Effective Client Assessment: Professional Standards, Ethical Considerations, And Open Disclosure Are Crucial In Essay.

Before undertaking a client assessment, what Professional Standards should you be aware of Effective client-nurse partnerships are essential in a client-centred model of care, with the client assuming a more active empowered role. The success of your client interview and examination is influenced by your awareness of ethical, cultural and spiritual concerns and your ability to create a relationship of trust in a therapeutic environment.  As a nurse you must assess with respect for human dignity and the uniqueness of the client, unrestricted by considerations of social or economic status, personal attributes or the nature of the health problems.  Discuss.

What is the ethical basis for open disclosure Open disclosure has been endorsed by Australian Health Ministers on several occasions over the past decade and it now forms a part of health service accreditation under the National Safety and Quality Health Service Standards (the NSQHS Standards).What are the NSQHS Standards Under what standard is open disclosure in the NSQHS Open Disclosure: A family’s perspective

Mr Silvestro was admitted to hospital with pneumonia and Chronic Obstructive Pulmonary Disease. He lived with his wife in a retirement village and they had strong support from their children and families. While in hospital he had a fall and sustained a fractured femur that was not diagnosed for some time.

Eight days after the fall he was operated on. After the surgery he was transferred to the orthopaedic ward and Mr Silvestro’s daughter asked the nurse looking after him why it took so long for the fracture to be discovered and acted on. The nurse was not sure so she said she would try to find out.

Three days later Mr Silvestro’s daughter again asked for an explanation as to why her father’s operation had been delayed. Because she was upset and angry that she hadn’t received any information or explanation the ward nurse immediately referred her to the Senior Nurse Manager. A discussion with staff from the medical and orthopaedic teams followed. It was decided that the Senior Medical Specialist and Nurse Manager should discuss what had happened with Mr Silvestro, his wife and daughter. The Nurse Manager consulted with Mr Silvestro and his family regarding the need for an interpreter because Mr Silvestro and his wife were not fluent English speakers.

Professional Standards and Ethical Considerations in Client Assessment

The Nursing and Midwifery Board (NMBA) regulates the health professionals such as nursing students, enrolled nurses and the registered nurses. The boards have standards of practice to which the registered nurses are accountable. Nurses should be aware of standard 4 of NMBA, according to which health care assessments should be conducted comprehensively and systematically, analyse the information, interpret data and communicate the outcomes. Nurses must conduct assessment with holistic approach, use range of assessment techniques, work in partnership, determine priorities of action, and inform planning after assessment of resources. The board also sets professional boundaries to guide the interaction of nurses with patients.

As per the Australian college of nursing client centred care is the key to quality health care. It is the philosophical foundation for nurses in all settings that is considering the needs and preferences of patients.  As per the ANMF and NMBA, the enrolled nurses work under direct supervision of registered nurses and must demonstrate the competence in client-centred model of care. ANMF sets national practice standards for nurse’s general practice. This model helps to build therapeutic relationship with clients. As per the NMBA standards for professional and collaborative practice, clients should be respected irrespective of culture, religion, ethnicity, values, and beliefs, physical and mental state. These standards ensure that during care or assessment the patient’s respect and dignity is maintained.

It is the national policy document that facilitates open communication between patients and clinicians/health care organisations/health care providers in both public and private hospitals. This document provides consistent platform for open disclosure when the health care does not go with plan. This framework helps in discussing with patients openly about the incidents or care that led to harm. It includes expression of regret or apology, narration of incident with factual explanation, potential consequences, way it was managed and preventive steps. The framework provides opportunity to the patients and the supporters to ask questions and get answered from the care providers.

The elements of open disclosure are-

• Open and timely communication with patients about the harm caused to them during care
• Acknowledgement of the adverse event and initiation of open disclosure
• Apology or expression of regret- for the harm caused and use of word “sorry”
• Supporting, and meeting the needs and expectations of patients, their family and carers- meetings clients expectation to be informed, treated with respect, dignity and empathy
• Supporting, and meeting the needs and expectations of those providing health care-
• Integrated clinical risk management and systems improvement- quality improvement activity to be ensured
• Good governance- system of accountability and incorporation of appropriate changes to prevent future harm
• Confidentiality- privacy of health records to be maintained

Clinicians have ethical responsibility to communicate honestly with patients and their family. It is important to improve the patient safety. The hospital staffs have ethical responsibility to support their fellow care workers during adverse event. It should be well balanced with elements of openness and transparency. Any discussion with the client must occur in regard to ethico-legal requirements related to privacy and confidentiality of clinicians and patients.

NSQHS Standards were developed by the commission with the aim to improve the health care service quality in Australia. The standards indicate the level of care that a care user can expect from the health care organisations. These standards provide consistent statements and focus on ten areas.

The Ethical Basis for Open Disclosure and the NSQHS Standards

The first standard of NSQHS Standards deals with the Incident and complaints management. As per this standards, maintaining the open disclosure is mandatory for the clinical workforce.

The characteristics of the effective partnerships are communication, coordination, collaboration and integration. Effective communication includes where each patient or health care member shall be inform about the action and coordinate with each other actions. Partnerships should work cohesively and must work together as one unit.  

Having the knowledge of “Core Standards for nurses who support people with a disability (NSW Family and Community Services)”- Would help the nurse to express the family about the delay in the operation  and engage in repetitive  communication regarding the  incidents after fall of patient. It would have helped her partnerships well with the family and interpret the health information. There would have been professional supervision after fall and ensured safe service delivery approaches. It would have enhanced the behaviour support.

