2. REVISI ´ ON BIBLIOGR ´ AFICA
2.3. Programaci´on din´amica aproximada (ADP)
5.3.1 Purpose and function of the conceptual framework
The participants asked general questions about how the conceptual framework was going to be used and what scope it might have for use within practice. All
participants reported that the definitions provided were important to the framework. It was suggested by one participant and agreed by all that an
introduction to explain the purpose of the conceptual framework and guidance on how to look at the content would be useful.
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5.3.2 Layout and design
Participants discussed how the iterative and changing nature of health could best be depicted. Everyone wanted to see the relationship between the central concept of ‘healthand wellbeing’ to the four domains of physical functioning, mental wellbeing, social wellbeing and spirituality represented by double-headed rather than unidirectional arrows. Two participants suggested employing a graphic designer to assist with the design and layout once the content was agreed.
5.3.3 Content: domain, sub-domain level and component level
The relationships between each domain, sub-domain and its components were considered throughout the duration of the discussion. Practitioners when discussing how each domain related to the next and how health status was not static but a fluid process, suggested that further explanation would be required in any supporting documentation linked to the conceptual framework.
Spiritual wellbeing: there was some debate about the inclusion of this domain. One participant was concerned that the CST profession could be “shooting
themselves in the foot” by including it, concerning the medical profession’s stance. The other participants disagreed and felt that it was important to challenge medical views as spiritual wellbeing is important to clients.
Social wellbeing: One participant recommended that the domain of social wellbeing be developed to include: significant relationships, support networks, patient safety, dependants, health of partner and financial status. The other participants agreed.
Physical functioning: The domain of physical functioning, was discussed at
component level in the context of ‘working and earning a living’ as part of ‘everyday life’, introducing the topics of ‘digestion’ and the ‘patient’s environment’ as
components were considered then rejected. It was suggested that ’energy levels’ influenced all areas of health and wellbeing and should not, therefore, be depicted under just one domain.
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Symptoms: the challenges of measuring symptoms were discussed. Pain, for example, was discussed in the context of the dimensions of severity, frequency and nature, noting that it could manifest as physical, spiritual, psychological or
emotional pain. Participants suggested that the subjectivity of an individual’s experience makes measurement difficult and the way that individuals learn to cope also has implications for measurement “if somebody’s ability to cope with pain has
changed so much through their experience of the [CST] work, that their self-
perception has changed so, I mean it’s difficult”. Pain was a motivator to get people to attend CST sessions.
Mental wellbeing: The meaning of the sub-domain termed ‘self-efficacy/self- agency/self-care’ was not clear to participants. Participants did not like the terms self-efficacy or self-agency. All participants emphasised that the terminology needed to be kept simple. Taking responsibility for one’s health was deemed as important, as was its connection to self-care. Participants related to ‘taking
responsibility for one’s health’ from the perspective of clients making choices about their health and as part of a mental process that happens through a shift in
awareness due to new insights about health. Participant 004 said “it’s probably the
education that goes along with the treatment”. The term ‘being heart centred’ was controversial and alternatives were suggested.
Other topics of discussion: The mental wellbeing sub-domain of ‘emotions’ and the spirituality sub domain of ‘being present’ were debated in relation to their position on the conceptual framework, but not what they represented.
Whether to include ‘sexuality’ on the conceptual framework and questionnaire were deliberated, ‘intimate relationships’ was suggested as a suitable term at conceptual framework level. Participants reported that ‘animals’ were important in people’s lives and could impact health, yet had been missed from the conceptual framework.
General comments were made about the language and semantics, alternative words heard within practice were put forward to ensure acceptability to clients, for
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example: confidence, empowered, focussed, resilience and connectedness. The overarching theme was considered satisfactory and central to the conceptual framework; participants wanted this explained in the conceptual framework’s introduction.
