Context of Nursing

The focus of this assignment will be on a case scenario of an elderly patient who has been admitted into hospital. The nurse??™s professional responsibilities in relation to safeguarding vulnerable patients will be identified and explored as will the roles and responsibilities of the nurse in promoting and maintain rights and autonomy. Confidentiality, consent, accountability and advocacy will be discussed and linked to the scenario given. A number of issues will also be identified and discussed including what is used to assess patients, abuse, how to build relationships with the patients and NMC codes of conduct. References will be included throughout to help understand issues concerned in patients care.The professional responsibilities of a nurse starts and ends with the patient in their care, according to Flectcher L, Buka P (1999) they describe that the very word caring implies while the patient is in a hospital or residential care setting then they should be safe and come to no harm. The NMC (2009, pg 14), state that ???It is every adult??™s right to be free from fear and live in safety???. NMC (Nursing Midwifery Council) is the regulatory body for nurses and midwives, they set standards and guidelines to ensure the health and wellbeing of the public is maintained at a high standard to offer the best possible care. The scenario is of a patient who goes by the name of Archie has been admitted in hospital with a fall. He has a past history of stroke two years ago and has become increasingly confused; this is the second admission relating to falls. Archie??™s son has stated that he feels his father is now unsafe to go back home to independent living as he lives in sheltered accommodation.There are a number of ways in which a person can be defined as vulnerable; within this scenario defines vulnerable as a person who is 18 years and over who is living alone in sheltered accommodation. As Archie lives alone, has had a stroke, is confused and had a number of falls, these issues are having a impact on his safety which is making him vulnerable. The nurse has a duty of care to ensure the patient is safe at all times. Tingle J, Cribb A (2000 pg13) Donoghue v Stephenson (1932) define duty of care as ???A person must take reasonable care to avoid acts of omissions that he can reasonably foresee would be likely to injure a person directly affected by those acts???. The nurse has a professional responsibility to the patient and is accountable for her actions when the patient is in her care. The responsibilities of the nurse is to promote, prevent, restore and alleviate health and ill suffering, but she must always work within her abilities. The nurse should raise their concerns to a senior member of staff if they have been asked to deliver care that they think could potentially harm the patient, NMC (2008 advice sheet). By using her knowledge and skills the nurse should make decisions only in the best interest of the patient and should be able to justify the reasons for the decisions. The nurse is held accountable to her employer, the NMC and the law. This is different for a student nurse as they cannot be held accountable by the NMC, but can be held accountable to the university or by the law. The registered nurse who the student works with will be held accountable as it is their responsibility to ensure the student nurse is working within her level of understanding and is always under supervision.Nursing is not just about treating a patient??™s illness; it??™s about caring, teaching and supporting a patient at a time when they need it the most. Building a therapeutic relationship with the patient will be a main priority for the nurse but in order to do this, appropriate communication is needed, ???Communication is a two-way process between two or more individuals where knowledge and information is shared??? Cutcliffe J R, McKenna H P (2005 pg 313). There are a number of ways in which people can communicate such as verbally, written, hands (sign language), computers (e-mail) or through an interpreter. Effective communication can help build trust with the patient; this in turn will help the patient become more open and honest. As Archie??™s son wants him to go into a nursing home the nurse will have to establish if there is an underlying reason for this. The nurse can act as an advocate to ensure the decisions are not being made for him. Riley et al (2002 pg 93) argue that professionals, although they need to be involved enough in patients care they should keep an emotional distance as to not complicate the relationship, this will enable the patient to disclose personal and painful feelings or worries to the professional. Therapeutic relationship is about acceptance, warmth, being genuine, listening, questioning and showing empathy. Once the relationship starts to build the patient may feel at ease to disclose personal information including if they have been abused. The World Health Organisations (WHO) (1995) states that ???Elder abuse is a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person.??? Abuse can vary from physical such as hitting, misuse of medication, psychological-threats or intimidation, sexual including rape or sexual acts, financial- theft or fraud, neglects and acts of omissions-ignoring medical or physical needs, discriminatory-racist or sexist abuse. (2000, pg9) state that ???Abuse is a violation of an individual??™s human and civil rights by any other person or person??™s???. Every person has the right to life and has the right to be free from torture and degrading treatment, in Archie??™s case either from his family or any professional that is treating him. By assessing Archie and communicating effectively may help him open up if there is any abuse going on. The NMC (2009 pg 2) state that ???You must respect patient??