CARE OF THE OLDER PERSON
The Flexible Care Service: a third-sector service for older people with mental health needs Elaine Ryder
T
he Department of Health (2012: 5) has stated that there is a need to:
‘Meet the needs of older people—the largest group of people who use services—and treat them with the dignity and respect they deserve in joined up health, care and support services’. Furthermore:
‘When the NHS was founded in 1948, 48 per cent of the population died before the age of 65 ... Life expectancy at 65 is now 21 years for women and 19 years for men ... and the number of people over 85 has doubled in the past three decades.’ (Office for National Statistics, quoted in King’s Fund, 2014) By 2030, one in five people in England will be over 65 (House of Lords, 2013, quoted in King’s Fund, 2014). As people age, they are progressively more likely to live with complex comorbidities, disability and frailty (King’s Fund, 2014). The King’s Fund (2014) states that health and care services have failed to keep up with this dramatic demographic shift and that, in addition, capacity in the community for support services is hugely variable. In spite of the twin challenges of demography and funding, local service leaders are already innovating, implementing and
ABSTRACT
Demographic patterns indicate that by 2030, one in five people in England will be over 65. Together with the fact that as people age they are more likely to suffer from comorbidities, it is of paramount importance that local services are designed to meet the needs of individual older people. The Flexible Care Service is a resource for older people with mental health problems. Through the use of client case studies, the Department of Health’s ‘six Cs’ (care, compassion, competence, communication, courage and commitment) are used as a framework to demonstrate how a third-sector service such as Flexible Care can offer a person-centred approach in order to meet the diverse needs of individual clients. The framework is also used to demonstrate the high level of skills needed by flexible carers in order to provide this support.
KEY WORDS
w Older people w Mental health w Third sector w Person-centred care
30
Email: [email protected] transforming services for older people, an example of which is the Flexible Care Service, a third-sector service administered and managed by the charity Age UK (Oxfordshire). Such an initiative highlights the responsibility of local community nurse leaders to identify the extent of local provision for meeting the needs of local populations, where the service gaps are and how they can proactively engage in addressing local population needs.
The Flexible Care Service The Flexible Care Service was originally set up in 1992, as the result of an initiative by a newly formed community mental health team. They had discovered that older people with dementia, depression and anxiety in a small market town in Oxfordshire were able to cope physically with the demands of daily life, but were becoming socially isolated and lacking the will to continue with their normal daily living activities. The results of this small pilot showed considerable success, which led to the scheme being widened in 1999 to cover the whole county, with funding being provided, at the time, through social services while being administered and managed through Age Concern. The aim of the Flexible Care Service is to help older people with mental health problems to identify ways to enhance the quality of their lives, help them to access appropriate resources and support and, where relevant, provide short-term respite to their carers. Trained staff visit clients to help them set the goals they wish to achieve. They will then help clients access resources and support in their local community in order to achieve, and maintain, those goals. The high level of skill demonstrated by flexible carers has been recognised nationally on two occasions. In 2001 the Oxfordshire Flexible Care Service was awarded the Department of Health’s Health and Social Care Award for Improving the Lives of Older People and, in 2006, it won the Care Services Improvement Partnership Award for Innovative Practice. The service has gone from strength to strength and is now contracted via the local county council, while remaining administered and managed by Age UK (Oxfordshire). Paul Cann, Chief Executive of Age UK Oxfordshire argues
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Flexible Care Service, Age UK, Oxfordshire
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CARE OF THE OLDER PERSON
‘A service which is literally priceless. Flexible Care supports individuals in the community who are often struggling to stay afloat and often having issues of memory or other cognitive impairment. The Flexible Care team works with an increasingly vulnerable group, with the flexible carer working on their own to help people enjoy and get comfort from an outing or visit. Skills of compassion and caring, understanding, patience, energy, planning and imaginativeness are paramount’. This description of the service highlights one of the most important values that underpins flexible care—that of person-centred care and support.
Person-centred care According to Abley (2013), person-centred care means valuing the person and their carer(s); treating people as individuals; looking at the world through the person’s eyes and providing a positive social environment in which the person can experience relative wellbeing. Abley (2013) also highlights the flexibility needed by staff in their caring role. Flexible carers work to do just this—to make a real difference to the lives of individual older people with mental health needs by helping them to maintain their independence and supporting them to make their own choices and decisions. Listening to the concerns of individual clients with sensitivity, acting as advocates for them when appropriate and raising their spirits by providing enjoyable, therapeutic activities are key features of the role. Every episode of care requires flexibility by the flexible carer to meet the changing needs of the individual older person and is an opportunity to promote individualised, meaningful therapeutic activity.
