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Models of Healthcare Delivery in Mental Health Nursing

Several different models of healthcare delivery in mental health nursing exist with respect to etiology, treatment and recovery. Medical health nursing however seems to be constrained by the medical model (or biomedical) used, that dominates the nursing practice. Psychosocial (and biopsychosocial) models were developed, however challenges exist in its implementation (Carlyle, Crowe and Deering 2011). I will argue in my essay, that the biopsychosocial model provides an efficient tool, to enhance our understanding of healthcare delivery. This model is both a “philosophy of clinical care” and a “practical clinical guide” (Borrell-Carrio, Suchman and Epstein 2004). In my essay I shall compare the biopsychosocial model with medical (or biomedical) model, using reviews from other studies; I shall try to further my argument, supporting the efficiency of biopsychosocial model over medical model.

Mental Health issues cover a wide variety of conditions like Depression, Anxiety, Phobia, Eating Disorders, Schizophrenia, Obsessive Compulsive Disorders, Personality Disorders and Bipolar Disorder. Such disorders commonly characterized by difficult feelings or behaviors like Panic Attack, Self Harming, Psychosis, Suicidal Tendencies and Paranoia. These conditions can be caused due to different factors like history of abuse, trauma or neglect; social isolation; loneliness; discrimination and stigmatization; poverty, debt or social disadvantage; long term stress; long term physical condition; unemployment and economic condition; homelessness; poor housing; drug or alcohol use; domestic violence; trauma; physical or physiological issues like injury, neurological condition. All such factors ultimately lead to variations in the brain chemistry, like the balance between serotonin and dopamine in the brain ( 2017). To me, it shows a clear relation between the multiple causalities of mental health issues, and why care for mental health should include psychological as well as social factors apart from the medical or biomedical factors. The role of Mental Health Nurse is to promote and support recovery of individuals suffering from mental health conditions, and facilitate an increased involvement and control upon their condition, and support them in leading a meaningful and healthy life, involving working closely with the patients, building relationships with them and their caregivers in order to improve the quality of care. It also involves identification of risks for the patients or to other due to the patient, as well as the legal contexts of care (Health Careers 2017). With such considerations in mind, I believe is rational justification why the biopsychosocial model should be further studied to facilitate better delivery of care for mental health patients.

Challenges in Implementing Psychosocial Models

Biopsychosocial (BPS) theory was developed by George Engel in 1977, and considers that variables like sociocultural, psychological and physiological factors effects health and diseases (Wideman et al. 2013). It was developed to address the “reductionist” and “holistic” approach of biomedical model, which was based on an understanding of general systems. Engel’s approach was to promote well being by promoting happiness at social, psychological and biological levels, an approach that is adhered to by the World Health Organization (Psychology Today 2017). The development of the BPS was fuelled by a drastic increase in the number of diagnosis for psychological disorders which had traumatizing and very strict routines for treatment.

The Biomedical model was developed early in the nineteenth century, and considers diseases to be solely due to cellular dysfunction, and considered health as a complete absence of dysfunction, pain or disease. This model developed when diseases caused by microbes were more prevalent and serious health concern, and mental health was still poorly understood domain. The model has its origins in the Doctrines of Species Etiology, supported by the studies of Robert Koch and Louis Pasteur, who found that disease are caused due to lesions (physiological or biochemical). This led to the belief that absence of lesions or adverse symptoms can be considered to be healthy, while unhealthy persons would consequently have lesions or adverse symptoms. This essentially differentiated health and disease based solely on the absence or presence of adverse symptoms or lesions. However, current scientific knowledge does not support such assumption any longer (Deep 1999).

Engel believed that clinicians need to attend the psychological and social needs of the patient, apart from the biological ones, to be able to alleviate the suffering of the patient. His method provides a holistic approach in healthcare (Borrell-Carrio, Suchman and Epstein 2004). Instead of considering just the biological component of the disease, it considers psychological and social components of it. The Biological component is related to the body’s functioning (at molecular, cellular, tissue or systemic levels), the psychological component is related to behavioral link to health problems, while social components is related to the effects of culture, socioeconomic status, beliefs and religion. Such levels of components exist as a hierarchy (Psychology Today 2017).

