The people with disabilities. The concept of critical practice

The critical practice theory is vital in the UK today because there are current issues around institutional discrimination and power imbalance. This theory will be analysed using dialogue between values and ethics in care, and the social model of disability. The target service user group for this essay is people with disabilities. The concept of critical practice will be analysed in two aspects. One, being linked to the idea of reflective practice. This is when practitioners are faced with challenging situations which they can reflect on and as a result, improve future practice. Two, being used as an inclusive practice that aims to make a difference while working in a respectful manner (Brechin, 2000). This will be illustrated using the concept Brechin’s critical theory on forging a relationship, seeking to empower and making a difference.

In health and social care, critical practice is a caring process which promotes empowerment and anti-oppressive behaviour. It allows the practitioner to positively support the idea of a person centred approach. Critical practice can be defined as a way of critically applying judgement to situations and actions. This process involves thinking critically in a reflective and reasoning manner (Facione et al., 1994).  Being reflective in practice allows the practitioner to review different perspectives and options before deciding on ‘best practice’.  A critical ‘best practice’ creates a perspective where learning occurs as a model for competences to achieve positive outcomes. However, critical practice is not merely about critical thinking, Brechin, Brown, and Eby (2000) illustrated a wider sociological lens on the notion of the term critical. They explained that “critical” is a process that requires the practitioner to be open-minded, reflexive and develop competence and knowledge, whilst considering different perspectives, experiences, assumptions and power relations. If an individual understands that the word critical is associated with negative connotations, then it is possible that the individual could result in having a negative frame of mind. Also, if reflection is done uncritically, prejudice and bad practice could be promoted. This could lead to practitioners following dominant cultural assumptions that work against challenges to power (Boud and Walker, 1998). Fook and Garner (2007) identified three aspects of critical practice. They are critical thinking, critical action and reflexivity, these are tools which can be deemed essential when seeking social justice and change.

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Additionally, there are theorists who have introduced their ideas on critical practice such as Rolfe (2011) who focuses on political, professional and personal practice. Another is Habermas (1997), he focuses on knowledge (critical, hermeneutic and analytical), and Barnett (1997) who has demonstrated three domains of critical practice; critical analysis, critical action and critical reflexivity. Barnett’s critical practice model is a reflective practice, as they both aim to improve personal and professional practice. Reflective practice is an aspect of critical practice, it is the idea of analysing a situation and learning how to perform effectively, to improve the quality of practice (Bowden, 2003; Coutts-Jarmn 1993). This can be done through self-evaluation and self-assessment (Gustafsson and Fagerberg 2004).

In health and social care, reflective practice is an important way of improving a professional’s skills to make decisions, cope with stress and respond to challenges. It also allows the practitioner to maintain and develop competence, so that care can be provided effectively.  However, reflective practice is not the only component of critical practice. Adams (2002) explained that critical practice goes beyond reflective practice. He explained that reflective practice is not effective on its own, as it views the situation as unchangeable, whereas critical practice emphasises change. Another form of reflective practice is a reflexive approach, this involves reflecting on experiences, values and beliefs that have an impact on practice. The idea of being reflexive in practice is outlined by REF (2018) as the ability to use self-analysis to ensure that the reflector’s knowledge is used, and their actions are consistent with professional values with the opportunity to learn and build progression. Adams (2002) agrees with the idea of being reflexive in practice as it ensures that reflective practice is done critically.

