Upon completion of this module, students will be able to:
1. Analyse the influences on care approaches
2. Evaluate theoretical underpinnings and understand how they relate to practice in a given field Ability Outcomes
3. Recognise and respond to an alteration in the condition of a patient/service user from your own field of nursing
4. Apply nursing concepts to nursing practice through the use of a case study from your own field of nursing (adult, child, learning disability, mental health)
5. Demonstrate competence in report writing.
Influences on Care Approaches
Good healthcare services should be: accessible, affordable, acceptable, private, available, appropriate, accurate, confidential and responsive (Schuster, 2014); Ovretveit, (2013) describes quality care as the delivery of care that surpasses the patients’ expectations and achieves the highest possible outcomes using the available resources. The healthcare services are influenced by the technical quality, amenities, interpersonal quality, government policy, and hospital policies. For example, the mental health services are usually given the least priority in decision making by the government. This has negative impacts on quality mental health care services.
The basic principle guiding any medical professional is to treat the patient as they themselves would want to be treated to the best of their knowledge. Francis, (2010) delivered a report on Mid Staffordshire Hospital which showed gross mishandling of patients. The health care providers were not compassionate, they failed to listen to the patients, they did not conserve the patients’ dignity especially the aged and they lacked accountability. This led to the formation of a council that came up with the 6Cs, the compassion in practice.
This framework guides the nurses in the provision of services. The 6Cs: care, competence, compassion, communication, courage, and commitment. The 6Cs aimed at maximizing the patients’ wellbeing, promoting patients’ independence, to improve the health outcomes, to ensure quality care delivery, strengthening and building leadership and making sure the hospital has the right staff, exercising the right skills at the right time, (Cummings, 2012). In addition to the 6Cs; the National Health Services constitution focusses on the patients’ core values, that is, dignity, respect, provision of quality care and compassion (Department of Health, 2013). The nursing and midwifery council, (2015), focusses on the 4Ps: prioritizing people, practicing effectively, preserving safety and promoting trust and professionalism. This report will focus on the patient care using the 6 C’s and a case study of a patient with a learning disability.
The patient is P.D, an eight-year-old second grader who was referred to our facility from a local primary school due to difficulties in learning. The presenting complains from his teacher were that he was a slow reader, often splitting words, omitting words and fragmenting letters. This was unusual when compared to the rest of his classmates who could read fluently. P.D attends school regularly, is hardworking and taught by skilled teachers. He is the third born in a family of three with no familial learning disability, mental retardation or pervasive developmental issues. Both parents are alive and concerned for his academic achievement. He is a social child and relates well with friends. His birth history was medically uneventful as no major issues arose. During his childhood, he attained major milestones within the time frame including talking and walking. No major illnesses occurred except for the minor colds and flu and he had received all major vaccines. He has no visual or hearing impairment as noted by his parents. An impression of learning disability was made with more suspicion of a reading disability (dyslexia). Initial reading and writing tests showed impaired reading speed, difficulty understanding text, gross reading accuracy errors with the splitting of letters, substitution of words and fragmentation of sentences. A diagnosis of reading disorder (dyslexia) was made in accordance with DSM-5 diagnostic criteria and interventions initiated through three sessions per week. This report will focus on the initial week of review where a series of three visits occurred with emphasis on the six C's of nursing care and how they were implemented in the case.
The 6Cs of Nursing Care
In the field of nursing provision of care has to be according to set standards of quality and safety. Quality care is care that is patient-centered, appropriate, ethical and timely. Good care is what defines the medical profession (Cummings and Bennett, 2012). According to the national health service definitions of core values of health, care was specifically mentioned as a core value of the national health service constitution (Department of Health, 2013). Good patient care should have the wellbeing of the patient in mind and ensure positive outcomes (DalPezzo, 2009). P. D’s case demonstrated good quality nursing care. The diagnostic criteria for mental health were followed as stipulated in the Diagnostic and Statistical Manual for Mental Health volume five (DSM-5) (American Psychiatric Association, 2013). This demonstrated the appropriateness of care. The case was highly individualized as is with most learning disabilities.
