Activity 1.1 pg 5
If you were asked, ‘What is nursing and what is a nurse?’ what would you say?
Nursing is an activity which involves caring for individuals at a time when they require physical, psychological, social, emotional, intellectual and spiritual support. The act of nursing can be carried out by many different members of society, such as parents, relatives or friends. Professional nursing can be best described as a caring role focusing upon the care of adults, children, families and/or whole communities, providing care and support.
A nurse is an individual who has achieved a national regulator’s (such as the NMC) standards of competence in a wide range of practical skills which they can support with a relevant and contemporary knowledge base, who works in partnership with a patient, their family or a group of patients, to meet their physical, psychological, social, emotional, intellectual and spiritual needs.
Activity 1.2 pg 11
List ten behaviours expected of a nurse.
Which three of those on your list do you think are the most important for a nurse?
4. Communicate effectively.
6. In partnership with others.
10. Appropriately dressed.
This list is far from exhaustive and you may have identified a range of other items. In my list the first three, honesty, compassion and knowledge were the ones I would say were most important. Discuss your thoughts with your lecturers, other students on your course, mentors and patients to investigate their views.
Case Study: Amina and Dave pg 19
Amina and Dave have to remember that they must uphold the NMC (2011) Guidance on professional conduct at all times, not just whilst they are on placement or in class. Their actions of drinking alcohol in a bar and putting red dye and washing-up liquid in the fountain in the university square, whilst wearing their nursing uniforms, does not uphold the reputation of their profession. A nursing uniform should only be worn when on duty caring for patients, and whilst it is not an expectation that nursing students and registered nurses never drink alcohol or have fun with their friends, they must always remember that their actions may be seen by members of the public who will expect them to act in a responsible manner. To become a registered nurse and remain so all nurses must abide by the NMC Fitness to Practise regulations, so it is essential to ensure at all times that your conduct is professional.
Activity 2.2 pg 20
Due to his duty of confidentiality Sameer cannot disclose any details to the mother. However, as she is showing concern it would be entirely appropriate to assure her that the child is being well cared for. If Sameer felt he did not know how best to answer these questions he should ask his mentor’s advice so they can work out together exactly what to say.
Activity 2.3 pg 22
It is very common to be concerned before starting a new placement; mentors will expect this and remember the feeling from when they were student nurses. Connie should be proactive in managing her learning, sharing the fact that she is dyslexic with her mentor and telling them that she finds it difficult to remember all of the information relating to the patients she is caring for, and, when it very busy, she worries about forgetting what she has been asked to do. Connie’s mentor will be able to help her develop her abilities in these areas and suggest that they apply strategies outlined in the RCN (2006) toolkit.
Case Study: Billie pg 24
Billie must tell her university what has happened, firstly because her ability to act as a professional is under doubt and secondly because it is likely that she has already signed an agreement with the university (at the start of her course) saying that if anything such as this occurs she will tell them.
Whilst it could be considered that Billie has already failed to abide by the principles of the NMC (2011) Guidance on professional conduct by driving under the influence of alcohol, not informing her university of the situation further fails to uphold the principles, as she then is also not being open and honest. These circumstances are very serious and it is likely that her university will review her case in light of the NMC Fitness to practise regulations, to ensure that she is fit to remain on the course. As long as Billie’s conduct has been exemplary apart from this incident it is possible that she will be given a formal warning but allowed to continue.
Activity 3.1 pg 31
Guidance from recognized authorities
Department of Health (DH), National Institute for Health and Clinical Excellence (NICE), World Health Organization (WHO)
Guidance from professional organizations
Nursing and Midwifery Council (NMC), Royal College of Nursing (RCN)
News and media
The BBC, The Times newspaper
Peer reviewed, research based
Non-peer reviewed, based on opinion
Activity 3.2 pg 32
Peer reviewed, research based
Guidance from recognized authorities or professional organizations
Journals, books, expert views, reflection
Non-peer reviewed, based on opinion
News and media, Information websites, Blogs, Own views
Journals and books can be based on either research evidence and subjected to extensive review by a group of knowledgeable experts, or the personal opinion of the author and not reviewed. This has a huge impact on their trustworthiness.
Journals are likely to be more up to date, as it takes only a matter of months for a journal article to be published. Books take considerably longer than this.
Guidance from recognized authorities and professional organizations is likely to be based upon research, so should be a trustworthy source, but you will need to ensure this is the case.
Expert views, news and media, blogs and your own views all have a similar problem. They are based upon the perspective of only one or maybe a few individuals. This means that they may be anecdotal, based on hearsay or myth. While what they say might be very relevant, you will need to confirm this with a more reliable source.
Information websites, such as Wikipedia, are very convenient and easy to use. However, there is one big problem, which is that anyone may add information anonymously to such sites. This means it is possible that information is incorrect. While peer-reviewing systems may exist with these types of sources, they may not be sufficiently robust to ensure information is trustworthy.
Activity 3.3 pg 34
Which type of research, qualitative, quantitative or mixed methods would answer these research questions most effectively?
How many jelly babies can a student nurse eat before they are sick?
Quantitative, as numbers would best answer ‘how many’.
Is the most effective analgesic always the one patients prefer?
Mixed methods, as numbers would tell you which was ‘the most effective’ and words would be important in finding out ‘the one patients prefer’.
Do patients think nurses should wear hats?
Quantitative, as the answer to this would be yes, no or unsure, so you could answer the question by finding out the percentage for each response.
What do student nurses enjoy most in the first year of their course?
Qualitative, as words could best be used to answer ‘what do’, but if you also wanted to know whether student nurses enjoyed the same thing or whether there were differences, a mixed methods approach could be used.
Case Study: Alex pg 42
Alex had intended to start work on her nursing care study in good time, but ended up leaving it rather late. She found some relevant material on various web sites, and then cut-and-pasted this into her essay. She intended to go back and put this material into her own words, discuss and apply it in the light of her chosen patient, and tidy up the references. But the submission deadline loomed and she handed it in as it was.
- Why is this poor academic practice?
- How would a marker detect that there was a problem with Alex’s work?
- What can Alex do to improve the quality of her work, and avoid the risk of being accused of plagiarism a second time?
Why is this poor academic practice?
- This is poor academic practice because Alex:
- has used unvalidated web sites, rather than academic text books and journals;
- has cut-and-pasted verbatim (word-for-word) quotations into her essay, thereby failing to demonstrate comprehension and application of this material;
- has not acknowledged her sources properly.
How would a marker detect that there was a problem with Alex’s work?
The marker might:
- notice one or more changes in style or formatting within the essay;
- observe a lack of application to nursing practice, and of reflection on Alex’s own clinical experience;
- discover, by running strings of text from the essay through an internet search engine, that Alex had used inappropriate or poorly referenced sources;
- take advice from one of the University’s Plagiarism/Academic Integrity Officers;
- seek to confirm any suspicion of poor academic practice by running the essay through text-matching software (in accordance with the University’s policy).
What can Alex do to improve the quality of her work, and avoid the risk of being accused of plagiarism a second time?
- Alex can improve her work by:
- devising and working to a study plan that will ensure that she allows sufficient time to prepare her academic work;
- keeping a careful note of the various sources she uses in preparing her essays;
- using the resources provided by her University (including her Personal Adviser and support provided by the Learning Enhancement Service). These will help build her confidence and skill in preparing and writing academic essays;
- using a publication such as Cite Them Right (Pears & Shields, Palgrave Macmillan, 2010) to check that she has referenced her work appropriately
Activity 5.1 pg 67
Some of the possible sources of information nurses might use include – the Code of Conduct and Ethics (NMC, 2008), other relevant documents produced by the NMC, national policies, local policies, legislation, experienced peers, patient groups, multi-cultural groups and literature.
Activity 5.2: Reflection pg 67
It is difficult to provide a definitive answer to this question since by definition your personal values will be individual to you. However, some of those you might have identified could include equality, justice, fairness, truthfulness, compassion, honesty, respect, integrity and trust. You will probably have identified that your values have developed as you have matured and have been influenced by a range of factors such as your family, your education, religious beliefs, personal experiences and the media. When comparing your values with those you held when you were fifteen this will probably depend on your current age – the more experiences we have the more we are exposed to different views and perspectives and this may influence our values. This is also true of your period of nurse education as even if your core personal values remain you may find them challenged at times and, in some instances, they may change.
Case Study: Gemma pg 70
It is possible that Gemma’s personal experiences and values have sensitized her so that she is more aware of these comments but as a nurse she is required to provide care in a non-discriminatory even manner and so in this instance her personal beliefs should concur with her professional beliefs.
This can, however, mean that she finds it challenging to provide care for people who express views such as these but her professional values require her to (to do otherwise would be discriminating against them).
Case Study: Peter pg 72
The principle of consequentialist ethics appears to be invoked here. However there is no consideration of the possible consequences that may emerge. For example does the CPN consider the issue of trust that may be broken if people think they may be coerced? The principle of autonomy is being violated here. Furthermore the principle of doing no harm (non-maleficence) is also being violated in the way in which Peter’s wishes are being ignored without concern for how he might feel.
Given that a person who experiences depression is likely to suffer from low self-esteem and may even be thinking about suicide, telling that person that he is letting everybody down is not the best way of supporting him. A more appropriate response would be to engage Peter in discussing what he wants to achieve and how he wants to achieve it. If he is unhappy with the anti-depressant what would he be happy to do? A transparent approach would also include Peter being told that any involuntary intervention would only be applied under the circumstances that would meet the criteria for treatment under the Mental Health Act and are not the sole decision of the CPN.
In applying Rowson’s framework the multi-disciplinary team might:
1. Consider whether the Mental Health Act applies in this case. Furthermore the nurse must act in accord with the NMC code.
2. Assuming that Peter does not meet the criteria for treatment under the act next consider the principles that might apply. Consequentialism would ask the nurse to consider fully what the possible outcomes of any action might be. This chimes with beneficence and would require the nurse to attempt to bring about a good outcome. The principle of autonomy would dictate that Peter’s wishes must be adhered to as much as is possible. Non-maleficence requires the nurse to attempt to do no harm.
3. Professional guidelines might suggest that the nurse seek clinical supervision to assist in reflection upon the issues raised. Furthermore the nurse would need to document all decisions and rationales for decisions in Peter’s care plan. The nurse should also reflect on whether any particular decisions are based on the nurse’s own personal preferences rather than Peter’s.
4. Assuming that the nurse has taken into account the issues in 3 it is unlikely that any adjustments to professional guidelines or rules of thumb might be made.
5. If the nurse decides that outcomes relating to Peter’s safety might be compromised by respecting his autonomy then the most pressing concern would be safety. Should this be the case then any involuntary approach must be mediated by consideration of Peter’s wishes as soon as is practicable either from Peter himself or the involvement of an advocate.
6. The breaching of any principle of autonomy would be mediated by involving Peter in what happens next and by helping him to express his wishes for now and in the future.
Having considered 1–6 the nurse could reach a decision.
Activity 6.1 pg 80
1. Would Roshan’s liability be increased if she was a third-year student nurse, only a few weeks from qualifying?
It is reasonable to expect a higher level of knowledge and skill from a third-year student nurse than that of a first-year student, but Roshan remains unqualified at this point. In consequence, the professional standard (i.e. the Bolam test) does not apply and will not come into play until she has been admitted to the Register. It should be emphasized, though, that this standard applies on the first day that Roshan qualifies and no allowances are made for inexperience (see Wilsher v Essex AHA  1 All ER 871 [HL]). The reasons for this are that every patient is entitled to a reasonable standard of care from every qualified nurse, regardless of their length of service. The moral of this story is that every nurse should ensure that s/he is competent before undertaking any task, and should be supervised by an appropriate senior colleague until this competence has been achieved.
2. If the healthcare institution looked after small children, people with severe learning disabilities, patients with reading difficulties, or blind people, what purpose would be served by a wet floor warning sign? What other measures would one expect to be in place?
The simple answer to this question is that a warning sign would only be of use if the people to whom it is addressed can read and understand it. Clearly, it would have no such value to the groups mentioned here, but the healthcare institution retains liability for their safety. Under the Occupiers Liability Act 1957, it is stated that an occupier (in this case, the healthcare institution) ‘must be prepared for children to be less careful than adults’ (s2 (3)). By logical extension, the same extra precautions are expected for other groups of people where the risk of harm is reasonably foreseeable.
The form that these precautions take may be context- and situation-specific, but at the very least the area where the floor is wet should be cordoned off so that it is difficult (if not impossible) to enter it. Ensuring that only small areas of the floor are made wet at any one time will go some way to reducing the risk. Similarly, if it is possible to dry the floor immediately (rather than merely allow the moisture to evaporate), this too will eliminate the hazard. Perhaps most importantly, the area should be closely monitored by a member of staff while it remains a hazard so that patients or visitors can be given an appropriate warning whenever they approach it.
Activity 6.2 pg 83
What strategies could you use to enhance Joe’s understanding of why he was not being allowed to go home?
Nobody should be under any illusions that this is going to be easy, and it probably represents one of the most advanced skills required of a nurse. Equally, when performed well, it can be extremely rewarding. The first step must be to attempt to establish a rapport with Joe so that he develops trust in you. The nurse should therefore talk to Joe in a calm reassuring manner, using simple straightforward language. It is also vitally important that Joe is listened to whenever he speaks, for this will give some clues to what is distressing him and what he would like to do. The expert on communicating with Joe, of course, is going to be his mother, and she will be in the best position to tell you what works, what does not work, and what certain behavioural patterns exhibited by Joe might mean.
Beyond this, there are several communication aids that are available to assist with this process. Perhaps the best known of these is Makaton, which is internationally recognized and which uses speech, signs and symbols. In addition, there are a variety of software applications that have a large library of photosymbols. Needless to say, these aids all require the training of staff before the latter can be considered competent to use them, but enhanced communication with Joe will go a long way to reducing his anxiety.
Activity 6.3 pg 84
What forms of physical restraint do you think are acceptable (if any) when dealing with confused, restless or aggressive patients?
For those patients sectioned under the Mental Health Act 1983, legal protection against prosecution in the criminal courts or litigation in the civil courts is afforded to healthcare professionals who physically restrain them ‘unless the act is done in bad faith or without reasonable care’ (s139). Similarly, the Mental Capacity Act 2005 acknowledges that restraint may be necessary for incompetent patients, provided that it is ‘a proportionate response’ (s6). No definitions of ‘reasonable’ or ‘proportionate’ are provided and it would be unfair to expect that they would be, given that each situation will be unique. Nevertheless, we could perhaps say that the level of restraint to be applied should be the minimum necessary to achieve the desired objective.
The Royal College of Nursing (2008: Let’s talk about restraint: rights, risks and responsibility) outlines a variety of measures that have been employed to restrain patients, including physical, mechanical, chemical and psychological methods. The key point to remember here is that they should only be used as a last resort (i.e. when all other strategies have failed), and that they should not be allowed to develop into the norm. The Department of Health (2008: Code of Practice: Mental Health Act 1983) states that restraint ‘must never be used as punishment or in a punitive manner’ (para. 15.8), and the best interests of the patient should always remain the top priority for healthcare professionals. The RCN (2008) goes on to say that ‘... a combination of well-considered environmental features and a workforce that has developed person-centred care reduces the need for inappropriate restraint’ (p4), and this should be the ultimate goal for nurses.
