I am a proactive, adaptable and conscientious writer with twenty years experience in Health and Social Care, both as a Mental Health nurse and a university lecturer in Health, Social Sciences and Physical Sciences. I have a BA (Hons) in Health and Social Science and a Postgraduate Certificate in Education. I overcome challenges through a tenacious and questioning approach - drawing on my wide-ranging expertise as a nurse, as a former undergraduate and post graduate and as a university lecturer. I have been successfully writing about health, nursing and social care issues for five years and I also write physiology and biology based papers. I know what is needed from an academic essay or research. I also have strong cognitive skills. I consistently work to the highest professional standards.

Sample

An analysis of a health visitor’s decision to assess a new mother for postnatal depression.
The aim of this essay is to analyse the decision to assess a new mother for postnatal depression (PND). This was chosen because the author is presently undertaking a placement with a health visitor and has the opportunity to experience the said health visitor assessing a new mother for postnatal depression. Health visitors have been working with women with postnatal depression for some time. Although this role has not always been seen as a priority, in many areas it has developed and broadened so that health visitors now have a real skill in this area (Cullinan, 2001). Community based research has found that when health visitors are given specific training and adequate support they can have a positive influence on the outcome for women in their care who are experiencing postnatal depression (Elliot et al, 2000).

Postnatal depression can be a devastating experience for a woman and her family. It also has important health and social consequences. Psychiatric disorders after childbirth are very common and many can be serious (Oates, 2000). Not only are women with a pre-existing condition more at risk of relapse, but also women are more likely to develop their first affective disorder in the perinatal period than at any other time in their life (Oates, 2000). Most health professionals are aware that 10-20% of all newly delivered mothers will experience postnatal depression (Yonkers et al, 2001; Peindl, 2005).

However, these figures should be treated with caution, as they are representative of above threshold DSM IV diagnosis among mostly a selective population of middle-class Caucasian women. A more detailed review of the literature shows that the reported figures vary among countries, and even within a country, from 0.5% to over 60%. Factors such as culture, socioeconomic status, genetics, ethnicity and style of reporting may contribute to the diversity (Halbreich, 2005). However, the true figure is likely to be much higher because many women suffer in silence, or are unaware that the symptoms and the way they are feeling are due to PND and so community-based healthcare professionals such as midwives and health visitors can expect to come into contact with women with PND (Goodman, 2004).

It is posited that this knowledge and the health visitor's many years of experience aided the health visitor in the decision to assess the client for PND. It is debated that at this time, the decision to assess may have been based on an intuitive judgement. However, it is argued that the decision to assess the client for PND and consequently deciding on the care needs of the client by the health visitor was more likely to be a combination of both the intuitive and the hypothetico-deductive approach. In this way, the strengths of unconscious processes (intuitive) and conscious thinking (hypothetico-deductive approach) can be combined to maximise complex clinical decision-making processes to the benefit of client's situations (Paley et al, 2007). The decision making theories mentioned will be discussed in more detail in the main part of this essay, with regard to the decision to assess the client for PND.

One of the main tasks of health professionals working with women during the perinatal period is to identify those experiencing, or at risk of, developing perinatal depression or other mental health difficulties, with a view to offering appropriate interventions including specialist services where needed (Henshaw, 2005). Similarly, the National Institute for Health and Clinical Excellence (NICE, 2006) Routine Postnatal Care guideline suggests that at each postnatal contact, women should be asked about their emotional well-being, what family and social support they have and their usual coping strategies for dealing with day-to-day matters. Women and their families/ partners should be encouraged to tell their healthcare professional about any changes in mood, emotional state and behaviour that are outside of the woman's normal pattern. The guidelines also suggest that healthcare professionals, such as health visitors utilise tools to aid detection of PND such as the Edinburgh Postnatal Depression Scale (EPDS). However, it is argued that assessment tools are not without their limitations and it is therefore proposed that health visitors may also rely on their professional expertise.

The client, whose name is withheld for reasons of confidentiality pertaining to the Nursing and Midwifery Council (NMC) code of professional conduct: standards for conduct, performance and ethics (NMC, 2004); is a 33 year old, degree educated woman who was a gravida 1.The client and her spouse have been trying for a baby for several years and the infant is a result of 'in vitro fertilisation' (IVF) treatment. The client had experienced a long labour and a traumatic emergency caesarian birth. According to the postnatal attending midwife, the client was showing signs of PND. The symptoms the client was exhibiting were a depressed mood, tearfulness, lack of drive and enjoyment, social withdrawal, insomnia, poor appetite, impaired concentration, and feelings of uselessness and helplessness. These are the most common symptoms of PND (Oates, 2002). The client's spouse had also commented on his wife's low mood.

