In part one the concept of user participation was explored. Part two continued the literature review and presented the research methodology of the present study. Here the emergent findings are discussed, together with their implications for practice development.
The findings presented here were obtained from 12 health visitors working in Southern Birmingham Community Health Trust.
Three of the sample were community practice teachers (with responsibility for training student health visitors) and one was a programme first parent health visitor (child development programme).
The ages of participants ranged from mid thirties to mid fifties and the sample was predominantly Caucasian with the exception of two participants who were of Afro-Caribbean descent. All but one of the participants were female.
The overall aim of the study was to identify, describe and provide a theoretical analysis of health visitors' perceptions of user participation in health care. The health visitors' perceptions broadly fell into four categories that will be discussed, these were:
Key features or conditions of user participation;
Driving and restraining forces (or context) related to user participation;
Action/interactional strategies to cope with the barriers to participation (antecedents);
Consequences of user participation.
From this study it is evident that health visitors' have internalised the ethical, legal and social ideologies supporting user participation but they face a huge obstacle. Their practice is being governed by 'powerful others' for example management and medicine. In order to be comfortable about their level of commitment to user participation they have to reconcile the demands of these 'powerful others' and their own professional values. This was the main issue or basic, social psychological process health visitors had to negotiate to integrate participatory approaches into practice which were more than manipulation, therapy (non-participation) and informing, consulting and placation (degrees of tokenism) described by Arnstein (1969). Practitioners had come to terms with this dilemma to varying degrees and this was evident in their perceptions.
Key features
On the whole user participation was regarded a dynamic process which was moving beyond users merely having a voice and being involved in evaluation of services towards actual planning of services and care delivery.
However, participation was also regarded by a minority in a more traditional vein concerning users utilising the service that was provided and defined by the professionals.
Literature on professional/client interactions and on nursing attitudes to user involvement suggest a major influence is whether nurses work in a nurse-centred or person-centred way (Gill, 1987; Conway, 1996). The above quotation equate conceptually with the nurse-centred, traditional approach where the professional is controlling information and making decisions about clients (normative) professionally defined needs. In contrast the person-centred practitioner is regarded as one who respects individual needs and autonomy, consulting as an equal and providing the information individuals need to participate in decision-making (Casey, 1995).
The majority reflected the more enlightened, person-centred philosophy concerning equality in the relationship, involving sharing where the health visitor acts as a facilitator in a supportive rather than a directive role.
The participants who responded in the nurse-centred approach had not successfully reconciled the organisational demands with their professional values. Thus in order to cope they demonstrated traditionalist views, the hallmark of which can be seen as survival and getting the work done (Conway, 1996). McAllister (1996) highlights that traditional teaching methods, where the student has to get it right, contributes to a loss of self-confidence, resulting in oppression and disempowerment. As Conway (1996) asserts:
'... developing expertise is about much more than taking on additional tasks or attending a specialist course. The culture that nurses work in, and their (emphasised) relationship to that culture is a highly significant factor in the process.' (Conway, 1996).
The participants who expressed person-centred views placed less emphasis on hierarchical constraints, although they were still alluded to. They perceived, in keeping with Fulton's (1997) study that they had more personal power. Moreover there was evidence that these participants had reflected on the client/practitioner exchange to varying degrees.
'This is a control issue, if you like being in control handing over some of that control can be difficult. If you don't mind losing control so long as you're working together that's great and it can also raise your own self-esteem.' (Interview 11).
Those who perceived they had little control in the environment in which they worked were the one's whose perceptions of client participation were more professionally defined and thus controlled. It is suggested that those with little sense of personal power may firstly not have the psychological resources necessary to challenge their practice. Secondly it should be considered that subconsciously these practitioners' may be reluctant to relinquish what power they do have. In contrast those who do not feel that the constraints they face necessarily make them powerless are more likely to express egalitarian views.
The data gathered indicates that the health visitors' perceived more restraining forces or barriers to user participation than facilitating or driving forces. Two themes emerged as significant. The organisation that health visitors' worked in, for example management and medical colleagues expectations, and their own / health visitor characteristics and those of their clients'.
The organisation
The participants perceived that they were not always in a position to facilitate participation because of their own position within the health care system. These findings are in keeping with Melia (1987) and Dingwall et al. (1988) which highlight that nurses do attempt to work with the individuals for whom they care but that the hierarchies and bureaucratic nature of organisational structures have militated against this. Fulton (1997) also found that nurses autonomy or freedom to function, was seriously limited by unequal power relationships with medical staff.
'... it would mean quite a radical change in the way we work I think and we would have to be free from a lot of the things that at the moment we are still obliged to do' (Interview 2).