™s right to confidentiality???. The Data Protection Act (1998) is in place to prevent breach of confidentiality. In the event that the patient may be coming to harm the NMC (2009 pg 2) that ???You must disclose information if you believe that someone may be at risk of harm in line with the law of the country in which you are practicing???. It is very important that Archie knows this before he discloses any information. If there is any cause for concern the nurse has a professional responsibility to report it or she can be held accountable if she chooses to ignore it. Social Services are likely to be informed and they will interview the patient to find out the severity of the abuse. Without using appropriate communication the patient won??™t be able to trust therefore they won??™t share their anxieties and worries as well as any requests and wishes they may have. The National Framework (2009) states that ???The individual??™s wishes and expectations as to how and where the care will be delivered should be documented and taken into account???.There may be a underlying reason for Archie not wanting to go into the nursing home, he may be scared as it??™s a big step, he may think that going into a nursing home means that it??™s the end and that he won??™t have a good quality of life or it could be a financial worry, that he??™s not able to afford the cost of going into a nursing home. The nurse can give him advice on what benefits he might be entitled to, what nursing homes are available next to his son and she will explain that it doesn??™t mean the end of life. Although it is important for the patient to be able to trust the nurse it is just as important for the nurse to ensure that professional boundaries are maintained throughout the care of the patient. NMC (2008, pg 4), states that ???You must refuse any gifts, favours or hospitality that might be interpreted as an attempt to gain preferential treatment???. If the nurse feels that the nurse-patient relationship is over stepping the boundaries, it??™s the responsibility of the nurse to ensure the professional relationship ends. If the patient is still in hospital at this point, another nurse would be appointed to continue with the care with as little disruption as possible. Throughout a nurse??™s career they will be expected to work with numerous health care and non health care professionals these are people who will contribute to the holistic care of the patient, Ellis.S (1999) states that ???The first step in providing patient-centred care (PCC) is an awareness and acceptance of what motivates action and intervention. These fundamental elements are the starting point for providing true holistic care.??? Holistic care is about looking at not just the reasons for the patient being admitted but making sure the patients basic needs are met including washing, brushing teeth, diet and fluid intake and making sure observations are recorded accurately. NMC (2008 pg 8) states that ???You must keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give and how effective these have been???. Every health care profession that??™s involved in the patients care must follow these guidelines, in the event that they don??™t it could cause confusion or a misdiagnosis. As well as basic needs the nurses role revolves around supporting the patient and their families as well as teaching them whether it be about the illness or about improving their lifestyle to prevent illness from re-occurring. They also support colleagues or other members of the multi-disciplinary team and can act as an advocate for patients.As Archie??™s son is implying he wants his father to go into care, the nurse must now take responsibility to ensure no undue pressure is placed on Archie to force his decision. With any patient the nurse must assess capacity, the Mental Capacity Act 2005 states that ???A presumption of capacity-every adult has the right to make his or her own decisions and must be assumed to have capacity to do so unless proved otherwise.??? Archie will need to be assessed by the multidisciplinary team including mental health nurses, doctors and social workers as well as offering the services of Independent Mental Capacity Advocate known as IMCA to determine his state of mind. ???The Independent Mental Capacity Advocacy service was created in the Mental Capacity Act 2005. An IMCA is someone appointed to support and represent a vulnerable person who lacks capacity, possibly because of dementia, a brain injury, a learning disability or mental health needs, who is also faced with certain decisions about serious medical treatment and long term care moves.??? IMCA would be drafted in if the patient didn??™t have any family or close friends that could act as an advocate. ( The IMCA??™s service will be used to speak for and represent patients who they feel are in a vulnerable position and unable to freely express their needs. One simple and straightforward assessment involves a word based question and answer form which can be completed by any health care professional, generally known as the Mini Mental State Examination (MMSE) Cognitive impairment can be measured by using the MMSE as it is a sensitive, valid and reliable tool which is used in many hospital settings to determine patient??™s state of mind (Kaasalainen et al., 1998)??? Pangan V C (2000). Once completed it will give an indication as to the patient??™s state of mind and the ability to answer simple questions appropriately. This is just one of many tools used to determine ability and from this point the nurse must act as the link to facilitate other professionals to become involved and work as a team to carry out their assessments and act upon the information gathered from their findings and also keep the patient informed of everything that is going on. According to Maslen B et al (1995 pg 506) ???Assessment is a skill we all possess in our everyday lives. We continually take in data, usually through our visual and auditory senses, process the data using cognitive ability and previous experiences, assess the situation and adjust our behaviour accordingly???.Older people are generally thought of as vulnerable adults for numerous reasons, ???people are vulnerable whenever their health or usual function is compromised??? . For example, dependency on others to help with daily activities, generally poor health and especially in Archie??™s case although he expresses a wish to go home, patients in hospitals report a feeling of helplessness and that decisions are made for them without consultation. Therefore the nurse??