Core NHS values In order to deliver person-centred care, the Compassion in Practice report (Department of Health, 2012) highlights six core fundamental values and behaviours that must underpin the work of all care staff, whatever their care environment, to ensure that every person supported receives high-quality, person-centred care. These six values and behaviours (often referred to as ‘the six Cs’) are: care, compassion, competence, communication, courage and commitment. These six Cs are of particular relevance for flexible carers since they support highly vulnerable clients and, indirectly in many instances, their family carers.
Flexible care and the six Cs Each of the six Cs will now be examined in relation to a client case study in order to demonstrate just how these values underpin the practice of the flexible carer to enhance the quality of life of highly vulnerable older people.
Care The Department of Health (2012: 13) suggests that:
‘Care is our core business and that of our organisations. People receiving care expect it to be right for them’.
is—and it can be difficult to define. One view is taken by Watson (1999), who has written extensively on the nature of caring and sees caring as involving a connection to the individual and building a relationship with the individual. If care is built on connection and relationship, an example from practice is that of Mrs A (in her nineties) who was referred to the Flexible Care Service from a local nurse case manager at the time. Mrs A was suffering from severe clinical depression and poor memory and, having had a busy life balancing a professional career and bringing up a family, she was now a widow. In recent times she had become withdrawn and uncommunicative. It was hoped that a flexible carer might enable Mrs A to re-engage with some of her former interests. Initially, ‘connecting’ with Mrs A proved extremely difficult as she was in bed constantly, mostly facing the wall and clearly preferred not to engage in conversation. However, by slowly reaching out to her, showing interest in her life and her interests, she gradually became more responsive. As the flexible carer visits continued, Mrs A was able to share some fascinating aspects of her early life and a trusting relationship began to develop. Through this ‘connection and relationship’, a colourful personal life-narrative portfolio was developed.
Compassion Compassion is seen by Chambers and Ryder (2009) as the very essence of care and is a profound and complex feeling— far more than just ‘being nice’. As one of the key values in the Department of Health (2012: 13) report:
‘Compassion is how care is given through relationships based on empathy, respect and dignity. It can also be described as intelligent kindness and is central to how people perceive their care.’ In an investigation of the concept of ‘intelligent kindness’, Hannah (2014) describes such kindness as lying at the heart of the therapeutic alliance, and argues that it takes a certain intelligence to be useful and wise in this way. Compassion was fundamental to the relationship that built up between Mrs B and her flexible carer. Mrs B (in her eighties) lived on her own. She was significantly visually impaired and also had some degree of memory loss. Mrs B was referred to the Flexible Care Service by the community mental health team, with a view to trying to help her to build confidence so that she felt able to leave her flat with support. Initially, time was taken to get to know Mrs B, to find out what was important to her and to build a trusting relationship. Mrs B said how much she loved music, so a CD of her favourite songs would be played to sing along to on her outings. With her vision being so compromised, it was so important to maximise on the other senses—she enjoyed visiting a particular local garden centre, where she loved to smell the different flower fragrances. She also loved to visit the ‘pet area’, where a member of the garden centre staff would lift a rabbit out of its pen so Mrs B could stroke it, as she loved the feel of the animal. Von Dietze and Orb (2000) argue that compassionate caring is about entering into the person’s experience in order to share their burden in solidarity with them. This is certainly what was experienced by Mrs B.
If this is the case, then it is important to consider what care
32
© 2015 MA Healthcare Ltd
that the Flexible Care Service is (Cann, 2014):
British Journal of Community Nursing January 2015 Vol 20, No 1
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on September 25, 2015. For personal use only. No other uses without permission. . All rights re
CARE OF THE OLDER PERSON Competence Competence is the third of the six Cs. According to the Department of Health (2012: 13), it means:
‘That all those in caring roles must have the ability to understand an individual’s health and social needs and the expertise, clinical and technical knowledge to deliver effective care and treatments based on research and evidence.’ When flexible carers join the service, a comprehensive induction programme is designed for them by their local coordinator. The coordinators of the Flexible Care Service are committed to offering continuing support to their flexible carers—for example, through having direct access to their local flexible care coordinator and, in particular, through monthly ‘supervisions’, which are undertaken on a oneto-one basis between the appropriate coordinator and the flexible carer. This offers the opportunity to share and discuss client progress, to share any concerns and learn from experiences for future practice. Feedback on client experiences of the service is obtained by the coordinators from clients and/ or their carers throughout their contact with the service. In addition to this supportive supervision, individual annual staff appraisal is undertaken. This offers the chance to review goals set for the year and to set goals for the coming year. Local Flexible Care team meetings are held in which local practice/experiences are shared. These take place in addition to the county-wide team meetings run by the manager of the Flexible Care Service. These meetings offer the opportunity for wider updates (e.g. clinical updates on current practice in dementia, clinical depression and sharing of experiences throughout the county). Age UK (Oxfordshire) also run regular staff training sessions for the organisation as a whole as well as specific training for flexible carers.
