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Helping skills

This essay will examine and critically reflect on the helping skills utilised by the author in relation to a client during one session. The helping skills used were based on Egan’s three-stage model (Egan 1998) utilising the six approaches of intervention detailed by Heron (1975). Although drawing on counselling techniques, this was not a true counselling session. It is approached from a midwifery perspective by a student midwife not qualified in specialist counselling techniques. Due to the personal nature of the discussion, this essay will be written from a first person perspective. For the purpose of confidentiality, all names have been changed throughout the essay. Consent was gained from the clients prior to writing the essay.

The client (Brenda) arrived for a booking interview with her partner (Paul) and four year old son (Timmy). From a midwifery perspective, this meeting is primarily used to gather medical and obstetric information about the client, and is routinely held at the hospital so that this information may be entered directly onto a computer. To ensure no interruptions, the door to the interview room is locked from the inside. 45 minutes is allocated to each appointment. Prior to this meeting, I had received no information about Brenda and Paul except that Brenda was 12 weeks pregnant.

Initial introductions were made, and I explained the aim of the interview. The couple were happy for the interview to be conducted by a student. The nature of the booking interview is such that a large number of questions on my part are involved. I warned Brenda and Paul of this before we started trawling through the required questions. The meeting also offers the opportunity for the client(s) to discuss pertinent issues. This introduction period is important to begin to build up a trusting relationship between the client and the midwife. The interview necessitates that the client discusses sometimes deeply personal experiences and information with the midwife. The client may be more comfortable divulging this information if she feels comfortable and confident with the attending midwife. It is probably the first meeting of many throughout her pregnancy, and the impression left after the first meeting may influence the development of the continuing relationship as her pregnancy develops.

Brenda was quiet, but fairly chatty and appeared happy. I noticed a slight trace of an accent in Brenda’s voice, which I enquired about. She informed me that she had moved to England from Germany ten years ago. Her English appeared to be excellent, and she confirmed that she had no communication difficulties. Paul remained silent throughout this time, and primarily appeared to concentrate on amusing his son. Timmy was extremely well behaved throughout the interview.

After we had confirmed demographic issues such as address and telephone number, I asked where Brenda was hoping to deliver this baby. Brenda looked at Paul, and Paul focussed his attention on me and leant forward to say

"We were hoping to talk to you about that". He sent his son off to play with the toys in the corner, and continued, "We would like to know if it’s possible to have an elective Caesarean section". He had a look of determination on his face, while Brenda appeared uncomfortable.

Realising this was an important and possibly sensitive issue for Brenda and Paul, I pulled my chair away from the computer to turn and face them fully. I tried to address my response to both Brenda and Paul, looking each in the eye in turn as I spoke. I told them that this was possible, but asked them why they were considering this. Paul continued to speak, and explained that Brenda had had a "horrible delivery" last time, and they would like to avoid this happening again. I replied

"I’m sorry to hear that. Why don’t you tell me what happened last time". By encouraging Brenda and Paul to ‘tell their story’, I hoped we might identify some key issues to explore further. Brenda started to explain that she had started to bleed in early labour, and had had to go into hospital sooner than she would have liked as she had hoped to remain at home for most of her labour. She said that blood had started to run down her legs, so they came straight into hospital.

"That must have been very scary for you" I said.

Paul agreed. "Yes, we didn’t know what was going on. When we got into hospital the doctor broke her waters and then said everything was fine. He said it was just a show, but there was so much blood. She was in a pool of it. I don’t understand why they broke her waters if everything was OK."

"Did the doctor tell you why you were bleeding?" I asked.

"No" said Paul. "The midwife said it was probably just a show, but there was so much blood. I don’t see how it could have been"

Brenda nodded in agreement, and added that she had also felt uncomfortable with the fact that she had had a male midwife looking after her "He was probably very nice, but I was really afraid and surrounded by all these men. I didn’t want ... no-one told me what was happening"

"and you just wanted to know what was going on ?" I re-iterated.