Activity 6.4 pg 85
- If you felt very strongly that the quality of care on a ward was unacceptably low, to whom should you report this?
Questions of this nature reflect an overlap between the concepts of Confidentiality and Whistle-blowing. There is a duty to report concerns about the quality of care, and the individual who does nothing simply becomes implicated in the wrongdoing. Equally, however, it is important to tell only those who have the means and ability to correct the situation. This does not, therefore, mean that the press or the public should be the first recipients of this information. It is a matter of some debate as to who should be the first point of contact. Ideally, I feel that this should be the manager of the ward, for it is the more open and honest approach. However, the position of the whistle-blower remains a perilous one and you can quickly be branded a trouble-maker if this situation is not handled with sensitivity (despite the fact that the Public Interest Disclosure Act 1998 gives protection to those who are victimized as a result of disclosing information in the public interest). In consequence, it may be preferable to involve your personal tutor. It is reasonable to assume that healthcare institutions should give more attention to such concerns following the publication of the Francis Report (2013) into the scandal at Mid-Staffordshire NHS Trust, but there are no guarantees of this. In consequence, it would be advisable to keep records of any correspondence that you have sent or received concerning this matter. In this way, you will be able to show that you have done all that you could reasonably be asked to do.
- If a patient had severe learning disabilities and no relatives, would a breach of his or her confidentiality cause him any harm?
A patient with severe learning disabilities lacks autonomy and is therefore unable to enter into a relationship of confidence. Similarly, it is extremely unlikely that any harm (psychological or otherwise) will be experienced by this patient if his medical details are divulged to others. Nevertheless, every patient has general privacy rights, and such rights extend to children, the unconscious, and the dead. In consequence, if information is to be divulged, it will be justifiable only if:
- It is in the patient’s best interests.
- The information is limited only to those who have a need to know and who are therefore in a position to serve those interests.
- It is the minimum necessary to serve the patient’s interests.
The legal penalties for breach of this patient’s confidentiality seem unlikely, but disciplinary measures remain a strong possibility and healthcare professionals should be mindful of this.
Activity 6.5 pg 86
Do you think patient confidentiality is more a myth than a reality? What can be done to ensure that patients’ medical details are kept safe while ensuring there is good communication between the individual careers invloved. How will this promote holistic care of your patient?
Given that healthcare today is a multi-disciplinary team effort, it is inevitable that patients’ medical details will be seen and shared with a large number of people. This is necessary to ensure that appropriate and optimum care and treatment are given, but it puts the concept of confidentiality into perspective. The fact that all healthcare workers (whether qualified or unqualified) are bound by a contractual duty of confidentiality may not be sufficient to allay patient fears or anxieties. Nevertheless, not only is there an individual responsibility to uphold confidentiality, but also every NHS organization has a corporate responsibility in this regard. The Caldicott Report (1997) clarified this responsibility by enjoining NHS organizations to uphold the following principles:
- If confidential information is required, there should always be a justification for this purpose.
- Patient-identifiable information should only be used when it is absolutely necessary.
- When patient-identifiable information is required, only the minimum necessary to achieve the desired purpose should be used.
- Access to patient-identifiable information should be on a strict need-to-know basis.
- Everyone who has access to this information is under a duty of confidence.
- Everyone should understand and comply with the law.
Assessments of compliance with this process are made on an annual basis and Trusts are expected to show year-on-year improvements. This alone should demonstrate the seriousness with which the NHS approaches patient confidentiality and how complacency is to be avoided.
Activity 7.1 pg 93
The skills you may not do as a student will vary across the country and in part depend on local Trust policies as well, it is therefore important to check locally, but your list may include:
- IV drug administration
- Administer a drug under a patient group directive (PGD)
- Skills such as cannulation, checking blood transfusions, using a glucometer and male catheterisation may only be possible if you have attended the relevant training session run in the placement or for some organisations students may not be allowed to do them regardless.
- Lone visiting of patients/clients in their own homes particularly for a 1st or 2nd year student.
Case Study: Safeguarding and Confidentiality pg 98
Your response will depend on how serious the breach of confidentiality in the post was and it may be that a quick word will be all that is required about being careful in what that person posts in future and asking for the post to be removed. However, more serious breaches of the code may need to be discussed in confidence with someone in your university who will be able to advise you. This would relate to:
- Breaches of confidentiality about a patient/client
- Raising of concerns about something seen in practice
- Making complaints about colleagues
- Evidence that another student is making contact with a patient/client outside of work
- Individuals being bullied
- Photos of patients/clients
This list is not exhaustive and if in doubt always talk to someone in the university about your concerns.
The Code: Standards of conduct, performance and ethics for nurses and midwives (2008):
- You must provide a high standard of practice at all times (preamble)
- You must work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community (preamble)
- You must act as an advocate for those in your care, helping them to access relevant health and social care, information and support (paragraph 4)
- You must respect people’s right to confidentiality (paragraph 5)
- You must consult and take advice from colleagues when appropriate (paragraph 26)
- You must make a referral to another practitioner when it is in the best interests of someone in your care (paragraph 28)
- You must act without delay if you believe that you, a colleague or anyone else may be putting someone at risk (paragraph 32)
- You must uphold the reputation of the profession at all time (paragraph 61)
Activity 9.1 pg 116
There is no right or wrong answer to this question. This question is reflective in nature and asks you to think about how new ways of working will enable patients in your field of nursing to access the care they require.
Activity 10.2 pg 131
Each country has a different set of standards:
England – has 24 standards of which 16 (the essential standards) relate directly to the quality of safety and care.
Northern Ireland –have standards with five quality themes, which are broken down into a series of criteria.
Scotland – has one overarching standard with five evidence-based clinical governance and risk management domains.
Wales – has 28 standards.
While they vary they can be grouped under five headings: patient focus, information focus, quality improvement, staff focus and leadership (RCN, 2013).
Activity 10.6 pg 134
The statements in the NMC’s Guidance on Professional Conduct for Nursing and Midwifery Students (NMC, 2011) that are particularly pertinent to your role in ensuring quality are:
Nos. 28–38, 46 and 49–51.
Case Study: Katie pg 146
Katie is ten years old and attends her local primary school. She was sent home from school because she was complaining of a sore tummy. Her mum took her to see her GP and he advised that Katie should be admitted to hospital. Katie has been diagnosed with appendicitis and you have been asked to help prepare her for theatre.
Using the information within the ‘Patient and Student Voices’ at the start of this chapter, what do you think is important to consider in delivering effective care whilst you prepare Katie for theatre?
The ‘Patient and Student Voices’ boxes highlight the following important elements, which I would consider are important in preparing Katie for theatre:
- To listen to Katie and her mum in order that I could tailor the care to meet her individual needs and provide patient-centred care. Note: A model is likely to be utilized in the clinical area and I should familiarize myself with this. I should also familiarize myself with the relevant documentation utilized in relation to a surgical procedure, for example, consent form, medicine kardex, etc. in respect to preoperative preparation. It is also essential that I am supervised by my mentor and also to acknowledge my limitations. If in doubt – ask!
- To consider my practice from a professional, legal and ethical perspective i.e. what is expected of me professionally? Note: The NMC Code should underpin what I do. I was provided with a copy by my university but I know that I can also access this online. This is a very useful source of reference.
- Is there a specific policy within the clinical placement area, which I should follow in order to ensure that all of the necessary preparation/safety checks have been carried out in preparing Katie for theatre? Note: I should discuss this further with my mentor in order that I am aware of the local policies and procedures.
- This is a valuable learning opportunity and should form part of my learning agreement and help contribute towards achieving some of my competencies. This experience will also contribute to my knowledge base and confidence. Note: I should discuss and reflect upon this experience with my mentor.
- What is the legal age of consent? In this instance because Katie is only ten years old, consent would be obtained from her mum as her parent/guardian. The explanation is usually provided by the medical staff but this is a valuable opportunity to observe this being carried out. This also links to the Patient’s Voice box and the importance of a clear explanation and the importance of communication when more than one staff member is involved in the provision of care. Note: What information is available in relation to the recovery period? Is written information available?
- What ethical principles are important in preparing Katie for theatre? Consideration must be given to: beneficence, maleficence, justice, veracity and autonomy. How do I contribute to upholding these? Note: I will refer to the other sections within this book and my lecture notes in order to inform my knowledge base.
Activity 11.1 pg 148
Think about your clinical experiences so far.
- Have you observed care or a skill being carried out in different ways?
- What questions would this prompt you to ask your mentor?
- Because care or skills are carried out differently by different people, does this necessarily mean they are being done wrongly?
- How can these different experiences help your learning?
Care provision or a clinical skill may have to be carried out in different ways in order to meet the specific needs of a patient. This may also be influenced by, for example, the age or mental capacity of the patient and the care setting. This should be clearly documented and be informed by a thorough assessment of the individual needs of the patient. A combination of a model of care and appropriate assessment tools will have been utilized in order to make this decision.
Example: within a community setting the nurse will modify the technique utilized in order to carry out a dressing change. The patient may well have a supply of all the required constituents in order to have a dressing change at home. However, it is unlikely that the nurse will utilize a trolley! The nurse is more likely to utilize a table or other suitable piece of furniture within the home setting after ensuring the patient’s consent. Other modifications may include handwashing in a sink, which does not have elbow taps. You may therefore observe the nurse utilizing disposable hand towels in order to switch the taps off.
You may ask your mentor about the specific policy or guideline relative to the procedure and discuss what you have been taught in relation to this procedure within your clinical skills lab.
A variation in practice will allow you to understand that adaptations are often necessary in order to meet the individual and sometimes varying needs of each patient but should not compromise the care being delivered or be detrimental to the patient.
Activity 11.2 pg 150
Reflect on what action you would take if you observed care or a skill being carried out in a substandard way.
- Who would you report this to?
- What questions might you be asked?
- What further actions might you need to take?
You may find the information contained within the student handbook provided by your university and the NMC website http://www.nmc-uk.org/Publications/Guidance/ (Raising Concerns: guidance for nurses and midwives, Section 8, page 6) useful in answering these questions.
I would inform my mentor, tutor or lecturer immediately. I would seek help from an appropriately qualified practitioner immediately if I felt that someone who is being cared for has suffered harm for any reason. I would also seek help from my mentor, tutor or lecturer if people indicate that they are unhappy about their care or treatment.
It is likely that I would be asked for a full verbal account of the circumstances, which may then result in a full written report.
You can also seek advice from your professional body or trade union who will offer confidential advice and support.
Activity 11.3 pg 151
Use the Ten Essential Shared Capabilities listed in Table 3.1 to reflect on the care you have been involved in delivering in practice.
- How have you observed person-centred care being delivered?
- Now write a reflection relating to your experience.
It may also prove useful to utilize the following learning resource link in order to explore these in more depth: http://www.knowledge.scot.nhs.uk/making-a-difference/resources.aspx
The Ten Essential Shared Capabilities
Working in partnership
Identifying people’s needs and strengths
Providing service user-centred care
Making a difference
Promoting safety and positive risk taking
Personal development and learning
A wide variety of responses is anticipated. However, an example has been provided for illustration.
Example: You may have been involved in securing a place at a day care centre for a patient (working in partnership), arranging a home visit at a time most suited to the patient’s daily routine (providing service user-centred care), etc.
Activity 11.4 pg 153
For your first-year OSCE you have been asked to assess, measure and record a patient’s temperature, pulse and respiratory rate.
- Using the headings ‘Psychomotor Domain’, ‘Cognitive Domain’ and ‘Affective Domain’, identify what you will need to do in order to demonstrate effective care.
Psychomotor Domain is the practical skill. In order to demonstrate effective care you will be graded on how you carry out the skill. This will include how you use the thermometer, locate the radial pulse, count the respiratory rate and perform hand hygiene.
Cognitive Domain is your knowledge. To demonstrate effective care you need to have the knowledge of the skill but also the theory behind this. You can demonstrate this to the marker by indicating the measurements of temperature, pulse and respiration you have taken are within normal expected limits, which demonstrates your knowledge of normal ranges in relation to vital signs. This is also demonstrated through correct hand hygiene, correct use of equipment and correct location of pulses.
Affective Domain is your attitude and professional approach. To demonstrate effective care within the affective domain your marker will be expecting you to communicate with your patient, to introduce yourself, gain consent, reassure the patient and provide an explanation of your finding
Activity 13.1 pg 170
If you were asked, ‘What is compassionate, caring, dignified, person-centred care and values-based nursing practice and why is this important in nursing?’ what would you say?
Explaining what compassionate, caring, dignified, person-centred care and values-based nursing practice actually is equates to a monumental task. This is then made more difficult because not only will nurses have differing views on what it is, but so will patients. However, our Code (NMC 2008) and the guidance on professional conduct for nursing and midwifery students (NMC 2009) highlight the fundamental importance these values hold in all aspects of nursing care.
Compassion, in a similar manner to caring, is directly derived from the ethical principle of beneficence, which requires that we seek to do or produce good for others. Despite the role of the nurse being diverse and multifaceted, all nursing practices shares the same ultimate aim to make the lives of those receiving care better.
Caring is frequently described as at the heart of nursing, but what that means exactly appears to differ between nurses. Some nurses focus upon attaining the skills which enable them to deliver care based on a range of specialist technical interventions, as they feel this is the most important aspect of care. Others however feel that caring is their ability to relate to their patients and ‘be there for them’.
It is frequently stated that the word dignity comes from two Latin roots – ‘dignus’ and ‘dignitas’. Both of these Latin roots have very similar meanings, ‘dignus’ means worth and ‘dignitas’ means merit.
Person-centred care is an approach based on the work on Tom Kitwood (1937–1998), an English gerontologist, which respects and values the uniqueness of every individual and seeks to maintain their personhood. This is done by creating an environment where personal worth, individuality, respect, independence and hope are all evident.
We all hold values and beliefs, which have been formed by our individual experiences throughout our lives so far. Our values and beliefs shape our attitudes, and so the way that we think, feel and behave. As a nurse the values and beliefs we hold can have an impact upon the care we deliver. Values-based practice is an approach to supporting care that provides practical skills and tools for finding out the values of an individual and negotiating how these can be upheld in care delivery. It aims to introduce a wide range of views and enable the recognition of specific values that may be held by certain cultures, small groups, or those held only by certain individuals.
It is easier to say why the values of compassion, care, dignity and being person-centred are important in patient care. The patients we care for are not just someone who needs, for example a bath. They have life histories and experiences that have made them into a unique individual which, in order to provide the care they find acceptable, we need to take into account. It is by upholding the values of compassion, care, dignity and being person-centred that enables us to deliver high quality care which is deemed to be acceptable by patients.
[Note: I deleted activities 13.2–9 as they all said after activity ‘no answer as reflection’, and no corresponding ticks in the book to these activities, so seemed redundant here?]