Communication According to Morrissey and Callaghan (2011), communication is an essential component of all therapeutic interventions and is featured in the Department of Health (2012: 13) report as one of the six Cs:
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‘Communication is central to successful caring relationships and to effective team working. Listening is as important as what we say and do and essential for “no decision about me without me”. Communication is the key to a good workplace with benefits for those in our care and staff alike.’ The following case study is an example of how a flexible carer was able to draw upon a range of appropriate and effective communication and engagement skills to be able to support Mrs C and her daughter. Mrs C (in her late eighties) lives with her daughter. Mrs C is profoundly deaf, with some memory loss, and has limited mobility due to a fall. She was referred to the Flexible Care Service by a local dementia adviser in the hope that a regular visit from a flexible carer would not only be beneficial to Mrs C but would also give her daughter (Mrs C’s main carer) some respite as she was under immense stress in her caring role. Mrs C is extremely ‘wary’ of strangers and this, together with her profound hearing loss, was an initial challenge in
British Journal of Community Nursing January 2015 Vol 20, No 1
finding out how to ‘communicate’—as was finding out how to build a trusting relationship with somebody who was initially very defensive. At Mrs C’s request, communication took place (with a lot of laughter) through writing conversations in a big book. ‘Memory books’ (from the local library) were also used, which offered a wonderful range of subjects and pictures. Egan (2013) has identified certain non-verbal practices, summarised through the acronym ‘SOLER’, which help to create the therapeutic space and aided the understanding of what Mrs C was saying. These skills and practices are as follows: S—sit squarely on to the client (preferably at a 5 o’clock position) to avoid the possibility of staring O—adopt an open posture, with arms and legs uncrossed L—leaning (at times) towards the person E—maintaining good eye contact without staring R—relaxed posture. As support for Mrs C evolved, a positive development was noted in seeing Mrs C’s daughter take more control of her situation by organising a network of support so she could get some respite.
Courage The Department of Health (2012: 13) claims that:
‘Courage enables us to do the right thing for the people we care for, to speak up when we have concerns and to have the personal strength and vision to innovate and to embrace new ways of working’. Courage, particularly in terms of advocacy skills, is evident through following case study of the experience of Mr D and his flexible carer. Mr D (in his late sixties) lived alone in a flat in a supported housing unit. He had been a widow for 10 years and was referred to the Flexible Care Service from social services. He suffered from anxiety and depression and had a history of alcoholism. He was also a heavy smoker and had poor mobility due to his fractured hip. Mr D was socially isolated and it was hoped that regular visits from a flexible carer might help him share some of his worries and concerns with somebody he could trust. Gaining Mr D’s trust was the biggest challenge for the flexible carer as, feeling marginalised and stereotyped, Mr D was extremely ‘wary’ of people and was likely to decline any help or support at any time. The flexible carer spent time getting to know Mr D and finding out what was important to him. In taking this time to talk together, it became apparent that Mr B used to enjoy playing draughts and he used to play guitar in a rock band. Visits became a combination of playing draughts and developing a list of pop/rock stars that he remembered in his earlier life and singing to the relevant songs. Because of Mr B’s highly vulnerable circumstances, the flexible carer needed courage to act as his advocate and support him to feel central to any decisions about the support that the Flexible Care Service could offer him. The ‘courage’ needed by the flexible carer was sustained through the advice and guidance of the supportive coordinator.