"Yes" both Paul and Brenda replied in unison.

"Do you think you would have preferred a different midwife?" I asked.

Brenda said she would, but was worried that this sounded silly. I re-assured her that this wasn’t "silly", and that if it made her more comfortable then it was right for her.

"We just didn’t get on" She explained. "I just wanted a woman there that had been through it all herself. He seemed more interested in the doctor than me"

"Do you think you might have felt more comfortable with him if he had explained what was happening?" I asked.

"Yes, but I think would have preferred a woman" Brenda replied uncertainly.

The couple both fell silent for a short time, and although keen to encourage this, the time constraints imposed by the appointment time unfortunately limited my ability to do this. I encouraged the couple to continue.

"How did the rest of your labour go?" I enquired.

"It was awful. When Brenda was in really strong labour and she wasn’t dilated enough, they made her have an epidural", Paul continued, "and I had to hold her down on the bed"

"That must have been very difficult for you" I replied. "Why did they do that?"

"I don’t know", replied Paul. "They just said I had to hold her really still and she was in so much pain"

"I can’t remember much of that" Brenda added.

"And then the baby got distressed, and I thought he was going to die." Paul continued, "They used forceps to get him out. They had to cut Brenda."

Paul appeared visibly upset by recalling this obviously traumatic experience. I hoped to acknowledge this, but I wasn’t sure how to respond. I was beginning to feel that a lack of information had resulted in a feeling of loss of control of the situation particularly for Paul. I used a confronting strategy to explore this. "It sounds like you were feeling a bit helpless while all of this was going on" I suggested.

"Yes, it was awful. To see Brenda in so much pain, and not be able to do anything to help her. I was in the way wherever I stood, so I couldn’t even hold her hand. Everything happened at once. No-one really told me what was happening, so I thought it was because the baby was dead or something."

I nodded to acknowledge this.

It was my belief that Paul had a lot of issues that he needed to explore regarding his sons birth, however, I obviously wanted to discuss them with Brenda also. This may not have been an ideal counselling situation, but in a midwifery context, this is a common occurrence, and the presence of a partner may have helped the other feel more at ease. I turned my attention back to Brenda. "How did you cope with all of this going on Brenda?" I enquired.

"I really don’t remember much of the delivery," she answered. "It was all a bit of a blur. I can only really remember being on the postnatal ward. I had so many stitches inside and out. It was terrible. I had some friends that had caesarean sections at about the same time, and they recovered much quicker than me. It took me about a month, but they were all up and about after the first week" Brenda said.

"Yes, she couldn’t even sit down," Paul added. "I felt terrible, because I could only get a week off work, and it was really hard for Brenda being at home on her own"

"I don’t have any family in England, and I didn’t really like to ask anyone else for help. I didn’t really know anyone well enough at the time." Brenda explained.

"Timmy’s great, but we weren’t going to have any more children because had such an awful time last time" Paul said.

"...and now that I’m pregnant again, I can’t enjoy it because I’m so worried that it will all happen again." Brenda added. "That’s why we’ve decided to look into having a caesarean section this time"

"I can see that this is something you’ve thought about." I said "but I do have to point out that a caesarean section is major abdominal surgery, and is not without it’s risks"

"We know, but it can’t be any worse than last time" said Brenda

As well as unfortunately having a genuinely traumatic previous delivery, a lack of information leading to a lack of control had emerged as a key issue for both Brenda and Paul.

"Did the two of you have the opportunity to talk to someone about what had happened afterwards?" I asked

"No" replied Brenda, "I think that would have helped. Even talking things through with you today has helped." Paul nodded in agreement.

"If you’re interested, the hospital offers a counselling service that gives couples the opportunity to talk to a counsellor about their birth experience. I can get you the number if you’d like to consider it." I suggested. Paul and Brenda had identified that talking had helped, so I felt it appropriate to suggest a referral to a more qualified professional. This can be a difficult topic to bring up with clients, as some can take offence at the suggestion, however, Paul in particular seemed enthusiastic.