Case Study: Hector pg 172
Hector is 9 years old, and whilst playing in the garden, tripped and fell through a pane of glass in his grandfather’s greenhouse. Luckily for Hector he sustained only minor injuries, but did need four sutures in a deep wound in his hand. When Hector was at his local hospital having the wound sutured he was very scared and crying, because ‘it hurt’ and he’didn’t like seeing the blood’. The nurse suturing Hector’s hand told him to ‘stop being a baby’, and as he was a ‘big boy now he was not to cry’ and that ‘the more he cried, the longer it would take, so the more it would hurt’.
Hector has arrived for an appointment to have his wound dressed at his GP’s surgery, where you are on placement. The receptionist comes to find you and your mentor to tell you that Hector, your next patient has arrived, but he is hiding behind a chair in the waiting room, because he doesn’t want to come and see ‘the nasty nurses who hurt’.
- What do you think might be the reason that Hector associates nurses with things that hurt?
- How are you and you mentor going to deliver effective and compassionate care to Hector in order to help him realise that not all nurses are nasty and hurt?
Hector’s previous experience of a nurse was that they were not kind and did not care for him in a way he found acceptable. Unless Hector experiences nurses who act in a different way to this he only has his ‘bad’ experience to base his view upon.
Hector needs time and a different experience of nurses to assist him to realize that not all nurses will act in the same manner as the one who hurt him. To do this it would be necessary for you and your mentor to coax him out from behind the chair, if possible enlisting the help of the family member or carer who is attending the surgery with him, by finding, for example, a toy, that he would be interested in. It is key to develop a relationship with Hector where he trusts you and your mentor. It is likely that this would take some considerable time and if he was becoming overly upset it may be necessary, for example, to enable his family member or carer, or even Hector himself, to be the person who removes his dressing and, if necessary replaces it with a new one. It is highly important to take this time and to establish a trust between Hector and the nurses, as otherwise he is going to constantly find it very stressful whenever he requires nursing care.
Case Study: Valery pg 177
Valery is 52 and has a long history of intravenous drug and alcohol dependency. She has ‘lived’ in a bus shelter for the last three weeks, because she was asked to leave the hostel where she was staying after punching another resident and causing £1,584 of damage, because she was in a ‘rage’. Valery often has mood swings, one moment appearing to be calm and the next becoming angry, provocative and rude for no reason. She is frequently late or completely misses the appointments you make to see her. Today she walks into your clinic, shouting, three hours late.
When you see Valery she is very dishevelled; her hygiene is poor and she smells overpoweringly of stale body odour and cigarettes. When she greets you her speech is slurred but you can just make out that she is saying ‘You! I have been waiting ages for you. There you are – wasting my time again. Just give me my drugs you idiot and get out of my way.’
- As you read the case story of Valery and imagined yourself as the nurse who she had come to see, what were your thoughts?
- Would your thoughts alter if you were to learn that Valery had been clean from drugs and alcohol for six months, the reason for this visit was to collect antibiotics for a recurrent chest infection and her slurred speech, forgetfulness, mood swings and poor hygiene were all due to pre-senile dementia?
There are no right or wrong answers for either question in this case study. The values you hold are your values and make you the person you are. However, you must remember that your values may not be the same as the patient’s. Inflicting your values upon a patient may be seen by them as judgemental and unprofessional (NMC 2008), resulting in a negative effect upon the care they receive from you. Think back to the ‘Hector’ case study – the nurse and Hector had very different values. The nurse valued what she viewed as being brave and acting in a grown-up manner. Hector was scared and hurting and could not appreciate this view. He needed a nurse who could understand his feelings and care for him in a way which didn’t make things, in his view, worse.
Imagine the scene. You are at a wedding reception and have been seated at the table between two people you don’t know. The conversation is becoming very stilted, so in an attempt to get everyone talking you say, ‘Well, what shall we talk about – religion or politics?’
- What do you think their responses will be?
- Is your attempt to liven up the conversation likely to be successful?
It is highly possible that you will not receive any responses at all! Topics such as religion and politics are normally viewed as highly personal. In the same way that you are unlikely to ask people about sensitive or intimate issues until you know them very well, if you mention topics such as these it is possible that they will either stop talking or feel they are being called to account for their personal view and become argumentative.
Your attempt to liven up the conversation is not likely to be successful and you may well provoke an argument!
Activity 14.3 pg 189
Reflect upon the care you have recently provided for one of your patients.
- How did it compare with the features of person-centred care identified by Manley at al. (2011)?
- What more could have been done to make the care and support more person-centred?
- What more could have been done to make the service more person-centred?
Since this activity asks you to reflect on your own experience of care delivery it is difficult to provide an ‘answer’. However, hopefully you will have found the framework offered by Manley et al. (2011) useful in supporting your reflection on practice and in identifying areas where care can be improved in order to make it more person-centred.
Case Study: Sarah pg 191
It is important that the nursing staff recognize that Sarah’s parents will, over the years, have developed a great deal of expertise in relation to her care and this must be respected. In terms of communication is it important that the family’s need for information and their possession of useful information is acknowledged and that two-way communication is established. This may also require the nurses to liaise with other staff to ensure that required information is provided in a timely manner. In relation to maintaining Sarah’s routine as far as possible a tool such as a hospital passport could be used. This document would record information such as Sarah’s strengths and support needs as well as her usual ways of doing things. For example, if she is able to feed herself with a spoon but not with a knife and fork it is important that she is supported to use a spoon rather than someone else giving her food since this could lead to a loss of skills. Similarly if she is unable to drink unaided from a cup it is important that staff know this rather than just leaving a drink for her on her bedside table. The hospital passport is a document that some people with learning disabilities will bring into hospital with them: it is important that all staff read them. However, even if they do not bring a passport in with them it is important that we establish what is ‘usual’ for an individual so that we can support this and also recognize when things change since this may be a sign of deteriorating or improving health.
Case Study: Jainil pg 200
Jainil is four years old and has become withdrawn and quiet, is refusing to play or drink. He just wants to sit on his mother’s lap and look at books, which is uncharacteristic for him as he is usually very active. When talking to his parents it becomes apparent Jainil has not had his bowels open for six days and that he has abdominal pain exacerbated by movement. Jainil’s behavior and his psychological and emotional responses have all been affected as a result of his physical pain.
- List the skills you need to perform an assessment upon Jainil. Think about how you assessed the object in Activity 15.1 and. relate these skills to performing an assessment of a patient.
The list might include: Observe. Measure. Listen. Question. Examine. Explore. Analyse. Interpret.
Case Study: Graham (2)
Let’s go back to Graham, whom you assessed earlier. It was identified that Graham had recently lost weight. Through a thorough assessment it was recognized that he had lost 8kg within the last three months and was malnourished and dehydrated.
Concerning Graham’s dehydration, a specific, measurable, achievable, realistic and timely short-term goal could be that Graham will have an oral fluid intake of 2.5 litres every 24 hours for 72 hours. A long-term goal might be that he maintains hydration by achieving a daily oral intake of 2 litres of fluid.
- Now write a SMART short-term goal for Graham’s nutritional needs.
The SMART goal for Graham’s nutrition could be that he gains 0.5kg weight per week and achieves a 3000 calorie oral intake per 24 hours.
Case Study: Graham (3) pg 206
Remember Graham? He had lost weight and was found to be malnourished, and you set a SMART goal? Now you need to think about how you will achieve it. Let’s say your goal stated that Graham gain a minimum of 0.5kg per week and achieve a daily oral intake of 3000 calories.
- Using the REEPIG criteria, write down what actions you will need to put into place in order to ensure this goal is achieved.
Your actions might include that you talk to Graham about his favourite foods and drinks, ensuring they are supplied and offered; with informed consent, refer Graham to a dietician to ensure a high calorie diet containing foods favoured by Graham; the maintenance of a food and fluid chart; assist Graham to eat and drink as required; ensure Graham is offered and provided with snacks every hour when awake; weigh Graham once a week (0900 hrs Tuesdays); weekly nutrition assessment tool completion; talk to Graham about his eating habits and possible reasons for weight loss.
Case Study: Graham (4) pg 207
Graham has been nursed by you for a week now and you are evaluating his care plan.
- What documents and data would you need in order to undertake this evaluation?
- How would you write your evaluation of Graham’s care?
Your evaluation might say something like Graham has gained 0.6 kgs in seven days, his nutrition score is X; he consistently consumes all meals offered when assisted to eat and has achieved an average of 2500 calories per 24 hours. Graham achieves a 2-litre fluid intake per 24 hours and says he looks forward to meal times although does not feel hungry in between meals. From this evaluation you can see Graham has gained weight but is not achieving the goal set of 3000 calories or 2.5 litres oral intake although he is eating all his meals and has a positive response to meal times. Graham is still malnourished and the need still exists; the actions and implementation are suitable since they are starting to achieve the short-term goal; it would be appropriate to continue and revaluate this in a week.
Case Study: Kim and Kerry pg 217
This scenario demonstrates the importance of what some might consider ‘non-conventional’ communication skills. When communicating with children in healthcare settings, how might play benefit the therapeutic relationship between the nurse and the child?
Besides satisfying a child’s normal need to play, play in hospital helps children to adjust to potentially stressful situations.
Play benefits children and young people by:
- · Helping them to cope with illness;
- · Helping them to cope with painful procedures;
- · Reducing stress and anxiety;
- · Providing an outlet for feelings of fear and frustration;
- · Helping children regain confidence, independence and self-esteem;
- · Aiding diagnosis;
- · Speeding recovery and rehabilitation;
- · Encouraging parents to be involved in their child’s care;
- · Developing new skills for children;
- · Helping them to achieve mastery;
- · Helping children experience and identify emotions;
- · Allowing children to practise roles; provides a way of acting out troublesome issues;
- · Being fun.
Case Study: Steven Hawking
The Motor Neurone Disease Association (MDNA) reminds us that not everyone with Motor Neurone Disease (MND) will experience problems with their speech, but for some people the muscles in the mouth, throat and chest can be affected. This can affect their ability to communicate and be understood. The person may experience weakness in the muscles of the tongue and lips, making it difficult to speak clearly. There may be particular difficulty with sounds such as consonants ‘p’, ‘b’, ‘t’, ‘d’, ‘k’, ‘g’ and a weakness of the soft palate, allowing air to leak out of the nose with the voice having a subsequent nasal quality. The vocal cords may be weakened, which can make the voice sound hoarse, low pitched and monotonous and speech to become slow, slurred and indistinct, making it difficult to produce intelligible speech. There may also be problems with muscles in the chest, which can affect breathing so that the voice becomes soft and faint (MDNA, 2013).
Activity 17.1 pg 224
- Make a list of situations that you find challenging in nursing.
- Why do these situations feel challenging?
Challenging situations often arise when we feel poorly equipped to deliver nursing care. Sometimes in nursing it can be difficult to know what to say or what to do, and this can be particularly challenging for us. As we develop our skills and knowledge and gain more experience and confidence, we begin to feel better equipped to deal with the personal challenges associated with providing nursing care.
Activity 17.2 pg 224
Common barriers in our communication with each other include:
- Language (not being able to understand another person because they speak – and perhaps can only speak – a different language).
- Culture (different cultures are likely to have different expectations about social interaction and conduct).
- Consciousness (people who have fluctuating levels of consciousness, or who are unresponsive, pose considerable communication challenges for the nurse).
- Sensory Impairments (such as people who are deaf, blind or cannot speak).
- Mental Health Problems
Activity 17.3 pg 224
- How might you overcome linguistic barriers in communicating with others?
It is important to ensure that information is readily available to all patients and service users. Key written information should be available in different formats (in writing, braille and so forth) and in all common languages and interpreters should be accessible to explain healthcare interventions.
Case Study Professor Stephen Hawking pg 226
For insight into some of the challenges a nurse may need to overcome when communicating with a patient diagnosed with motor neorone disease visit: http://www.mndassociation.org/life-with-mnd/everyday-living/speech-and-communication/
Consider for example, the difference between ‘aural’ and ‘oral’ care.
- How might this lead to confusion?
Aural refers to hearing or relating to the ear while oral refers to the mouth or that which is spoken rather than written. One of the key problems here is that the terms sound very alike. While the term oral is in common usage, aural is not commonly used.
Activity 18.1 pg 241
Your list may comprise a variety of types of risk: for example; risk related to the environment and risk related to care delivery and treatment. This might include:
- Increased risk if patient is confused
- Inadequate staffing levels
- Poor collaboration or leadership within the team
- Moving and handling issues
- Risk related to medication administration
- Risk related to tissue viability
- Meeting the nutritional needs of patients.
Activity 18.4 pg 245
Risk management can be defined as a function of administration of a hospital or other health facility directed towards identification, evaluation, and correction of potential risks that could lead to injury to patients, staff members, or visitors and result in property loss or damage.
This definition can be found in Mosby’s Medical Dictionary, 8th edition, Elsevier.
Activity 18.5 pg 247
Write down your thoughts and ideas as to how you could identify the risk/s present within the case study. Are there any assessment tools that you could use?
It might be that you have identified an obvious departure from good practice. There was a protocol in place should the ‘trial by forceps’ proceed to emergency caesarean section. The drugs were prepared, drawn up and labelled correctly. There are policies in place in relation to medicine management, including the administration. Although, human error/performance was the cause of the incident, the departure from safe practice could have been influenced by the working environment and the wider organizational context, for example, a telephone call that caused a distraction. Closer analysis could possibly reveal a series of events that influenced a departure from good practice. Human error is routinely blamed for such incidents that occur in practice, but this often only masks a more complex truth.
Risk can be identified through:
- Incident reporting
- Knowledge sharing
Now consider the evaluation component of the incident.
Risk evaluation is about the process of determining the potential severity of the loss/harm with an identified risk and how likely that such a loss or harm with occur. In more simplistic terms what would have been the most harm/loss caused in the situation with Emily and her baby and what are the chances of that outcome actually happening?
What factors could have influenced the undesirable outcome for Emily?
- Short cuts and deviation from best practice e.g. protocol, policy, guidelines
- Communication breakdown
- Inadequate training
- Lack of clarity in relation to roles and responsibilities
- Poor leadership/no clear leadership
- Poor interdepartmental working
Think about correction and what recommendations you could suggest to reduce the likelihood of a similar situation occurring again.
You might have considered:
- Clinical guidelines
- Evidence-based practice
- Effective communication
- Robust documentation
- Education and training
- Situational awareness in relation to individual roles and responsibilities
- Effective, cohesive team work
- Clear leadership
Activity 18.6 pg 247
Systems that are commonly in place throughout the NHS for reporting incidents include:
IR1 and datix
Having the confidence to report incidents will very much depend on your own personal and professional development to date. What you should be mindful of is that an organisation with a culture of reporting is much safer than one where no reporting occurs. Good leadership will encourage an open, honest and supportive approach to the value of a reporting culture.
Probably one of the greatest barriers to reporting incidents is the fear of being blamed, or reprisal. Other fears might include job loss, or being singled out as a whistle-blower.