Commitment ‘Commitment to clients’ is one of the six C’ and is seen by
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CARE OF THE OLDER PERSON
‘A commitment to our clients is a cornerstone of what we do. We need to build on our commitment to improve the care experience of our patients, to take action to make this vision and strategy a reality for all and meet the health, care and support challenges ahead’. This ‘cornerstone’ of practice underpins the following case study of the experiences of a flexible carer with Mr E (in his late seventies) who lived with his wife, who was his main carer. Mr E suffered from Parkinson’s disease, memory loss, loss of hearing and arthritis. He was referred to the Flexible Care Service via the nurse at the local memory clinic, with a view to visits from the flexible carer helping to re-energise him as he had become very low in mood. Mr E was a local figure and had an excellent ability to recapture his childhood and early life. Together, Mr E and the flexible carer would go on regular outings in the local area, capturing the places where he was born, where he had played as a lad, went to school, etc. Some photos were taken of Mr E at his ‘special places’. Outings were fun occasions, with laughter and singing. Trying to ensure that Mr E maintained his sense of identity and purpose was the ‘commitment’ that the flexible carer had to Mr E, as he was very aware of his changing circumstances—both physically and mentally. This ‘commitment’ extended to one of his grandchildren, who had written a profoundly moving poem about her grandfather that had, at the time, been ‘put in a drawer’.With support and encouragement from the flexible carer and co-rdinator, this poem was published, much to the absolute delight of Mr E and his wife. It was incredibly important for Mr E to find different ways to achieve what, according to Bridges et al (2010), older people want from their care and support, which is to:
‘See who I am, what is important to me’ ‘Involve me—to be part of decision making’ ‘Connect with me—building a trusting relationship’
Conclusion In conclusion, by drawing on the richness and diversity of client case studies, it is hoped that this article has demonstrated the invaluable role this third-sector service plays in the support of local vulnerable older people with mental health
KEY POINTS
w Demographic patterns indicate an increase in longevity with concomitant increase in comorbidities
w Health, care and support services, including the third sector, need to
work together to ensure local services meet the needs of individual older people
w An example of such a service is the Flexible Care Service for older people with mental health problems, administered and managed by Age UK (Oxfordshire)
w Using the six Cs (care, compassion, competence, communication, courage and commitment), client case studies demonstrate how a person-centred approach can be achieved in supporting individual older people with highly complex needs
34
needs. It has shown that the service is flexible to meet the needs of clients, who either live on their own or with family. It has shown that contact can be through home visits or outings and it has shown the high level of skills needed to support highly vulnerable older people with comorbidities. In addition, it has shown the support it can also offer to family carers and it has demonstrated the range of services that the Flexible Care Services interacts with. Some of the ‘drawbacks and dilemmas’, as highlighted in Hall (2007), still remain, such as discharge from the service. Clients receive the Flexible Care Service for a maximum of 6 months and the feelings, described by Hall (2007), for both the client and the flexible carer, remain. For example, clients have reported feeling bereft and abandoned and flexible carers have been left with feelings of sadness and ‘letting clients down’. However, evidence from clients when the service ends for them demonstrates just how valuable they have found the experience. For example:
‘Thank you for so many wonderful weeks—you have given me so much pleasure and enhanced my life’. ‘Many thanks for your friendship and help over the last 6 months.You being there for me has helped my recovery more than words can express’. For older people, it is important that care is shaped not only by illness or frailty but also by the wider context of the older person’s life and relationships. They should be treated with respect and supported to maintain their dignity, and their identity should not be lost when they enter the care system. (Commission on Dignity in Care, 2012: 9). In the complex care system that exists today, it is hoped that this local initiative has demonstrated the importance of community nurses being proactively involved in the identification of local requirements and the effectiveness of collaborative working when a gap in service provision has been identified.
BJCN
Abley C (2013) Person-centred care. Nurs Older People 25(10):14 Bridges J, Flatley M, Meyer J (2010) Older people’s and relatives experiences in acute care settings: systematic review and synthesis of qualitative studies. Int J Nurs Stud 47(1): 89–107 Cann P (2014) Friday five, 11 April. (Unpublished communication.) Chambers C, Ryder E (2009) Compassion and Caring in Nursing. Radcliffe, Oxford Commission on Dignity in Care (2012) Delivering Dignity: Securing Dignity in Care for Older People in Hospitals and Care Homes. Local Government Association, NHS Confederation, Age UK report. http://tinyurl.com/kxfhgoa (accessed 8 December 2014) Department of Health (2012) Compassion in Practice—Nursing, Midwifery and Care Staff: Our Vision and Strategy. Department of Health, London. http://tinyurl. com/ls5wjq3 (accessed 8 December 2014) Egan G (2013) The Skilled Helper, 10th edn. Brooks/Cole Cengage Learning, Belmont, CA Hall S (2007) Giving a life back with flexible care. Practice Nursing 18(4): 178–80. http://dx.doi.org/10.12968/pnur.2007.18.4.23295 Hannah M (2014) Intelligent kindness: reforming the culture of healthcare. NHS Managers Network, guest editorial. http://tinyurl.com/mcfo3l5 (accessed 10 July 2014) King’s Fund (2014) Making our Health and Care Systems Fit for an Ageing Population. King’s Fund, London. http://tinyurl.com/n9k6ewk (accessed 8 December 2014) Morrissey J, Callaghan P (2011) Communication Skills for Mental Health Nurses. Open University Press, Berkshire von Dietze E, Orb A (2000) Compassionate care: a moral dimension of nursing. Nurs Inquiry 7(3): 166–74. doi: 10.1046/j.1440-1800.2000.00065.x Watson J (1999) Postmodern Nursing and Beyond. Churchill Livingstone,Toronto, ON
