If case managers diversified into producing cars, they would be hand crafted in the hue of client choice. This is because of the widely accepted guiding principle that we as rehabilitation professionals and case managers are client centred in our work.
Working in the medico-legal setting can be a key factor in enabling the case manager to be client centred. I recall how excited I was by the scope of the role as a new brain injury case manager.
The opportunity to be effective, creative and flexible in client work was a welcome change from the restraints of statutory eligibility criteria and limited service provision that characterised my previous role.
However, 17 years later, it is interesting to consider the potential challenges and conflicts for the client centred case manager when working with brain injured clients in this context.
The principle of personal injury law is to return an injured party, in so far as possible, to the position they would have been in, but for the injury. To that end, brain injury case managers are often instructed by the claimant’s lawyer to set up and manage a support package, or co-ordinate an interdisciplinary rehabilitation team.
Our instructions and role vary, but our clients are often significantly cognitively impaired, have various neurobehavioral difficulties and may have some neurophysical impairments.
In the medico-legal context, it is very helpfully established that the practitioner case manager’s duty is to the client. This was set out in a Court of Appeal ruling (Wright V Sullivan, 2005), with Lord Justice Brooke stating that the relationship between the case manager and the claimant had to be therapeutic.
Also, the case manager should owe his duties to the patient alone. He must win the patient’s trust and, if possible, his co-operation.
While it may be in the patient’s interest that he should receive a flow of suggestions from any other experts who had been instructed in the case, the case manager must ultimately make decisions in the best interests of the patient and not be beholden to different masters.
Clearly our duty, therefore, is to be client centred. In practice, however, even the most dutifully client centred case managers can face various conflicts and pressures.
Conflict one: Timescales
The first principles of case management are to establish and maintain a positive working relationship with your client. Some clients and their families may throw the door open, delighted to have someone to help them get their show back on the road.
However, you may find that with other clients, getting past the front door is a major achievement in itself. Your client may have reduced insight into their injury and limited motivation to explore sources of support or rehabilitation.
They may have neuropsychological or psychiatric issues that present barriers to engagement. They may have a very limited ability to understand the purpose of litigation or accept the need for a case manager.
On occasions such as these, the case manager is required to put all other issues to one side and go back to the basics of finding some common ground to engage the client.
I have used various methods for this, taking cues from anything in the house, from talking about football, taking dogs for walks or in-depth discussions on the merits of various albums.
If you can engage the client in discussion, you can work on developing rapport. Rapport enables you to listen to what’s going on in their life, what’s important to them and what is it that they would like to change or achieve.
This process can take a long time to get to a place where your client trusts that you ‘get them’ and are really listening to what life is like for them, without judgement.
Once you have established that you are working in partnership, only then can you begin the process of trying to move forward to where they want to be.
The establishment of a trusting partnership is a vital part of the client centred approach.
All of which is fine, as long as you have an experienced, patient-instructing lawyer that understands the nature of working with your brain injured client and is prepared to accept your identified timescales.
Lawyers fight hard to gain interim payments to fund case management, care and rehabilitation.
Getting these frameworks in place in a timely manner and collecting the evidence to demonstrate an established need for the purposes of the case, may be their priorities according to their case strategy.
Some case managers may find themselves working with lawyers (either on the claimant or defendant side) who don’t fully understand the client’s brain injury and barriers to engagement.
There may be pressure for speedy outcomes and the case manager may feel required to progress apace.
The case manager here faces a conflict and the only client centred solution is to stand firm and explain the rationale. In order to ultimately achieve anything, the case manager has to persevere with the challenging process of building up a trusting partnership at the client’s pace, and not at the lawyer’s.
Although I refer here to the initial process of building up the relationship, the same principle applies to maintaining it.
You establish your working relationship at your client’s pace, and then you maintain it by moving two steps forward, one back, (or even sideways) then forward again, with the case manager gently pushing the dynamic to achieve jointly agreed goals.
Good documentation is crucial in evidencing the input hours involved in supporting clients to achieve their goals and will ultimately be very helpful to the experts. It must also be said that it is essential for the brain injury case manager to have suitable skills and experience to facilitate and maintain engagement.
Another timescale issue is that of medico-legal expert assessments. Timescales for expert reports are determined by the courts, and the constraints of busy experts’ diaries, rather than clients.
This can be a problem for clients who are trying to engage in a structured programme of support/rehabilitation that periodically is interrupted to accommodate lengthy expert assessments, sometimes at home, sometimes at clinics in different parts of the country.