Activity 19.3 pg 253
- What do you feel are the main principles of accurate record keeping? Consider areas such as safety, practicalities, key information, storage, language and legal and ethical considerations.
- In relation to each of the four fields of nursing, what additional considerations would you need to make? For example, children, people with learning disabilities, dementia or mental health needs.
Some of the main principles of accurate record keeping are that they need to be factual, understandable, secure, identify risks and proposed actions, logical, confidential, signed and dated and in line with local policy and national guidance (see NMC 2009 Guidance on record keeping for nurses and midwives).
Additional considerations for all four fields centre on access, consent and involvement. For example, people with learning disabilities may need records produced in an accessible and understandable format. Older people may need larger print size to be used in order to see, read and understand their records. There may well be difficulties in obtaining consent from people with mental health needs such as those with dementia and again with people with learning disabilities. All groups of people should be encouraged to be involved with their own record keeping and planning of their care including children and vulnerable adults. This will often involve seeking the support of family members and carers.
Case Study: Claire and Ian pg 257
Claire and Ian outcomes
Claire was removed from the register.
The fact that this was a second offence, following a previous supervision of practice order was taken very seriously, as she had not changed her original behaviour, despite being provided with support and guidance.
Ian was subject to a supervision of practice order and had to undertake a course on record keeping.
Case Study: Bianca pg 268
Bianca is a 14-year-old girl who has attended a sexual health clinic. She is accompanied by her friend Abby, who is of the same age. Bianca admits to having unprotected sexual intercourse (UPSI) two days ago and is requesting the emergency contraceptive pill. Her boyfriend is of similar age (15) and she admits that they were both under the influence of alcohol at the time of UPSI so condoms were not used.
Bianca is adamant that her parents are not informed as due to religious beliefs they do not agree with sex before marriage. This was her first sexual encounter and she says she bitterly regrets it. She says ‘I know I have let my parents down – I feel so bad…’ She also says that since the episode of UPSI she has been getting a stinging sensation when she passes urine.
Sharon, the nurse, asks a series of opened ended questions which allow Bianca to explore her feelings so her emotional needs could be assessed. This also enables Sharon to appreciate the patient’s spiritual and cultural health beliefs, so these can be considered when making decisions about her care.
Bianca’s physical needs are assessed by asking relevant questions and taking specimens for clinical tests. These indicate that Bianca has a urinary tract infection and that, as her last menstrual bleed was two weeks ago, she is mid-cycle and so at high risk of pregnancy.
In assessing Bianca, Sharon decided that she is Fraser-competent. Bianca has stated that she did not feel coerced and that they both consented to sexual activity although she now regrets it.
Sharon encourages Bianca to consider talking to her parents or a responsible adult whom she feels safe to confide in.
The emergency contraceptive pill is prescribed for Bianca with follow-up advice on sexual health screening. Sharon is also aware of the high incidence of teenage pregnancies in the United Kingdom and their financial and emotional impact, and so she talks to Bianca about awareness of the use of long-term reversible contraception. Furthermore, she invites Bianca and her friend to attend the youth clinic that she runs with voluntary and public health organisations.
Using Figure 20.1, can you identify the core aspects of the holistic care provided to Bianca?
Psychological needs –Through a facilitative approach the nurse helps Bianca to explore her feelings. Through the use of open-ended questioning Bianca expresses feelings of guilt and regret. The nurse is then able to offer support to Bianca and advise her to consider the possibility of confiding in her parents or responsible adult.
Physical needs – The nurse addresses this by taking a detailed medical history and performing the relevant tests. She is then able to treat Bianca for her urinary tract infection and prescribe her the emergency contraception.
Ethical decisions– A non- judgemental approach to decision making is essential. Consent, mental capacity and informed choice will be ensured.
Social needs – Lifestyle and support network will be considered in the decision-making process. The nurse has offered Bianca and her friend the opportunity to attend a youth clinic where health promotion will be considered within a safe and comfortable environment. The nurse has also elicited the age of Bianca’s sexual partner thus ensuring safeguarding issues are explored.
Economic needs– The nurse is aware of the high rates of teenage pregnancies and considers future planning to develop a preventative approach e.g. Use of long-acting reversible contraception and sexual health screening.
Spiritual and cultural needs – Through active listening the nurse facilitates Bianca in expressing her feelings and beliefs. This will help Bianca and the nurse to identify specific needs centred on spiritualty that will help to promote preventative care in the future.
Case study: Tony pg 269
Tony is 19-year-old male newly diagnosed with Type 1 diabetes and who has been admitted to the ward due to a third episode of ketoacidosis. Initially, Tony was given intravenous fluids and put on a sliding scale insulin infusion pump so that his blood glucose and dehydration could be corrected.
Once ketoacidosis was corrected, it was hoped that Tony would be willing to take control of his health and actively take part in the decision-making process for his care.
However, Tony seemed withdrawn and distant. He did not make eye contact when the nurse delivered his care and refused take part in in checking his blood glucose or self-injecting his insulin. Tony says he ‘doesn’t see the point in any of it as having diabetes has stunted his dream and ambitions’.
The nurse decided that Tony would benefit from seeing a counsellor to explore his feelings and come to terms with his diagnosis. A referral was made to the counsellor with Tony’s consent.
- What decision types has the nurse used in caring for Tony? (Use Table 20.1 for reference.)
- What factors do you think influenced the nurse’s decision to refer Tony to a counsellor?
There are a number of decision types the nurse has implemented in the case with Tony.
Prevention – The nurse wants Tony to take control of his condition so that future complications of diabetes can be avoided.
Timing – This was crucial as the nurse knew that Tony’s condition needed to be stabilized before he could consider counselling and taking ownership of his health.
Referral – The nurse was able to identify the appropriate healthcare professional (counsellor) that Tony needed to see in order to have the correct expertise in helping him to come to terms with his condition.
Communication – Active listening and a facilitative communicative approach was applied in the decision-making process.
The nurse was able to empathetically respond to the verbal and non-verbal cues that Tony demonstrated and recognized that Tony was grieving and worried about having diabetes. Responding to Tony’s emotions and awareness of the anxiety and worry patients face with having a new diagnosis of a long-term condition influenced the nurse’s decision in referring Tony to a counsellor.
Case Study: Mark pg 283
Implementing some of the ideas for improving health promotion in other settings:
A children’s outpatient department
As well as informing them about their condition, every patient needs to be spoken to about one health issue – either an issue obvious in their case history or as an alternative strategy, talking to everyone about the one issue chosen for that month e.g. oral health in May, sunbathing protection in July.
Posters (changed monthly to keep stimulating interest) on appropriate walls e.g. healthy eating near catering outlets.
Free gifts offered when you can get hold of them e.g. apples, colouring books and crayons on health issues, for example accident protection, appropriate things such as toothbrushes in dental clinic, little bags for holding inhalers in asthma clinic.
Good quality attractive leaflet displays – remember to have an age-appropriate selection and keep them tidy.
CCTV showing cartoons alternating with health messages for children.
A drug rehabilitation centre
Raise the issue of safer sex with every patient, in relation to looking after themselves.
Arrange free food parcels through the local food bank scheme.
Keep the place looking lively with health posters between the wall decorations. Remember to use appropriate posters and images – many of the customers will not be in the ideal family set up with 2 parents and 2.4 cheerful-looking children playing and helping Mummy in the kitchen.
According to the local policy, set up an area for needle exchange and free clean works, with extra freebies such as washing materials, new socks or whatever else you can find.
A district nurse visiting patients at home
Every patient visited can be spoken to about a health issue, this could be the one most relevant to their care e.g. smoking. It may be better though for these long-term patients, for the district nurse to choose one issue at a time and talk to every patient about that until the list is completed. Then every patient will have the conversation, teaching and its outcomes recorded in their care notes.
As well as everything else the district nurse has to carry around (!) a few quality leaflets could be distributed.
These days, district nurses and their patients are more likely to make use of technology. Communicating by email, Facebook, etc. could include the regular sending of health messages – topic of the month perhaps. It would be interesting to work with the local libraries as well, to continue the messaging locally. Librarians already work to teach people computer skills through going onto health websites and apps.
Case Study: Dan pg 287
- Dan’s reasons for not eating healthily are a complex mix. Depression, loneliness, lack of self-esteem, poor environment, not much money, lack of education, no chance to store or cook food. What he seems to need is treatment for his depression, treatment for his leg, a place to live and a better job – but life is not simple, and change is not easy or quick.
- Motivation to change cannot, of course, be isolated from his circumstances, but anything you can do to help him see his worth will begin the improvement. Gaining, somehow, a support network, a few skills and pride might be the aim of a project for all the residents of the hostel. Knowledge and understanding of healthy eating is perhaps surprisingly, the least of your shorter-term aims. Setting up a self-help group, enabling life and job skills development may be a more powerful and empowering start.
- Continuing to longer-term aims, persuading Dan to undertake a back-to-work course, or a computer course may help. He does not need a cookery course, as some people may think, he has no resources for this, and it will probably try to teach him inappropriately for his lifestyle. What about working with the hostel warden to provide individual food storage lockers first?
- Wider still, you would wish to work at borough level or mental health service level to improve the lives of people in Dan’s situation. Making appropriate jobs available for people recovering from depression, improving knowledge and access to financial benefits, working with local shops and cafes on cheaper, healthy food provision are all suggestions for the interagency work a nurse could be involved in.
Activity 22.1 pg 300
- What do you understand by the term ‘safeguarding’?
- What are the main differences between children and adult safeguarding?
Safeguarding has moved on from being viewed purely as protecting people from harm although this is still an essential component. Safeguarding is now viewed as a much broader concept and includes notions of empowering vulnerable people, taking measured risks and working in partnership with key stakeholders.
The key differences between child and adult safeguarding are that there are separate pieces of legislation for each group. Children are generally viewed as being unable to protect themselves due to lacking the necessary maturity and mental capacity. Decisions are often made in their best interests by parents or guardians. Adults on the other hand are assumed to have mental capacity to make decisions and consent to treatment unless it has been established that they lack capacity to do so. Therefore adult safeguarding may be more problematic for the professional as most adults have mental capacity to make informed decisions which include making what others may feel are unwise decisions. Those adults who lack mental capacity may have ‘best interest’ decisions made on their behalf. This is explained in more detail in Chapter 22.
Case Study: Peeshe pg 301
Peeshe is a seventy-five-year-old man who lives at home with his wife. He has three sons, two daughters, seven grandchildren and three great-grandchildren. Peeshe has recently been diagnosed with dementia. His wife, many friends and neighbours had suspected for some time that there was something not ‘quite right’ with Peeshe at times as he had become very forgetful, confused and had difficulty with his verbal communication. At other times he is still the life and soul of the party and keeps his family entertained with his passion for music and singing. He has always been a very healthy and active person. Peeshe and his wife have visited their family doctor for a medication review and the doctor was concerned Peeshe did not have the capacity to consent to the new medication regime.
- Referring to the Mental Capacity Act 2005, what would you do if you were concerned Peeshe lacked the capacity reach a decision about his care or treatment?
- Consider the impact of Peeshe’s dementia on each of the following people.
- Grandchildren and great-grandchildren
- Friends and neighbours
Never assume that just because Peeshe has dementia that he lacks capacity to make decisions about various aspects of his life. Depending on the type of treatment proposed, then Peeshe may well have capacity to make an informed decision particularly in the early stages of dementia. However, as his dementia progresses it is likely that he will lack mental capacity at some point. The Mental Capacity Act (2005) has provision for when people lack capacity to make decisions by allowing for a ‘best interests’ decision to be made on their behalf. This usually involves key people who know Peeshe well such as relatives and also those engaged in his care. They come together and work out what would be best for Peeshe and then develop a course of action for him. Although Peeshe may lack capacity his views should still be sought and taken into account.
The impact of Peeshe’s dementia on both his wife and children is likely to be profound. Witnessing the changes taking place in someone you love and cherish can be very difficult particularly with confusion and memory loss. At some points Peeshe may not be aware that he is married let alone has children and great-grandchildren. This can be very difficult and frustrating for all concerned particularly Peeshe. There may also be extreme behaviour changes which may make you laugh when something humorous occurs and equally cry when you witness some aggressive behaviour. His wife is likely to take on the majority of care and therefore will be his main carer. However, she too will be ageing and may find it difficult to support him at times. His children being younger may be obliged to help out although this is not always the case. Often the obligation is stronger for his daughters as there is still the notion that caring is a female responsibility. It is important that his wife and children seek support and talk through their feelings with someone they trust.
Activity 22.2 pg 303
In view of the discussion relating to vulnerability or adults at risk, what reasons can you think of for why people with learning disabilities, older people, children and people with mental health needs may be more at risk of being vulnerable to abuse?
These vulnerable groups of people tend to be more at risk for a number of reasons. One of the main reasons is that they are often dependent on others for their needs to be met. This can be disempowering for such individuals as this dependency tends to create a power imbalance in which others have more control over the lives of the people they support or care for. There is often a stigma attached to a diagnosis of a mental health issue and learning disability with older people feeling less valued in the UK. Vulnerable adults and children are particularly at risk of abuse as they often cannot defend themselves. Recent high profile abuse scandals have shown that children and people with learning disabilities have not been believed when they have reported abuse, allowing it to continue for many years.
Case Study:Jim, Kevin and Gertrude, and you pg 308
Consider each of the case studies carefully and then answer the questions at the end of the box.
While on placement in a children’s nursery you notice Jim, a 4-year-old boy, playing on his own for long periods of the time or just staring out of the window. He is never taken out on trips and instead the nursery staff leave him with very young children (1–3 years).
When you ask a nursery nurse why they do this she states that he has autism and ‘such children are all like that’. She then laughs and says that you should know this and they don’t teach you much in University.
Kevin and Gertrude
While on placement with a community mental health nurse you visit Kevin, a 54-year-old man with schizophrenia living in his family home. He lives with Gertrude, his 70-year-old mother. You notice that Gertrude looks pale, smells strongly of urine and has bruising on her face and leg. You speak to the community nurse and he tells you he just deals with the mental health side of things with Kevin and that Gertrude is always falling over the clutter in the house.
This is your last day of placement on a busy ward in a large general hospital. Today there has not been sufficient time to provide adequate care to all of the patients, due to a cardiac arrest and two patients falling. Most of the older patients you are helping your mentor care for require full continence care. You have noticed that three patients appear wet or soiled, but it has not been possible to have the assistance you need to change them for over 4 hours. The ward team is also behind with assisting people with their meals and bathing and there are two patients still in the corridor waiting to be admitted to the ward.
Your mentor tells you that you will have to work late to help out and, although it is your final day, she will not have time to complete your assessment today, so you will have to come back at a later date.
Questions to consider for Jim, Kevin and Gertrude and you
- Do you have any concerns regarding poor or abusive practice in any of the cases? If so, what forms of abuse have occurred?
- If you did have concerns, what actions would you take?
- What potential barriers may prevent you from raising a concern?
- How would you overcome such barriers?