The management of dyslexia is a multidisciplinary approach with the goal of improving the specific learning disability, emphasizing the importance of a patient-centered approach to care. It was decided that a personalized reading and writing programmed would be initiated, to be implemented in English and it was to take place within the three designated sessions per week for at least an hour for each session. Best care should be evidence-based to minimize error and guarantee quality (Melnyk, Fineout-Overholt, Sitwell, & Williamson, 2010). Evidence supports management of dyslexia following the format of treating the specific learning disorder and psychotherapies to manage comorbid psychiatric conditions common being anxiety, depression and attention deficit hyperactivity disorder (Schulte-Körne, 2010). P.D was enrolled in group therapy with kids with a learning disability to help him cope and alleviate anxiety and feelings of low self-esteem. The dyslexia assessment tests and intelligence measurement for children were followed. Another rubric of quality care is care given at the right time, in the right place by the right people. The treatment of P.D involved the psychiatric nurse, a child psychiatrist, a psychologist and a resident social worker. This ensures no aspect of his management was missed. The sessions were conducted at the department of psychiatry where the atmosphere was friendly. This helped make him feel more relaxed than he would be in a more traditional hospital setting. There were no delays in starting therapy even though the disorder has a chronic course. This ties in with the principle of timely patient care with the patient as the priority. All this was clearly documented in file and electronic form for reference and record keeping because in nursing something not documented is assumed to not be done.
Case Study of P.D
According to Cummings and Bennett, (2012), compassion in patient care involves giving care while having in mind the suffering of your patients and having the desire to change the same. It involves care that takes into account the dignity of the patient, with respect to their humanity and with empathy for their suffering (Bramley and Matiti, 2014). The nursing staff should treat the patient like they would want to be treated if they were patients (Beretta, Braga, & Casiraghi, 2012). Patient dignity is a large part of being compassionate to the plight of patients (Phillip, 2013). Most of the core values taught in nursing revolve around compassion to your patients including human dignity, altruism, social justice, autonomy, and integrity.
There was demonstrated compassion in the assessment and management of P. D’s case all the way from reception, history taking, physical examination, management, and follow-up. The history taking process was non-judgmental and was done in private to ensure confidentiality. The parents who were most alarmed by the learning disability of their child were comforted with the assurance that all the best will be done to make sure the problem was identified. The patient was visibly anxious and disturbed at being taken to a doctor and feared the notion he had of being slow and stupid being confirmed. He was assured that it was an explainable scenario and he would be fine. There was a quick establishment of a good rapport with the patient and with the caregivers by use of kind and patient language. Once the diagnosis of learning disability and specifically dyslexia was made, the patient and parents were called after which the diagnosis was revealed. It was explained that the condition is chronic but manageable and all avenues would be used to help the patient attain the normal learning level of his peers. They were educated on the condition and helped to understand that it is a valid medical problem with valid proven medical interventions. The patient was also treated with respect by letting him choose the best time when he was able to learn and tailor those hours to fit the review sessions. The feedback from the parents was encouraging as they were relieved with the care and had confidence that the nursing staff and the medical team would help their son.
According to Cummings and Bennett, (2012), the nursing staff should have courage in the patient care by being able to do the right thing, at the right time, standing up for the truth in patient care, criticize others and be open to criticism and be able to report bad practice to safeguard the overall patient care process. The national health service constitution has a provision for courage as one of the core values and has added the emphasis on those who cannot stand for themselves to be safeguarded (Department of Health, 2013). Hence all nursing personnel should have the courage to raise issues that they deem vital for patient care (Thorup, Rundqvist, Roberts, & Delmar, 2012). A concept termed positive defiance fits this narrative as it is the defiance of rules when you know you are doing the right thing and standing by the decision (Dobos, 2015). This is done at great personal risk (Price-Dowd, 2017). Personal risk can be a risk of ridicule, falling out of favor with seniors, actual physical risk and in some cases disciplinary measures.
