El modelo de Construcción-Integración (MCI)

MAJOR THEME SUBTHEMES CONCEPTS

Barriers to mental health promotion Inadequate communication Barriers to building therapeutic relationships Barriers to communicating with parents Inadequate time Medical influence Incongruent models of care

Workforce barriers – NEEDS SH Target platform

Inadequate funding

Acute care practices

The dominance of the biomedical model of care (cure) and its practitioners (doctors) continues to be supported as a social script politically, economically, and socially, despite the centrality of the nursing resource

(Porter-O’Grady & Malloch 2006).

This next subtheme of medical influence within this chapter’s major theme of

‘barriers to mental health promotion’ highlights the potentially detrimental impact on mental health promotion of the influences of medical dominance and a biomedical framework in midwifery and child health nursing practice.

There were a number of responses which described the biomedical model as being a hindrance to mental health promotion for parents due to its non-holistic approach. Most of the responses for this finding of medical influence emanated from midwives. For example, one midwife discussed how the biomedical framework uses a systems approach and that as midwives when we learn about women, about birth and

pregnancy, women are separated into little pieces and we learn about little pieces.

She stated that it's the way we’re taught about it. Furthermore, shedescribed how the biomedical approach was incorporated throughout antenatal care, arguing that a lot of antenatal care is typically foetal surveillance andmaternal surveillance and yet care involves a lot more than just physical surveillance and looking at the physical parameters. Finally, this midwife commented that much of the antenatal education centred on preparing a woman for a series of procedures that’s going to happen to

her in hospital, preparing her for something that’s described in purely medical terms (10M).

Another midwife described her work as very much medically- oriented in the sense that we focus on the physical health; it’s not so much mental health. Similarly she discussed practice as being very much focused on the immediate, you know, bleeding, contraceptives; all this physical stuff, but in terms of keeping healthy, getting on with your parenting role and getting to know your baby, we do a very poor job, I

The biomedical framework is embedded heavily within both services through the adoption of routine schedules or clinical pathways that include the term

‘surveillance’ to describe the care given to foetus, infant and mother throughout the perinatal period. In Tasmania, child health nurses follow a schedule of appointments with parents which commence within the first week post discharge. Midwives follow specific frameworks called schedules in the antenatal period, and then within the intrapartum (labour/birth) and postnatal periods they follow clinical pathways. Many participants discussed how routine schedules of surveillance, and the tasks within this surveillance process or clinical pathway, were both supportive and a hindrance to mental health promotion. Some child health nurses commented on how the ‘baby checks’ (surveillance) helped them to talk about other issues and this has been noted as hidden or covert conversations (Shepherd 2011). However, more common was the complaint that these schedules interfered with mental health promotion:

It cannot be a standardised care package that every person that walks in the door has a normal birth, gets two sleeps and they're out the door. Every person who walks in the door has a Caesar, gets four sleeps and they're out the door. I think a little bit of support and nurturing at that point, means you won't get them bouncing back into kids ward with feeding issues, with parenting issues, with acopic issues; if you've done that promotion and support, then they know where to go for help (15M).

Each of the three examples just presented within this concept of medical influence highlighted particular issues with the biomedical model that concerned them. In the first example, the midwife was concerned that in breaking down a parent’s health into physical elements, there was no holistic overview of the parent. This has implications for mental health promotion in that the construct incorporates many diverse understanding of cultures and beliefs and is non-aligned with a biomedical model that uses a systems approach incorporating surveillance of, mainly, physical parameters. The second midwife criticised the medical model for being very focused on the present (and mostly physical complications) to the detriment of any

anticipatory guidance for the future. In being thus focussed, she contended that parents fail to receive supportive information about their parenting after discharge and again, physical parameters are emphasised to the detriment of a holistic

admission as being a ‘standardised package’ and thus how parents are packaged (not parent-initiated) into receiving the care that the hospital institutes. This adoption of institution-driven care means that those who implement the medically dominated policies and protocols become potentially complicit in doing so. However, it also means they ultimately have little choice but to do so, when there is little choice in what they have to implement in the first place. Furthermore, it means parents have fewer choices, leading to potentially no voice whatsoever in the type and content of care they receive.