Jim – this shows the ignorance and in some respects the arrogance of the nursery nurse. The response she gives is likely to deter you from asking any further questions for fear of ridicule. However, an important lesson is to be learnt from this interaction in that you should not be deterred if your initial instinct is that there is something not quite right or wrong. Individuals on the Autistic Spectrum do not have a natural instinct to be alone but do have difficulties in understanding the social rules or norms in which others expect them to behave. Human beings are naturally social animals and need the company of others. If you don’t understand the rules then you are likely to avoid situations which you don’t understand because it makes you anxious. Therefore what the nursery nurse is doing could be seen as abusive practice because it is isolating the individual and thus neglecting their needs.
Kevin and Gertrude – Similar to the case of Jim, you would probably have a gut feeling that something was not quite right with the community nurse’s response to your question. All nurses have a responsibility to ‘do something’ if they suspect someone is at risk of harm. You seldom treat individuals without also considering the needs of their family, carers and community. Nurses often find themselves in unique situations in which they are able to gain insight into the private lives of others. Therefore the community nurse and the student would need to be able to demonstrate that they have taken action to protect Gertrude from harm by raising concerns. At the very least there are potentially signs of neglect or self-neglect. There are also possible signs of physical abuse by Kevin or other person who may visit the family home.
You – Sadly this is can be an all too familiar situation in which to find yourself as providing suitable healthcare during busy periods can be very difficult. The first point to bear in mind is that patients’ needs are first and foremost and completion of your coursework is always a secondary consideration. Leaving patients uncared for over any period of time is unacceptable regardless of the circumstances and pressures of work. However, if events are unpredictable or unexpected then some allowance needs to be made but this should not prevent concerns being raised. The real danger is that these types of situation become acceptable and therefore people stop complaining and accept these poor and abusive practices. This is a key feature of institutional abuse where such practices become normalized.
In all three case studies there is enough information for the student at the very least to ask questions with clinicians in practice and depending on their responses to raise concerns with their mentor or personal tutor.
The potential barriers which are likely to deter students from raising concerns are likely to be from a lack of knowledge. In the case of Jim you may well not have a great understanding of Autistic Spectrum Disorder (ASD) and in Kevin and Gertrude’s case you may not understand the role of the community nurse or your role in safeguarding. Another barrier is that most clinicians have more experience and also a higher status than you and it can be difficult to challenge their responses. You may also want a good report and as such may not want to ‘rock the boat’ by complaining. You may also lack confidence and fear being made a fool of.
All these barriers must be overcome in order to safeguard people in your care and for you to become a competent and safe practitioner. In order to overcome these potential barriers then you will need to gain more knowledge of such topics and responsibilities of clinical staff. This requires a strong commitment from you towards lifelong learning and seeking out up-to-date information from reliable sources such as this text book! You will also need to develop your assertive skills in order to challenge negative comments and interactions which may undermine your confidence. It is never easy to raise concerns but it is a vital part of becoming a professional. Confidence building takes time but you need to work on this during your training and learn from both negative and positive experiences.
Case Study: Vincent pg 353
Vincent is eight years old and has cerebral palsy. He lives at home with his parents at weekends and attends a residential school during the week. Although he has a good level of understanding, he struggles to express his thoughts in speech. His parents and carers are able to interpret his expressions and therefore his needs.
He was admitted to the children’s ward yesterday as he has a chest infection, which is not uncommon for him over the winter period.
A priority during Vincent’s admission to hospital is to monitor his clinical measurements for signs of improvement in his condition or to detect early signs of deterioration, allowing timely interventions.
- How can you ensure that you count Vincent’s respiratory rate accurately?
- What would you expect Vincent’s respiratory rate and SpO2 to be, taking in to consideration that he has a chest infection?
Ensure Vincent is resting and then count Vincent’s respiration rate for a full minute whilst looking as though you are counting his pulse rate.
You would expect Vincent’s respiratory rate to be slightly elevated between 20-30bpm, as he is having to increase his respirations to ensure adequate gaseous exchange. His SpO2 may also be slightly lower than his normal 97–99%, as his respiratory tract will be inflamed with a build up of mucus preventing oxygen exchange to occur at alveolar level. He may require supplemental oxygen to maintain his oxygen levels.
Activity 25.7: Critical Thinking pg 373
The values provided in Table 25.10 relate to a healthy adult. What effect do you think the following would have on a patient’s fluid balance?
- Being pyrexic (having a high temperature)
- Having diarrhoea and vomiting
- Being a child
- Pyrexia increase the body’s metabolic rate, causes vasodilation and activates the body’s sweat glands to try to lower the core temperature. All of these three elements will increase the need for additional fluids as there is a risk of dehydration.
- Persistent diarrhoea and vomiting can cause the Gastro Intestinal (GI) tract to lose excessive amounts of fluid and electrolytes which can result in hypovolaemic shock.
- Young children are more susceptible to dehydration due to larger body water content, renal immaturity, and inability to meet their own needs independently. Older children show signs of dehydration sooner than infants due to lower levels of extracellular fluid (ECF).
Glucose (Normal value – negative)
Activity 26.2 pg 386
Identify a pain assessment tool that you have used in practice with your group of service users. Reflect on how you communicated with the service users.
- Were there any barriers?
- Did you gain enough information?
- Whom did you share that information with?
There are many pain assessment tools that are currently used in practice and you could have chosen any of them. The main focus of this reflection should be how you communicated with the service user. Your reflection should consider the following points (this list is not exhaustive but will give you key aspects):
- Could the service user understand you and could they communicate their feelings, thoughts and/or emotions?
- Did they have an impairment that may have affected their ability to communicate effectively i.e. visual, speech or hearing deficit?
- Did they have a cognitive impairment? This could include having dementia, head injury or being under sedation.
- Were they in so much pain that they could not, or did not want to, talk with you?
- Did your service user have a learning disability that affected their ability to communicate?
- Did your service user have a mental health illness that prevented them from communicating their pain i.e. depression, catatonia or paranoid thoughts?
- Were they too young to express their thoughts, feelings or pain?
- Did the assessment take place in a suitable environment? Think about the noise level, the actual setting– was it private?
- Did you learn anything new?
- What did you find out?
- Could you tell the service user anything?
Did you undertake the assessment at a suitable time? Were there any other considerations that should have been taken into account? You may identify that the patient was in so much pain that undertaking a full assessment was inappropriate at this time or that the patient was impaired by analgesia/medication that they could not communicate effectively.
- What are you going to do about the information that you have gathered?
- Where will you document this information?
- Who are you going to tell about the assessment results?
- How and when are you going to review this assessment?
It is always important to consider the service user’s emotional state and whether they are well enough to complete any assessment and how they felt after the assessment. Most importantly you should always remember to return to the service user and inform them of your actions and how their pain is going to be managed – this will reassure them that they will not be forgotten.
Case Study: Pinja pg 454
You will have engaged with Pinja’s case in the chapter. It demonstrates the link between health and work activities and they are integral to nurses maintaining a healthy working life. If you are aware of risk factors then you are more likely to embrace safe handling manoeuvres for patients and moving equipment which is part of the nurses’ working conditions.
Review the case study and questions again.
Pinja is 56 and has worked in healthcare for 35 years. Initially this was in Estonia, her home country, but she now works part-time in the UK whilst raising her three children. She enjoys her job and commutes to work by car, which is a total journey of one hour.
Pinja used to work in the community, but after ten years has returned to work on an acute ward at her local NHS Trust. Pinja is required to work shifts, including three night shifts per month, which she detests. Pinja never never sleeps well when she is working on night shift, which leaves her feeling tired and unsure of when and what to eat, and she finds the shifts too long. She misses the interaction of her colleagues on day duty and feels there are insufficient staff on night duty to provide proper care to all patients. Pinja is very keen to reduce her night shifts, especially as these make it more difficult for her to care for her mother, who has osteoporosis.
Today Pinja has attended a well women’s clinic at her local health centre and is feeling upset because the screening results show she is overweight (but not obese) and she was told she should stop smoking. Pinja states she has little time for recreational exercise and feels caring for her family and working part-time demonstrates she is active. Pinja thinks she has reached the menopause which, combined with her work, makes her feel physically tired. and she often experiences backache in the lumbar region by the end of her working shift, although it disperses after a period of rest.
Here you can review against your responses:
- Identify and make a list of Pinja’s working and lifestyle risk factors and how may these contribute to her history of low back discomfort.
Look at the list you have made and identify any evidence to suggest Pinja is predisposed to back discomfort and link the evidence to your list of Pinja’s risk factors.
Risk factors include:
- Unknown work history for ten years in Estonia including safer handling training.
- Ten years’ work in community setting – higher risk working in varied settings increases risk of musculoskeletal disorders (MSD) – risk includes lone worker.
- Current work place and work conditions includes balance of workload and staffing levels.
- Working nights interferes with circadian rhythms, deprivation of sleep and rest – impacts on health including eating patterns.
- Spends two hours per shift driving to and from work – may add to postural stress and concentrations levels for driving may be impaired, especially after a night shift.
- Age (56) the physical process of aging impacts on health of bone including intervertebral disc. Bone density decreases with age, but can be maintained if the individual remains physically active. Bone density is reduced in sedentary people but Pinja is active at work and you should have identified other risk factors for Pinja’s health –
- Family history of osteoporosis. You should have identified the causal links of osteoporosis and/or other bone degenerations with increased reporting of MSD.
- The impact of three pregnancies to term may impact on spinal and pelvic alignment.
- From a psychological perspective, positive aspects are she enjoys her job but misses her colleagues and the interaction with others when working nights and prefers day work.
- Social demands placed on her to care for her mother – her days off may not be restful and the demands of family life add additional stress. If you review sickness reporting in 2011–2012 health workers had the highest sickness rate of stress-related disorders than any other occupation. www.hse.gov.uk .
Suggest how Pinja could improve her work/lifestyle in order to improve her musculoskeletal health.
- Attending well women’s clinic to help support and motivate to review lifestyle and health such as referral to smoking cessation programme. Consider family history of osteoporosis with referral to General Practitioner.
- Meet with dietician for health eating plan and guidance on weight reduction with ongoing support.
- Exercise(s) to improve back muscles may reduce current back discomfort.
- Refer to Back Care Advisor in her workplace to review Pinja’s ability to attain safer handling techniques and review working practices in her current workplace.
- Ward audit of safer handling techniques including equipment audit to improve handling methods to reduce MSD’s amongst the workers.
- Pinja could contact her manager/Occupational Health Department to review her physical wellbeing to make adjustments in her workplace.
- Sourcing care support for Pinja’s mother would reduce Pinja’s workload and therefore more recovery time when away from the workplace.
Case Study: Charlie pg 456
Charlie needs assistance to turn in bed every two hours and prefers to be moved on a slide sheet. He has a height-adjustable profile bed, with one side placed against the wall. A ceiling track hoist to move between his bed and bathroom is fitted above his bed. The floor covering is carpet. The free floor space is about 2 m x 1 m 40 cm, and this is the space in which the carers work. Charlie’s personal space and belongings are organized by him, so his family and carers must gain his permission to change his environment.
- Use the risk assessment criteria as described to plan your answer.
- First identify and justify the optimal safe handling manoeuvre for Charlie.
Turn using a full-length glide sheet to reduce friction of the skin and maintain skin integrity, prevent pressure ulcers and reduce infection. Equally, immobility increases the risk of Charlie developing thrombo-embolic disorders especially in the lower limbs. Choice of equipment is less invasive than hoisting. Charlie’s choice.
Having decided how Charlie is moved in bed, now refer to the risk assessment criteria to identify possible risk factors associated with your selected move. Note there may be some sections of the assessment you cannot complete given this is a scenario. The aim of this exercise helps you to identify possible hazards and risks when required to move Charlie.
Risk Assessment using TILEE
Task – Turn to reposition for comfort and adjust Charlie’s view. Requires two people to complete manoeuvre. Adjust height of bed for the carers’ working comfort.
Individual Capability – Consent from Charlie, Safeguarding of Children, consider language skills, communication aimed at Charlie’s age group.
Load – Charlie compliant and understands rationale for being turned frequently. Consider privacy and dignity as adolescent. Consider Charlie’s physical needs i.e. muscle wasting, may not be able to assist, supporting limbs, able to breathe when repositioned.
Environment – Risk factors include bed against the wall, no access for workers. Carpeted floor, risk of injury pulling and pushing bed away from wall, every two hours. Consider negotiating with Charlie to alter layout of his room, to allow carers access around his bed.
Equipment – Choice of glide sheet may not be the best option given the limited access to the bed. May have to recommend use of overhead hoist.
Charlie is not legally an adult, how does legislation such as Children Act 1989 section 17 help him in terms of available services to assist him?
Legislation section 17 covers Local Authority Support for Children & Families
Safeguarding of children
Ascertain child’s wishes – due regard
Provide assistance for Charlie to meet his daily needs
Ensure standards to maintain Charlie’s health
TILEE categories and Risk Assessment Criteria to be included on companion website please
TASK: What is required? Identify the aim and achievement for safer handling.
Example: Transfer of patient with limited standing ability from bed to chair in the home setting.
Does the manoeuvre involve:
Reaching above shoulders?
Excessive lifting or lowering distances?
Extensive carrying distances?
Holding a patient for a period of time?
Holding the load a distance from the trunk?
Excessive pulling or pushing of loads?
Risk of unpredictable movement?
Use of handling aids?
Frequent and/or prolonged physical effort?
Work rate in care support?
Examples – does it involve:
Reaching for equipment?
Gathering equipment at floor level?
Accessing equipment from shelves?
Moving loads from the floor?
Carrying a patient to the bathroom?
Holding a limb when dressing a wound?
Reaching across a double bed?
Pushing a bed along a hospital ward?
Selecting and skill of using handling aids required?
Pushing several patients in wheelchairs?
Time constraints are a factor – working in the community?
Changes in health of patient; equipment failure?
INDIVIDUAL CAPABILITY (of the handler). Identifies the handler’s physical ability to execute safe handling manoeuvre.
Example: Ensure the handlers are working safely to avoid injury to themselves or the patient.
Does the manoeuvre:
Involve additional considerations?
Require a specific height of person?
Impede the handler’s ability?
Involve occasional workers?
Examples – does it involve:
Safeguarding of children, consent, communications skills, appropriate touch, language, skills employed for patient group?
Ability to work around equipment distance and reach safely?
Pregnancy; handlers have to modify working practice?
Physiotherapists, doctors, speech therapists. occupational therapists
LOAD (patient or object)
Does the manoeuvre:
Involve participation of the patient?
Other patients’ considerations?
Physical differences & diversity?
Example – does it involve?
Independence in mobility; consider patients’ wishes; assess patients’ mobility and cognition; how much help is required; ability to communicate?
Skin viability; infection; pain assessment; impact of medication on orientation and mobility?
Patient’s response to safer handling techniques, trigger behaviour, cause stress?
Different expectations, gender, dignity? Privacy?
Body shape and size using correct fitting equipment; referral to bariatric advisors; impact of current health on selected manoeuvre e.g. following surgery, spasms, seizures, contractures, stroke, balance?
Selecting the best equipment and manoeuvre for the patient?
Type of equipment?
