to define reflective practice, however,
Atkins & Murphy
(1993) argue that the whole concept is poorly defined. Reflection and reflective practice is a process allowing the practitioner to explore, understand and develop meaning, highlighting contradictions between theory and practice (Johns, 1995).
Moon (1999) defines reflection as ‘a set of abilities and skills, to indicate a critical stance, an orientation to problem solving or state of mind’. Reflection is a window through which an event or situation is broken down and evaluated upon in an attempt to understand what has happened, to improve practice and aid learning and development (Reed, 1993, cited in Burns & Bulman, 2000). Kolb (1984) states that reflection is central in theories of experiential learning and argues that within nursing, this form of learning is the most dominant.
Platzer, Blake & Ashford (2000) state that there are many benefits to learning through reflection, however, they are critical of individual reflective accounts and acknowledge the barriers to this form of learning. They explain how group reflection is more potent when attempting to understand complex professional issues and believe that through sharing, supporting and giving feedback in these sessions will facilitate learning with greater effectiveness. Wilkinson & Wilkinson (1996) share this view, but highlight the importance of respecting and maintaining confidentiality.
Schon (1983) describes reflection in two ways
: reflection in and reflection on action. The differences in these types of reflections are reflecting whilst the situation unfolds and reflecting retrospectively on an event (Greenwood, 1993, Fitzgerald, 1994). Atkins & Murphy (1994) improve upon this and suggest that for reflection to make a significant difference to practice, the practitioner must follow this up with a commitment to action, as a result. Interestingly, Greenwood (1993) also states that reflection before action is an important preparatory element to reflective learning as it allows the practitioner to formulate plans ahead of situations arising. There are other writers on reflective practice and conflicting arguments exist about when best to reflect. (Wilkinson, 1999).
There are some critics of reflective practice, these highlight issues including the surveillance and self-regulation of reflective practice (Taylor 2003). Bulman & Schutz (2004) suggest that when bringing personal feelings and emotions into the public domain that this can act as a barrier to reflection. They also acknowledge other limitations to the reflective process, including a lack of effective tools for assessment, political and financial pressures and the knowledge and skills required by facilitators. Taylor (2003) proposes that due to the confessional nature of reflection, debate can be raised over the legitimacy and honesty of the process. Schutz (2007) states that insufficient research has taken place to assess the benefits of reflection in nursing, leaving some debate about its appropriateness. Taylor (2003) argues however, that reflective practice is considered a positive approach to learning and is an important educational tool.
There are many models to guide a practitioner through the
reflective cycle
. Reflection was first explored by Dewey (1933), Boud et al (1985) Cooper (1975) Powell (1989), Jarvis (1992), Atkins and Murphy (1994), Reid (1993) and others. More recently, models used to guide reflective practice, include Gibbs (1998) Johns (1995), Bortons (1970), Smyth (1989) and others.
Health is a broad concept and can embody a variety of meanings, of which there is no particular right or wrong answer. There is no ideal meaning of health, making it a highly contested topic (Aggleton, 1993). The word ‘health’ derives from the old English word to heal (hael) meaning ‘whole’ (Naidoo and Wills, 2000). This statement suggests that health relates to the individual and concerns their holistic well-being. However, the literature suggests that opinions vary and that some perspectives disagree.
Health is defined in many ways, generally divided into two types of understanding; official and lay perspectives. The main difference between the two, is that one is the view held by professionals and the other represents the views of lay people (non professionals).
Official definitions of health have two common meanings in every day use; positive and negative (Cribb 1998, Aggleton 1993). The positive view represents a state of well being and the negative view surrounds absence of disease. The World Health Organisation (WHO) (1946) encapsulated a holistic view of health,
‘Health is a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity.’
Whilst setting high targets to be achieved, this definition has been criticised for being too idealistic and impossible to attain (Aggleton, 1993). In view of the criticism, the WHO changed its definition:
‘health is the extent to which an individual or group is able to realise aspirations, to satisfy needs and to change or cope with the environment. Health is therefore seen as a resource for everyday life not the object of living. Health is a positive concept emphasising social and personal resources as well as physical capabilities’ (WHO, 1986).