Quality and Safety of Patient Care
Courage was demonstrated in the case management of P.D. Since the management was team focused rather than by an individual psychiatrist, varied opinions arose as to the accuracy of the diagnostic decisions made. One member of the nursing staff pointed out a glaring issue as concerns the diagnostic criteria. In the DSM-IV the spectrum of this disorder is termed learning disorders but in DSM-V as specific learning disorders (American Psychiatric Association, 2013). The diagnostic criteria have overlaps with language disorders and intellectual disability. She was able to raise the issue and the team agreed that although variations occur the DSM-V criteria and ICD-10 definitions would be used. The nursing officer in charge a model of courage, dictating the flow of patients and criticizing nurses under her whenever things were not done in the correct manner. The nursing staff talked to the patient in all honesty and in a manner that was ethically risking psychological trauma and backlash but knowing that it was the right thing to do. They put the patient first even with the risk of falling out of favor with the administration. Another form of courage demonstrated was when the some of nursing staff accepted criticism for not being familiar with the diagnostic criteria for learning disabilities or not knowing updated works such as DSM-V being an update to DSM-IV. They accepted the challenge and the learning opportunity taking that time to know as much as possible about the diagnosis.
Being competent in your field is knowing what is to be done, how to do it, when and by who. It encompasses being knowledgeable and skillful in the care of patients (Garside and Nhemachena, 2013). It can be cultivated by constantly appraising work done, improving on the methods used, continuous learning and using evidence-based approaches to care of the patient (Cummings and Bennett, 2012).
Competency was applied throughout the management of P.D. His case was managed by a team of qualified medical and nursing staff including a mental health nurse, a child psychiatrist, a psychologist and a social worker. This multidisciplinary team allowed for the provision of competent care as no one opinion is implemented without the input of the entire team. The nursing staff was on mandatory supervision and accurate documentation for all work done was required. This was before, during and after each session. The work was appraised and any needed improvements noted. The right equipment to undertake all nursing duties was available as not to undermine any work done. The senior nurse in charge was at the forefront of nurturing competence in her juniors through ongoing learning. Any new information that was encountered had to be internalized and taught to the nurses who did not have a grasp of the concept. Of note was the comprehensive health assessment in psychiatry including mental status assessment, psychosocial assessment, and risk assessment. This was further enhanced by the continuous medical learning meetings (CME) that were regularly organized for the discussion of mental health. Guidelines for the diagnosis of specific learning disability were from the diagnostic and statistical manual of mental health (DSM-V) (American Psychiatric Association, 2013). The patient fulfilled all the major criteria required for the diagnosis of specific learning disability. The care of the patient was evidence-based as the assessment and management were done in accordance with dyslexia guidelines in the annals of dyslexia. This included the reading tests, speed tests, intelligence tests and the management plan (Schulte-Körne, 2010). The patient outcomes also support that competent care was given. In addition to having a specific learning disorder, the patient had co-morbid feelings of anxiety and low self-esteem. By the third visit, however, most fears had been dealt with and the patient had a better outlook of the future having previously believed he was stupid and slow.
Patient-Centered Approach to Care
To have a successful caring relationship and a team that works together effectively, communication is key. Listening is as important as speaking as no decision can be made about someone without their know-how. For a good working place, effective communication is important (Cummings & Bennett, 2012). In the communication process, nurses and nursing staffs play the major role. They assess the patients, record their health continuum, report on the care given to the patient and their reactions to medications. The nurses and the nursing staff handle this information with confidentiality and sensitively. They deal with the patients complains and they report the issues of concern. Quality care is provided to a patient when communication between patient-nurse and nurse-other disciplines is therapeutic (Hinkler & Cheever, 2013).
In patient-nurse communication and in this case, the communication between patient PD and the nurses, it observed the nine communication skills: listening actively, use of non-verbal communication, asking question, being succinct, clear, summarizing, clarifying, being empathetic, providing feedback, developing rapport, trust and being present (Bennett, 2015; Anastasi, 2016; Arnston, Droge & Fassi, 2014).
Quality care was provided to Patient PD who has a reading disorder (dyslexia) because one, there was the development of trust and rapport between him the nurse. The nurse working with him understood his condition making her empathetic. This led him to trust and opening up to her. Two, there was actively listening, as explained earlier, “no decision about me can be made without me.” PD concerns were listened to and acted upon. Three, there was the provision of feedback to him and his parents, especially on his progress. Four, the nurse was able to understand PD’s use of the non-verbal communication. This made their communication to be effective as there was an understanding between them. With this therapeutic communication was achieved.