Visits often appear to occur in phases when several assessments happen in a relatively short time.
Clients may not always understand the relevance of the assessment and require persuasion to attend, with the case manager often asked to accompany them.
The appointments themselves can be illuminating for clients and their families, but on occasion can also be very distressing and trigger unhelpful changes in behaviour or negatively impact fatigue and engagement.
This necessary part of the process of litigation should be dealt with as sensitively and practically as possible, and often requires significant support from the case manager.
Client centred case managers must advocate firmly for their client, be the voice of reason and consistently seek to work with lawyers to make expert assessment schedules as painless and non-disruptive as possible for the client.
Conflict two: Goals and opinions
In terms of defining goals, everyone has an opinion. The client may feel strongly about what support they do or don’t require, what activity will benefit them and what they actually want to achieve.
There are also opinions expressed by the family and everyone else involved in their care or rehabilitation. Finally, there is the medico-legal expert opinion.
On Case Manager Cloud Nine, all opinions of what the client needs happily coincide with that which they identify themselves.
However, back on Earth, reality dictates that more often than not, opinions are divided. The expert is a key person in litigation and their opinion evidence is essential in the acquisition of interim funds and eventual damages.
Experts make recommendations about the client’s long term needs for the purposes of putting together a schedule of damages, ultimately for the court’s consideration.
Their support of the existing input at the time of assessment is important to the case and ongoing funding. There is therefore some pressure on the case manager to implement services along the line of their recommendations.
However, what the experts recommend may be quite some distance from what the client actually wants to do.
Often the case manager also believes the course of action recommended by the expert would be beneficial to the client, and may have been trying to engage the client in exploring this option for some time.
Capacity issues are outside the scope of this article but addressing client capacity and best interests is very relevant to the ongoing work of the case manager.
Common scenarios are where a medical expert reports that the client requires intervention, such as residential rehabilitation, which is rejected outright by the client, or a care expert recommends a level of support that is more than the client is prepared to accept or can tolerate at that time.
Another difficulty can occur when the expert opinion sets out the timescales in which they expect to see specific outcomes, which may not always coincide with the timescale the client is working to.
The case manager may feel conflicted when faced with expert expectations and recommendations which are rejected by the client; a dilemma for the case manager who is trying to keep the client at the centre of their practice.
The case manager may agree with the expert opinion but are unable to progress it because the client rejects it. They know that support from the expert is important to their ongoing input and possibly their continued funding.
They may also be painfully aware of court cases where case managers have publicly come under criticism for not following the recommendations of experts.
In working with the client on these issues, the case manager has to manage client engagement, welfare, capacity, risk issues and family needs in negotiating a realistic way forward that is acceptable to the client and in their best interests.
The way forward frequently starts off looking like one path, changes over time, and is not always as mapped out by the expert.
Experienced case managers understand the medico-legal context and also the function of the expert, whose duty is to the court. The case manager may also find it reassuring to remember that the opinions of experts are often hotly contested by opposing experts on the same case.
Fundamentally, the case manager deals with this pressure by remembering that their own duty is to the client.
When an expert or treating professional recommends a course of action that the client is unwilling to engage in, the case manager should present options to the client, explore and encourage potential ways forward, and address capacity and risk issues.
Their role is to try to enable (via rehabilitation or support) the client to pursue their goals as far as is possible within the boundaries of funds, safeguarding and the law. The golden rule is to document what you have done, including barriers to pursuing various recommended options, and the expert can review the evidence available to them.
Conflict three: Evidence and relationships
As discussed, a positive relationship between the client and the case manager is essential for client centred practice.
However, a further challenge created by the medico-legal setting is the disclosure of evidence whereby case management records are open to scrutiny by legal teams and experts, and potentially the client or their litigation friend (often a family member).
Although intrinsic to the medico-legal process, it can cause difficulties for the case manager. Case management documentation often includes analysis of potentially contentious issues, and may refer to difficult family dynamics or other sensitive issues that are relevant to intervention.
Disclosure of this information can affect the quality of the relationship between case manager and client or their family. You may feel conflicted by the knowledge that revealing tricky issues may have a substantial impact on your relationship and be faced with the dilemma of what to record.
Another issue caused by disclosure is that the client who is cognisant of the fact that notes are disclosed may choose not to share issues with you, which may also hinder a meaningful relationship. It is relevant to note that your role is ‘Witness of Fact’.
