Free Nursing Essays - An analysis of the management factors influencing a chosen aspect of care for a specific client group during one of your branch practice placements.
Introduction
Nurses are among the largest professional care group within the health services industry responsible for provision of quality care and by moving their clients/patients towards independent and healthy living. The ability to diagnose and treat clients depends on these nurses' professional empowerment. Empowerment derives from professional confidence and nurse's understanding of the concept of inters professional working within a health care system. In the UK the care management greatly relies on nurses' empowerment and their contribution to the health service organization especially for those who have undergone major operations such as total hip or knee replacements. However, care management (that is the management of admission or discharge of patients) have not yet been streamlined in many special care services system creating patient dependence on postoperative nursing and clinical care. Despite the widespread introduction of multidisciplinary services in the National Health Service (NHS) many practitioners require assistance in orienting them to the professional, ethical and client centric working environment. Considering the changing working environment, practitioners like nurses are required to adapt to changes in professional expertise as well as to the humanitarian needs.
Rationale
Care management (hereafter refer to discharge management) is a point in care process where the patient departs from the health service organization and become independent of medical assistance. Deciding whether a patient can initiate independent care without the help of a nurse is a critical decision as it has to be based on empirical knowledge and ethical judgments. Clinical nurse managers make their decisions based on their involvement and understanding of the patient's condition but for learning nurses this is not exactly clear as they do not have enough experience, professional knowledge and involvement in clinical decision making. In care management of total hip or knee replacement, knowledge as well as experience in cases of similar nature is critical for training nurses in making the required clinical decisions. Similarly, for experience nurses have to gather information on case by case basis before making the required clinical decisions. Activities in care management therefore require user involvement, understanding and ethics both by patient and carer.
Analysis
Total hip or knee replacement patients though do not have overall risk of fatal pulmonary embolism nevertheless they require postoperative acute care. According to data of controlled groups of patients on total hip or knee replacement by Scottish Intercollegiate Guidelines Network (2005) reveal that surgery of total hip or knee replacement may be considered as high risk but they have low incidence of fatality. Postoperative care includes routine UFH or LMWH prophylaxis as well as use of antiplatelet drugs to reduce risk of asymptomatic DVT and PE. They require regular monitoring of the INR as well as the increased risk of postoperative bleeding. But more importantly is the fact that postoperative pain relief is not ideal. The problem remains one of the predominant factors for the need in pain management amongst health professionals.
Although total hip or knee replacement surgeries are not as fatal compared to other kinds of surgeries nevertheless intervention carers such as nurses and consultants should understand the driving need for high quality care in pain management and complications development for postoperative patients. Seers et al (2004) indicate in their study through a randomized controlled group that despite efforts in pain management introduction of multidisciplinary pain services in the NHS, postoperative pain remains an issue. Inadequate pain control remains a problem due to inappropriate analgesics. According to Seers et al (2004) analgesics is not a straightforward clinical decision as it requires evidence based guidelines. There are no clear guidelines for practitioners to follow within the dynamic clinical environment.
This seems to be so because of the inter professional setup of the health care organizations. Various teams of experts working on one patient may or may not agree on the duration and extent of care consequently creating delay in clinical decisions and discharge time frame. Experts such as Wondrak (1998) is of the opinion that clinical experience help one understand the inter professional roles of health care workers. Communication with patients is critical to develop a therapeutic relationships as well as enabling them to carry out their tasks in a confident manner. Total hip or knee replacement patients depending on their age group and mental state require personalized care during their hospital stay. However, they also require an estimate of what happens during the discharge process. In cases of total hip or knee replacements, patients undergo pain trauma as well as the dependency on care professionals during and after surgeries. Sarah Mullaly and George Alberti (2004) are of the opinions that patients identify delays in discharge of hospitals are where the standards can be improved. Professionals can improve discharge by ameliorating multidisciplinary teamwork. Reducing delays at all stages of patient discharge as well as predicting planned discharge dates help in setting up treatment plans for patients after discharge as well as allow them to have confidence in independent care themselves. Not only this but multidisciplinary team can make a difference by improving the anticipated length of stay and expected date of discharge of admission; predicting discharge for effective bed management; and deciding patient clinical stability.