According to Price and Harrington (2013), there are several reflective frameworks that are used as guidelines to analyse a situation in detail. These are person-centred activities that are centred around critical thinking (Price, 2004). A popular model of reflection is Gibbs’ Reflective Cycle (1988). This model was constructed from Kolb’s model as a learning cycle (Kolb,1984), that offers theory and practice in a never-ending cycle. The concept of Gibbs’ reflection model uses basic questions that may help the professional to look back on their practice (Gibbs,1988). Although, this model is commonly used, some argue for a more comprehensive model that includes critical reflexivity. John’s model of structured reflection uses a reflexive approach, he sees reflective practice as being ‘aware of self’, during or after practice. John explained that reflective practice is a development process that includes learning through everyday tasks, with the idea of practice being a lived reality (John, 2007). Some practitioners already doubt the value of reflection, hence the reason John’s (2007) model, which adds complexity due to loss of clear prescriptions for reflection, could leave some practitioners feeling alienated. Health and social care practice can be unpredictable and complex. Schon (????) explained that for professionals to cope with challenging situations, they must do more than follow their structural policies. Professionals analyse their practical experiences and theories during practice as they make a judgement on a situation, and then naturally be artistic.  Schon’s model of reflective practice allows the practitioner to learn, change and improve on their expertise. He believes that as professionals become more skilled, they may develop the ability to monitor and adapt to their practice instantly.

Critical practice brings into focus ethical dilemmas, policies and strategic issues. It acknowledges that there are no definitive ‘right’ answers and that established voices in the field will often hold power over newer, alternative ways of viewing things. Likewise there are a range of structural issues such as empowerment, sustainability and wellbeing that coincides with the reflective process. This is a process that encourages awareness of personal lens and critical reflection on values and beliefs which may have an impact on communicating with others.

Fundamentally, critical practitioners should develop a sound knowledge base and apply their principles to their relationship with their patient. This is to ensure the understanding that everyone has a different viewpoint and accepting a viewpoint does not mean that they have to fall apart from their values. Values are defined as ideas, principles, and hypothesis that an individual or a group of people think about themselves as well as society (Eby,2000). Health and social care services have their own professional values that they expect their workers to abide by. Professional values are ethical principles that emphasises on how clients should be treated and what they believe is right or wrong in their practice. Further on, it’s important that professionals equally value each service user and ensure that services understand that everyone’s needs are different and so should adapt to their needs (MENCAP, n.d). The Nursing and Midwifery Council (NMC) (2015) expand on this and have stated that all nurses and midwives must practice effectively, promote professionalism and put people first. There are values and behaviours that are upheld by health and social care services, as cited by the Department of health (2012), compassion, care, competence, courage, communication, and commitment are labelled as the 6 C’s that ensures clients are put first in terms of care provision. However, practitioners are often faced with a conflict between their personal and professional values. This may cause the service user to have a negative experience during hospitalisation. Therefore, critical practice would be beneficial as it allows the worker to critically reflect on the different values and help them to identify ways in which different discourse can affect their decision making. If their values are not aligned with humanitarians’ principles, critical practice allows changes to social structures which enacts discrimination and prejudice.    

Another way of understanding critical practice is through the social model of disability. The social model of disability, is labelled as the ‘big idea’ of British disability movement (Hasler,1993). This model was produced by a physical disability activist and has a reflective impact on how persons with IDD are perceived.  It distinguishes the difference between an impairment found in an individual and the disability that arises from barriers within society, such as inaccessible buildings and prejudicial attitudes that limit the participation and achievements of disabled people. It thereby defines disability as a form of social oppression (Oliver,1996). This model supports the idea of Brechin’s three pillars of critical practice, as it aims to empower others, relationships and making a difference to the clients’ quality of life. On the contrary, the medical model of disability describes people with IDD as individuals who are affected by their disability (Patron,2009). In hospital care, the medical model is applied and those who have a disability are labelled as the ‘problem’, who needs medical treatment. However, this way of thinking is disempowering (Bricher,2000).

People with an IDD suffer from different patterns of illness and mortality to the general population. They are generally in need of greater healthcare, as they are more likely to have an illness which may not have been diagnosed or managed correctly. Whilst using the hospital services, those with an IDD will have individual needs which are unique to themselves, for example medication usage. During all the stages of hospitalisation, the patient must have received the correct quality of care. This includes their admission; diagnostic testing, placement on a ward, medication use as well as their discharge. If an individual has an IDD, they are at greater risk of being hospitalised for behavioural and mental distress. This is often because of the difficulties in recognising psychiatric disorders (Lunsky et al., 2009).