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the Department of Health (2012: 13) as follows:
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The Flexible Care Service: a third-sector service for older people with mental health needs Elaine Ryder
T
he Department of Health (2012: 5) has stated that there is a need to:
‘Meet the needs of older people—the largest group of people who use services—and treat them with the dignity and respect they deserve in joined up health, care and support services’. Furthermore:
‘When the NHS was founded in 1948, 48 per cent of the population died before the age of 65 ... Life expectancy at 65 is now 21 years for women and 19 years for men ... and the number of people over 85 has doubled in the past three decades.’ (Office for National Statistics, quoted in King’s Fund, 2014) By 2030, one in five people in England will be over 65 (House of Lords, 2013, quoted in King’s Fund, 2014). As people age, they are progressively more likely to live with complex comorbidities, disability and frailty (King’s Fund, 2014). The King’s Fund (2014) states that health and care services have failed to keep up with this dramatic demographic shift and that, in addition, capacity in the community for support services is hugely variable. In spite of the twin challenges of demography and funding, local service leaders are already innovating, implementing and
ABSTRACT
Demographic patterns indicate that by 2030, one in five people in England will be over 65. Together with the fact that as people age they are more likely to suffer from comorbidities, it is of paramount importance that local services are designed to meet the needs of individual older people. The Flexible Care Service is a resource for older people with mental health problems. Through the use of client case studies, the Department of Health’s ‘six Cs’ (care, compassion, competence, communication, courage and commitment) are used as a framework to demonstrate how a third-sector service such as Flexible Care can offer a person-centred approach in order to meet the diverse needs of individual clients. The framework is also used to demonstrate the high level of skills needed by flexible carers in order to provide this support.
KEY WORDS
w Older people w Mental health w Third sector w Person-centred care
30
Email: [email protected] transforming services for older people, an example of which is the Flexible Care Service, a third-sector service administered and managed by the charity Age UK (Oxfordshire). Such an initiative highlights the responsibility of local community nurse leaders to identify the extent of local provision for meeting the needs of local populations, where the service gaps are and how they can proactively engage in addressing local population needs.
The Flexible Care Service The Flexible Care Service was originally set up in 1992, as the result of an initiative by a newly formed community mental health team. They had discovered that older people with dementia, depression and anxiety in a small market town in Oxfordshire were able to cope physically with the demands of daily life, but were becoming socially isolated and lacking the will to continue with their normal daily living activities. The results of this small pilot showed considerable success, which led to the scheme being widened in 1999 to cover the whole county, with funding being provided, at the time, through social services while being administered and managed through Age Concern. The aim of the Flexible Care Service is to help older people with mental health problems to identify ways to enhance the quality of their lives, help them to access appropriate resources and support and, where relevant, provide short-term respite to their carers. Trained staff visit clients to help them set the goals they wish to achieve. They will then help clients access resources and support in their local community in order to achieve, and maintain, those goals. The high level of skill demonstrated by flexible carers has been recognised nationally on two occasions. In 2001 the Oxfordshire Flexible Care Service was awarded the Department of Health’s Health and Social Care Award for Improving the Lives of Older People and, in 2006, it won the Care Services Improvement Partnership Award for Innovative Practice. The service has gone from strength to strength and is now contracted via the local county council, while remaining administered and managed by Age UK (Oxfordshire). Paul Cann, Chief Executive of Age UK Oxfordshire argues
© 2015 MA Healthcare Ltd
Flexible Care Service, Age UK, Oxfordshire
British Journal of Community Nursing January 2015 Vol 20, No 1
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on September 25, 2015. For personal use only. No other uses without permission. . All rights re
CARE OF THE OLDER PERSON
‘A service which is literally priceless. Flexible Care supports individuals in the community who are often struggling to stay afloat and often having issues of memory or other cognitive impairment. The Flexible Care team works with an increasingly vulnerable group, with the flexible carer working on their own to help people enjoy and get comfort from an outing or visit. Skills of compassion and caring, understanding, patience, energy, planning and imaginativeness are paramount’. This description of the service highlights one of the most important values that underpins flexible care—that of person-centred care and support.
Person-centred care According to Abley (2013), person-centred care means valuing the person and their carer(s); treating people as individuals; looking at the world through the person’s eyes and providing a positive social environment in which the person can experience relative wellbeing. Abley (2013) also highlights the flexibility needed by staff in their caring role. Flexible carers work to do just this—to make a real difference to the lives of individual older people with mental health needs by helping them to maintain their independence and supporting them to make their own choices and decisions. Listening to the concerns of individual clients with sensitivity, acting as advocates for them when appropriate and raising their spirits by providing enjoyable, therapeutic activities are key features of the role. Every episode of care requires flexibility by the flexible carer to meet the changing needs of the individual older person and is an opportunity to promote individualised, meaningful therapeutic activity.