PND has significant health implications for the mother. It can also have a negative impact on the woman and her long-term relationships, an adverse effect on fathers and the family as a whole (Bradley et al, 2004). In addition, there is a strong evidence base that documents the adverse effects of PND on the infant and child development process. For example, infants can develop disturbed patterns of communication, exhibit withdrawn and unresponsive or hostile behaviour and longer-term cognitive and emotional impairment (Meredith and Noller, 2003). Between 1.5% and 25.5% of fathers have also been shown to suffer depression following the birth of a child, the number rising to between 24 and 50% if their partner is depressed (Goodman, 2004). Some women who have experienced PND will change their plans for future pregnancies because of fears of recurrence, effects on the family or severity of the illness (Peindl, 2005). One third to a half of all depressions occurring after birth will be continuations of an episode that began during or before pregnancy and research has revealed that depression during pregnancy is as common as PND (Bennett et al, 2004).

Health visitors first meet families at the new birth visit. This generally happens around 10–14 days postnatally. This visit is really the foundation visit for all other contacts. This is the time when the health visitor is able to observe interactions between the parents and infant and then discuss the parents' own emotional wellbeing as well as establishing whether there is any personal or familial history of mental health problems. The family is given information about the core visiting programme for that area which generally includes a re-visit at six weeks postnatally to look more in depth at depression using the Edinburgh Postnatal Depression Scale (EPDS) (Lewis 2004).

As mentioned, community based research found that when health visitors are given relevant training and sufficient support they can have a decisive influence on the outcome for women in their care who are experiencing postnatal depression (Elliot et al, 2000). This research was supported by Painter (1995), who found that using the Edinburgh Postnatal Depression Scale (EPDS) and supportive counselling led to an increased detection of depression with symptom reduction in those mothers identified as depressed as well as an increased confidence in the health visitor.

The EPDS was designed in the late 1980s to help health visitors identify women who were depressed. It is a ten point self-reported questionnaire which the woman is asked to complete bearing in mind how she has felt over the previous seven days. Initially the score was taken quite literally with any women scoring 12 or above being possibly depressed and any women scoring less than that being seen as well. However, it is now well established that there are false positives and negatives with the scale and hence the Community Practitioners' and Health Visitors' Association (CPHVA) now recommends that the scoring should not be the only point of assessment but that the health visitor should also use their professional judgment and experience (intuition), together with a fuller mental health assessment using a clinical interview.

The EPDS certainly laid down the foundations of this work enabling health visitors to detect women with postnatal depression and then to offer more support and needs-led interventions. Consequently the detection and management of postnatal depression by health visitors has now been recommended in a range of reports and policy documents (Department of Health (DH), 2002; Hall and Elliman, 2003; DH, 2004).

One of the key things health visitors do when they first meet new parents at the new birth visit is to take a full history of any mental health issues. This might have been done already as part of midwifery assessment at the antenatal booking clinic.
Midwives should then liaise with health visitors to ensure that the transfer of care is swift and seamless. If this is not the case (as in this case) then health visitors need to identify women who have had a history or family history of mental illness, but they must also identify those who are experiencing a condition at the present time. A decision then needs to be made on how best to help the family (Lewis 2004).

As mentioned, at the initial visit, the health visitor had an intuitive instinct that something was not 'quite right' with the client. Therefore, it is posited that the health visitor's decision to assess the client at this time could be said to be an intuitive judgment.

The idea of intuition and its use in complex clinical decision-making has, over the years, created points of debate, discussion and tension (Parahoo, 2006; Paley et al, 2007). One reason for the ongoing debate on the use of intuition in clinical practice is that it is difficult to underpin how intuition informs clinical decision-making. Recent developments in psychological research make it possible to understand more and explain better the basis of intuition. It is suggested that this research is an important step towards the empirical validation of intuition in today's nursing profession that is attempting to develop a research base to support its actions (Kennedy and Lockhart-Wood, 2005). One of the principle notions of the psychological research on intuition and clinical decision-making is that of the physiological basis of intuition. The 'gut' feeling that some nurses get when they feel that something is wrong with a patient. With regard to the client in question, the health visitor could be said to have had a 'gut level' feeling that made her decide to more formally assess the client. It is debated that these 'gut level' feelings of intuition have a physiological basis.