In the UK, many high-profile scandals in healthcare have highlighted the importance of tackling discrimination and power imbalance. There are reports and government commissions that have emphasised on the lack of effective care and institutional discrimination (Mencap, 2002; 2012, Michael, 2008). According to Phillip (2015), those with an IDD, experience poor care when hospitalised due to lack of power, communication, control and decision making. Similarly, the report by Mencap (2007; 2012) pointed out that services are failing to change the way they deliver care, and acknowledge the different needs of service users. Michael (2008) expresses that people with an IDD have a higher level of unmet needs and receive less effective treatment even though legislations such as;  the Disability Discrimination Act and Mental Capacity Act set out a clear legal framework for the delivery of equal treatment. However, with the use of critical practice, service users can be positively affected, as Glaister (2008) stated, critical practice is about making a difference by forging relationships to empower others.

The next section will focus on Brechin’s concept of critical practice and illustrate how it can positively affect those with an IDD throughout hospitalisation. A current issue, which has been highlighted above, is people with IDD experience a high level of unmet needs.  According to … practitioners need to develop a strong partnership to eradicate this problem. Brechin’s first pillar of critical practice supports this idea. She identifies the act of forging a relationship as an important part of delivering effective care. It is about creating connections, learning about different perspectives, mutual respect and discovering a constructive way to communicate (Brechin, et al. 2000). A critical practice approach ensures that relationships are built with a wide range of people within care settings. This will ensure that relationships are forged not only with the client but also their family carer to effectively provide care. To provide effective care, the caregiver requires sophisticated interpersonal skills, the ability to communicate effectively and to forge relationships. Gilbert et al. (2008) agrees and stated that relationships that embraces cultural sensitivity and the absence of coercion, can positively build trust and have the client feeling safe in the hospital environment. Additionally, many people with an IDD, may find it difficult, or sometimes impossible to communicate about their mental or physical sensations or feelings (Lennox et al., 2015). They often require someone to interpret and convey their messages; this may cause them to feel vulnerable when communicating, due to misinterpretation.

Consequently, the absence of relationships may create trust issues and this could result in incorrect information being provided, this can potentially be a risk to service user’s health and wellbeing (The Kings Funds,2012). Thus, critical practice can positively create relationships and allow the practitioner to use the appropriate skills and sustain their duty by finding a way to interact effectively with service users. According to the Nursing Times Clinical (2004), this can be supported by regular reflective practice, for example, communication towards people with IDD must involve a patient-centred approach which addresses their needs and includes both verbal and non-verbal communication. However, if the relationship built between the client and a professional becomes challenging to forge, or threatens to break, the act of negotiation would be beneficial.  Negotiation is being critical in practice, it is a process that allows both the client and the professional to work together towards a mutual understanding of different needs. The concept of forging relationships does however, have some limitations, this means that professionals need to establish a form of boundaries between them and their client. Brechin (2000) comments that being a good communicator and building good relationship is key, but she also recognised the negative aspect of building relationships, and ensure that professionals understand the importance of professional boundaries.  

The second pillar of critical practice is seeking to empower others. Empowerment is defined by selecting your own choices. If someone has the power to exert choice, they can therefore maximise control in their lives (Jackson, 2006).  Health and social care practitioners are often accused of being paternalistic and taking the approach which they are most familiar in regards to treatment options (Jackson, 2006, cited in John et al., 2007). The understanding of empowerment regarding persons with an IDD is underpinned by applying the social model of disability as a tool (Oliver,2004). A social model approach to empowerment, positions relationships between disabled people and the services they access as rooted in dependence and powerlessness.  However, the social model proposes that the ultimate position for disabled people would be autonomy rooted in independence. In contrast, numerous ethical theorists such as (REF and REF) highlights that we are not fully independent and we must always be understood in a condition of interdependence. The act of interdependence is vital and central to effective practice (Ruch,2005). Persons with IDD tend to become oppressed and professionals are a part of the status quo. Critical practitioners need to work to promote equality and work to rebuild power imbalances (Fraser, et al,2007). It is also necessary to support the challenges of disabled people for their rights, rather than interoperating their situation as dependent people who need care (Morris,1997; cited in Adams).