The development of mental health nursing was made possible due to several advancements made in psychology, social learning theories and cognitive behaviour theory. These theories provided valuable insight into how might a complex interplay between biological, social and environmental factors influence the mental health of an individual, and how the mental health in turn can influence the social cognition. I shall try to briefly discuss some of the important theories that helped in the development of mental health nursing.

Variations in the Brain Chemistry and Mental Health Issues

The Social Representations theory approaches health from the context of psychosocial interactions. The concept was introduced by Miscovici, and is used in health studies. This theory suggests that social representations represents the contents of the thought process and ideas that helps us make sense of our beliefs and ideologies that are created spontaneously, and helps us to classify objects and persons or explain behaviour (Moscovici 1982; Moscovici 2001) . This can be helpful to explain mental health issues going beyond the bio-medical model. Social representations additionally are modified by continued social interactions, as are they modified by the representations themselves, providing a two way interaction between these factors.

The social component in mental healthcare started with the development of models f learning. Theory of Social Learning proposed by Miller and Dollard (1941), which was further developed by Bandura (1963) by the inclusion of observational learning, and reinforcement. Social Cognitive theory considers the cognitive, behavioral and emotional aspects to explain change, involving psychology into the domain (Bandura 1969). The theory explains how behavioral patterns are maintained or acquired, and how they can be intervened. It includes factors like environment, behaviour and and people. The Environment can be social like family, friends or social circle or physical like location, while the behaviour refers to how a person reacts or behaves to situation and people component is the unit of the social factor like territory, privacy and personal space or crowding (Altman 1975).

Utilizing such theoretical framework, the Cognitive Behavioral Theory was developed to help the cognitive performance of the individuals. The therapy essentially considers the interconnectedness between actions, thoughts, physical sensations and feelings to explain action causalities (Kennerley Kirk and Westbrook 2016). This therapy model combines both psychotherapy and behavioral therapy, and was developed by Aaron Beck (1970). The theory implies that negative thoughts and not the events causes grief or anxiety, that is, we are more influenced mentally by the meanings we ascertain to objects or events more than the objects or events they. For example, having a negative outlook towards certain event can increase anxiety towards it, and cause avoidance to it, while having a positive perspective towards the same will not cause aversion to that event. This negative outlook can be a product of dysfunctional assumptions, and can lead to incorrect judgment. The Cognitive Behavioral Therapy is aimed to help people understand how the cognitive bias can influence the thought and action of the individual, and therefore alter the perception of it, helping to rectify the misinterpretations of situations, helping self efficacy or exercise emotional control over pain apart from increasing mindfulness of patients (Schwarzer 2014; Bushnell et al. 2013; Davis et al. 2015; Velden et al. 2015)