Examples – does the:
Equipment work in the intended space e.g. hoisting systems, tracking hoist versus free-standing hoists?
Space interfere with handler’s ability to adapt safe working postures; confined space in the home, poor workplace design.
Carpets impede movement of free-standing hoist; slippery floor when wet in bathrooms; pushing wheelchairs rough surfaces?
Working in the community; moving equipment in/out of vehicles; negotiating stairs, door thresholds impact on working conditions?
Lighting levels to see adequately; working at night impact on working environment?
Excessive heat or cold impact on ability to work including high humidity?
Is appropriate equipment selected to promote patient independence?
Is the equipment used correctly; training for its use – including carers?
Can equipment be used in the space available?
Does protective clothing interfere with the task?
Does the equipment comply with a LOLER (HSE 1998) maintenance programme?
Is there access for advice from specialist including back care advisor?
Case study: Julia pg 493 Woops! Were sorry but there is a small error in the book. No solution to this question is available, however you can read further about working with patients who exhibit psychotic behavior here: http://www.cci.health.wa.gov.au/docs/Psychosis%20Manual.pdf
Activity 32.1 pg 510
Malnutrition is defined as state in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue, body form, function or clinical outcome (Elia and Russell, 2009).
- Make a list of which patients you think will be at risk from malnutrion.
Being at risk of malnutrition can affect many groups of people and factors include those who are:
- more elderly
- having mobility issues
- unable to get to the shop or cook for themselves
- living alone
- living with mental health conditions, such as depression, dementia and mania
- misusing substances such as alcohol or drugs
- prone to dental or mouth problems.
Activity 32.3 pg 512
Consider which groups of patients may have communication difficulties?
- Those with learning disabilities
- Acutely ill
- Those with severe depression/anxiety disorders/hallucinations/mania
- Those with sensory deficits
CASE STUDY: Roisin pg 521
Roisin is three years old and has been admitted to hospital for an appendectomy. She will usually only eat food when her mother is present. Unfortunately her mum, who is pregnant with her second baby, has had to be admitted to hospital for bed rest. Roisin’s dad works on an oil platform and will be away from home for three weeks.
- How can you encourage Roisin to eat and drink?
- Allow Roisin to choose own cup/crockery colour or character
- Use of sticker chart
- Use of reward from the ‘fairy box’
- Praise for even small amounts
- Goals setting and return to see if accomplished
- Use of ice lollies instead of fluids if not drinking
- Socialize meal times so sitting with other children who are eating
- Who else could you involve?
- Contact other relatives/carers if possible
- Involve play specialist
Case Study: Miss Jones pg 537
You and your mentor, a district nurse, have been asked to make a home visit to assess a patient called Miss Annie Jones, whom you met at the start of the chapter. Miss Jones contacted her GP for advice about changes in her normal bowel routine.
Miss Jones has a past medical history of osteoarthritis in both knee joints, which has greatly reduced her mobility over the past three years, mainly due to pain. Miss Jones takes co-codamol 30/500 mg and a non-steroidal anti-inflammatory drug (NSAID) as prescribed, but her pain continues to be a problem and she suffers from one of the side effects of these analgesics, constipation. Miss Jones has discussed this with her GP, who advised her to eat a high-fibre diet and has also prescribed laxatives when required.
Despite doing this, however, Miss Jones continues to experience constipation. Over the last 72 hours she has not opened her bowels and has abdominal cramps and a distended abdomen.
- What essential nursing skills do you think will be involved in taking Miss Jones’ history and carrying out an examination within her home?
When entering Miss Jones’ home ensure that you and your mentor have gained consent to carry out an examination. Using effective communication and ensuring person-centred care, maintain Miss Jones’ dignity at all times. When carrying out an assessment use a systematic approach (e.g. Roper, Logan & Tierney’s Activities of Living) ensuring the patient understands all the questions and actions that you and your mentor carry out. All information must be documented appropriately and counter signed by your mentor. When carrying out a physical examination, ensure all infection control precautions have been performed including hand washing and the wearing and disposing of appropriately personal protective equipment. Allow an opportunity for Miss Jones to ask any relevant questions or discuss any issues of her condition.
- What are the signs and symptoms of constipation, why do they occur and how would you describe them to a patient?
Constipation is a slowing down in the frequency of bowel movements. A normal symptom is the hardening of stools and a feeling of discomfort and straining when defecating.
These symptoms can occur when a patient becomes immobile, dehydrated, has inadequate fibre intake and due to the use of some analgesics.
Activity 33.4 pg 546
Maintaining dignity has been mentioned frequently throughout this chapter, as attending to our elimination needs is personal and intimate, and normally something we undertake in private. The loss of dignity people with continence problems feel can be devastating and many feel it reduces their self-worth as a competent adult.
Receiving assistance with elimination needs can be acutely embarrassing for a patient, but can also be uncomfortable for the nurse providing the care.
- What skills, in addition to accurately performing a procedure, does a nurse need to apply in order to maintain a patient’s dignity when assisting a patient to meet their elimination needs?
- Does the fundamental importance of maintaining a patient’s dignity when assisting with elimination needs alter if the patient is confused, disorientated, unaware of their surroundings, or is a child?
In addition to performing the physical aspects of elimination care for patients, nurses need to use a range of additional attributes in order to support the patient such as demonstrating empathy and compassion. This can include communication skills such as reassurance, speaking softly and appropriate use of touch (e.g. placing a hand on the shoulder of the patient). It is also important to think about your non-verbal communication. For example, think about your facial expressions. You may be dealing with unpleasant smells for example, but it is vital that the patient does not feel you are disgusted by the procedure you are undertaking.
The fundamental aspects of patient care in relation to dignity when assisting with elimination needs are the same regardless of the patient group you are working with. You will, however, have to alter elements of your interaction in order to support and reassure the patient. For example, when working with children, you may need to use different language to make them feel safe. You may also want to have their parent(s)/guardian(s) in attendance if this is appropriate. If someone is confused, disoriented or unaware of their surroundings, you may need to take more time to explain things. Repetition of information may be needed. You may also require additional support from other members of the healthcare team to allow you to perform elimination care in a safe manner.
Case Study: Adam pg 568
Adam is twenty-five, has a moderate learning disability and lives in a supported-living home. Whilst returning from shopping four days ago he was hit by a car and sustained fractures of both wrists, which have been immobilized in a plaster cast. He also has a severely sprained left ankle, on which he is unable to weight bear, which is being treated by analgesia, rest, elevation and ice packs. Adam has numerous contusions and a cut over his right eye, which was sutured. He came home from hospital yesterday and is in bed because he says he ‘feels wobbly’. Adam is desperate to have a bath and shave because he says he ‘pongs like the hospital’. Normally he needs minimal assistance with hygiene, but he now needs full assistance.
- How are you going to assist Adam to maintain his hygiene in a manner he finds acceptable?
In order to assist Adam in maintaining his hygiene in a manner he finds acceptable it is necessary to discuss with him what he would like to do and how he would like to do it. Encouraging and assisting any patient to maintain their usual routine, enabling them to be as independent and feel as in control as possible, is an important aspect of every nurse’s role. However, as indicated in the case study, Adam has sustained a range of injuries that mean he is unable, at present, to be able to follow his normal routine.
If you apply each stage of ‘CLEAN’ (chapter 31) you would:
Consider and assess Adam’s needs
- What are his exact personal hygiene needs at the moment?
- Exactly how much assistance does he require at the moment?
Listen to the patient’s preferences and devise a plan
- How does Adam want his hygiene needs to be met?
- Does Adam have any religious/cultural issues we need to consider?
- Adam is not able to go to the bathroom at present, so we will need to assist him to meet his hygiene needs whilst he is in bed.
- Adam must consent to the care we are providing and ensuring he is safe during this is of fundamental importance. Because Adam feels ‘wobbly’ we would need to consider his safety needs (see questions 2 and 3 for more details). If at any point we were uncertain what was appropriate for Adam’s care we would ask for advice.
Environmental and equipment factors
- Are we able to safely meet Adam’s hygiene needs in his current environment, or does he need additional care?
- Will Adam’s additional needs at the present put any of those caring for him at risk, for example, can Adam’s bed be made sufficiently accessible and at an appropriate height to unsure we care for our backs?
- Do we have all the equipment we need, including Adam’s toiletries?
Provide Adam with the care he requires. See question 2 for further details.
’Nowledge and skills
Whilst providing Adam’s care is there any information we would tell him to ensure that he can continue to maintain his hygiene needs until he is recovered? See question 2 for further details.
Caring for Adam in this way would enable us to promote his independence as far as is possible at the present, take account of his preferences, treat him as an individual and maintain his dignity. It is our role not just to assist Adam to maintain his hygiene to keep him physically clean, but also for personal, social, and psychological reasons.
- Which of the step-by-step clinical skills guides would be relevant for Adam’s care? Would you need to make any modifications to these?
The step-by-step clinical skills guides appropriate to Adam’s care would be:
- Bathing a patient in bed
- Teeth brushing
Although Adam has only mentioned having a wash and a shave it would be an opportunity to ask him whether he would also like to clean his teeth.
The modifications you would need to make to these would be similar for all three activities. Adam has told us that he feels ‘wobbly’, so be very careful when asking him to move himself or sit up. If he can manage to tolerate sitting up in bed, resting on a couple of pillows, without feeling too ‘wobbly’, shaving and cleaning his teeth will need to be done in this position. If Adam is not able to sit up at all, shaving and cleaning his teeth can be done whilst he is flat. As Adam has plaster casts on his wrists he will only have very limited, if any ability to use his hands to perform activities for himself, so you will need to perform these for him.
It would be sensible to ask Adam if he would find his care more acceptable if, rather than doing everything in one go, you spread the procedures out over a period of time, so he could rest in between.
- What will be your priority and what additional assessments will you undertake?
Your priority would be to maintain Adam’s safety. To ensure this you would make sure he could tolerate each of the procedures without feeling too ‘wobbly’ or causing additional pain. You would also need to make sure that those delivering his care were not being put at risk, from, for example, a back injury.
You would need to constantly assess whether Adam was feeling ‘wobbly’ due to the hygiene procedures, and offer frequent rests. Whilst assisting him to maintain his hygiene you would also assess:
- the condition of his skin
- the many contusions he has sustained
- the cut over his right eye
- that his plaster casts were not rubbing
- the condition of his left ankle
- that Adam was receiving sufficient analgesia and was not in pain.
Case Study: Mohammed pg 572
Mohammed is three and attends a local nursery four days each week. After lunch he asks to clean his teeth, as he recently went for his first dentist appointment and was told this is important.
- Using the relevant clinical skill guide as a resource, what are the important health education points to stress to Mohammed?
- How could you do this in a way he understands?
1. Using the teeth brushing clinical skill guide, the important health education points you would want to stress to Mohammed would be that:
- he should clean his teeth before breakfast, after meals and at bedtime
- holding the brush at 45 degrees and using small circular motions, starting with his upper teeth, brushing all surfaces and paying extra attention to the area where his teeth and gums meet is the most effective way to clean his teeth.
2. Ideas of how you could do this in a way Mohammed would understand include:
- making a chart with Mohammed which indicates breakfast, meals and bedtime with space for him to draw a picture of a toothbrush whenever he cleans his teeth
- use a suitable soft toy/doll and a toothbrush to show Mohammed how he should clean his teeth and then get him to practise on the soft toy/doll.
Case Study: Josette pg 572
Josette is fifty-two and has a long history of severe depression. The community mental health nurse has visited Josette at home today and finds her looking dishevelled. Her clothes are stained and smell of sweat, her hair is greasy and matted and her fingernails are long and dirty.
- What would your priorities be in assisting Josette to maintain her hygiene?
- How will you assist Josette to maintain her hygiene in a manner she finds acceptable?
- What additional issues do you need to consider due to the setting of her care?
1. The priorities in assisting Josette to maintain her hygiene would be:
- ensuring that her dishevelled state is due to her depression rather than another cause, such as a physical illness that is limiting her ability to care for herself
- devising a plan to enable Josette to be assisted to maintain her hygiene in a manner she finds acceptable that supports her current independence and control.
2. In order to assist Josette to maintaining her hygiene in a manner she finds acceptable it is necessary to discuss with her what she would like to do and how she would like to do it. Encouraging and assisting any patient to maintain their usual routine, enabling them to be as independent and feel as in control as possible, is an important aspect of every nurse’s role. However, as indicated in the case study, Jane has a history of depression which may result in her required assistance to maintain her hygiene.
If you apply each stage of ‘CLEAN’ (chapter 31) you would:
Consider and assess Josette’s needs
- What are her exact personal hygiene needs at the moment?
- Exactly how much assistance does she require at the moment?
Listen to the patient’s preferences and devise a plan
- How does Josette want her hygiene needs to be met?
- Does Josette have any religious/cultural issues we need to consider?
- Is Josette happy to go to her bathroom for a bath or shower?
- Josette must consent to the care we wish to provide and her safety is of fundamental importance. Josette’s reduced ability to maintain her hygiene may also indicate that she is not taking care of herself in other ways, such as preparing and cooking meals, so we would also assess this at an appropriate time.
Environmental and equipment factors
- Are we able to safely meet Josette’s hygiene needs in her current environment, or does she need additional care?
- Will Josette’s additional needs at the present put any of those caring for her at risk, for example, can we deliver the care Josette requires within her home whilst abiding by manual handling guidelines?
- Do we have all the equipment we need?
- Provide Josette with the care she requires.
’Nowledge and skills
- Whilst providing Josette’s care is there any information we would tell her to ensure that she can continue to maintain her hygiene needs until she recovers?
- Caring for Josette in this way would enable us to promote her independence as far as is possible at the present, take account of her preferences, treat her as an individual and maintain her dignity.
3. As we are caring for Josette in her own home, we may need to consider whether her needs can be safely met, as we are unlikely to have access to a wide range of additional equipment. We would also need to assess whether Josette was able to remain within her home, or whether her lack of ability to maintain her hygiene was a sign that her condition had deteriorated sufficiently for her to need a level of care that could not be delivered in this care setting.
Activity 35.1 pg 579
A strict Orthodox Jewish patient has died on the operating table. He was only the second on the list, there are still a number of patients awaiting surgery and all the other theatres are busy. It is clear that this patient will have to be moved from the table onto a bed.
- How would you manage this task while respecting the cultural needs of this patient?
There are a number of options here:
- The least acceptable option would be for a nurse who is wearing gloves to gently remove the body of the deceased from the operating table and place on a trolley which can then be removed to a quiet area in the department until those designated by the family to perform Last Offices arrive. However, unless this is witnessed by someone trusted by the family, they may still feel that their cultural needs have not been met as they have no guarantee that their loved one was not desecrated by being touched by unsuitable ungloved hands.
- If there is a spare operating table in the operating theatre department the patient could remain on the table and be removed to a quiet area in the department until those designated by the family to perform Last Offices arrive.
- Whenever possible, arrange for the chevra kadisha to attend to prepare the body of the deceased for burial. Ideally this should be done before removing the body from the table, but, if there is no option but to remove the deceased, this can be done following this.