 Attempting to empower individuals, and challenge oppression and discrimination will need more than just recognition, as well as challenging models of identity and social relations. It has to be a part of a wider project of critical practice, aiming to create more flexible roles and boundaries so that everyone can develop more dialogic ways of working together. It is about supporting the inclusion of service users as equals and allowing room for negotiation, which as a result will improve service planning and delivery.

 

The relationship between professionals and persons with IDD is one of unequal power, this is a negative factor a person with IDD may experience. Reasons for unequal power are because the health professionals have an influence, authority and the knowledge to make decisions on behalf of the individual (CHRE, 2009). They know what is appropriate in regards to professional practice, but on the other hand, the patient receiving care may not know what appropriate (CHRE, 2009) is. The appropriate use of power enables health care workers to care for their patient and their needs.

The third pillar of critical practice is about making a difference. Health professionals must respect the personal autonomy of the people who use their services. They must also try to do good (beneficence) and avoid harm (non-maleficence). A proper understanding of consent is as central to the ethics of what we do as it is to its legality (British Medical Association and Law Society, 2004). This pillar requires practitioners to put their own values aside and make the correct decisions for people with IDD. Practitioners must assess and intervene with the sole objective of improving something for the better; this could be by helping heal a wound, either physically or mentally, or helping to improve someone’s situation. For the best interventions, the practitioners must be up to date in regards to relevant research, if they are up to date then they must apply the research to evaluate the different possible outcomes.

To expand, an approach to making a difference through the use of critical practice is to use evidence based practice. The main purpose of evidence based practice is to use hard scientific evidence, clinical expertise and the individual needs of the patient (McKibbon, 1998). This allows the practitioner to use evidence to effectively reflect on different interventions (Aarons, 2004). McKibbon (1998) states that effective evidence based practice must be carried out in five steps. The first step is creating the questions which meet the needs of the patient. The questions which are asked are all unique and should tailor to each specific patient, this means the questions would be vastly different if one patient was a child and the other an adolescent (Hoagwood et al., 2001). The second step is the retrieval of the correct information, this is arguably the most important step of evidence based research (Brechin, 2000). The third step is using the information found to make a clinical decision, this allows room for adaptation as the patients’ needs will not always be the same. The fourth and fifth steps are following through with your decision and then evaluating after completion, this again allows time for critical reflection (Gray et al., 1997), which as a result can lead to positive differences in the patient’s life.

Evidence based practice can also be separated into two cultural styles, they are referred to the east and the west (Brechin, 2000). The original goal of the eastern psychologists was to enlighten and respect subjective experiences, whereas the western psychologists believed that stats and facts are the key to understanding (Fernando, 1991). There is not a definitive ‘better version’ out of the two styles, however the choice of style will more than likely affect the type of interventions. Dutt and Ferns (1998) expanded on Fernando’s cultural styles to create 3 dimensions. The first dimension is for understanding; western views will achieve understanding via formal information, whereas the eastern view would understand through greater self-awareness. The second dimension focuses on the response of the patient. This could be either to control the symptom (western) or the acceptance of restoring balance (eastern). The last dimension is for the assumptions about outcome, this could be re-establishing the patients independence (western) or on the other hand, integrating the patient into their own social group.  The three dimensions are still relevant to date and can be used to help empower others (Dutt and Ferns, 1998).

To conclude, critical practice can be used and applied to positively affect adults with an IDD in hospitals. Critical practice allows the practitioners to take into account different perspectives in order to find the best practice for their patient. It supports empowerment and rebukes prejudice, which as a result could benefit adults with an intellectual and neurodevelopmental disability in hospitals.

  

 

             

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