This suggests that more recent definitions see health not as a state, but as a process towards the achievement of each individual’s potential (Seedhouse, 1986). Negative definitions focus on the absence of disease or illness (Aggleton 1993, Naidoo & Wills 2000). One definition of health suggests that people are healthy so long as they show no signs of bodily abnormality (disease). This definition fails to take into account how the person feels about themselves. The individual may feel ill in situations where health professionals are unable to find any underlying pathology (Aggleton 1993). Alternatively, an individual may have a disease and feel perfectly well. The main point being made here is that subjective perceptions cannot be overruled or invalidated by scientific medicine (Naidoo & Wills 2000). The negative meaning of health is utilised by the “medical model”, which is explored later in the text.
Whilst in the workplace, it is apparent to me (who is also a Registered Nurse) that both positive and negative meanings of health are used. Doctors focus on health from the negative viewpoint e.g. a doctor may review a patient and whilst not being able to find evidence of an acute illness, decides that the patient is fit to be discharged. Alternatively, I may focus on the positive view. In this context, a holistic approach to the patients’ health and social well-being is being explored, and therefore a comprehensive assessment of these needs are being made prior to discharge.
As previously mentioned, lay beliefs are the views of those who are not professionally involved in health issues (Aggleton 1999). Whilst this is so, they must not be totally discounted as they can be as important as official definitions. They often influence the behaviour and understanding of an individual, and ultimately, the way they respond to health issues. An example of this can be demonstrated when reflection takes place after an incident e.g. a gentleman was admitted to the assessment area complaining of chest pain. After investigation, he was diagnosed with a myocardial infarction. Immediately after diagnosis, he remained on bed-rest for twenty-four hours, then after this period, the patient stated (when asked how he felt), that he felt well and had infact never felt better. At this point the patient proceeded in an attempt to get out of bed and mobilise locally. Thus, it was his belief (a positive view) that because he felt well (he had no symptoms of feeling unwell) then this was a signal for him to carry on, in his normal manner, which was not the case. If the patient had been told he needed to rest, then it is likely that his behaviour would have changed.
Beliefs about health can also vary from place to place (Aggleton 1993). Having nursed in various locations throughout the United Kingdom, my experience of this is first hand and from this experience, I share the views of Aggleton. There seem clear distinctions between health needs and health interpretations between different social class groups. e.g. in deprived areas, beliefs of health are that you ‘just get by’, however, in more affluent areas, health is not seen as merely being free from ill-health, but looks at other dimensions too, like keeping fit, eating healthily and being active.
According to Jones (1994), health is subject to widely variable individual, social and cultural expectations, produced by the interplay of individual perceptions and social influence; suggesting that individuals create and re-create meanings of health and illness. This is done by our lived experiences. This view is supported by researchers, who have identified social class differences in concepts of health (Blaxter 1990, Calnan 1987). Their findings concluded that middle class respondents had a more positive view of health and found this to be linked to perceptions such as enjoying life and being fit and active. Through the same research, working class groups viewed health as functional and avoiding ill health. One explanation for these findings is that compared to working class people, middle class groups have greater control over their lives, due to income thresholds and job security, generating higher standards of living. According to Naidoo & Wills (2000), this leads to people in different social classes holding different beliefs about autonomy and fatalism. These views are confirmed by my experiences in the workplace. The majority of patients I see are from working class backgrounds. This information is obtained from the patient during admission, when asked about their occupational status. It must be acknowledged however, that someone’s occupation doesn’t necessarily denote their social group. These patients do have a tendency to view health as functional and this further supports the explanation offered by Naidoo & Wills (2000).
The United Kingdom is undoubtedly classed as a multicultural society, therefore it could be argued that a range of cultural views about health co-exist (Naidoo & Wills, 2000). Alternative practitioners offer therapies such as acupuncture, reflexology and massage, which are based on cultural views of health and disease and run in conjunction with therapies offered by the National Health Service, which focuses on scientific medicine. The use of complementary alternative medicine (CAM) is largely unregulated but due to recent government pressures, a regulatory body to govern the use of some of these practices is to be set up (Hawkes, 2008).
It is also evident that differences in chronological age and lifestyle also play a key part in influencing our views about health. For many young people, health may be seen as the ability to take part in sporting activities or being at the peak of their fitness (Blaxter 1990, Aggleton 1993). Alternatively, health for the older person is more likely to relate to the ability to cope and to be able to undertake a more restricted range of actions (Williams 1983, Aggleton 1993).