Role of Mental Health Nurse and the Need for Biopsychosocial Approach

Orem’s “Self Care” theory is based on ideas  like individuals should be self reliant and responsible for the care of themselves and members of the family, who needs caring; people are individuals; nursing as a practice is an interaction between two people (the caregiver/nurse and the patient); primary healthcare involves addressing the overall and developmental needs; knowledge about health issues is necessary for their treatment and intervention; self care can be learnt within sociocultural context ( 2017). This theory has 3 related components: Theory of Self Care, Theory of Self Care Deficit, and Theory of Nursing System ( 2017). The theory was developed by Dorothea Orem (1959-2001) that can be used in nursing practice. It identifies self care as the activities initiated and performed by the individual for their own selves to maintain well being. The theory assumes the following points- (i) Humans continually communicate and connect among themselves and the environment to stay alive and functional. (ii) Deliberate acts allow identification of the needs and make judgments based on them. (iii) Actions that are self sustained and regulate functions allow privations of self care (iv) Input to self as well as others are being discovered, developed and transferred via human agencies. (v) Care for members of a group is mediated through groups with a structured relationship and ranks that helps in the distribution of the responsibilities of care (Denyes, Orem and Bekel 2001). The Concepts involved in the theory are: Nursing (as a profession), Humans (the objects of care), Environment (physical, biological and social), Health (structural and functional well being), Self Care (activities performed by the individuals for their own selves), Self Care Agency (factors that facilitate self care), Conditioning Factors (gender, age, health status, developmental status, sociocultural status, family system, lifestyle, and accessibility and availability of resources) Self Care Demand (Sum of self care activities needed to meet the requisites of self care), Self Care Deficit (when an individual is unable to or incapable of conducting self care activities), Nursing Agency (an organization that provides education and training for nurse that enables them to perform the acts to meet the self care demand of the patients), Nursing System (a product of the nursing practice, involving the nurse and the patient). The requisites of self care, outlined in the theory are: maintenance of sufficient intake or air, water and food; care for elimination or excremental processes; balance between physical activity and rest as well as between social interaction and isolation; preventing hazards to the mental, physical and psychological wellbeing; promoting human development and normalcy. This shows how the self care theory amalgamates the bio-psycho-social elements into the concept of healthcare, for treatment, rehabilitation and recovery of patients.

Biopsychosocial Model Compared to Medical (Biomedical) Model

The Francis Enquiry Report (Feb 2013) was published to examine the cause of failure in care at the Mid Staffordshire NHS Foundation between 2005 and 2009. Certain recommendations were made by the report which includes the involvement of candor, transparency and openness as fundamental for healthcare systems, as well as an improvement of support by compassionate and committed care and strong leadership ( 2017). The 290 recommendations and proposals outlined by the report has been incorporated into the standard nursing practice by the Nursing and Midwifery Council (NMC), with provisions for further improvements in the delivery of healthcare ( 2017). The enquiry was initiated in response to the death of hundreds of hospital patients in Mid Staffordshire, due to a lack of care by the staff in two hospitals. This occurred due to the irresponsibility of the hospital trust, and thereby causing the patients to be neglected, and even administered wrong medications. The responsibility of patient care instead fell upon the junior, inexperienced staff, and critical equipments for patients’ care were not utilized for lack of knowledge in their operation and usage. The patents were left completely unattended, and neglected of their needs. They would be often thirsty and starving, some even drinking dirty waters from the flower vases and the bedclothes never changed. In the span of 139 days of enquiry, several witnesses provided harrowing accounts of how severely the needs of the patients were ignored by the staff, making hospitals a very dangerous place for the patients. By 2009, about 1200 patients have already died. In the elderly wards, the patients were also in the similar plight, not receiving medication, and many in severe pain. Pleads from the family of the patients went unacknowledged and unanswered as well. Callous mistakes like errors in cataloguing, led to the death of four members from a single family in the span of less than 2 years. The public enquiry by Andrew Lansley (2010) suggested that fines and even closure is warranted for covering up of medical errors and poor treatment by the hospitals, and they should be persecuted for such actions. It was considered that the shift of focus of the hospital trust occurred as a measure to cut expenses to acquire the “foundation status”. This led to understaffing at the hospitals, and existing staff risked getting fired by failing to meet their business requirements. This further caused the nurses and doctors to abandon patients who were seriously ill or needed long term care, instead focusing mostly on the emergency patients. A target to discharge emergency patients in 4 hours also lead to those patients being rolled out before recovery, or even without complete treatment. The increased pressure on the staff, due to the threat of unemployment also meant an increased number of errors, especially during the paperwork’s (Reporters, T 2013). This event clearly highlights the importance of a holistic care for the patient, and how proper healthcare practice should be considered an ethic, while malpractices and neglect of patients be shunned, especially considering the trauma and suffering that is caused to the patients as well as their family.