Core NHS values In order to deliver person-centred care, the Compassion in Practice report (Department of Health, 2012) highlights six core fundamental values and behaviours that must underpin the work of all care staff, whatever their care environment, to ensure that every person supported receives high-quality, person-centred care. These six values and behaviours (often referred to as ‘the six Cs’) are: care, compassion, competence, communication, courage and commitment. These six Cs are of particular relevance for flexible carers since they support highly vulnerable clients and, indirectly in many instances, their family carers.
Flexible care and the six Cs Each of the six Cs will now be examined in relation to a client case study in order to demonstrate just how these values underpin the practice of the flexible carer to enhance the quality of life of highly vulnerable older people.
Care The Department of Health (2012: 13) suggests that:
‘Care is our core business and that of our organisations. People receiving care expect it to be right for them’.
is—and it can be difficult to define. One view is taken by Watson (1999), who has written extensively on the nature of caring and sees caring as involving a connection to the individual and building a relationship with the individual. If care is built on connection and relationship, an example from practice is that of Mrs A (in her nineties) who was referred to the Flexible Care Service from a local nurse case manager at the time. Mrs A was suffering from severe clinical depression and poor memory and, having had a busy life balancing a professional career and bringing up a family, she was now a widow. In recent times she had become withdrawn and uncommunicative. It was hoped that a flexible carer might enable Mrs A to re-engage with some of her former interests. Initially, ‘connecting’ with Mrs A proved extremely difficult as she was in bed constantly, mostly facing the wall and clearly preferred not to engage in conversation. However, by slowly reaching out to her, showing interest in her life and her interests, she gradually became more responsive. As the flexible carer visits continued, Mrs A was able to share some fascinating aspects of her early life and a trusting relationship began to develop. Through this ‘connection and relationship’, a colourful personal life-narrative portfolio was developed.
Compassion Compassion is seen by Chambers and Ryder (2009) as the very essence of care and is a profound and complex feeling— far more than just ‘being nice’. As one of the key values in the Department of Health (2012: 13) report:
‘Compassion is how care is given through relationships based on empathy, respect and dignity. It can also be described as intelligent kindness and is central to how people perceive their care.’ In an investigation of the concept of ‘intelligent kindness’, Hannah (2014) describes such kindness as lying at the heart of the therapeutic alliance, and argues that it takes a certain intelligence to be useful and wise in this way. Compassion was fundamental to the relationship that built up between Mrs B and her flexible carer. Mrs B (in her eighties) lived on her own. She was significantly visually impaired and also had some degree of memory loss. Mrs B was referred to the Flexible Care Service by the community mental health team, with a view to trying to help her to build confidence so that she felt able to leave her flat with support. Initially, time was taken to get to know Mrs B, to find out what was important to her and to build a trusting relationship. Mrs B said how much she loved music, so a CD of her favourite songs would be played to sing along to on her outings. With her vision being so compromised, it was so important to maximise on the other senses—she enjoyed visiting a particular local garden centre, where she loved to smell the different flower fragrances. She also loved to visit the ‘pet area’, where a member of the garden centre staff would lift a rabbit out of its pen so Mrs B could stroke it, as she loved the feel of the animal. Von Dietze and Orb (2000) argue that compassionate caring is about entering into the person’s experience in order to share their burden in solidarity with them. This is certainly what was experienced by Mrs B.
If this is the case, then it is important to consider what care
32
© 2015 MA Healthcare Ltd
that the Flexible Care Service is (Cann, 2014):
British Journal of Community Nursing January 2015 Vol 20, No 1
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on September 25, 2015. For personal use only. No other uses without permission. . All rights re
CARE OF THE OLDER PERSON Competence Competence is the third of the six Cs. According to the Department of Health (2012: 13), it means:
‘That all those in caring roles must have the ability to understand an individual’s health and social needs and the expertise, clinical and technical knowledge to deliver effective care and treatments based on research and evidence.’ When flexible carers join the service, a comprehensive induction programme is designed for them by their local coordinator. The coordinators of the Flexible Care Service are committed to offering continuing support to their flexible carers—for example, through having direct access to their local flexible care coordinator and, in particular, through monthly ‘supervisions’, which are undertaken on a oneto-one basis between the appropriate coordinator and the flexible carer. This offers the opportunity to share and discuss client progress, to share any concerns and learn from experiences for future practice. Feedback on client experiences of the service is obtained by the coordinators from clients and/ or their carers throughout their contact with the service. In addition to this supportive supervision, individual annual staff appraisal is undertaken. This offers the chance to review goals set for the year and to set goals for the coming year. Local Flexible Care team meetings are held in which local practice/experiences are shared. These take place in addition to the county-wide team meetings run by the manager of the Flexible Care Service. These meetings offer the opportunity for wider updates (e.g. clinical updates on current practice in dementia, clinical depression and sharing of experiences throughout the county). Age UK (Oxfordshire) also run regular staff training sessions for the organisation as a whole as well as specific training for flexible carers.
