Essay: Using the 6Cs (MDT) in the management of Cerebral Palsy (CP)

The Francis Report was released in 2013. This report outlined failures by individuals, tiers of management and regulators in the Mid-Staffordshire NHS Foundation Trust. The Francis Report made 290 recommendations to prevent these failures in the future (Francis, 2013). One of these recommendations were that nurses, midwives and care staff, as well as stakeholders at national and organisational level, implement plans to support the delivery of the values and behaviours of the 6Cs defined as care, compassion, competence, communication, courage and commitment (Department of Health, 2012). The Department of Health (DOH) stated that the 6Cs were introduced to reinforce the enduring values and beliefs that underpin care wherever it takes place (DOH, 2012). It gives healthcare staff a consistent way to explain the values as professionals and hold themselves accountable for the care and services that they provide. The DOH aims to embed these values (6Cs) in all nursing, midwifery and caregiving settings throughout the NHS and social care in order to improve care for patients. The theory behind the 6Cs aims to instill the focus on putting the person being cared for at the heart of the care they are given. The 6CS enable healthcare professions to look at the patient holistically to promote individualised, seamless care for patient and family (DOH, 2013). This assignment will focus on how the 6Cs can be translated into practice in the Multidisciplinary Team (MDT) management of Cerebral Palsy (CP).
Cerebral palsy is a syndrome of motor impairment that is a result of a lesion in the developing brain (Sankar & Mundkur 2005). Glinac et al (2013) describes CP as a general term covering a number of neurological conditions that affect a child’s movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing foetal or infant brain. Patterns of movement disorders are commonly subdivided into spastic, dystonic and ataxic forms, depending on the area of the brain that is mainly affected (Nice Guidelines, 2014). Literature indicates that the relevance of CP is 2-2.5 cases per 100 born. (Rosen & Dickinson 1992).
Cerebral Palsy can be caused by infection in early pregnancy, a difficult or premature birth, bleeding in the baby brain or abnormal brain development in the baby. Cerebral Palsy can occur prenatal, perinatal and postnatal. As much as 75% – 80% of the cases are due to prenatal injury with less than 10% being due to significant birth trauma or asphyxia (MacLennan, 1999). Children with CP often have other related conditions or problems, including epilepsy, learning difficulties, incontinence, visual impairment, hearing impairment, difficulties speaking or understanding other people’s speech, delayed growth, curved spine and drooling (NHS, 2013).
Learning of a child’s diagnosis of disability has historically been known as a catalyst for parental crises (Hatton et al, 2003). A lot of parents react with shock and refuse to accept diagnosis which can lead to uncertainty and fear about the extent of the disability. Parents may find the acceptance of ill health to be onerous. The resulting anger at medical staff due to concerns of poor treatment can lead to difficulties in accepting abnormal motherhood and the inability to fulfil societal expectations of what is perceived as a healthy child. As a result, parents may feel isolated and unable to cope with the demands and expectations of a disabled child (Huang et al, 2010).
An MDT approach is essential to optimise the child’s development and learning to enable them to reach their potential (Kasser, 1999). At the time of diagnosis there are lots of members of the MDT involved with the intention of providing the best care and support to the individual possible. Nurses are present to help with medication management, physiotherapists to analyse movement and to help parents understand expected changes as well as teach parents and children how to maximise their function. Family members are crucial at the point of diagnosis as they need to communicate with healthcare professionals to make sure they have adequate information to support and bring up their child effectively. Finally, doctors are involved to conduct tests on the child to confirm their diagnosis of CP. (Miller et al, 2006). The purpose of this combination of professionals is to communicate efficiently, share their experiences and offer advice and guidance, particularly to those patients with complex needs (Kasser, 1999).
Communication from the MDT should be implemented at this stage in order to help the parents understand the disease process and how to deal with changes that may occur due to having a child with CP. A study by Reid found that parents were appreciative of health care professionals who showed respect toward their child, treated the child as a human being, communicated with them directly and built relationships (Reid et al, 2011). Communication between the MDT and the parents enables joint decisions concerning the care of the child. Compassion and an empathetic approach from health care professionals can be vital when dealing with parents struggling through this challenging period. Healthcare professionals should be aware of their roles and responsibilities in providing a crucial support network to those parents that are in the process of coming to terms with their child’s diagnosis. Commitment and courage are essential when approaching diagnosis, as healthcare professionals need to be able to inform those involved about the diagnosis in a way, which is professional and informative (NMC, 2008).
As the child develops and starts school, daily activities such as bathing and toileting may become more cumbersome. Some children may also still have problems with speech and language and may feel isolated. They may find it difficult to write (due to fluctuations in tone). Children with severe motor disabilities may experience a sense of loss at their inability to mix with other children and may withdraw and act out (Miller et al, 2006).
Miller drew upon the difficulty, faced by parents, of choosing the right school for a child with CP (Miller et al, 2006). Parents will be required to make an educated decision of which school is more appropriate: mainstream or a special school for complex needs. Holt described how one of the main concerns for parents should be whether the school can meet the child’s educational and care needs (Holt, 2010). Nadeau & Tessier (2006) demonstrated that children with CP in mainstream classes had fewer reciprocated friendships, exhibited fewer sociable/leadership behaviours, and were more isolated and victimised by their peers than their classmates without a disability. In addition, Gaskin, (2012) stated that children experienced feelings of inferiority and indifference when placed in mainstream school, which made it difficult for them to create and maintain friendships. Gaskin also stated that social exclusion was seen in the form of play, when people with CP were put in mainstream schools, as their disability limited their ability to do the majority of tasks.