6.4.1

Discussion

In this subtheme, medical dominance (Friedson 1970; Evans 1983) has arguably negatively influenced the roles of midwives and child health nurses and the content of their work and in turn parents, as consumers of perinatal education. Although some bio/socio ecological concepts are encountered within the child health nursing sphere (Schmied 2008a), biomedical frameworks (Mischler 1989) that hinder mental health promotion were still perceived by participants to be visible and dominant in midwifery care. It is acknowledged that nursing practices are determined by the dominant discourses of medical professions (Powers 2002; Tovey & Adams 2003; Hyde et al. 2005 in Whitehead 2009) and that these practices are governed by biomedical frameworks (Mischler 1989) that do little to support broader

determinants of health and health promotion. Furthermore, medicalised tasks, with their “biomedically oriented diagnosis and treatment regimes” are given greater prioritisation by management and policy structures as they are appear to be more respected than health promotion (Whitehead 2009, p.122). These prioritisations from biomedical origins within general nursing are transferable to midwifery and child health nursing due to a number of factors of which medical dominance is one. Medical professional dominance and autonomy are viewed to have decreased in the past three decades within Australia due to concerns over patient safety and increased health consumerism (Germov 2002). However, in broader terms, control,

subordination of other occupations (Coburn 1992), sovereignty over all matters to do with health (Willis 2006), together with a subjugation to structural interests in which “institutions of society operate” (Alford 1975, p.14) are arguably still embedded

within midwifery and child health nursing care delivery. Doctors are the

“gatekeepers” (Willis 1983;2006) of both of these professions within the healthcare system of Australian, due to their governance over diagnosis and treatment – “enshrined in Australia’s medicare system” (Willis 2006, p.424) – and control over evaluation of care (Harrison & Armad 2000) of families and children. As such, the medical profession from its early alliance with civil servants in the 1940s (Colwill 1998 cited in Harrison & Armad 2000), is one structural interest that determines how both parenting services in this study are organised and administered – potentially subjugating health promotion to the dominance of detection and treatment of physical illness (Whitehead 2009). This dominance in ‘all things mental’ is particularly the case in Australia where access to primary mental health care is ‘gatekept’ through the Division of GPs in policy (Reifels et al. 2012). Another competing structural interest is “economic rationalism” (Willis 2006) or neoliberalistic funding and that is addressed later in this chapter.

Lewis (2006) contends that medical dominance is still evident in Australia: “While many claim that the medical profession has lost power in health policy and politics, this analysis yields few signs that the power of medicine to shape the health policy process has been greatly diminished in Victoria.

Medical expertise is a potent embedded resource connecting actors through ties of association, making it difficult for actors with other resources and different knowledge to be considered influential” (p.2125).

This dominance can be viewed at the level of a midwife or child health nurse as an inability to make decisions about the care he/she delivers (Long et al. 2006). In particular, the delivery of care still appears to participants to be organised in such a way as to hinder a Primary Health Care framework of parent-centredness, and access to midwives and child health nurses when needed. It could be argued that this

impediment of Primary Health Care principles is due to biomedically-focussed surveillance practices that appear to have restricted midwifery and child health nursing to task-oriented praxis. Institutionalised expectations drive these practices (Cowley et al. 2004). As both services in Tasmania are governed by ‘structural interests’ both locally, state-wide and federally that are arguably medically dominated (e.g. specifically in midwifery see Fahy 2012), expectations will run

along surveillance and risk assessment lines – and for the most part physical surveillance (Hanson et al. 2009) as described in Chapter Five regarding the child surveillance book (child health nursing) and clinical antenatal, intrapartum and postnatal schedules and pathways (midwifery).

6.4.2

Summary of the subtheme of the barrier of medical influence

The effect of the medical influence on nursing is well documented globally and there has been much discussion over many decades about the creation of nursing holistic models to counter the influence of a biomedical approach. In recent times, midwifery models of care have attempted to incorporate the overriding goal of Primary Health Care by incorporating women-centred principles of care. In doing so, midwifery aimed to move away from medically dominated models that do not prioritise a more holistic provision of care. Child health nursing claims to do the same – in their case, family centred – and to have greater ability to do so within their community-based setting that arguably allows for greater access to them by parents. However, some participants in this study contested how successful these attempts at being founded upon a Primary Health Care framework have been – culminating in questioning how well parents are engaged and supported by these services, when the vestiges of medical dominance continue to pervade the two services and arguably oppress salutary interests. Significantly, surveillance and risk-based assessments that are prioritised by policy in both services leave little room for communication, therapeutic engagement and health education – and thus little time for mental health promotion.