Having the knowledge of “Communication and Behaviour Support for Nurses Practice Package Communication and Behaviour Support for Nurses Appraisal”-  Would have prevented the nurse from failing to give adequate behavioural support to the patient’s family after fall. This knowledge would have increased the skills of the nurse in  explaining how the “communication and behaviour support skills” can improve patient outcomes. Thus, the patients daughter would have received her answers in first attempt from the nurse instead  from nurse manger.   

The effective communication skills that were used in the scenario was nurse immediately referring Mr Silvestro’s daughter Senior Nurse Manager. It was followed by discussion with Senior Medical Specialist that satisfied the queries of the family. Further, use of the medical interpreter used in this case ensure effective communication as it eliminated the language barrier.    Open disclosure of the patient’s delay in surgery was also effective communication

Factors that are a barriers (inhibit) effective communication are- cultural sensitivity, language barriers, poor communication skills of the nurse and failure to integrate the information. National Boards regulating registered health practioners in Australia defines social media as the tool that helps people share information, experiences, information, video clips, audio images and websites or applications for social networking  

The enrolled burse must-

• maintain the confidentiality online,
• avoid defamation
• Do not cross the professional online boundaries  
• Maintain privacy using safety measures  and report the concerns

In relation to my role in social media, my roles and responsibilities in social media and information technology is to avoid use of authorised photographs of the patients, avoid defamation, and maintain the privacy and security of the social media account and confidentiality of the fellow workers and patients.  My responsibility is to consider the regulation regarding advertisement and evaluate all the postings on social media.

Effective Communication Skills and Barriers to Effective Communication

I will ensure documenting the discussions with the patients on social media abuse. I will ensure reporting of the incident with factual discussion where the health care delivery was questionable at individual delivery system. Documenting and reporting of unethical, incompetent, illegal or impaired practice by other fellow nurses. Documenting and reporting to supervisor or designated person on the  event where the privacy was threatened and the patients health and welfare was at stake.  

In the clients of dementia the depression is very common. It is found in 40-50% of the people with Alzheimer’s disease.The non-pharmacological interventions are instruction given to patent’s wife on behavioural management of agitation and aggression.The patient and his wife was encouraged to contact the Alzheimer’s Association for caregiver support group.

Other nursing interventions to be considered are engaging patent in mindfulness activities counselling and social work support. Nurse can advocate by enhancing the patient-caregiver interaction, acknowledge the patient's emotions and employ strategies of distraction. The principles of interdisciplinary team are- cognitive assessment, implementation of Assessment Results into Care/Service Plans, education of the consumers, quality assurance, coordination and collaboration among team members,   

The team members that may be providing care for clients are-

• Nurses
• Social worker
• General Physician
• Dietician
• General physician
• Hospitalist
• Psychiatrist

The effective communication skills that assist in keeping the focus on the client and/or carer are-

Active listening,

Verbal skills

Non verbal skills such as eye contact, body language

Interpersonal relationships through empathy, sensitivity and cultural awareness

Asking open questions

Skills that demonstrate listening:

Respond to queries, listen and paraphrase what client said, ask for repetition where necessary, reflect, acknowledge, empathise, summarise the information and checking

Skills that assist with information giving-

Assess the patient’s knowledge,

Give small information avoiding jargon

Avoid unnecessary details

Pausing and waiting for a response

Check the effect of information  

The role of the nurse as advocate is to collaborate with doctors to find alternate solutions for treatment, educate patient about illness, explain the diagnosis to the patients, communicate with patients, family and doctors about the best treatment and represent the patients about the difference in the   wishes of the patients to that of doctor.

I will review the risk of future fall and explain the patient empathically about factors that can prevent further injuries.  I will ensure comfort and patient centered care to prevent anxiety and panic. I will talk to the patient politely to explain her about any irrational thoughts and assure that the pain will be resolved within weeks. I will explain that nothing is dangerous and fall is preventable.   

As a enrolled nurse I will openly disclose about the factors that caused the fall and apologise for not supervising on time. I will explain the strategise being taken to prevent future fall.

Quality documentation will include the reflection of nursing assessments, changing state of patient’s health, care given, patients medical history and current situation, real time progress notes as adverse findings, patient outcomes after interventions, Family centred care (family participation in care) and social issues associated with it.

The meeting procedure involves conducting the meeting when scheduled and discuses the prepared agenda, communicate powerfully, focus discussion (meaningful conversation), and redirect the negativity, follow up and distribute the minutes of meeting. Meeting would involve disseminating important information and in compliance with the policies and procedures at workplace. Meeting may include respecting everyone’s ideas and  conflict resolution skills to address issues while maintaing harmony and supporting the arguments with facts.

Nursing student receives constructive feedback is essential to boost the morale, encourage the teamwork, and support career progression. Constructive feedback ensures that the efforts and the contributions of the nurse is valued.    

I will ask for constructive feedback by writing letter to my nurse manger and explain how the feedback will help me better focus on my profession. I will explain that I am committed to deliver quality care and that would need awareness of personal strengths and weakness. I would emphasise on team work and cooperation in nursing and how feedback can help me oblige professional instructions.

Debriefing will be conducted within 48 hours after a critical incident. The procedure will include addressing the shortcomings identified by any care giver or respondents. The procedure involves discussing specific clinical aspects of situation. Depending on the severity the social workers, and counselors. The elements of debriefing includes emotions, analysis,  application and summary.

The NMBA standards for registered nurse guide the Debriefing procedure in Australia. The Ninth standard of NSQHS Standards deals with the “Recognising and Responding to Clinical Deterioration in Acute Health Care” highlights debriefing as part of the outputs of improvement processes.