It’s helpful for the court and experts to know the situation on the ground, however difficult for the client or family to read, in order to make accurate assessments and recommendations to meet long term needs.
It’s essential to work closely with the lawyer to address this issue and deal with disclosed information as sensitively as possible, and with reference to the client’s best interests. Case managers need to be prepared for this situation, and how to deal with it through supervision.
Many lawyers offer excellent training on recording and disclosure of evidence. In summary, although the medico-legal context provides the opportunity to work in a client centred way, case managers also have various issues to navigate in order to remain truly client centred.
It is important that we hold on to the fact that our duty is to the client, if faced with conflicts or challenges, and seek supervision in dealing with them.
‘Don’t be alone, don’t be too proud to reach out for help’
After Vasili Kalisperas was born a healthy baby, his jaundice was left undetected by midwives and led to him being left with cerebral palsy and needing round-the-clock care. Here, his mum Elena discusses the huge mental health challenges of being a parent in such a position and how she learned to admit it’s OK not to be OK
I’ve always been a very optimistic and positive person, which I do think helps during such traumatic times, but that’s definitely not to say it hasn’t been a struggle. As equipped as you might be in terms of your outlook on life to deal with challenges, when something so traumatic happens to you, it is of course going to be a struggle to come to terms with that.
No-one tells you how to cope, you can never prepare yourself for something like this. There is no right or wrong way to do things and you can only get through it as best you can.
My husband and I dealt with things so differently in the early days. He found comfort in talking about what had happened to Vasili, by sharing a lot of information on social media, whereas for me I was more introvert, I didn’t want to do that.
I was diagnosed with PTSD, which stemmed from the fact our situation was so completely preventable. I became fixated with Vasili still being in the womb, when things were still fine, and I so desperately wanted to find a way to turn back time. I had a water birth with Vasili, and every time I had a bath I’d be in there for hours crying, reliving the whole experience of giving birth to him, feeling the exact pains I felt.
My husband made sure I was cared for and was OK, but finding help was hard. I did try and get medical help but the waiting list was huge. I waited for over a year to see a therapist but I didn’t find it helpful – she wasn’t trained in my needs and was a general counsellor, so I didn’t get anywhere. I was then referred somewhere else, but that was in the same place I had my check ups when I was expecting Vasili, and that in itself was too traumatic.
After being bounced around for a couple of years, eventually, I went privately and found an amazing therapist. It does take a huge amount of time and energy to relive the experience, but I found that opening up and talking about how I felt was so important. I also discovered EMDR therapy through these sessions, which was fantastic and really helped me so much. I realised how far I had come through taking that decision to open up and look for support.
If you have a support network around you, then that can be vital in times of trauma. Even if friends don’t know quite what to say, the fact that they’ll listen can be so valuable. My mum and sister were always there, anytime I needed anything. There were times when no-one could say the right thing, no-one could fix what had happened, but just being able to talk and cry and share what I was going through helped me so much. You need to allow yourself time to grieve, as it really is a grieving process.
In society, while things have thankfully changed massively in recent years, there is still a feeling for many people that showing emotions is a sign of weakness. There is still a stigma in admitting you’re struggling with your mental health, but I see that it’s like your physical health – you’re never going to breeze through life without any problems at all, it’s going to happen to us all at some point. No-one should ever be afraid to admit they’re struggling and they need support.
Lockdown has been difficult for us all, and seeing the impact on the children and my oldest daughter in particular, has been awful. She is in high school and not being able to leave the house has had a big impact on her mental health. But as a family, we share our feelings and talk about it, and I teach my children the importance of positivity and an optimistic outlook to help them cope with challenges.
In learning to deal with what you face and move on with your life, you need to accept it and forgive yourself by recognising it isn’t your fault. It has been a long journey for me – Vasili will be nine in May – but we’ve made so much progress.
While Vasili and our other children are of course our priority, I’ve learnt the importance of making time for self love and care. Without making time for that, you’ll run yourself into the ground. For the last two-and-a-half years, the children have been at school every day, which has meant I’ve had time to take control of my mental and physical health. I started doing daily exercise, which began by making sure I got out to walk every day, and I now regularly go to the gym. It’s a big release for me.
I’ve also reached a place where I’m able to look to the future and I’ve started my own business as a hairdresser, working from home in a salon we’ve created in an outbuilding. Being a hairdresser gives me a chance to help other people to open up and discuss anything that’s on their mind, which for many people may be the only chance they have to do that. And also, I’m training to be a personal trainer – I’m already a mental health first aider, and I’ve seen for myself the impact that exercise can have during the most trying times, so I think the combination of mental and physical wellbeing support is so important and I’d love to help people with those.