"Yes, that sounds good" he responded, and we discussed when and where sessions were held.

From what had been said throughout the meeting, I had the strong impression that Brenda and Paul not only needed to talk about the delivery, but also felt they needed to know why things had happened the way that they had, and to get some of the information that they felt they missed out on at the time. This was more than I was able to offer them at this time, so again I felt it appropriate to suggest another referral.

"It sounds like the two of you have a lot of unanswered questions about last time. Do you feel it might be helpful to talk to the consultant further about your delivery ?" I asked.

I explained that I couldn’t tell them why things had happened the way they had, as not only was our time limited, but I didn’t have Brenda’s medical notes. I also explained that in order to arrange a caesarean section, they would need to see the consultant. As well as discussing the impact of an operative delivery, he would also be able to discuss the previous delivery in more detail with them. They both seemed pleased at the prospect of some answers, and agreed to see the consultant. He may be able to answer some of their medical questions, and offer re-assurance as to the likelihood of a re-occurrence. I arranged an appointment for them immediately so that we could find a time appropriate to Brenda and Paul.

Time limitations dictated that we had to quickly run through the remaining questions on the booking form, however, Paul and Brenda appeared much more relaxed and comfortable. We were able to laugh and joke through much of the remainder of the session. They seemed pleased when they left the booking clinic with both a number to call for birth counselling services, and an appointment to see the consultant. As they left, Brenda thanked me for listening, and said that she would be happy to have a normal delivery if I was there to deliver her baby.

I felt this was an enormous complement, and I thanked her for the complement while pointing out I was just doing my job.

Although this was not a true counselling session, aspects of Egan’s model for counselling practice (1986) were utilised within the midwifery setting. Some aspects of the model were utilised intentionally, while others emerged naturally and unintentionally on the part of the midwife. Egan’s model shows a three stage progression from defining and exploring a problem as identified by the client (stage 1), through understanding the underlying problems and setting goals (stage 2), to eventually planning and taking action (stage 3). This natural progression fitted well into the session, and the majority of input was encouraged to be from the client(s), with minimal prompting from the midwife. The couple appeared to find it easier to discuss issues as the session continued, and disclosed more as their ‘story’ developed. This implies the development of a trusting relationship between the client(s) and the midwife. The time limitations of the session dictated that a limited time was allowed to discuss these issues, as booking forms also had to be filled in, however, Brenda and Paul appeared happy with the issues that had been discussed, and had a plan for further action. The session time, aims and content of the interview had been clearly identified at the start of the session, which helps the client(s) know what to expect from the interview. The midwife was able to refer to qualified professionals on matters that were outside her capabilities. Again, Brenda and Paul appeared satisfied with the rationale for this.

In retrospect, it may be identified that both authoritative and facilitative interventions as identified by Heron (1975) were used by the midwife throughout the session. These interventions are utilised within Egan’s model of practice (1986). Initially, a facilitative catalytic approach was used to encourage Brenda and Paul to ‘tell their story’. The midwife was supporting throughout this time. A more authoritative approach was required with some midwifery aspects of the discussion, such as when discussing caesarean section, and when the couple were informed about further counselling options. The use of these interventions was primarily unintentional on the part of the midwife, but can be identified in retrospect.

Many of the helping skills and interventions identified by both Egan (1986) and Heron (1975) occurred quite spontaneously, which demonstrates how naturally they occur as part of a session. The stages of Egan’s model (1986) were utilised by the midwife to the limit of her abilities within the midwifery setting, and a satisfactory outcome was achieved as a result. Although no problem was ‘solved’ as such, Brenda and Paul were able to identify and explore the problem, and a plan was put in place for further exploration of the issues, which is a realistic achievement for a single session. This identifies the effectiveness of the model within the midwifery setting in which it was utilised.

Source: Essay UK -

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