Throughout the abdomen, extensive nervous system cells form part of our autonomic nervous system. The complex circuitry in the abdomen looks very similar to a brain; with the same cell types and neurotransmitters operating. This enteric nervous system shows an anatomical and functional independence from the brain and the spinal cord (Smith, 2007). However a human being can not formally think with this system but one's feelings and experiences can be 'remembered' and recalled. Mayer et al, (2000) call this our 'belly brain' as opposed to our 'head brain'. These two brains have a permanent connection, without individuals being aware of it. A persons 'belly brain' is much more communicative than our 'head brain'. They suggest that 9 out of 10 pieces of information go from the 'belly brain' to the 'head brain'. The response of different viscera to distinct, emotion-specific patterns of autonomic output is fed back to the head brain. Even though this process unfolds largely without conscious awareness, it plays an important role in emotional function and may influence rational decision-making (Mayer et al, 2000).

It is suggested by (Smith, 2007) that chills down the spine and muscle tightness can occur when intuitive functioning is identified. In these circumstances, experienced nurses describe postural tightness, restlessness, general uneasiness, increased heart rate, racing blood flow, stomach tightness, and 'all senses turned on'. This is intuition presenting at a physical level. It is proposed that when there appears to be no logical explanation for intuition, people tend to call this experience an 'inner voice', not realising that there is a physiological explanation for it (Smith, 2007). It is posited that it may have been these feelings, especially the stomach tightness that led to the decision of the client being formally assessed by utilising the EPDS.

As mentioned at the initial interview with the client the health visitor's decision to assess the client at this time could be said to be an intuitive judgment. However, after certain cue interpretation and data gathering that were acquired from utilising the EPDS tool, it is debated that the health visitor used a more analytical decision-making process (hypothetico-deductive approach) to identify the care needs of the client. Another cue for assessing the client for PND using the EPDS was the husband's observations of his wife's low moods.

It is suggested that the hypothetico-deductive approach to decision-making is frequently utilised by healthcare professionals. This approach has four stages: data collection, the process of gathering and collecting information; hypotheses generation that is the process of generating alternative formulations of the problem; cue interpretation, the process of interpreting the evidence in light of the hypotheses and hypotheses evaluation that is the process of combining information to reach a diagnostic decision or judgment. It involves selecting cues from the presenting situation and building up hypotheses of possible problems. Nurses quickly generate one or two working hypotheses that may explain the observed cues. The nurse will then look for further cues to support or refute the problems identified. It is argued however, that nurses may overestimate the value of information that appears to support their working hypothesis and disregard other information which may be equally relevant to the decision-making process such as the intuitive approach (Banning, 2008).

With regard to assessing the client for PND, clinical data was collected by using the EPDS. The resulting score then produced the assumption that the client had moderate PND, in other words the formulation of the hypotheses. Further cues such as the spouse's observation of the client's enduring low moods and the resulting score from the EPDS assisted in interpreting the hypotheses. On evaluation of the hypotheses a decision was made that the client had specific care needs. On processing the information gathered, the health visitor decided to refer the client to her General Practitioner (GP) for treatment. This is supported by Cox and Holden (2003) who highlight the need for support from mental health services. They maintain that the decisions health visitors make about mental health need to be in the first instance supported by GPs, but if concerns are heightened then ready access to a mental health professional is essential. This is where Integrated Care Pathways (ICP) assists in care. An ICP provides practitioners with guidance to the most appropriate interventions and works towards each woman receiving a seamless service (Middleton and Roberts, 2002).

In conclusion, health visitors when attending to an individual who has PND often need to make decisions to meet the complex physical and emotional needs of the patient and their family and this is part of the nursing process. If health visitors can apply decision-making theory to their daily practice they may be more likely to have a sounder basis on which to make decisions. Intuition is knowing without knowing how one knows. This view is held because 'intuitive ideas' are the product of unconscious processes. The use of unconscious thought can lead to valuable ideas that might not have emerged if one relied solely on conscious thinking. On the other hand, it should be acknowledged that even the strongest intuition can also be fallible at times. Such fallibility is also common in other sources of knowledge like the hypothetico-deductive approach to decision-making. Therefore, intuitive ideas should on one hand be taken seriously and be treated as hypotheses of what could be going on in a clinical situation. On the other hand they should always be checked or complemented with information from other (more rationally based) sources of knowledge whenever and as much as possible. In this way, the strengths of unconscious processes and conscious thinking can be combined to maximise complex clinical decision-making processes to the benefit of patient situations.

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