It is clear from this discussion, that there are a variety of forms that can be taken from a concept. It is felt therefore that it would be useful to use an analytical framework which brings together defining features of ‘concepts of health’ and demonstrates their relationship to each other. One such framework is by Alan Beattie (1987, 1993).
Beattie (1987, 1993) suggests that concepts of health can be characterised by a focus on health as the property of individuals through to the property of people collectively, on a continuum. Further concepts can be seen as open to authoritative definition (or scientific principles), or alternatively as socially negotiable within the context of people concerned. This lead Beattie to set out two interlocking axis – the horizontal and vertical axis. The horizontal axis represents individual people to families, groups and whole communities. The vertical axis represents a stance from expert led (authoritative – usually represented by expert knowledge) to client led (negotiated – using peoples own interpretations of their health and viewing them as experts in their own right) interventions. From this, the four quadrants of Beattie’s concepts were born.
Biopathological models of health are related directly to the individual, them being the focus for treatment and free from illness or disease. Health is proclaimed in an authoritative manner through investigation and diagnosis. This model relates closely to the ‘medical model’ of health.
Biographical models of health focus on the individual subjective experience of health. Health is seen as part of everybody’s life story and is therefore seen as being linked to our individual biographies. Health is not established through science but the personal opinion of the individual in the context of their lived experience.
Environmental models view health as a property of populations as opposed to individuals. The emphasis is on the use of statistical data to describe epidemiology, in order to determine the health of the population.
The communitarian concept states that health is the property of the social contexts of peoples’ lives in their communities. Health is seen to be influenced by how people respond to their material and cultural circumstances of their lives and not being shaped by authoritative monitoring of patterns of health.
Beattie (1987, 1993) suggests that these models are not mutually exclusive. They can co-exist in differing circumstances, however, the emphasis may be more or less dominant.
Having explored these models, it becomes evident that within my practice the Biopathological model is the most dominant between the members of the health care team e.g. a patient is admitted to the assessment unit with complaints of chest pain. The medical team (or the technician as Beattie would refer) would see the individual as the focus for treatment and will carry out expert, scientific led investigations. The diagnosis would then be proclaimed in an authoritative manner. This model has been criticised for being too narrow and it can be argued that medicine is not as effective as it is often claimed (Naidoo & Wills 2000). The twentieth century has seen a reduction in mortality and increased longevity in developed countries and it is often assumed that medical advances have been responsible for this. McKeown & Lowe (1974) would argue that this is not necessarily the case. In their historical analysis they concluded that social advances in general living conditions had been responsible for most of the reduction in morbidity, whereas the contribution of medicine had played a much smaller role. However, within the professions and institutes of medicine, ‘mechanistic’ approaches to analysis are still dominant (Beattie et al 1993).
In practice, the biopathological model of health is usually adopted when dealing with the nominated patient group, but it must be acknowledged that sometimes, due to the nature of nursing (even in an acute area), I may utilise other models within Beatties framework, particularly the biographical model of health. Here, the focus is still individual, but the care is negotiated as opposed to prescribed. Interestingly, the NMC (2004) code of professional conduct also advocates that patients be treated individually, with respect and with their best interests in mind.
An example can be given to the reader of when this overlap occurs. A patient is admitted to hospital, following an acute exacerbation of chronic airways disease. The individual is seen by the doctor and in an authoritative manner prescribed a course of treatment, which included smoking cessation. The patient did not respond well to this demand. He believed that because he had been smoking for most of his adult life, that this did not contribute to his current health breakdown. Utilising previous experience in this area, I talked through the issues of smoking cessation and gave a rationale for the proposed treatment. I listened to the patient, with their concerns and anxieties and found that previous attempts at stopping smoking had been unsuccessful. The patient highlighted that no help had been offered previously from the health care team and that he had no financial compensation for his treatment. After a discussion about the support and available services, the patient accepted my offer to a free and confidential stop smoking service and agreed to a referral being sent.