Participants articulated their difficulty in getting new initiatives supported because of a lack of evidence in the form of outcome measures. Strategies which seek to improve the quality of the service, such as working in partnership on client led issues are difficult to make visible because they are not readily quantifiable. This is in contrast to breast-feeding and childhood accident statistics that are collected to demonstrate health visitor effectiveness or ineffectiveness.
Indeed the utility of health visiting like nursing, as a caring profession, is not easily apparent because the focus is on the process component (caring) of health care rather than the outcome of health care (curing). The perception that the organisational constraints were an obstacles almost too huge to overcome recurred throughout the data. The data reflected the notion however that a culture change, especially in the attitudes and priorities of these 'powerful others' could facilitate participation with users.
Characteristics
The participants felt that their own characteristics, and those of their clients, were also a factor in whether meaningful participation occurred. The type of relationship between health visitors' and their clients' was a recurrent theme. Openness and the ability to express positive regard was considered important to facilitate a trusting, productive relationship.
Many participants suggested that clients socio-economic circumstances affected clients ability to enter into an open participatory relationship with health visitors.
Some perceived that clients' from more deprived backgrounds were less trusting and consequently less likely to engage with professionals on anything other than a superficial level.
'Distrust and fear, they see you as an authoritative, threatening figure rather than in areas where perhaps professional or slightly more informed families would not have that perception, would see you more as a resource and would see that relationship as more equal anyway.' (Interview 2).
This quotation mirrors Hagan's (1988) findings that, those who seriously underused the health visiting services, their non-participation was because of their sense of vulnerability to personal undermining aspects of health care provision. Ashworth et al. (1992) have also noted that participation is threatened unless the person is able to think there is a possibility of satisfactory self-presentation. The participants exemplified that, although they were aware some families tended to use the service less, they did not always reflect upon why this was so. Indeed when describing an incident of non-participation one participant said:
'I don't think in this particular example it was hostility. I think it was her own personality (the client's) she had this need to be the perfect mother and that was the problem here.' (Interview 11).
Nonetheless this health visitor did not consider why the client should feel that her self-image as a perfect mother needed to be dented by participating with the health visiting service. This quotation exemplifies the views of many participants' that the more disadvantaged families tended to have less self-esteem and therefore this prevented them from entering into an equal relationship with a health visitor. The data generated supported the literature reviewed, which highlighted that some practitioners may regard some clients as more equal than others (McIntosh, 1979; Kendall, 1993). Kendall's (1993) study indicated that health visitors still attempted to control practitioner / client interactions, especially with families from the lower socio-economic groups. It is forwarded here that some practitioners coped psychologically with the contradictions of their professional egalitarian ideologies and the hierarchy in which they worked by internalising the belief that it was the clients' fault meaningful participation did not occur. The clients' low self-esteem or motivation prevented them from participating at a partnership level. The quotation below is an example of such an instance of attributional bias.
'The GP practice that I'm attached to, they're very much into user participation and trying to improve service and get the client, patients perspective and point of view and quite often the stumbling block is the lack of motivation from the client leading to well, oh we've tried and it's not worked from a professional end but there have been several attempts to include and listen to the user, it's one thing that the practice do value.' (Interview 6).
As attributional theory illuminates, people attempt to make sense of undesirable events by implying personal or impersonal causes (Heider, 1958). In this instance, it was apparent that the practitioner had made an attributional bias. Despite the practitioners' knowledge of predisposing factors, that disadvantaged clients are not a powerful group, the complexity of the situation was over simplified. Affleck (1987) highlight, this may be beneficial in terms of coping as self-attribution may have negative outcomes personally.
Others however recognised their part in undermining, or not undermining, the users. The participants with a greater sense of personal power regarded it to be the health visitor's responsibility to encourage clients' to engage in how services should be delivered. It will be seen that more barriers to participation are perceived than facilitating factors.
As this quotation and the data consistently reflects, power to change, or to cope with changing, circumstances includes not only material sources, but psychological and cultural aspects, which are equally effective in limiting or channelling people (Naidoo & Willis, 1994).
Strategies
In order to be comfortable about their level of commitment to user participation, practitioners had to reconcile the demands of the budget holders and their own professional values. Thus coping was the main issue or basic, social, psychological process. Davis (1995) suggests that in a world that has expressed gendering through bureaucracy and profession the dilemmas or nursing are particularly acute. Some coped by practising in the traditional nurse-centred fashion, getting the work done, and others, those with the greater sense of personal power, coped by tackling the issue in small steps. Those who thought theoretically about short-term objectives and were realistic, rather than more abstract long term goals, relating to integrating participatory working with service users, were more confident about their ability to make this a reality.
