The Role of the Nurse in the Decision-Making Process when Caring for Patients with Complex Needs - Case Study Example

Patients With Complex Needs Discuss The Role Of The Nurse In The Decision-Making Process When Caring For Patients With Complex Needs Rationale for choice The patients I chose have complex needs because they have several needs which have to be filled and they need regular monitoring and care from the nurse and other health professionals. The needs of the patient shall be outlined below. The physical endurance of patients with congestive heart failure is lower as compared to normal patients. Consequently, their emotional and physiological concerns cause major changes in the quality of their lives. These patients often perceive the quality of their lives based on their health status and limitations in self-care. They also see programs which focus on patient education and disease management as programs which can help improve the quality of their life and decrease hospital readmission rates (Chelho, et.al., 2005, p. 1). Congestive heart failure is a disease which reduces the patients’ ability to care for themselves mostly because of weakness caused by their weaker cardiac and respiratory systems (Hosenpud and Greenburg, 2007, p. 3). It afflicts many patients past the age of 70 and most of them are often readmitted to hospitals because of poor disease management (Hosenpud and Greenburg, 2007, p. 4). The congestive heart patient in this case has the following problems or health issues: activity intolerance caused by lower cardiac output and weakness; possible non-compliance caused by knowledge deficit and low self-esteem; inability to care for self caused by weakness and decreased mobility; decreased social interaction caused by fear, anxiety, and trust; inadequate coping caused by disease process. For the breast cancer patient, she manifests with the following issues or problems: acute pain; body image disturbance due to the significant loss of her right breast; anxiety; fear; imbalanced nutrition at less than the body requirements; impaired physical mobility; impaired skin integrity; ineffective coping; ineffective role performance; risk for infection; and bathing or hygiene and self-care deficit. There are various care models which are available for nurses and other health care professionals. As apparent from the issues enumerated above, the CHF patient has physical, social, emotional, and/or education needs (Anderson and McFarlane, 2010, p. 111). There are various models which focus on different aspects of the patient’s health. For this patient, Lydia Hall’s Care, Cure, and Core Model shall be used as an assessment and care model. Lydia Hall’s model specifies that patients have basically three needs – the physical, the medical, and the social needs (McCoy, 2011). By fulfilling these needs, chronically ill patients can be adequately cared for. This model can be used in order to assist with patient education, management of maintenance medications, and delivery of physical and emotional support. Through medication management and provision of social support, patient hospitalization can be reduced; the patient’s ability to self-manage his disease can be ensured; exacerbations can be prevented; and hospital readmissions can be reduced (Quaglietti, et.al., 2000, p. 259). Lydia Hall’s model provides a framework for open communication between patients and nurses and it has three interrelated elements which refer to medical and clinical management of patients. The care circle of the Hall’s model emphasizes on the intimate care provided by the nurses to the patients – in terms of assistance during bathing, dressing, and in the conduct of their daily activities (Tuohy and Birnbach, 2001, p. 135). In caring for the CHF and the breast cancer patients, the care model of Hall’s framework refers to the hands-on care provided by the nurses to the patients. This care includes the process of providing a relaxing environment for the patients, especially one which encourages open communication and trust between nurses and patients. Through open communication, the patients can express their thoughts and fears about their condition. Opening up about patients’ feelings can help reduce their anxiety (Brunner, Sudarth, and Bear, 2000, p. 24). When patients are relaxed and when they communicate openly with their caregivers and their nurses, they can experience feelings of security; and as they feel more secure, they can also freely express their concerns on disease management and on the emotional and social concerns they are experiencing (Tuohy and Birnbach, 2001, p. 136). In effect, by openly communicating with the patient, it is possible to put them at ease and to develop a trusting and comfortable nurse-patient relationship with them. Consequently, this process would allow them to open up about their emotional and social concerns in relation to their disease. The cure model in Hall’s framework is manifest when nurses perform physical assessment and care management plans for congestive heart failure patients and breast cancer patients (Tuohy and Birnbach, 2001, p. 135). In this phase, the nurses assess the patients’ ability to perform activities of daily living in relation to the physical changes brought on by the disease currently afflicting them. The nurse would therefore monitor the patients’ stress and fatigue level, as well as their respiratory and pulse rate, blood pressure, and oxygen saturation (McCoy, 2011). For the CHF patient, the nurse would also have to osculate the