School nurses will play a key role in supporting children with CP in schools. The child needs to be comfortable with the nurse to enable them to raise concerns or issues and in exchange empower the nurse to resolve those issues. Educational staff are also important at this stage of the enabling process. The child will be required to overcome physical and environmental barriers, learning difficulties and sometimes bullying from other students and it is crucial that educational staff are able to facilitate and aid this development. Having effective communication between the school nurse and educational staff will contribute to making the child feel safe and more comfortable in their environment (Holt, 2010). Commitment by the MDT, of which the above contributors are a part of, to find the most effective way to help the child whilst at school is critical at this point. For example, the Nursing and Midwifery Council (NMC) describes the need for courage, to be shown by the MDT, to speak up when there are concerns about the standard of care for the child (NMC, 2008).
Mahon and Cusack described the importance of physiotherapists in training teachers to manage children with disabilities (Mahon & Cusack, 2002). In addition, occupational therapists are needed for support and advice on equipment, play and adaptions, speech and language needs as well as therapists for guidance on eating and communication. Orthapedic surgeons help the child with problems with bones, muscles, tendons, nerves or joints (Ganjwala, 2011). Social support, or the extent to which a person receives assistance and help from others, is one of the most common resources used by families to counteract the demands of looking after a child with a disability (Polita & Tacla, 2014). Family support groups can also help the child increase self-esteem (Miller et al, 2006). The importance of social and clinical care during childhood, and into young adulthood, is on facilitating function and inclusion, minimising activity limitation and enabling individual participation (Nice Guidelines, 2014).
Challenges caused by CP are not limited to childhood and, in fact, challeneges in adulthood are unavoidable. Adults with CP are inclined to participate in activity, physical therapy and fitness programs less so. Loss of strength and contractures, overuse syndromes, chronic pain, fatigue, osteoarthritis and osteoporosis are also prevalent in the adult CP population and are common factors in the loss of mobility, self-care, and daily performance over time (Gage et al, 2009). Adults with CP ordinarily participate less in social interactions, employment, marriage, and independent living according to Liptak, (2008). Reddihough et al, (2013) indicated that those with CP have lower educational level, higher unemployment, are more likely to be living with parents, be single, and have limited financial resources.
In several studies, a discontinuity of care was reported when young adults with physical disabilities entered adulthood and a diminished contact with health care was reported after leaving school (Beecham et al, 2001; Sy et al, 2003). Therefore it is crucial for the MDT to be involved in the transition from childhood to adulthood. Health care professionals involved in adult services should involve; rehabilitation physicians, orthopedists and physiotherapists with the goal of helping the adult maintain mobility and independence or become involved in leisure activities or sports. Social services, occupational therapists are required to enhance independence when it comes to daily activities, psychologists are important in helping patients to cope with special stresses and the demands of CP. It is the opinion of Nieuwenhuijsen et al, (2008) that all of the above, in addition to, speech and language therapists, neurologists and dieticians should be involved in the MDT support network.
Communication is needed in the transition phase from childhood/adolescence to adulthood. Communication, between paediatricians to the adult-oriented health care services, need to be efficient and sufficient enough to support the person during this transition (NMC, 2008). Families reported that a large void occurred following discharge from the paediatrician’s care, creating a sense of diminished support and increased burden of care on the family according to Young et al, (2009). Communication between the General Practitioner and the patient with CP is also vital to enable the provision of support, help and advice. Commitment is needed from the MDT to help the family through this transition period and to offer advice on such things as where to go for further assistance. Care should be employed during adult life to enable the patient to achieve their potential in respect of employment, societal expectations, independence, maximising their wellbeing and improving their health outcomes (NMC, 2008).
The ability to consent to changes throughout the life of a person with CP can differ throughout the different stages of their life. In accordance with a directive from the DOH, (2009) it was decided that in order to gain valid consent, a patient must be capable of making the decision, been provided adequate information and not be under the duress of any other individual. Children under sixteen may be competent to give valid consent to a particular intervention if they have sufficient understanding and intelligence to enable them to understand fully what is proposed, this is known as Gillick competence (DOH, 2009). This transitional period reflects the child’s increasing development to maturity. If a child under the age of sixteen lacks the capacity to consent, consent can be given on their behalf, by any one person with parental responsibility or by the court (The DOH, 2009). For patients to have the capacity to make decisions, they must be able to; comprehend and retain information to the decision, especially consequences of having or not having the intervention and use and weigh this information in the decision making process (The DOH, 2001).
If the patient reaches sixteen, they are presumed in the law to be competent to give consent for themselves. If a child of sixteen or seventeen is incompetent to make a particular decision, then a person with parental responsibility can make that decision on their behalf, although the child should still be involved as much as possible in the decision making process as laid out by The DOH, (2009). However, once children reach the age of eighteen, no-one else can make decisions on their behalf. If an eighteen year-old patient is judged to be incompetent to make their own informed decisions, clinicians can provide treatment and care that is in their best interests (DOH, 2009).
The 6Cs were introduced to reinforce the enduring values and beliefs that underpin care wherever it takes place. It is essential that the 6Cs are firmly embedded into the culture and foundations of any healthcare professionals or indeed any person that is involved in the Multidisciplinary team and support network. In doing so this will enable the best care for individuals with CP. The MDT must communicate effectively, be decisive and courageous in their decisions and offer informative and honest advice to families involved in the car of any child or adult suffering from the disease. It is this combination of people and beliefs that will ultimately enable the correct care, compassion, commitment, competence, communication and courage to be implemented at every stage of life for a person with CP. This will in turn ensure that the patient is given the best quality of care, support, advice and guidance to facilitate them to achieve their full potential throughout their lifetime from beginning to end.