The patient-relative communication was effectively done. Dyslexia is a chronic condition. Raising a child with a learning disability is a journey. It has challenges that the relatives have to overcome (Guyton, 2015; Hinkler & Cheever, 2013; Barret, 2009). Communication between the nurse and PDs’ relative aimed at counseling them, educating the relatives about the condition, teaching them on how to assist P.D to overcome his day to day challenges. This was achieved through, one, the communication at the appropriate time not when the relatives were stressed out or watching their favorite programs or when they were intoxicated. Two, the communication starts from the known to the unknown, small talks about small things. Three, listening to the relatives’ questions and concerns without interrupting them. lack of interruptions shows that one is interested and respectful of other peoples’ opinion. This made the relatives open up and share more. Four, the nurse helped the family live day by day, bit by bit. Five, the nurse read the relatives non-verbal cues which made her understand them more.
Compassion in Patient Care
The nurse-other health care providers’ communication was effective. Patient care is a multi-disciplinary effort. Different disciplines work together as a team so as to provide quality care to the patient (Adler, 2013). The nurse coordinated the child psychiatrist, the psychologist, occupational therapist and the resident social worker. The teamwork ensures quality care was provided to P.D.
Commitment to the patients and the population at large is the cornerstone of patient care. commitment translates into quality patient care and good experiences of the patients. Commitment is whereby one does the best that they can do, feels happy about it and makes an impact/difference (Cummings & Bennett, 2012). Commitment to patient care focusses on delivering healthcare to the patients that are of high quality. It helps in developing a sense of pride due to our achievements. It also leads to the celebration of the good practices and rewarding the staffs. It helps in developing teams that can manage themselves attaining the needs of the patient. In committed care the staffs are regularly reviewed, this ensures that staffs deliver quality care (Baillie, 2015; Bradshaw, 2016).
- D’s care demonstrated commitment because, one, the team working on his case: nurse psychiatrist, child psychiatrist, the psychologist, occupational therapist and the resident social worker were all qualified and competent. This is because the recruitment process ensures that only the qualified staffs get employed. They also had undergone scrutiny/review ensuring they provide quality care.
Two, PDs nurse was committed to PDs care as holistic care was provided. PD care entailed emotional, physical, spiritual, mental, and social aspects. According to Erick Erickson psychosocial development, PD is at the stage of autonomy versus shame and doubt (Erickson, 1993: Carver & Scheiler, 2014). At this stage, he is expected to make his decision for example on what to wear, become independent. The learning disability is a challenge in the successful completion of this stage. He has difficulty reading, spelling, and has the splitting of words. This hinders social interaction with his peers. The nurse helps P.D in coping with this stress and boosting his self-esteem through making him feel special and loved. Developing a sense of belonging to him. This will make him feel confident.
Three, PD care demonstrates commitment as; the dignity, respect and there is patients’ involvement in their care. The nurse ensures that PD and his family are involved in the treatment. The nurse explains what dyslexia is, the clinical manifestations, and treatment modalities. The nurse listens to the patient and the family questions and concerns and acts on them appropriately. The contacts of the parents and the school were on file and the team talked to them regarding the progress of P.D. Whenever they had a session the nurse was to deal with only one case at a time so that no patient feels unattended to. This was also the case in P. D’s management and it helped foster trust with the management team.
The paper has focused on the care of patient P.D who has a specific learning disorder (Dyslexia). The care used the 6Cs as the framework to assess the care given to the patient. From the above it is clear that the patient care is of high quality, it is compassionate, competent, has the commitment, with effective communication, and the care exhibits courage. This influences his outcome positively. All have been achieved through teamwork; psychiatrist nurse, child psychiatrist, the psychologist, the management and the resident social worker. They all worked together to provide patients care. The nurse coordinated the different disciplines, gave compassionate care, was courageous, competent and committed to patient PD.
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