patient’s breath sounds to note signs of crackles or fluid in the lungs (LeMone and Burke, 2004, p. 870). The patient shall also be monitored for pulse strength, oedema, and temperature because he may indicate issues or problems with decreased cardiac output and pooling of fluid in the lower extremities (LeMone and Burke, 2004, p. 870). For the breast cancer patient, her pain levels shall be assessed regularly in order to evaluate severity and duration of pain. Her wound site also has to be regularly monitored for infection. Her management of ADLs shall also be assessed to determine how well she can carry these out without injuring herself. Her emotional and psychological health has also to be monitored in order to evaluate her emotional state, her fears, and her level of anxiety. Her condition predisposes her to anxiety and feelings of inadequacy. For some patients, these feelings can also cause depression (Weiner, et.al., 2003, p. 272). There is a need therefore to assess the patient for signs of depression. Health education is an essential part of managing CHF of patients. Health education increases the patients’ understanding of the disease while also improving their medication compliance. With improved compliance in medications, it is possible to improve disease symptomatology and patient outcomes (Chelho, et.al., 2005, p. 12). Through health education, the patients can also improve their body’s management of the disease. As the patients understand the importance of maintaining a healthy diet, they can also prevent weight gain and ensure their intake of essential vitamins and minerals (Helms and Quan, 2006, p. 745). Moreover, the CHF patient who is imparted with adequate health education can comprehend the importance of informing the doctor if the following symptoms manifest: weight gain, increased shortness of breath, and fatigue (LeMone and Burke, 2004, p. 872). And the breast cancer patient can be educated on symptoms which she may need to refer to her physician. These symptoms may include: chronic and unrelieved pain; signs of infection; impaired mobility; and pain radiating to other parts of her body. In the third model – the core model – the nurses and the patients are already able to express their issues and distress to the changes caused by the CHF and the breast cancer. In these cases, the patients can address their emotional issues due to their ability to manage their disease, to live alone, and due to their fears about the general disease process (Tuohy and Birnbach, 2001, p. 136). An important role of nurses in the healthcare delivery is to assist in the management of the CHF and breast cancer patients through the provision of medical, physical and social care. Hall’s framework covers all these areas and is therefore appropriate for these cases. How, why, and whom were the decisions made? The decisions were made in relation to these patients through proper consultation and proper coordination with the other members of the interprofessional team, as well as the patients and their family members. There is a need to consult with the other members of the interprofessional team because each member of the team has a different expertise in relation to the patients’ care (Jasper, 2007, p. 241). It is important to consult with the other members of the team because their input into the patients’ care is a valuable tool which can ensure holistic patient care. The nurses’ role is to help implement the recommended care for the patient. Her role is to monitor the patients’ condition and help ensure that the patients understand their condition and the care they need in order to prevent the deterioration of their health (Heineman and Zeiss, 2002, p. 5). Her role is to educate the patients about the different signs and symptoms they have to report to the physician. Her role is also to teach the patients about the different ways by which they can work around their condition – like, how to conduct their ADLs without assistance (Heineman and Zeiss, 2002, p. 6). The role of the other members of the interprofessional team is to assess the patients and determine whether or not they can be discharged safely to their homes. The occupational therapist can assess the patients’ ability to carry out their ADLs and to teach them how to manage these activities without assistance (Turner and Johnson, 2002, p. 632). The physical therapist can assess patients’ muscular and bone strength and teach the patients how to strengthen these muscles in order to ensure safe mobility (Smith, p. 2005, p. 456). The physician’s role would be to comprehensively evaluate the patient; prescribe their medications; and ensure that they understand the full implications of their disease, as well as the implications of their home discharge (Turner and Johnson, 2002, p. 700). A psychologist is also a necessary part of the interprofessional team and his role would be to evaluate the mental health of the patients, to counsel them, and possibly to recommend a more comprehensive or in-depth therapy (Smith, 2005, p. 457). Social workers are also a necessary part of the interdisciplinary team because they can provide emotional and moral support for these patients. They can also help coordinate the services which would be needed by the patient in the community setting. They can also monitor the patient in the community setting, making home visits and coordinating with community-based health professionals in order to monitor the progress of the patient and if necessary, to run errands for the patients (Tomer, 2000, p. 