According to Beattie (1987, 1993) the focus for learning concerns the type of knowledge a health care practitioner needs in order to practice within their setting. Within the biopathological model of health, the focus for learning is that of essential knowledge applied by the competent worker (the technician). This is consistent with my focus for learning and is utilised frequently in every day practice. It is the most dominant over other focuses suggested by Beattie (1987, 1993) within other models of health. An example of when I might use this form of knowledge could be when managing a deep vein thrombosis (DVT) clinic. I assess the patients’ risk of having a DVT, then, by following the trusts protocol decide the patient’s management plan. To ensure the effective running of the clinic at a competent level requires me to have essential knowledge about the diagnosis and treatment of DVT including a thorough understanding of the anatomy and physiology involved, the treatments, radiological investigations, complications and side effects to treatment.
Carper (1978), suggests that there are four fundamental patterns or types of knowing in nursing. These are known as his taxonomy’s of knowing and include, the empirics, aesthetics, personal knowledge and ethical domains. The empirics’ element of his taxonomy relates to the science of nursing and having the ability to describe, explain and predict. The aesthetics dimension relates to the art of nursing. Personal knowledge relates to the knowledge that an individual has from their past experiences in nursing and the ethical component of Carper’s taxonomy relates directly to the decision making, the rights and wrongs, holding values and applicating.
A method of enquiry, concerns the formal ways in which knowledge is generated and used by practitioners (Beattie 1987, 1993), often referred to as research and is vital in informing practice (Rolfe 1996). Research has two main paradigms for which there are different terms. Here, they shall be referred to as positivism and interpretivism. Positivist research is concerned with facts based on objective information, which is tested and systemised e.g. a randomised controlled trial. Interpretivist research deals with meanings based on subjective information e.g. a patient satisfaction survey (Parahoo 1997).
Previously, I have identified that the predominant method of enquiry in the workplace is the positivistic approach, directly relating to the biopathological model of health. In nursing, the use of evidence-based practice is prevalent and Naidoo & Wills (2000) agree is firmly established. This is consistent with the use of randomised controlled trials to establish what forms of treatment are most effective for most people. Sackett, Rosenburg, Muir Gray, Haynes & Richardson (1996), describe evidence based practice to be a conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. This suggests that evidence based practice is crucial to the effective delivery of care and to the role and status of the nursing profession (Hardey & Mulhall 1994, Roper, Logan & Tierney 1996). An example of positivistic research, used within my practice, would be the use of diabetes mellitus, insulin glucose infusion in acute myocardial infarction (digami regime) (see appendix 1, for summary of research findings).
Following these findings, the digami regime has been implemented throughout the NHS Trust in which I am employed, and is now standard procedure for staff to use on the appropriate patients. The data to support the use of the digami regime evolved from randomised controlled trials, which Hardey & Mulhall (1994), maintains provide high reliability. Further more, the randomised controlled trials have been described within evidence-based practice as the ‘gold standard’ (Naidoo & Wills, 2000). On the negative side, Parahoo (1997) argues that positivistic research studies human beings as objects and does not provide knowledge of the patients’ views of the treatment.
Conclusion
It is undoubtedly clear that health is a complex and multi-faceted area for discussion. There are many meanings and definitions to health with no simple answers. It has become clear that lay and professional views should be regarded equally due to their equal stature. The practitioner has always regarded these as so, but the essay has highlighted this important area and has increased my awareness of this for future clinical practice. The practitioner will continue to view health positively and holistically and will endeavour to promote this practice amongst other members of the multi-disciplinary team.
The practitioner has learned that using an analytical framework is a useful tool when mapping concepts of health in particularly Beattie’s framework. The framework was easy to follow and relates well to practice.
The focus for learning was found to be predominantly around applying essential knowledge. The method of enquiry that informs practice was dominantly positivism which linked closely with Beattie’s biopathological model. Not surprisingly, this model prevails as the most dominant in my clinical practice.
From this module, I feel that I have developed both personally and professionally. The knowledge gained through the undertaking of further study has helped me bridge the theory – practice gap and has made me more aware of issues surrounding this complex area of health.
Appendix 1
This study was initiated to test the hypothesis that rapid improvement of metabolic control in diabetes patients with acute myocardial infarction by means of insulin – glucose infusion decreases the high initial mortality rate and that continued good metabolic control during the early post infarction period improved the subsequent prognosis of myocardial infarction (Malmberg et al 1995, Malmberg et al 1994, Malmberg 1997).
Conclusions from this study, support the immediate use of insulin glucose infusion followed by multi-dose insulin in diabetic patients with acute myocardial infarction (Malmberg et al 1995, Malmberg et al 1994, Malmberg 1997)
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