For me, in being able to find acceptance of our situation, I’ve been able to move on and find time for myself and what I want to do with my life. I’ve definitely found my purpose, both as a mum and as a woman, and I’m in a much better place now. But without having the strength to open up, to reach out and admit I needed some help, I don’t think I’d have reached this point in my journey.
The one thing I’d say to people who are struggling, whatever their situation or circumstances, is to talk. Don’t be alone, don’t be too proud, and reach out to someone. I’m so pleased I did.
‘I’m a rehab professional attempting to rehab myself’
Having contracted COVID-19, which has now become Long COVID, assistant neuropsychologist Alarna continues to battle a number of effects, including fatigue. Here, she shares her reflections on her experience, which has enabled her to gain a greater understanding of her patients’ wish to return to their ‘normal selves’
My name is Alarna, and I am an assistant neuropsychologist at a specialist private neuro rehab hospital. I have worked in both supported living and rehabilitation settings for the past 14 years, with various mental health conditions, psychologically rooted illnesses, degenerative diseases, and rare neurological presentations.
Today in discussion with our company director responding to the question of “How are you?” I found that I had reached a new level of understanding for every patient that I had worked with. I found on some level I could identify with their journey as I am attempting to rehab myself. I answered, “I just want to get back to my normal self”.
In December 2020, I tested positive for the coronavirus and was severely unwell for a period of 2-3 weeks. I initially was unaware that what I was experiencing was anything other than being run down or having a common cold. It was not until day four when I woke up feeling as though someone was sitting on my chest, each time I moved I had to take shallow rapid breaths to remain upright and when I coughed it felt as though I was being punched with weighted gloves from all angles.
This was unlike anything I had experienced in my life. Being someone who would be over a cold within 3-4 days (and very ironically did not know how to properly rest) the situation was entirely foreign to me.
Having thankfully recovered some weeks later I began to find myself falling asleep involuntarily every 2-3 hours, I was still breathless on exertion (from walking up a flight of stairs to carrying a handbag) and generally feeling weak. After seeking advice from NHS 111 I was reassured that this was to be expected following a virus and should subside in a week or so.
Throughout this period, I had regular contact with my supervisors at work who were (and still are) extremely supportive, reassuring, and understanding. It was not until several weeks later that we discussed an action plan to help me ease my way back in to work.
This brings me back to today, four months after having COVID-19 and still suffering with chronic fatigue, occasional breathlessness, and migraines. I am unable to complete a full day at work and once I get home at approximately 3:30pm I have no choice but to stop everything and sleep.
Just a key point I would like to throw in here. Fatigue is not the same as being tired!!
I have been burnt out before, I have been exhausted, and I have been tired, but this unexplainable experience is not like any of the aforementioned. It is like an involuntary shut down. People who mean well advise me to just rest or sleep more not realising that I am sleeping up to 14 hours most days and still waking up feeling exhausted.
In my attempts to help the process along I have completely changed my diet, dropped 20lbs of excess fat, complied with resting when my body tells me to, and my energy levels remain poor. Some days it feels as though my speech is unnaturally slow and slurry, though when asking my colleagues, it is not so for the listener. In summary I cannot function without having a 2–3-hour nap in the early afternoon as well as a full night of sleep.
Though there are so many unknowns with this virus, from my experience I have learnt the following:
– The importance of self-care and rest. Sometimes in the busyness of life what we think we are doing to take care of ourselves really is not self-care.
– To appreciate the stillness and tranquillity of silence
– Spending time alone and reflecting is so peaceful.
– Your health is one of the most important things you have and needs to be a priority. Facts that I knew before but like so many, have taken for granted.
Personally, as a woman of faith I believe that this situation has and will work out for my good in the end, there is always a lesson or a positive to be taken from every experience. This has also fuelled my ever-burning desire to be instrumental in changing lives for the better, starting with my own.
This situation is only temporary but for many of my patients it is not and returning to their former self is a distant memory not to be realised.
I take this opportunity to thank my incredible supervisor/mentor at Renovo Care, Dr Anita Rose, and Margreet, as well as my amazing colleagues Ana, Chris, and Simone for being so caring and supportive during this difficult time.
Rest in peace to all of those who have lost their lives because of this horrible virus, including my dear Grandpa. May we find and be the solution! Stay safe.
A rehab professional attempting to rehab herself.