232). These errands may include grocery shopping, doing laundry, picking up medicines, cleaning house, and carrying out necessary household chores. The patients’ role is to strictly comply with the medication regimen. Their role is also to evaluate the appearance of signs and symptoms which may indicate a worsening of symptoms. Once these symptoms are detected, they need to inform their physician of the presence of these symptoms (Smeltzer, et.al., 2009, p. 817). Significant others also play an important role in assisting the patients in carrying out their daily activities; in regularly checking in on the patients to assess their needs and condition; and to provide emotional support and encouragement to these patients (Smeltzer, et.al., 2009, p. 817). The decisions are communicated to the patients in the presence of their family or caregivers. These decisions are detailed and carefully explained to the patients using words which are easily comprehensible to the patients and using the patients’ language (Angelelli, 2004, p. 18). The patients are then asked if they understand the instructions and are encouraged to ask questions about the decisions being made. The situation which the patients would face in being discharged shall also be explained to the patients’ family members, in order to express the importance of their support for and supervision of the patients. In establishing a clear understanding of the implications of the patients’ condition, the members of the family may be more inclined to assist in the patients’ care (Angelelli, 2004, p. 19). They may also be encouraged to make the proper adjustments in their lives in order to ensure that the patients have adequate and appropriate care at all times. Decision-making process The decision-making process is informed by the national policy guidelines and ethical considerations. Based on the NICE clinical guidelines, patient involvement in the decision-making process is achieved in two ways. First and foremost, the process of public consultation carried out at the different stages of the clinical guideline’s development ensures that patient stakeholder associations can mould the clinical elements of the guideline (Huisarts en Wetenschap, 2009). Secondly, at least two patient carer members participate in the multidisciplinary guideline development group (GDG). The NICE has a Patient and Public Involvement Program (PPIP) which assists in the recruitment of patient and carer members under the GDG, while supporting them in the guideline development process (Huisarts en Wetenschap, 2009). The decision-making process as guided by the NICE guidelines include the following aspects: identification of issues of concern to patients or carers; reading of summaries on research evidence from patients; making sure that patients’ and carer’s perspectives are included in the decision-making process; and helping produce patient versions of the guidelines (Huisarts en Wetenschap, 2009). The decision-making is also guided by shared decision-making processes. In this case, the sharing is a two-way process whereby consultation and deliberation are made by health care professionals and by patients (Huisarts en Wetenschap, 2009). This shared decision-making process is very much in contrast to the paternalistic model wherein data is given to the patient and deliberation is made by the health care professional. NICE sets forth the shared decision-making process in order to ensure that the clinical guidelines address issues of importance to the patients and health care professionals (Huisarts en Wetenschap, 2009). In effect, the NICE guidelines helped support the shared decision-making process which was applied in the patients’ case. The ethical decision-making process for these patients was guided by four ethical principles, namely beneficence, autonomy, non-maleficence, and justice. The principle of beneficence is basically the principle which specifies that the process of care and decision-making must be made based on what would benefit and what would be best for the patient. More specifically, health caregivers should “prevent harm, remove harm, and promote good for the patient” (Snyder and Gauthier, 2008, p. 11). In the case of the CHF and the breast cancer patients, efforts were made to prevent harm from befalling the patient by teaching him and his family adequate skills and knowledge in the management of symptoms outside the hospital setting. The principle of autonomy was also used in order to guide the decision-making and care process. This principle basically sets forth that the autonomy of the patient must be respected at all times. In other words, “capable patients must be allowed to accept or refuse recommended medical interventions” (Snyder and Gauthier, 2008, p. 11). In effect, the patients in this case were properly consulted on their care and early discharge. Their family members were also consulted and they also agreed to the care rendered in their favour and to the early discharge recommendation of the hospital. The principle of non-maleficence is basically supported by the statement, ‘first, do not harm.’ In other words, the health practitioners must not act in ways which would harm the patient (Snyder and Gauthier, 2008, p. 12). Decisions and health care services administered to the patient must not cause him harm or worsen his condition. For these patients, the care administered and the decisions made in their care did not cause them any harm. In fact, they benefitted from these care and decisions. Finally, the decisions and the care administered to the patient were also guided by the principle of justice. This principle is basically about giving a person his due (Beauchamp and Childress, 2001, p. 54). The justice principle emphasizes that if a patient is due care and respect from medical and other health practitioners, then he should receive such care of the utmost quality. The doctors, nurses, and other health practitioners should therefore carry out their duties as specified in their legal and ethical functions. In the case of the CHF and the breast cancer patients, the appropriate care was administered to them. The quality of care rendered by the different health practitioners were based on their ethical and legal duties. In other words, they received the health care that was due them. Although they had to be discharged to their homes, the care they received while they were in the hospital was based on quality services as supported by legal, ethical, clinical practice, and hospital standards. The psychological considerations made during the decision-making process focused on the mental health of the two patients – in relation to their disease, to living alone, and to coping with the different symptoms of their disease (Ingram, 2009, p. 375). The elderly gentleman’s mental health was assessed and evaluated. He felt sad about his illness but he was not depressed about his condition. He also felt better about being alone and being independent in his daily activities. He felt sad that his life may already be nearing its end, however, he already accepted it as a natural process of life. At times, he felt sad thinking about leaving his children and grandchildren, but he also did not want to be a burden to them. He felt some fear and anxiety about dying and being alone in his house, however, he felt more at ease about facing death and living with his illness in the comfort of his own home. For the breast cancer patient, she was suffering from a significant amount of anxiety and depression. She feared for her husband and children and what would happen to them if she passed on. She was also depressed because of her disease. She was therefore recommended to attend twice weekly cognitive behavioural therapy sessions with a psychiatrist. Moreover, she was also recommended to join a breast cancer support group in order to assist her in coping and living with her illness. The elderly gentleman suffering from CHF has a strong community support system. This makes up the bulk of his social life. He sometimes joins some of his elderly friends during weekend card games. Sometimes, he also joins his friends for community-based activities. Since his mobility was compromised by his CHF, his friends were the ones who visited him – and they carried out some of the card games at his house. The breast cancer patient has a limited social life. Her parents and siblings do not live in the area and she only has a small circle of friends. This further exacerbates her feelings of depressions and anxiety. As a result, the social worker’s assistance was essential in the patient’s care because she was able to coordinate community-based activities for the patient. Referral for ongoing practical support/emotional support/health promotion I referred these patients to the social workers, to the community-based nurses, and the psychiatrist for practical support/emotional support/health promotion. More particularly, I referred the patients to the social worker, to family members, to the psychiatrist for practical support. Practical support came in the form of family visitation, talking with the patients’ children and grandchildren, encouraging the patients to spend more time with the patients and to be more involved in the patients’ care, doing groceries for the patient, running errands for the patients, and providing financial assistance to the patient. The patients were also referred to their family members and the members of the health care team for emotional support. The family members were consulted and the condition of the patients was explained to them. The importance of emotional support for the patients was emphasized to the family members. The members of the health care team – from the physician to the social worker were also consulted in terms of providing as much emotional support and encouragement for their patients. The patients’ religious leaders were also consulted for possible emotional and spiritual support. Both patients were Catholics and were regular churchgoers so their parish priests were contacted and consulted to offer additional emotional support to the patients and their families. In terms of health promotion, all the members of the nursing staff, as well as the community health nurse were recruited for assistance. The members of the nursing staff provided as much health education they could impart to the patient. The community health nurse was also contacted to check in on the patient and help monitor the patient’s progress. She was also asked to continue providing health education and health promotion activities to the patient. This included the conduct of regular exercise and having a balanced and healthy diet. The process of health promotion for both patients was also carried out with the assistance of a dietician who helped come up with a diet plan for both patients in order to ensure adequate and appropriate food intake. The assistance of the occupational therapist was also availed of in order to help train and teach the patients how to safely and properly conduct their daily activities; the