Communication According to Morrissey and Callaghan (2011), communication is an essential component of all therapeutic interventions and is featured in the Department of Health (2012: 13) report as one of the six Cs:
© 2015 MA Healthcare Ltd
‘Communication is central to successful caring relationships and to effective team working. Listening is as important as what we say and do and essential for “no decision about me without me”. Communication is the key to a good workplace with benefits for those in our care and staff alike.’ The following case study is an example of how a flexible carer was able to draw upon a range of appropriate and effective communication and engagement skills to be able to support Mrs C and her daughter. Mrs C (in her late eighties) lives with her daughter. Mrs C is profoundly deaf, with some memory loss, and has limited mobility due to a fall. She was referred to the Flexible Care Service by a local dementia adviser in the hope that a regular visit from a flexible carer would not only be beneficial to Mrs C but would also give her daughter (Mrs C’s main carer) some respite as she was under immense stress in her caring role. Mrs C is extremely ‘wary’ of strangers and this, together with her profound hearing loss, was an initial challenge in
British Journal of Community Nursing January 2015 Vol 20, No 1
finding out how to ‘communicate’—as was finding out how to build a trusting relationship with somebody who was initially very defensive. At Mrs C’s request, communication took place (with a lot of laughter) through writing conversations in a big book. ‘Memory books’ (from the local library) were also used, which offered a wonderful range of subjects and pictures. Egan (2013) has identified certain non-verbal practices, summarised through the acronym ‘SOLER’, which help to create the therapeutic space and aided the understanding of what Mrs C was saying. These skills and practices are as follows: S—sit squarely on to the client (preferably at a 5 o’clock position) to avoid the possibility of staring O—adopt an open posture, with arms and legs uncrossed L—leaning (at times) towards the person E—maintaining good eye contact without staring R—relaxed posture. As support for Mrs C evolved, a positive development was noted in seeing Mrs C’s daughter take more control of her situation by organising a network of support so she could get some respite.
Courage The Department of Health (2012: 13) claims that:
‘Courage enables us to do the right thing for the people we care for, to speak up when we have concerns and to have the personal strength and vision to innovate and to embrace new ways of working’. Courage, particularly in terms of advocacy skills, is evident through following case study of the experience of Mr D and his flexible carer. Mr D (in his late sixties) lived alone in a flat in a supported housing unit. He had been a widow for 10 years and was referred to the Flexible Care Service from social services. He suffered from anxiety and depression and had a history of alcoholism. He was also a heavy smoker and had poor mobility due to his fractured hip. Mr D was socially isolated and it was hoped that regular visits from a flexible carer might help him share some of his worries and concerns with somebody he could trust. Gaining Mr D’s trust was the biggest challenge for the flexible carer as, feeling marginalised and stereotyped, Mr D was extremely ‘wary’ of people and was likely to decline any help or support at any time. The flexible carer spent time getting to know Mr D and finding out what was important to him. In taking this time to talk together, it became apparent that Mr B used to enjoy playing draughts and he used to play guitar in a rock band. Visits became a combination of playing draughts and developing a list of pop/rock stars that he remembered in his earlier life and singing to the relevant songs. Because of Mr B’s highly vulnerable circumstances, the flexible carer needed courage to act as his advocate and support him to feel central to any decisions about the support that the Flexible Care Service could offer him. The ‘courage’ needed by the flexible carer was sustained through the advice and guidance of the supportive coordinator.