Case Study: Jake and Zoe pg 585
Jake was six years old. He had been in and out of the children’s ward for the past two and a half years, having been diagnosed with a brain tumour at the age of four. Initially it was thought that the tumour was benign and surgeons believed they had successfully removed it, but it came back in a malignant form. Despite further surgery, the tumour could not be removed and Jake had been receiving palliative care for the past six months.
Jake’s mother, Terri, and his father, Max, had cared for Jake at home for much of the time he was sick, but he had wanted to die in hospital ‘with his favourite nurses around him’ so, when it became apparent that the end was near the family came into hospital for the final time. They took over Jake’s usual cubicle and Terri, Max and Jake’s 12-year-old brother James all stayed there with him. There were pictures of other family members, the family’s dog and cat and cards all around the room and it didn’t really feel like a hospital cubicle.
After a bad night, Jake deteriorated and died in his mother’s arms around 10am; he did indeed have his favourite nurses around him. Terri, Max and James sat with Jake for over an hour after he died until it was time to perform Last Offices. Zoe, the nurse, tried gently, but firmly to ask the family to leave, but they were insistent that, having cared for Jake in life, they wanted to perform the final caring acts for him. Although she felt very uncomfortable, the nurse reluctantly allowed Terri and Max to stay, but was adamant that James was too young and should leave.
James’ response was to take Jake’s towel and gently dry the areas that his parents had just washed – talking to Jake all the time, telling him what a special brother he had been and that he (James) would look after their mum and dad. He helped Terri and Max to dress Jake in his Manchester United kit and when the time came to put identity labels on Jake’s body, James took them out of the nurse’s hand and carefully placed them around his brother’s wrist and ankle. He then went to the pile of toys that Jake had accumulated whilst in hospital and picked out his favourite cuddly bunny, which he placed in Jake’s hands before the body was prepared for transfer to the mortuary.
As the family left the cubicle Terri simply said ‘Thank you’, but James turned and ran back to Zoe to give her a big hug.
- Why might Zoe have been reluctant to allow Jake’s family, and particularly his brother James, to participate in performing Last Offices?
- How could being involved in this procedure have assisted family members in managing their grief both in the period immediately after Jake’s death and in the following months?
1. There are several possibilities here:
- Some nurses believe that this procedure should be undertaken by nurses and that family members should not be involved. It is possible that Zoe was trying to protect the family from something she felt they should not see and therefore she asked them to leave the room.
- Another option is that Zoe is herself lacking in confidence in undertaking this procedure and therefore would have felt uncomfortable having the family present.
- Zoe might be worried that she would become upset in front of the family and possibly believes that this would be wrong. Many children’s nurses do cry in front of parents and this is often greatly appreciated by the families concerned.
- With regard to James, the protectionist approach identified above is the most likely reason why Zoe was so reluctant to involve him. There is a mis-conception that death is something that only adults should manage and that children should be excluded, but recent research suggest that doing this might be detrimental to a child, particularly those involved in their sibling’s care throughout their illness.
2. The most important reason for allowing Terri, Max and James to be involved in performing Last Offices is that it gave them the opportunity to continue in their role as his carers and undertake the final act of caring for Jake. They have all been actively involved in Jake’s care over the past six months and have undoubtedly discussed this moment on a number of occasions.
By enabling them to be involved they can genuinely say that they did everything they could for him. Their grieving process is likely to be full of mixed emotions – relief because Jake is no longer suffering, alongside the sadness that only the death of a child can bring – and giving them these precious last minutes with Jake would bring tremendous relief.
Activity 36 .1 pg 597
How effective is nurse leadership?
- Why were nurses’ voices were largely absent at this important time?
- How influential are nurses as leaders in the NHS today?
- What professional organizations exercise leadership on your behalf?
Nurses were not socialised nor developed educationally to adopt national leadership roles at this time. It seemed to be taken for granted they would accept whatever changes were imposed on healthcare and this still often seems to be the case for many nurses, up to the present day. Although nurse leaders do exist at many organizational levels throughout the NHS, they still tend to be absent from the national stage, although the RCN does have a nationally and locally recognized presence. The importance of developing leadership in nursing has been increasingly recognized and there are a number of leadership programmes – with the RCN, the Kings Fund and the NHS Leadership Framework, available.
The professional organizations which exercise leadership on your behalf include: the Royal College of Nursing, which has professional and trade union roles; and UNISON which is a large trade union with many nurse members.
Case Study: Gordon Walters pg 625
Gordon Walters is a fifty-seven-year-old publican. He is married and his wife (Gloria) works in the pub with him. He has two grown-up children who are both married, but do not live nearby. Gordon and Gloria live above the pub. Gloria comes from St Maarten, an island in the Caribbean, and loves cooking traditional Caribbean food, but has had to curtail this (to a degree) since Gordon developed diabetes.
Four years ago Gordon experienced several episodes of chest pain, which prompted him to go to his GP, where he was diagnosed with hypertension and type 2 diabetes, which are now both well controlled.
Gordon has come to see you, the practice nurse at his GP surgery, because three weeks ago he tripped on a concrete step. When he removed his socks that night he noticed a small blood blister on the side of his left big toe. Over the next couple of weeks this has developed into a small wound and he decided that as it was getting bigger he should seek your advice.
The wound has affected Gordon’s mobility, he is limping and has recently been experiencing pins and needles in both feet. Gordon is concerned that he may lose his foot, as his uncle, who was a diabetic, had an amputation following an ulcer on his foot.
Gordon is also worried that he may need to take time off work.
- What other healthcare services or professionals might Gordon have consulted prior to seeing you for his wound?
- If Gordon were to be in hospital rather than at home, what other healthcare professionals would be involved in his care?
Professionals that Gordon might have seen before coming to the practice nurse for his wound:
- Doctor – GP
- Local pharmacist
If in hospital professional staff would include:
- Medical staff – diabetic consultant, nephrologist to check kidneys
- Nursing staff – ward nurse, diabetic nurse
- Specialist dietician
- Vascular lab technician to do further studies to check out arterial blood flow.
Case Study: Antoinette Thomas pg 626
Antoinette Thomas is a seven-year-old child who has been admitted to your ward with an acute attack of asthma. Her mother is with her and she tells you that she has had episodes of wheezing in the past, but this has decreased since she was started on another inhaler.
Antoinette has recently had a runny nose and has been coughing a lot, and this evening she developed shortness of breath, which was not relieved by taking her inhalers. Antoinette is having difficulty breathing – she has a respiratory rate of 46 breaths per minute, is using her accessory muscles to help her breathe and you can hear a wheeze on expiration.
Antoinette’s mother tells you that Antoinette is extremely frightened.
- What professionals will need to be involved in managing Antoinette’s asthma, both in the short and longer term?
- If Antoinette were to have severe learning disabilities what additional support could she and her mother require?
Professionals involved in Antionette’s care would include:
- Medical staff – respiratory consultant, paediatrician if this is not the respiratory consultant
- Nursing staff – ward nurse (children’s), respiratory clinical nurse specialist
- Practice nurse
- Diabetic nurse specialist
If severe learning disability:
As well as the above –
- Disability nurse
- Patient’s advocate.
Case Study: Sarah pg 636
Sarah is a businesswoman who perceives herself to be unsuccessful. However, the external reality and the perception of others is that she is excellent at her job. This discrepancy between her self-perception and that of the people around her are related to her self-image. Her distorted self-image may have developed in childhood when her parents offered her love only when she behaved well, rather than giving her unconditional positive regard.
Rogers suggests unconditional positive regard and acceptance is important to use in psychological therapy, as the person is not being judged and feels supported so they are more likely to develop trust in the therapeutic relationship and talk honestly about their problems.
- How would this approach be beneficial for Sarah?
Unconditional positive regard offered in therapy means that whatever Sarah says and does, it will not negatively affect the therapeutic approach used with Sarah. Unconditional positive regard will help her to build confidence in her achievements.
Acceptance and acknowledgement of Sarah as a person in her own right will help her develop a healthy self-esteem and confidence.
Case Study: Poppy pg 646
Poppy is a nursing student on her second placement in a medical ward and was told by the Sister to take a drink to a patient in a side room. She was not given any further information. When she opened the door she saw a man in bed with severe burns to his face and chest. His skin looked like a log of wood that had burnt on an open fire and was blackened, blistered and flaky. Poppy was shocked, but managed to stop her jaw from dropping.
The patient’s wife was sitting next to the bed with other relatives and said to Poppy, ‘It’s all right for you nurse, you see this sort of thing every day, but this is my husband. I am struggling to cope!’
This comment was miles from the truth of the situation and not how Poppy was feeling, but she managed to compose herself and replied, ‘Yes, it must be really difficult for you’. Poppy did not say how shocked she was as she had been unaware of the patient’s condition when she entered the room and had never seen severe burns before.
Poppy’s actions were correct. Despite the lack of information from the Sister, she did not have permission to share her feelings of shock with the patient and his wife. This would have been meeting her own needs to express her feelings rather than meeting the patient's.
- What could Poppy do to prevent a similar incident occurring in the future?
- How would using PERFORM have helped Poppy in this situation?
- What could Poppy do to prevent a similar incident occurring in the future?
Poppy could have asked the named nurse or checked nursing records of the gentleman so that she knew his reason for admission prior to entering the room.
- How would using PERFORM have helped Poppy in this situation?
Although Poppy managed the situation correctly she was intuitively responding to it. Her focus was the task and she was anxious about her performance in relation to this and so did not focus on the patient. If she had been using PERFORM she would have prepared herself before entering the room for meeting with him and his relatives by finding out his name and preparing herself by thinking through all the aspects of PERFORM (her eye contact, facial expression and managing herself, etc.).
Case Study: Rachel pg 653
Rachel lives with her husband and two children in a town in the south of England. The family moved there three years ago when Mark, her husband, had to either take redundancy or to move with his firm. Two years earlier Rachel had given up her job as a teacher following the birth of their child, Tom, who suffered anoxia during his birth leaving him with severe physical and intellectual disabilities. The family felt they had to move when Mark’s firm moved as they were reliant upon his wage, but this meant moving away from their supportive parents.
Six months ago Mark again learnt that he was being made redundant but with no possibility of re-employment. Rachel then found that she was pregnant. Around the same time Mark started to become depressed as he couldn’t find a job and the family were beginning to have financial worries.
Recently Rachel’s mother (who lives in the north of England) has been in hospital following a stroke. Rachel has been telephoned by her brother (who lives close to their mother) to say that the hospital wish to discharge their mother but that either someone will need to move in to care for her or she will have to move into residential care. He says he cannot help due to his work so he has told the ward staff that Rachel will help. Rachel feels torn: she can’t leave Tom in Mark’s care, as he is now so depressed that he rarely gets up before lunch.
- Can you identify the social factors affecting Rachel and her family?
The social factors affecting Rachel and her family include socio-economic factors (for example redundancy and not being able to work due to a caring role), the social effects of illness and disability (Tom's disability, Mark's depression and Rachel's mother's stroke are all impacting on her and her family's well-being), the role of the family (loss of support due to geographic distance and also requirement for additional support due to ageing), gender roles (for example, the assumption that Rachel will provide care for her mother), stigma (following depression Mark may find it more difficult to get another job if he discloses he has had depression).
Case Study: Lisa pg 657
At handover, a ward sister informs her staff team that they are expecting a new admission. She adds that the medical notes say the woman ‘suffers from Down’s Syndrome’. One member of staff says she once nursed someone with Down’s Syndrome and that they were really difficult. Another says she wouldn’t know where to start in terms of providing care and hopes a carer is coming to look after her. The sister also admits she doesn’t have much experience in this area and thinks that they should put the patient in a side room on her own. Having undertaken a placement working with people with learning disabilities, Helen (a first-year nursing student) asks whether she could do the admission as she needs to develop her communication skills.
When Lisa Barton later arrives with her sister, they are met by Helen and taken to the side room. Helen chats with Lisa and finds out about her fears and concerns about the procedure and also about her life, her likes and dislikes. Lisa lives independently although her sister supports her with some things. She works as a carer in a residential home for older people and doesn’t like missing work to come to hospital. She also says that she likes going out with her friends, reading and listening to music. She asks why she has been put in to a room on her own – she had hoped to be able to talk with other patients.
- What assumptions did the ward staff hold about Lisa before she arrived and on what did they base these assumptions?
- How might these assumptions impact on the way in which they provide nursing care for Lisa?
- What could be done to try and prevent such situations from occurring?
- What assumptions did the ward staff hold about Lisa before she arrived and on what did they base these assumptions?
The staff seemed to have based their view of Lisa on their (possibly sterotypical) views of someone who has Down's Syndrome/Learning Disabilities rather than on her strengths and abilities. Therefore they assume that she will be 'difficult' and that she will require additional care that they are not equipped to provide.
- How might these assumptions impact on the way in which they provide nursing care for Lisa?
The staff decided that she should be nursed in a side room rather than in the main ward and if Helen (the student nurse) had not been there and spent time with Lisa getting to know her and her needs there is a danger that she may not have received appropriate care and that she may have been very isolated during her stay on the ward.
- What could be done to try and prevent such situations from occurring?
It is important that all staff working in healthcare settings have disability awareness training (preferably delivered by disabled people) so that any stereotypical assumptions they hold can be identified and challenged. It is also important for staff to be supported to work directly with people with learning disabilities so that they can increase their confidence and competence especially in relation to developing and using appropriate communication skills.
Activity 40.1 pg 652
You will have chosen your own area to examine for this activity but the following is offered as an example:
In relation to health care we might ask:
- What is the aim of healthcare provided by the state?
- What should be the aim?
- Why is the health service structured in the way it is?
- Why are nurses the largest professional group within the health service but have traditionally lacked power?
- Who should decide how the health service is run?
- Who makes the key decisions in the health service?
Activity 40.2 pg 654
Again you will have chosen your own perspective for this exercise but the following is offered as an example:
- It can help us to understand the gendered nature of care that can impact both on the role of nurses and on the informal carers that nurses may support.
- It can alert us to the ways in which power is often exercised within the family and within wider society.
- It can encourage us to question existing structures both within healthcare and more widely and also to challenge their legitimacy.
Activity 41.1 pg 665
Construct a timeline of the main policy developments within healthcare, over the past thirty years. The following documents will help you to do this.
- The Nuffield Trust: The history of NHS reforms, an interactive timeline covering the past seventy years.
- ‘Back to the community – disability, equality, rights and inclusion 1945 to the present day’.
Can you identify any themes within the policy developments you have placed upon your timeline?
Back to the community
The timelines below follow the NHS from 1940 to 2013 and identify many of the main developments:
This website includes many of the main legislative changes since the 1940s and includes an interactive component, which will help you to explore particular issues in more depth.
This website is useful for providing some of the key legislative developments and also the medical milestones, running from 1948 to the present.
1980 – The Black Report on Health Inequalities – established social class differences in health. Thus those defined as social class 5 have poorer health than those in social class 1.