Decision pertaining to fit to discharge is inherent in the physiological, social, functional and psychological factors associated with the patient and the multidisciplinary assessments (Mullaly and Alberti 2004). However, in the process care professionals should not neglect the client focus. According to the NMC's Code of Professional Conduct which states that nurses at all times should maintain appropriate professional boundaries in the relationships they have with patients and clients and to focus on their needs. But more importantly, care professionals must respect the patient's decisions pertaining to care. Preferences with regard to nursing should be within the standards of practice and existing legislation, yet it should also achieve the goals of therapeutic relationship, that is to promote and protect the interests of clients in their care irrespective of gender, age, race, disability or sexuality etc. (NMC 2005).
Issues of conflict arise when multidisciplinary teams do not agree on moral, professional and clinical ideologies. According to Thompson et al (1988) professional carers tend to develop conflict with patient needs and their preference. Disregard of patient decisions to clinical choices can lead to difficult decisions and delays in discharge. Total hip and knee replacement patients for example require monitoring visits up to 5 appointments. Some clinicians recommend up to 7 times over a 10 years period of post surgery follow up. Others follow up three times in the first year of discharge. These initiatives are followed with the aim to decrease the workload of the consultants and increase use of physiotherapists. However, sometimes patients develop complications which require the appointment of consultants after discharge. The client's interests and choices here are imperative in making the decision for consultancy and appointments but due to the constraint for time and consultant's busy schedules, patients do not actually get to see their consultants at the desired time frame. This develops rehabilitation needs as well as conflict. Professional carers can help in ameliorating the clinical choices by predicting the degree of care required after discharge and the regularize monitoring appointments. According to a study by Bhatia and Obadare (2003) postoperative complication and intervention based on clinical and radiological assessment should be the platform upon which clinical professionals make decisions for follow-ups. Furthermore, they also indicate that only a 10 percent of patients with hip or knee replacement operations require some kind of intervention with justified visits. Otherwise the intervention usually is required for monitoring purposes only.
Discharge of hip or knee replacement complications however, should be detected earlier for effective interventions. Vevsi et al (1998) indicate that the complications can be minimized if the total follow-up visits are of the duration between 3 to lesser months. Postoperative appointments can help patients understand their condition better and allow care professionals to review the conditions of the patients. It is during discharge process that clinical decisions must be effective as to the transition of postoperative attendants as well as clinical measures for primary care (Birrell et al 2003). In another study Offredy (2002) analysis of decision making in primary care for patients with total hip or knee replacements indicate the new roles and new ways of working to modernize delivery of health service and improve public health. In this scenario nursing practitioners are important in the modernization of the process. Decisions pertaining to discharge and treatment after discharge are baffling for patients or clients as they have to learn to make clinical decisions and become independent of their carers. Nurses can be the critical component to ameliorate decision making process for both the consultants as well as for the patients by explaining to the two groups to think aloud the procedure and justify the diagnoses or treatment plans.
Nurse’s intervention however is dependent on empowerment (Tomey 2000), specialization in technology and knowledge and understanding of patient as an individual (Gorman 1998). Inter professional working require knowledge and empowerment at all levels including nurses to be able to make effective team decisions. In conditions such as those in total hip or knee replacements, modern health care providers have consider multidisciplinary team efforts and success by facilitating communications in teams as well as the role of the individuals within the team and the patient. This kind of amalgamation of efforts develops congenial working relationships as well realize better decision making in a team. Disparity according to Gorman (1998) can only be the result of dysfunctional teams who become responsible for poor quality care and eventually delay in discharge process. Study by James Coles (2003) indicate assessment is the critical process for associated outcomes of total hip replacement patients as it decides the kinds of primary care required and also predict the length of stay for patients. These aspects are important for effective discharge of patients because it emphasize on the efficiency and cost-effectiveness of hospital performance and tied up resources. As part of the management team carers must realize how usage of resources can affect their performance.