™s link with other multidisciplinary teams becomes vital and the need to oversee and protect vulnerable adults in their care turns into a priority.From a medical point of view the multi-disciplinary team (MDT) must also look at the reasons for the patient??™s current admission and past medical history. In Archie??™s case he has been admitted with a fall, the MDT must now assist the nurses in deciding from gathered evidence, medical tests (assessments) and past medical history whether there is a medical, social or mechanical reason. Medical reasons include urine infection, which can be treated with anti-biotic or it could be as simple as a medication review to adjust any medication Archie may be on, as any of these could cause disorientation which may lead to the falls. Mechanical factors include tripping and/or walking into objects, lumps under the carpet or the floor may be slippery. Alterations to the home and installing a panic alarm could rectify the problems with falling if it was a mechanical reason. Social factors include alcohol consumtion, undernourished, may need eye sight testing, and sleep walking as these can impair judgement. A more sinister reason may be an underlying health problem such as diabetes, Parkinson disease or Alzheimer??™s disease. If it is decided that this is a non new medical onset and is more to do with the patient being unable to cope with living at home then the onus will once again be passed to the nurse and other professionals to carry out more assessments and look to other solutions to the problem.If any member of the multidisciplinary team decided at any point in the assessment process that the patient is at risk either physically or mentally then they can request that the patient be classed as a vulnerable adult and the necessary documentation needs to be completed by whoever states the vulnerable as at risk. Castlelne G (2007) believes that nurses should take more of a lead role in identifying and protecting older people who could be at risk of harm.Leadership equalities of the nurse are effective in planning meetings and organising multidisciplinary team to facilitate assessing the patient, once the nurse organised the medical and social aspects she now needs to identify other needs which can be identified through the assessments of the 12 Activities of Daily Living (Roper et al 2000). This assessment will be done by the physiotherapists and occupational therapists. These teams can help in the rehabilitation of the patient and begin the slow process of recovery and recuperation.A change in a person??™s knowledge, attitude and actions will be helped if they feel good about themselves. Anxiety, self doubt and guilt can have a detrimental effect on where and how they live or where they are looked after. According to Alexander L (2002), ???when health problems strike a person??™s self-esteem can take quite a knock, so it is important for you to help boost their confidence as part of the healing process???. Praise of progress and achievement however small can have a significant impact on self esteem and progress, enabling and empowering people to take control of their environment and their lives can have determine the route they follow for discharge and the planned outcome once they leave hospital.There are a number of factors that can enable a patient to be more autonomous, one factor is making sure that a patient is given correct information about any procedures, assessments or care plans and make sure the patient is consulted every step throughout their stay but can also understands what they are being told to be able to give informed consent. The nurse must make sure the patient understands the benefits, risks, implications and consequences before consent can be obtained. If the nurse feels the patient has been given insufficient information then she will become an advocate for the patient. ???If the nurse does not feel that sufficient information has been given in terms of readily understandable to the patient so as to enable him to make a truly informed decision it is for the nurse to state this opinion and to seek to have the situation remedied??? UKCC guidelines Tinlge J, Cribb A (1995) If the nurse decides not to raise concerns about the patient receiving improper information, again she can be held accountable for her actions. If this is proven the nurse will go before the Nursing Midwifery Council (NMC) which could lead to being struck of the register and be sued for negligence. Wheat K (2009) states that ???Totally autonomous decision-making might at best be aspirational (it can be difficult to provide sufficient resources to facilitate fully informed decisions) but stressing its importance is key to moving away from the old paternalism of ???doctor knows best??™.??? This quote is especially true to elderly patients as they tend to go along with what the doctor wants without really questioning it, therefore its vitally important that a patient??™s rights are promoted and respected, and also explore any unusual thoughts or ideas that an individual may have, encourage people to think for themselves even though this usually takes longer than instilling one??™s own ideas and to encourage people to follow through on their own decisions and resist the urge to make decisions for them. That is why becoming the advocate for the patient if necessary is important as it protects and promotes the patient??™s rights by making sure their decisions are respected. Physically empowering someone through functional activities or mentally empowering someone through assisting with decision making is essential.At this point Archie will need the intervention of the multidisciplinary team involved in his care and a complex string of assessments will need to be undertaken, to determine whether or not he has the functional ability to return home and whether or not he has the mental capacity to decide for himself whether or not it is safe for him to return to independent living.As Archie expresses his desire of staying in the sheltered accommodation, two of the most important professionals involved in the assessing of the patient and his safety are the Occupational therapists and the Physiotherapist.