assistance of the physical therapist was availed of in order to help teach the patients muscle strengthening activities. At every opportunity, these patients were taught by the medical team the different precautions they had to take in order to prevent the exacerbation and to ensure the favourable outcomes of their medical condition. Rationale/evidence basis of decision-making The decision-making process which was carried out in the care of both patients is based on evidence or research supporting the practice and applications chosen in the delivery of care. In the study by Gibbon (1999, p. 246), the author set out to examine the team processes seen in team conferences in a stroke unit. The study was able to successfully establish that team conferences give opportunity for all members of the team to report on the patients’ progress and suggest on possible alternatives or options of care. The study further emphasizes that team conferences need to be undertaken in order to discuss and consider decisions and to give rise to a sense of team collaboration (Gibbon, 1999, p. 246). In the study by Huby, et.al., (2007, p. 55), the authors set out to evaluate the different ways by which the dynamics of interprofessional work has affected the participation of older patients in the decision-making process in relation to their discharge from hospital care. The study revealed that care routines which focused on the assessments and the decisions flowing from such assessments sometimes did not include the staff or patients in active decision-making (Huby, et.al., 2007, p. 55). The authors emphasized that research and practice in the discharge of decisions have to focus on the organizational context – which affects patients’ and staffs’ interactions. The shared and inclusive decision-making process must therefore be considered and applied on the patients and the staff members in order to allow them to be empowered in their decisions and activities. In yet another study, the importance of patient-centred decision making was evaluated. Ruhnke, et.al., (2000, p. 1172) sought to compare the attitudes towards ethical decision-making and the autonomy issues among community physicians and patients in outpatient clinics in the US and Japan. The study revealed that both US physicians and patients, and a minority of Japanese patients and physicians agreed that patients should be informed of an incurable cancer diagnosis before their family is informed (Ruhnke, et.al., 2000, p. 1172). The study also revealed that patients’ families and physician’s opinions are given a larger role in the clinical decision making by the Japanese physicians and patients than by those in the US. Even as both patients do emphasize on patient preferences – not so much on patient or family preferences, the culture in Japan is very much in a different context and setting as the US culture. It is therefore important for clinicians to respect and consider patients’ cultures and personal preferences prior to the decisions-making process (Ruhnke, et.al., 2000, p. 1172). In effect, this study was able to point out that the decision-making process is a dynamic and often complicated process which needs to be more inclusive and patient-centred. Elwyn, et.al., (2000, p. 892) set out to evaluate general practitioners’ attitudes to patient involvement in the decision-making process. The study revealed that experienced GPs with educational roles had positive attitudes about involving their patients in the decision-making process, as long as the roles were ones which the individuals wished to play (Elwyn, et.al., 2000, p. 892). They also saw clinical issues as appropriate to the cooperative approach to decision-making. They saw involvement as implied in the practice and this should also cover medical practice, so long as clinicians respect patients’ individual preferred roles in the decision-making. This study helped support the process applied in the care of both the CHF and the breast cancer patient – making the decision-making process more inclusive and cooperative. Compare the decision-making process in the two scenarios In both scenarios, the nurses had a great say in the decision-making process. The nurses participated in making decision for the care of the CHF patients, in terms of delivering much needed assistance in the patient’s mobility and health promotion. The nurses also participated in the decision-making process for the breast cancer patient – in terms of delivering health education, assisting with pain management, and teaching patient how to spot early signs of infection. The nurse was able to make recommendations in the patients’ care and to participate in the implementation of these remedies or interventions. Works Cited Anderson, E. & McFarlane, J. (2010) Community as Partner: Theory and Practice in Nursing, London: Lippincott Williams & Wilkins Angelelli, C. (2004) Medical interpreting and cross-cultural communication, Cambridge: Cambridge University Press Beauchamp, T. & Childress, J. (2001) Principles of biomedical ethics, Oxford: Oxford University Press Brunner, L., Suddarth, D., Bare, B., & O’Connell, S. (2000) Brunner and Suddarth's textbook of medical-surgical nursing, London: Lippincott Chelho, R., Ramos, S., Prata, J., Bettercourt, P., Ferreira, A., & Cerqueira-Gomes, M. (2005), Heart Failure and Health related Quality of Life, Clinical Practice and Epidemiology in Mental Health, volume 1, number 19, pp. 1-13. Elwyn, G., Edwards, A., Kinnersley, P., & Grol, R. 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