Conclusion
From the above discussion and theoretical framework one understands that discharge process starts from the time of admission as it require the accurate assessments of the patient's condition and the required care. Depending on the multidisciplinary efficiency and effective decision outcomes, the patient may or may not have a long duration of hospital stay. Discharge process, if managed effectively can reduce the duration of stay as well as reduce usage of resources per patient. This is achievable if carers understand their roles in the discharge process as well as becoming attuned to patient needs. In total hip or knee replacement cases, patients are not as such fatally at risk but rather they require constant care way after the postoperative surgery to prevent risk of developing complications. Intervention may be required at the consultant's level and review of medical records. To prevent patient from developing such complications, discharge process managers (the team and the carers) should be able to assess the patient's conditions in an effective manner without developing conflicts and consequently reduce medical complications. In this regard objective decision making is required as well as understanding of client involvement. The above aspects of care help the research understand that medical intervention and care does not rest at the admission stage only but also after the patient has been discharged. Effective care is inherent in critical decisions and multidisciplinary assessments and at the same time the realization of client involvement. In fact for any kind of medical intervention, apart from total hip and knee replacements, care should be based on the patient's choices as well as the medical practitioners. Conflict should be avoided when handling patients whether at the admission level or during discharge process to improve care management. This process should be integrated within the Essence of Care guidelines for others to become attune to the required standard of quality care.
References
Author not available, (2005) Prophylaxis of Venous Thromboembolism: Section 5: Orthopedic surgery and trauma. Scottish Intercollegiate Guidelines Network http://www.sign.ac.uk
Bhatia, M. and Obadare, Z. (2003) An audit of the out patient follow-up of hip and knee replacements. Review of Medical Records.
Burnard P & Chapman S (2003) Professional and Ethical issues in nursing. 3rd ed. Edinburgh: Bailliere Tindall
Cannon-Bowers, J.A. and Salas, E.A. 1998. Making Decisions under Stress: Implications for Individual and Team Training. Washington DC. American Psychological Association.
Coles, J. (2003) An assessment of the impact of reduced length of stay on the outcomes of total hip replacement and the associated demands on primary care. CASPE Research, Accessed on 15-10-2005 from: http://www.dh.gov.uk/PolicyAndGuidance/ResearchAndDevelopment/ResearchAndDevelopmentAZ/PrimaryAndSecondaryCareInterface/PrimaryAndSecondaryCareInterfaceArticle/fs/en?CONTENT_ID=4015459&chk=U6jwHG
Department of Health. (2001) The Essence of Care. Patient-focused benchmarking for health care practitioners. London: Department of Health.
Gorman, Paul. (1998) Managing multi-disciplinary teams in the NHS. London: Kogan Page.
Mackenzie J ed.(1998) Organisational Behaviour. London.
Mullaly, S. and Alberti, G. (2004) Achieving timely simple discharge from hospital. Best Practice Guidance. NHS.
NMC Code of Professional Conduct. (2005)
Seers et al (2004) Evidence-based postoperative pain management in nursing: is a randomized-controlled trial the most appropriate design? Journal of Nursing Management 12, 183–193
Thompson, I., Melia, K. & Boyd, K.,(1988) Nursing Ethics. Melbourne: Churchill Livingstone.
Tomey A M (2000) Guide to Nursing Management and Leadership. 6th Ed.
Wondrack R (1998) Interpersonal Skills for Nurses and health care Professionals. Oxford: Blackwell Science.
Veysi et al. (1998) Out-patient follow-up after total hip replacement in one health region. Survey of 33 Consultants.
Birrell et al. Predictors of hip joint replacement in new attenders in primary care with hip pain. Prospective multicentre cohort study.
Offredy (2002) Decision-making in primary care: outcomes from a study using patient scenarios. Scenario analysis.