Taking time to look back – so the way ahead is clearer
Reflective practice within healthcare settings is widely talked about, but not always so easy to implement in the workplace. NR Times speaks to one neurological centre about how it benefits patients and staff there.
Reflective practice and discussion in healthcare settings is a professional requirement for nurses, as laid out by the Royal College of Nursing revalidation requirements as part of their continuous professional development.
It allows professionals to take time to pause and reflect, communicate and plan, which undoubtedly leads to better outcomes for patients and staff.
But in reality, reflective practice can often be left to the bottom of the pile, underneath many of the competing responsibilities facing staff who are often pressed for time.
It could be argued that this is also why reflective practice is so important – healthcare staff are facing so many pressures that it actually makes less sense to neglect the important work of individual and team reflection.
The Royal College of Nursing defines reflective practice as: A conscious effort to think about an activity or incident that allows us to consider what was positive or challenging and if appropriate
plan how it might be enhanced, improved or done differently in the future.
Staff at Elysium St Neots Neurological Centre in Cambridgeshire started doing regular, weekly reflective practices when its new hospital director, Fiona Box, came into the role a few months ago.
The nurses and healthcare assistants from a ward are invited into the meetings and in their absence the therapy staff monitor patients and provide activities.
“We thought it would be helpful for team members to give them the opportunity to think, learn, and to hear their opinions,” says charge nurse Jemima Vincent.
“If we have an incident with a patient, we discuss it in the session” she says.
Sessions are led by the management team, with added input from psychology teams on each ward.
They will talk through any strengths, weaknesses and opportunities, and work through an analysis to learn from the incident and create an action plan.
They talk about the worst-case scenario in relation to an individual situation and discuss how staff would manage that, so they’re better prepared in the event of it happening.
While they focus on one patient at a time, issues arise during conversations that bring in their wider experiences.
In an article* published in the Nursing Times in 2019, Andrea Sutcliffe, chief executive of the Nursing and Midwifery Council said: “In these challenging times for health and social care, it’s so important that collectively we do all we can to support our health and care professionals, and their employers, in devoting time to individual, reflective, personal and honest thinking.”
Fiona has received encouraging feedback from staff, who say the meetings help the staff feel much more involved in a patient’s care and allow the team to increase their knowledge and understanding resulting in a more consistent way of working.
“Healthcare workers often don’t fully understand patients’ diagnoses or why they’re reacting in a certain way, for example,” Jemima says.
“They know a patient presents with certain behaviours and may be taking medicine to help them cope but they’re not aware why the patient is showing signs of aggression and the best response to deescalate the situation,” she says.
“It’s a learning opportunity for staff, because reflective practice means that they can understand a patient’s diagnosis and why they behave how they do,” Jemima says.
“Reflective practice answers their ‘why’ questions, and gives them a more open mind.”
Jemima also benefits from the meetings; it’s a way for her to get to know staff better, especially when it comes to learning opportunities.
“I’m able to understand what level of support each member of the team requires, including training needs and if they need more knowledge on a specific topic.”
In her final year as a mental health nurse student on extended clinical placement at Elysium St. Neots, Jo took part in a reflective practice session.
She had just finished her dissertation, in which she looked at how settings can increase the opportunities and variety of reflective practices within hospital settings.
The aim of Jo’s session was to reflect on the recent deterioration in a patient’s mental state and the resulting impact on their well-being to ensure staff had a consistent approach to support the patient.
The hospital’s director Fiona asked the team about the patient’s care plan, diagnoses and needs and wishes.
Where staff were unsure of the answers to questions, Jo says Fiona gave them answers and encouraged the team to share their knowledge of the patient, problem solve and come up with an agreed plan to move forward with.
Jo found the session helpful and was impressed with how the healthcare assistants were so involved in the discussions about all aspects of the patient’s care, including the more clinical elements.
Healthcare assistants told her they found the session helpful too and that it made them feel like they had a better understanding of the patient’s changing mental state, behaviours and needs.
Jo says having the opportunity to reflect on practice is a crucial skill for all healthcare workers to help them learn from their experiences and increase self-awareness, which, in turn, can improve individual professional standards, strengthen teams and enhance patient-centred care and clinical outcomes.
For referrals to Elysium St Neots Neurological Centre or other Elysium centres visit: www.elysiumhealthcare.co.uk/neurological
Reference source: https://www.nursingtimes.net/news/ professional-regulation/nmc-highlights-importance-of-nurses- reflection-on-practice-18-06-2019/
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