'One of the things we've set up here is a support group for post-natally depressed mothers and we sought the advice of the community psychiatric nurse from the mother and baby unit. It wasn't a working party as such we had a group discussion and one of the clients who would be part of the group was involved in that.' (Interview 5).
Research does support these findings. Warner (1984) demonstrates the value of negotiating with clients' specific short-term objectives. These studies show that when nurses thought theoretically in terms of short-range goals, this was associated with success in work because all the parties involved had a better understanding of how the nurse was aiming to help.
Many participants also talked about their own sense of discomfort in not being able to move practice forward. This suggests that although practitioners were knowledgeable about working in partnership with the communities they serve, they did not always have the skills to negotiate the barriers previously highlighted.
Lewin (1951) de0scribes this sense of discomfort as an antecedent for planned change to occur. Thus despite the restraining forces exemplified in the preceding analysis including the perception that practitioners may be fearful of changing practice. Change theory exemplifies that many practitioners are in fact ready for change. Schon (1987) specifies that it is not possible to teach practitioners what they need to deal with the messy problems of practice, but suggest that it is possible to coach them to do this.
'(The practitioner) has to see on his own behalf and in his own way the relations between means and methods employed and results achieved. Nobody else can see for him, and he can't see just by being told.' (Schon, 1987).
Johns (1995) suggests guided reflection, where the practitioner accepts and invites feedback on difficult case scenarios from their day to day practice from a more experienced colleague, has the power to transform practice if it is practised in a non-depreciated manner. Literature does support the belief that when developmental strategies and coping behaviours are linked 'cognitive control' results.
Sutton and Smith (1995) assert the advancement of practice to be dependent on personal attributes and dispositions of nurses coupled with knowledge associated with caring, human communication and relationships. In this study the data indicates that before participation at the partnership level (Arnstein, 1969) can occur, health visitors' need to feel right about themselves, have a sense of personal power and strength the relationship with the multidisciplinary team.
Consequences
In keeping with Arnstein's (1969) theory, the data generated indicated that participants saw, the consequences of integrating participatory approaches as positive or negative depending on how much power was actually divested to health service users. Positive consequences were stated as client empowerment, and a responsive health visiting service that met clients' expressed needs. Negative consequences were regarded as disillusionment. Whether positive or negative consequences occurred was found to be dependent on how successfully practitioners' reconciled the organisational demands with their own ideologies and the needs of their clients.
Positive outcomes of working in a truly participatory manner, in partnership with clients, were cited as client empowerment. The health visitors felt that this would give clients' courage to change adverse circumstances in their lives and open doors to new experiences.
'I think one would hope they would feel more powerful, that it would give them more confidence if they actually feel a sense of achievement and help them to move and give them the confidence to become more involved and make changes in their lives.' (Interview 4).
Others, however, felt since they were powerless to alter the context of the practitioner/client exchange, it was best not build clients hopes up and suggest things could change as this would lead to disillusionment. If clients were asked for their views and then these were not acted upon participants felt it would led to mistrust. Arnstein (1969) considered such quasi-participation to be tokenism and therefore manipulation. His views are mirrored in the data that, tokenism only produces short lived positive effects which turn negative when clients realise their views are not being taken on board.
The consequences of whether participatory working was successful or not were also perceived to affect the health visitors. Increased job satisfaction or burn out and stress were the two extremes which again can be seen to relate conceptually to how practitioners coped or reconciled the demands of bureaucracy, their own ideologies related to participation, and their clients needs. Participants' who saw user participation as an abstract concept, which was out of their hands and too large to tackle, coped by getting the work done in the traditional nurse-centred fashion described by Bevis (1982), Gill (1987) and Conway (1996) because they perceived themselves as powerless.
'You would ultimately burn out, you could be very frustrated in your work, very stressed in your work because you're not able to deliver what's being asked of you.' (Interview 6).
Implications for practice
The data generated from this study do indicate that health visitors' personalities are highly significant in how they coped and whether meaningful participation occurs. It would appear that those who perceived themselves as powerless are less able to effect meaningful participation with service users. This is because in order to cope with their perceived constraints these practitioners' demonstrated traditionalist nurse-centred views, the hallmark of which can be seen as survival and getting the work done (Conway, 1996). McAllister (1996) highlights that traditional teaching methods, where the student has to get it right, contributes to a loss of self-confidence, resulting in oppression and disempowerment.