The role of the Physiotherapist is to treat people with physical problems in illness and ageing, particularly those that effect muscle, bone, heart circulation and lungs. Occupational Therapist role is to assess patient??™s houses to make sure they are safe enough for patients to return to. If the patient??™s home was deemed unsafe, even after alterations were in place and the patient even though acknowledged the risks still wants to live there, the nurse must act in the best interest of the patient and has the power to deprive the patient of their liberty. There is a legislation in place to protect the patient if this was needed ???The Deprivation of Liberty Safeguards is an important new protection for people in hospitals and care homes who may need to be deprived of their liberty in order to protect them from serious harm??? Depriving someone of their liberty is last resort and can only be used if the patient has been deemed incompetent. It will need to be applied for through the council by the person who thinks the patient needs it.Once assessments are completed and evidence gathered the usual process would involve everyone coming together to discuss the care in a case conference where ultimately a decision can be made but further evidence may be requested. The nurse involved in Archie??™s care has a duty of care to Archie not his family. Although the nurse can help make a decision with Archie by advising and supporting him on what will be in his best interest by weighing up the pro??™s and con??™s of staying in sheltered accommodation. Overall Archie??™s decision will be the final one unless he is incompetent, although the patients safety is priority maintain autonomy is just as important. If Archie was proved to be incompetent, the nurse can act as his advocate and try to adhere to Archie??™s wishes; if this is not possible then she must act in his best interest. It??™s important for the nurse to contact all the relevant people for his future care if he is to go in a nursing home. Social Services and IMCA will help, support and assist Archie and his family in the process of him moving to the nursing home.For a patient to be cared for safely, a nurse must have the appropriate skills and knowledge to perform even the simplest tasks. This assignment gives a brief overview of the importance of nurse-patient relationship with communication being one of the key issues, as without using it appropriately the nurse will find it hard to bond and build a relationship with the patient. As discussed all the health care professionals need to work together and communicate not just with each other but with the patient and his family to ensure patients need are met and to ensure they receives the best care possible. Also the importance of using assessment tools to assist in decision making as this helps identify where the patient needs help. It is just as important to document the findings accurately so a true outcome can be achieved. When nurses care for elderly patients many issues are raised mainly the patient being vulnerable, it has been discussed how the nurse has a duty to protect patients and how she protects them. How to safeguard the patient and to promote their rights and autonomy, sometimes it can be difficult as it means speaking up against other professionals if they feel the right information hasn??™t been delivered to the patient but in extreme situations it could mean life or death so it is vitally important for the nurse to have the confidence to speak up otherwise she can be held accountable in the event of something going wrong. The importance of using assessment tools to help identify problems is essential as they can help plan and implement changes to patients care plan and environment. By using relevant resources it was proved assessment tools and using the initiative of professional??™s, patients can go back to living independently. We have discussed the importance of guidelines and codes as they are there to help protect not only the patient but also professionals involved in the care, one being-making sure patient gives informed consent without the pressure of family, professional and non professional people and but the nurse acting as the patients advocate can help assist in any decisions needed to be made. Patients should be awarded every opportunity to live independently and with the help of other health care professionals. Once the patient is assessed we have acknowledged that a care package can be implemented to ensure the home they live in is safe and that adequate changes are made to accommodate the patient. 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