5.3.4 Summary of focus group 1
The feedback from focus group 1 was practical and improved the clarity of the conceptual framework in relation to the design and layout. The suggestion of creating an introduction or a ‘how to read the conceptual framework guide’ and recruitment of a graphic designer was most useful in the early development phase. At this stage, between focus groups 1 and 2 ‘energy’ was re-categorized from a component within the ‘physical wellbeing’ domain to a sub-domain located outside of the other domains, as ‘energy’ underpins all aspects of the conceptual
framework. No further changes were made at this point but the comments relating to recommendations for additions to the social wellbeing domain, the inclusion of the spirituality domain, terminology of the mental wellbeing sub-domain of ‘self- care, self-efficacy and self-agency’, whether to include ‘sexuality’, and whether to re-categorize ‘symptoms’ were taken forward for use at the next focus group.
5.4
Focus group 2
5.4.1 Purpose and function of the conceptual framework
Participants assumed that the conceptual framework would be used within practice to provide an overview of the potential effects of CST, pinpointing those areas of a client’s life where they might experience change. Participant 005 “this is something
I would like to use in my practice when I’m trying to explain what cranio-sacral
therapy…. this feels really lovely to give the possibilities…”.
5.4.2 Layout and design
One participant felt there was a subtlety in the depiction of the conceptual
framework and liked the way it had been structured but the purpose of the heavy line placed around the central construct of health and wellbeing was unclear (see
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Figure 7). Participants recognised that domains inherently overlap. One participant wanted scope for clients to personalise the framework to add their deficits.
5.4.3 Content: domains, sub-domains, items
Spiritual wellbeing: participants wanted this domain to include components that addressed a more philosophical element of spirituality and how individuals may integrate spirituality into their lives. One participant considered if an ‘existential reference to existential being’ was more relevant. Suggested components included: ‘reflecting on the meaning of life (existential)’ and ‘living my core values’.
Social wellbeing:participants identified that ‘engaging in life’ had internal and external implications. The comments from Focus Group 1 were shared and discussed, the participants of Focus Group 2 disagreed with the previous group’s thoughts about the inclusion of ‘patient safety, dependants, health of partner and financial status’ in to this domain. Yet, they liked the suggestion of ‘significant relationships and support networks’ being included. Recommendations were made to develop this domain to include ‘engaging with local community and society’. Mental wellbeing: Participants homed in on the topic of self-agency and self-care and, once again, this was most debated. Participant 005 emphasised their
perspective about self-care, “perhaps self-care is the most significant thing in wellbeing, is [having] the choices, the capacity and the motivation to take
responsibility for one’s own being”. The topics of ‘sexuality’ and ‘financial security’ were introduced for discussion based on the data in Focus Group 1. Two
participants had concerns about including ‘sexuality’ on the conceptual framework, the other participant disagreed with them. Regarding ‘financial security’ one participant suggested that the topic of ‘financial security’ may influence a client’s sense of self-worth and impact on health, the other practitioners disagreed, as the following quote explains. Participant 006 said “I feel like what you’ve got here
[items on the conceptual framework] is qualities about people and how they [are] relating to aspects of their lives, whereas, trauma, sexuality and money [are events or determinants that impact on health] more like facts and that feels different
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[rather than outcomes or health states]”. The participants did not reach a consensus about either of these topics.
Physical functioning: It was proposed by NB that the sub-domain of ‘symptoms’ and its components be repositioned to outside of the other domains to reinforce the point that symptoms can manifest in any of the domains, participants agreed that this would be a good idea.
During reflections on this domain and its components, the sub-domain of ‘sleep’ was reframed based on discussions with supervisors and renamed ‘sleep quality’ and the component of ‘disturbed’ was deleted.
5.4.4 Summary of focus group 2
Participants discussed whether they might use the conceptual framework in practice with new clients as a tool to show the potential areas of effect that CST may have. There were no negative comments about the layout or design. Participants recognised that domains inherently overlap. Suggestions on how to improve the content of each domain were made. Participants liked the potential and scope the conceptual framework had for further research into the use of CST.