Commitment ‘Commitment to clients’ is one of the six C’ and is seen by
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CARE OF THE OLDER PERSON
‘A commitment to our clients is a cornerstone of what we do. We need to build on our commitment to improve the care experience of our patients, to take action to make this vision and strategy a reality for all and meet the health, care and support challenges ahead’. This ‘cornerstone’ of practice underpins the following case study of the experiences of a flexible carer with Mr E (in his late seventies) who lived with his wife, who was his main carer. Mr E suffered from Parkinson’s disease, memory loss, loss of hearing and arthritis. He was referred to the Flexible Care Service via the nurse at the local memory clinic, with a view to visits from the flexible carer helping to re-energise him as he had become very low in mood. Mr E was a local figure and had an excellent ability to recapture his childhood and early life. Together, Mr E and the flexible carer would go on regular outings in the local area, capturing the places where he was born, where he had played as a lad, went to school, etc. Some photos were taken of Mr E at his ‘special places’. Outings were fun occasions, with laughter and singing. Trying to ensure that Mr E maintained his sense of identity and purpose was the ‘commitment’ that the flexible carer had to Mr E, as he was very aware of his changing circumstances—both physically and mentally. This ‘commitment’ extended to one of his grandchildren, who had written a profoundly moving poem about her grandfather that had, at the time, been ‘put in a drawer’.With support and encouragement from the flexible carer and co-rdinator, this poem was published, much to the absolute delight of Mr E and his wife. It was incredibly important for Mr E to find different ways to achieve what, according to Bridges et al (2010), older people want from their care and support, which is to:
‘See who I am, what is important to me’ ‘Involve me—to be part of decision making’ ‘Connect with me—building a trusting relationship’
Conclusion In conclusion, by drawing on the richness and diversity of client case studies, it is hoped that this article has demonstrated the invaluable role this third-sector service plays in the support of local vulnerable older people with mental health
KEY POINTS
w Demographic patterns indicate an increase in longevity with concomitant increase in comorbidities
w Health, care and support services, including the third sector, need to
work together to ensure local services meet the needs of individual older people
w An example of such a service is the Flexible Care Service for older people with mental health problems, administered and managed by Age UK (Oxfordshire)
w Using the six Cs (care, compassion, competence, communication, courage and commitment), client case studies demonstrate how a person-centred approach can be achieved in supporting individual older people with highly complex needs
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needs. It has shown that the service is flexible to meet the needs of clients, who either live on their own or with family. It has shown that contact can be through home visits or outings and it has shown the high level of skills needed to support highly vulnerable older people with comorbidities. In addition, it has shown the support it can also offer to family carers and it has demonstrated the range of services that the Flexible Care Services interacts with. Some of the ‘drawbacks and dilemmas’, as highlighted in Hall (2007), still remain, such as discharge from the service. Clients receive the Flexible Care Service for a maximum of 6 months and the feelings, described by Hall (2007), for both the client and the flexible carer, remain. For example, clients have reported feeling bereft and abandoned and flexible carers have been left with feelings of sadness and ‘letting clients down’. However, evidence from clients when the service ends for them demonstrates just how valuable they have found the experience. For example:
‘Thank you for so many wonderful weeks—you have given me so much pleasure and enhanced my life’. ‘Many thanks for your friendship and help over the last 6 months.You being there for me has helped my recovery more than words can express’. For older people, it is important that care is shaped not only by illness or frailty but also by the wider context of the older person’s life and relationships. They should be treated with respect and supported to maintain their dignity, and their identity should not be lost when they enter the care system. (Commission on Dignity in Care, 2012: 9). In the complex care system that exists today, it is hoped that this local initiative has demonstrated the importance of community nurses being proactively involved in the identification of local requirements and the effectiveness of collaborative working when a gap in service provision has been identified.
BJCN
Abley C (2013) Person-centred care. Nurs Older People 25(10):14 Bridges J, Flatley M, Meyer J (2010) Older people’s and relatives experiences in acute care settings: systematic review and synthesis of qualitative studies. Int J Nurs Stud 47(1): 89–107 Cann P (2014) Friday five, 11 April. (Unpublished communication.) Chambers C, Ryder E (2009) Compassion and Caring in Nursing. Radcliffe, Oxford Commission on Dignity in Care (2012) Delivering Dignity: Securing Dignity in Care for Older People in Hospitals and Care Homes. Local Government Association, NHS Confederation, Age UK report. http://tinyurl.com/kxfhgoa (accessed 8 December 2014) Department of Health (2012) Compassion in Practice—Nursing, Midwifery and Care Staff: Our Vision and Strategy. Department of Health, London. http://tinyurl. com/ls5wjq3 (accessed 8 December 2014) Egan G (2013) The Skilled Helper, 10th edn. Brooks/Cole Cengage Learning, Belmont, CA Hall S (2007) Giving a life back with flexible care. Practice Nursing 18(4): 178–80. http://dx.doi.org/10.12968/pnur.2007.18.4.23295 Hannah M (2014) Intelligent kindness: reforming the culture of healthcare. NHS Managers Network, guest editorial. http://tinyurl.com/mcfo3l5 (accessed 10 July 2014) King’s Fund (2014) Making our Health and Care Systems Fit for an Ageing Population. King’s Fund, London. http://tinyurl.com/n9k6ewk (accessed 8 December 2014) Morrissey J, Callaghan P (2011) Communication Skills for Mental Health Nurses. Open University Press, Berkshire von Dietze E, Orb A (2000) Compassionate care: a moral dimension of nursing. Nurs Inquiry 7(3): 166–74. doi: 10.1046/j.1440-1800.2000.00065.x Watson J (1999) Postmodern Nursing and Beyond. Churchill Livingstone,Toronto, ON
© 2015 MA Healthcare Ltd
the Department of Health (2012: 13) as follows:
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