Development and Working of Biopsychosocial Model

I believe that the recovery model of mental health issues is an invaluable tool for healthcare delivery. Recovery from mental illness usually means getting back control over their lives, and not getting back to the previous dysfunctional state. This model puts focus on the resilience and control over the problems of the patient rather than just on the symptoms of mental health issue (Ramon, Healy and Renouf 2007). This approach suggests that support be given to patients to overcome and build resiliency towards the challenges posed by mental health issues, and to overcome distress. Studies suggest that model based on self- management is more effective compared to models based on just physical health (Davidson 2005). Due to this recovery is being increasingly incorporated in the delivery of healthcare in mental health services as well as in psychiatric studies (Ramon, Healy and Renouf 2007). I believe an effective approach towards the delivery of care for mental health patients should include the biological, psychological and social aspects of treatment and recovery. Several studies have shown that environment has a significant impact on mental health. The impact of work and unemployment, having negative mental impact was studied by Warr (1987), and supported by other studies that showed links to mental health issues and suicide rates (Strandh et al. 2014; Milner, Page and Lamontagne 2014). Cacioppo (2014) also pointed out that isolation can have toxic effects on mental health. Isolation can be caused due to social stigmatization, or poor cognitive development, or social awkwardness as argued by Cornwell and Waite (2009). I think that rehabilitation or recovery measures needs to target this aspect of mental health and cognition. Supporting the patients to develop skills to acquire a job, can help them to be self confident, and can improve their cognitive performance. Similarly, support given to develop social cognition through rehabilitation and training, can help them to become more social, and develop a friends circle. This can prevent a sense of isolation or at least reduce the extent of such feeling. Incorporating the Orem’s Theory, I can also suggest that rehabilitation process needs to incorporate in the patient a sense of independence by developing the ability to self care. The intervention/rehabilitation/recovery model can include a hierarchical approach of bio-psycho-social model, placing the biological needs at the centre, followed by the psychological and the social needs, and providing support in that order. Additionally, helping the patients to build up resiliency to the disease, overcome the challenges of mental health issues, supporting them in leading a meaningful life, can be a much better and more efficient method of care delivery, compared to models that focuses solely on a single aspect of health (Tompson et al. 2015; Fortinash and Worret 2014). Furthermore, delivery methods, keeping in mind the centrality of patient’s experience is invaluable and vital in the providence of their care. This supports my argument that biopsychosocial model, that considers multiple levels of causatives and controllers of mental well being, and based on theories of social cognition, and recovery, is an effective learning and healthcare delivery tool (Townsend and Morgan 2017).

Importance of Social Representations and Learning Theories in Mental Health Nursing

The process of recovery itself is a journey, rather than a destination (Jacob 2015). This means that recovery is a continuous process that builds and develops over time, drawing closer to an increased well being of an individual. The same goes for moth mental and physical health and both entail time and effort for recovery. Physical recovery can be achieved by the healing of the dysfunctions or damages of the disease while mental recovery can be achieved by getting back control of the mental faculties (Petersen et al. 2016). Successful and efficient practice in mental health nursing can be achieved by incorporating the different aspects that have been highlighted by the biopsychosocial model, Orem’s Theory, and the recovery model. Over the period of medical and healthcare history, a shift of focus have occurred from an approach where health and disease were considered based on the absence or presence of adverse symptoms, and provided a very “holistic” and “reductionist” approach in care of patients. However, such an approach proved to be a constraint towards the nursing practices, that kept the experiences of the patients at the centre of care, especially so, in case of mental health nursing, where assertion to the presence of adverse symptoms is not always evident. The bio-medical approach failed to acknowledge how physical and social / psychosocial environment influenced the mental health, and behaviour, and how individual behaviour in turn affects the physical and social or psychosocial environment around them. As evidenced by different studies that experiences shapes the development of the brain, and past experiences can be linked with mental dysfunction (Tnabet et al. 2016; Sexton et al. 2015; Panter?Brick et al. 2015). It can be inferred that consideration of these factors in addition to the biological or physiological basis of health was needed to develop the profession. Furthermore the South Staff scandal and ensuing Francis report showed how mistreatment, medical errors, and neglect of patients caused due to poor practice standards can cause suffering and death. To avoid such incidents from reoccurring stricter policies were undertaken.


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