Traditional teaching methods are therefore not the answer. Indeed this study exemplifies that practitioners are knowledgeable about the concept of user participation but many are unable to take this forward in their practice because of perceived feelings of powerlessness. To meet the educational needs of an oppressed group a liberationist philosophy is required (Fulton, 1997).
Commentators have suggested the importance of reflection in experiential learning, specifically because it affords practitioners the ability to identify and integrate theory in practice (Kolb, 1976; Schon, 1983; Benner, 1984; Knowles, 1984; Conway, 1994). Boyd and Fales (1983) assert reflective learning to be the critical difference between whether a practitioner repeats the same experience many times merely becoming proficient at that action, or learns from the experience which involves changing his/her meaning structures. Consequently reflective learning often results in perspective transformation (Mezirow, 1978). That reflection can result in a cognitive or affective change is not surprising considering the first stage in the reflective process is described as sensing an inner discomfort, in a situation, requiring a reaction not yet available to the conscious intent of the practitioner (Boyd & Fales, 1983). These data do indeed depict that many participants were uncomfortable with the situation they find themselves in: Embracing philosophical principles related to egalitarian interaction with clients that they feel constrained from realising.
In order to advance practice, therefore, energy must be directed away from feelings of powerlessness and security from the past, towards opportunities for the future (Lewin, 1951; Scotte & Jaffe, 1993). It is therefore suggested that a formal process of guided reflection, through clinical supervision, has the potential to liberate practitioners. Clinical supervision and the insight generated within this humanistic and caring framework is concerned with developing the personal effectiveness of self to be used in working with clients in unique and responsive ways (Conway, 1994). Clinical supervision is defined as:
'An exchange between practising professionals to enable the development of professional skills.' (Butterworth, 1992). Many benefits, of clinical supervision, have been described including its ability to empower practitioner (Kohner, 1994).
The key issue is that guidance through clinical supervision creates the possibility that reflective practice can fulfil its intention, to enable the development of practitioners therapeutic potential, to make a qualitative difference to clients live (Johns, 1995). Reflective practice necessitates the needs of the client to become paramount. This was demonstrated by Paunonen's (1991) study which exemplified a correlation between the implementation of a supervision programme and an increased ability and willingness to meet client's needs.
Nonetheless it is pertinent here to ponder whether a strategy, such as clinical supervision, can influence the practitioners' perceptions of the culture in which they work. McCormack and Hopkins (1995) highlight that peer supervision is in fact synonymous with model ii working behaviour as described by Argyris and Schon (1989). Argyris and Schon contrast model ii approaches to leadership and learning within an organisation to model i. In model i working the leader maintains control over the environment and strategies are initiated that achieve the leader's own agenda. Model ii behaviour is regarded advantageous because of:
'its ability not to be self-sealing, its tendency to permit progressively more effective testing of assumptions and progressively greater learning about one's effectiveness.' (Argyris & Schon, 1989).
Indeed it can be observed that reflective practice and model ii behaviour share two key principles. Firstly establishing open communication networks, where ideas are shared and practice is constructively challenged; and secondly emancipation of individuals (McCormack & Hopkins, 1995). Thus literature supports the view that guided reflection through clinical supervision should direct energy away from feelings of powerlessness and therefore alter practitioners' perceptions of their ability to negotiate the barriers, in the culture in which they work, to their clients' advantage.
Future research
Whether clinical supervision does actually alter health visitor's perceptions related to the barriers of user participation may be tested by an action research project. Rapoport (1970) highlights the dual nature of action research. Firstly it aims to contribute to the practical concerns of people in an immediate problematic situation. Secondly it attempts to contribute to the goals of social science by joint collaboration within a mutually acceptable framework. The aim being to improve practice and evaluate these developments concurrently. Indeed improvement and involvement seem central to all uses of the term (Robson, 1993). Carr & Kemmis (1986) assert that the key features of action research are:
'firstly the improvement of a practice of some kind; secondly, the improvement of the understanding of a practice by its practitioners; and thirdly, the improvement of the situation in which the practice takes place. Those involved in the practice being considered are to be involved in the action research process in all its aspects of planning, acting, observing and reflecting.' (Carr & Kemmis, 1986).
This democratic aspiration is important especially when working with an oppressed group such as nurses (Lovell, 1982; Street, 1992; Robson, 1993; Ford & Walsh, 1994). Lewin (1951) saw action research as a tool for bringing about democracy. Later action researchers see it more as an embodiment of democratic principles in research (Robson, 1993). Thus action research, in addition to changing practice and its theory generating potential may also act as liberating strategy by involving practitioners so that the conditions under which they work can be changed (Robson, 1993).
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