1982 – NHS reorganization
1983 – Griffiths Report on NHS management
1986 – Project 2000, which moved nurse training into higher education
Cumberledge Report, reform of primary health care
1987 – Improving Better Health, White Paper for improving patient choice
1988 – NHS Review chaired by Margaret Thatcher
1989 – White Papers, ‘Caring for People’ and ‘Working for Patients’ established a broad framework for NHS reforms, including the internal market, the purchaser/provider split and GP Fundholding. It also led to:
1990 – National Health Service and Community Care Act
New GP contract with a greater Health Promotion focus
1990 – John Major replaces Margaret Thatcher as Prime Minister
1991 – White Paper Health of the Nation identifies a number of important areas for improving health
The Patients Charter, advocating the view of the patient as a customer
1994 – NHS reorganization, the number of regional health authorities were reduced
1996 – NHS White Paper, Primary Care: Delivering the Future
1997 – The NHS Primary Care Act, increasing choice in primary care
1997 – May: Election of a Labour government
NHS White Paper, The New NHS: Modern and Dependable
1998 – Acheson Report into inequalities in health
1998 – A first class service: Quality in the new NHS aimed to end ‘unacceptable variations’ in care and setting up the National Institute for Health and Clinical Excellence
The Bristol Royal Infirmary Inquiry was set up to investigate the failings in providing care to children requiring cardiac surgical services. It reported in 2001
NHS Direct set up to provide a national help line
The Acheson Report into inequalities in health, found inequalities by socioeconomic and ethnic group and gender across a wide range of measures
1999 – Royal Commission on Long Term Care reviewed funding options for Long Term Conditions for older people
NHS reorganization, abolished GP Fundholding and established new Primary Care Groups
White Paper Saving lives: Our healthier nation, follow up to the 1991 White Paper
2000 – The NHS Plan, a 10-year modernization programme of investment and reform
2001 – Commission for Health Improvement created, the first organization to formally assess NHS hospital’s performance
The Health and Social Act, sets out the NHS plan
Introduction of hospital star rating system
2002 – NHS reorganization, District Health Authorities are replaced by Strategic Health Authorities and Primary Care Trusts
Wanless Review, established the need for increased health and social care resources
2003 – New contract for GPs and hospital consultants, changing delivery of services to patients
Agenda for Change, standardization of pay/conditions for the majority of NHS staff
2004 – Establishment of first 10 Foundation Trusts, with more control over their budgets/services
Plans for GP practices to be involved in commissioning healthcare services through ‘practice based commissioning’ policy
White Paper on public health, Choosing Health: Making healthy choices easier
2006 – NHS reorganization, Strategic Health Authorities decreased from 28 to 10 and number of Primary Care Trusts decreased from 303 to 152
White Paper Our health, our care, our say: A new direction for community services, to encourage patient choice and move services from hospital to community
2007 – Gordon Brown replaces Tony Blair as Labour Prime Minister
Conservative Party publish a White Paper setting out their vision for the NHS
Smoking ban introduced in England
2008 – NHS Next Stage Review, by Professor Sir Ara Darzi, a 10-year vision for the NHS
2008 – Scotland’s ‘Equally We’ Report, into health inequalities
2009 – NHS Constitution
New health and social care regulator created, The Care Quality Commission
NHS Chief Executive David Nicholson warns NHS needs to prepare for major
efficiency savings, of £20billion by 2014
2010 – Sir Michael Marmot’s ‘Fair Society, Healthy Lives’ Report
February, publication of Robert Francis’ Inquiry Report into the Mid-Staffordshire NHS Foundation Trust
May, General Election leads to no overall winner, but a Coalition emerges between the Liberal Democrats and Conservative parties, with David Cameron as Prime Minster
June, a public inquiry into Mid-Staffordshire announced
June, White Paper, Equity, excellence: Liberating the NHS, led to major criticism
November, government’s vision of public health, Healthy lives, healthy people
2011 – Increasing opposition to the Health and Social Care Bill, led to the Prime Minster ‘pausing’ its passage through Parliament for a ‘listening exercise’ by the NHS Futures Forum
2012 – March, after 18 months and numerous amendments the Health and Social Care Act is passed
2013 – February, publication of Sir Robert Francis’ Public Inquiry report into Mid-Staffordshire NHS Foundation Trust
April 1st, ‘new’ NHS comes into being as responsibilities shift to newly created bodies
POLICY DEVELOPMENT THEMES
- Increasing awareness and evidence about health inequalities
- Shift of power from acute hospital sector to primary care
- A growing recognition of the importance of public health
- Shift of power and decision making from professionals to patients (service-users)
- Introduction of General Management and systems for quality monitoring
- Introduction of free-market ideas and increasing privatisation in NHS services in England.
Activity 41:2 pg 667
The four nations of the UK have some divergent and convergent health policy approaches, particularly since devolution in 1999.
Access each country’s health department website and identify the policies relating to health inequalities.
http://www.dhsspsni.gov.uk Department of Health, Social Services and Public Safety (Northern Ireland)
http://wales.gov.uk/topics/health/?lang=en Department of Health (Wales)
http://www.scotland.gov.uk/Topics/Health Department of Health (Scotland)
http://www.dh.gov.uk Department of Health (England)
List these policies according to nation and make a comparison of their approach.
The health of the population in the UK has improved dramatically over the last century, in terms of morbidity and mortality. However, these health gains are not equally shared, thus people with higher incomes tend to live longer and healthier lives than people living on lower incomes (Marmot, 2010). Income tends to be equated with social class and other characteristics tend to make a difference to people’s life chances, including gender, ethnicity, sexuality, age and geography. The socioeconomic determinants of health clearly link social conditions and health and this is a crucial aspect to improving health (Marmot, 2010). Thus health inequalities have been defined as the ‘differences in health status or in the distribution of health determinants, between different population groups’ (WHO, 2013a). The social conditions of health relate to the conditions in which people are born, grow up, live and work and include housing, education, financial security, the built environment and the health system. The WHO (2013b) argues that these conditions are then shaped by each country’s economic, social and political policies. It is generally recognized these social determinants are responsible for significant levels of unfair health inequities. However, political ideology drives the UK governmental response to this. It is imperative nurses understand and recognize the impact these social determinants have on health (RCN, 2012). Therefore tackling health inequalities is an important aspect of UK public health policy and of concern to all healthcare professionals.
Northern Ireland adopted a broad strategy on social justice and equality, and since the early 1990s due regard must be paid to inequalities and this is a legislative duty in Section 75 of the Northern Ireland Act which followed the 1998 ‘Good Friday’ or (Belfast) Agreement. Targeting Social Need (TSN) was first launched by the Conservative government in 1991 to tackle significant socio-economic differences between the Catholic and Protestant communities in Northern Ireland. In 1997 the new Labour government strengthened this policy and re-launched it as New TSN and published a White Paper in 1998 entitled ‘Partnership for Equality’.
The New Targeting Social Need (New TSN) was a cross-departmental policy aimed at tackling social need and social exclusion and has similar strategies to Britain, designed to combat deprivation, disadvantage, poverty and social exclusion. The policy requires resources to be targeted towards people, groups and areas in greatest need. New TSN has three complementary elements: tackling problems of unemployment and increasing employability; social need in areas such as health and social care and includes Promoting Social Inclusion in (teenage pregnancy and motherhood, ethnic minorities and the Travelling community); and a cross-departmental and evidence-based approach to tackling the causes of social exclusion.
Northern Ireland’s main public health policy is ‘Investing for Health’ (IFH) (2002) and it focuses on the social determinants of health with the goal to improve the health status of all Northern Ireland’s citizens and reduce inequalities in health. It sought to shift the focus towards tackling the factors which adversely affect health and perpetuate health inequalities. It also sought to implement action to address the wider determinants of health, using a framework based on inter-sectoral partnership at the governmental and local levels. It adopted a range of approaches to address the issues of: smoking, drugs and alcohol misuse, obesity, suicide and mental health.
In 2010 it was proposed the ‘Fit and Well – Changing Lives 2012–22’, strategy would replace the IFH public health strategy. It is based on the same principles, aims and values as IFH, whilst adopting a life course approach. It is planned to be outcomes focused, with an emphasis on health inequalities and the social gradient to engage and empower individuals, families and communities. The strategic priorities are focused on early years and supporting vulnerable people and communities. The priority areas for collaboration are: support for families and children; equipped for life; employability; volunteering/giving back; use of space and assets and using arts, sports and culture. This is to be implemented in a whole systems manner with partnership at the following levels: governmental, regional and local. This is currently awaiting policy approval by the Northern Ireland Executive (early 2014). The recent review of health and social care ‘Transforming Your Care’ also identified the need to tackle health inequalities and to refocus care provision from acute to community settings.
Wales also places great emphasis on equity in terms of health inequalities and unequal access to healthcare, which was acknowledged in Better Health: Better Wales (1998). It included renewed efforts to tackle poverty and inequality, a health inequalities fund, evaluation of the impact of NHS spending on equity and a new formula to allocate health resources on the basis of need. The health inequalities fund was established in 2001 to target resources at disadvantaged populations, relating to heart disease, workplace health and lifestyle advice. Wales has a unified public health system, Public Health Wales, which provides specialist public health support.
Our Healthy Future set the foundation for public health and this was underpinned by a number of national plans. Thus the action plan aimed at reducing health inequalities was called ‘Fairer Health Outcomes For All: Moving the Agenda Forward’ (2011) and there were also plans for tobacco control and sexual health and well-being. The action areas were: building health into all policies; giving every child a healthy start; developing health assets in communities; improving health literacy; making health and social services more equitable; developing a healthy working Wales and strengthening the evidence base. It aims to tackle avoidable and unfair differences in health, including: alcohol and drugs misuse, unhealthy diets and inactivity; smoking; reducing the number of teenage pregnancies; improving people’s mental well-being; increasing immunization rates and decreasing the number of accident and injuries. It includes unfair impact on individuals, from service provision or taxation policy. It supports other government objectives linked to health, including the environment, economic development and child poverty.
Scotland has some of the worst life and health life expectancy rates in Western Europe and tackling them has remained difficult, despite on-going Scottish government commitment to tackle health inequalities, as part of a wider social justice programme. The poverty and social exclusion strategy ‘Closing the Opportunity Gap’ is cross-departmental and it set targets to reduce health inequalities between people in deprived and affluent areas. In 2008 the ministerial review of the health inequalities strategy ‘Equally Well’ set out four priority areas for action to reduce health inequalities. These were: children’s early years intervention, mental illness and well-being, the ‘big killer’ diseases such as cancer and heart disease and drug/alcohol problems, especially amongst young men. The underpinning philosophy was on prevention and to improve circumstances and environments to improve people’s lives and health; to address intergenerational factors which perpetuate inequalities; to engage individuals, families and communities in their own health and to deliver public services that are targeted to those most in need (Ham, 2011).
This included further development of support services for families with young children, increased investment in the Family Nurse Partnership model, healthy weight initiatives and more help for those with depression and anxiety. A target was set to increase the proportion of income received by the poorest 30% of households by 2017 and increase healthy life expectancy at birth, in the most deprived areas. The Scottish Chief Medical Officer has adopted a so-called ‘asset-based approach’ which aims to build community capacity, resources and control to improve health, and broad political support continues for preventative activity.
In 1997 the Labour government health policy had a central focus of tackling health inequalities. In 2004 it set a target to reduce the gap in life expectancy in the population by 10% by 2010. It also recognized the importance of improving the life chances of children, to tackle inequalities (Every Child Matters, 2003). Economic well-being was one of the key goals here, with the aim to halve child poverty within a decade. However, neither target was or has been met.
The current coalition government has stated it is committed to decreasing health inequalities and it did broadly support the Marmot Review. However, public health policy seems to have shifted towards focusing on ways of changing health behaviour by encouraging personal responsibility for health and transferring this responsibility to local authorities (Healthy Lives, Healthy People, 2010). Thus, direct responsibility for improvements in health lies with local authorities and Health and Well-being Boards. The aim is for them to maximize the health benefits in all policies. There is also an awareness of the interdependent nature of different government departments and policies and how they impact on health outcomes. However, Ham (2011) argues that the current coalition government’s economic policy and public expenditure cuts are likely to lead to a widening of health inequalities.
Common themes across the four UK countries include: recognition of the complexity of tackling health inequalities; the importance of early years interventions and the need to give children the best possible start in life; the use of evidence-based practice; the need to work across government departments in partnership and approaching this from the framework of Marmot’s social determinants of health.
Divergent themes across the four UK countries include: health, housing and changes to the UK welfare benefits system. The other three countries are concerned about the operation of the welfare benefits reforms in their countries as well as the differing approaches to reducing poverty, unemployment and inequalities.
Baggott, R. (2011) Public Health: Policy and Politics ( 2nd edn). Houndmills: Palgrave Macmillan.
Marmot, M. (2010) Fair society, healthy lives: Strategic review of health inequalities in England post 2010. (The Marmot Review). UCL Institute of Health Equity.
Royal College of Nursing (2012) Health inequalities and the social determinants of health. (Policy briefing 01/12). London: RCN.
World Health Organisation (2013a) Social Determinants of Health. WHO. Available at: http://www.who.int/social_determinants/en/. [Accessed 20.3.14].
World Health Organisation (2013b) Social Determinants of Health: Key Concepts. WHO. Available at: http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/ [Accessed 20.3.14].
Activity 41:3 pg 668
Fast forward to the 2015 general election and the largest Westminster political parties –Labour, Conservative and Liberal Democrat – are setting out their manifestos.
- List their main health and social policies. (Use Brindle et al. (2010) from the going further section, to help you.)
- A commitment to increase spending on the NHS by approximately 4% p.a.
- Guarantee, legally binding – a GP appointment within 48 hours, also an increase in GP opening hours over the 7-day week
- A root and branch review of Accident and Emergency services
- A range of new NHS primary care services
- Waiting times guarantee – to see a cancer specialist and for diagnostic tests
- Renewed focus on preventative care and public health
- Palliative care guarantees
- Reversing of NHS private services provision
- Increase in child care provision via tax credit system, targeted at less well-off families
- Extension of SureStart provision
- School – wraparound care for less well-off families
- Review of long-term care
- Prioritizing prevention services
- Increasing choice for patient treatment
- Increasing dementia research and developing dementia policy
- Increase access to mental health services
- New GP and Consultant contracts
- Use of patient contracts to partnership health behaviour change
- Guaranteeing respite care for carers
- Address retirement policies and enhance access to employment market
- Increase parental leave – shared between both parents
- Increase NHS performance measures
- Setting targets for the care and treatment of long-term conditions
- Increase patient choice to choose any approved healthcare provider
- Link practitioners pay to health outcomes
- Increase service privatisation
- Increase respite care for carers
- Increase the ‘Big Society’ policy
- Develop citizenship for the unemployed aged 16-18 years
Case Study: Freya pg 673
- Did the nursing staff treat Freya in an acceptable manner, with the compassion she deserved?
Freya was virtually ignored by the staff. Her learning disability was not recognized and she was not communicated to adequately. The level of staff communication was minimal and inappropriate and she was not treated with any degree of compassion. As she was a vulnerable adult, her safety was compromised and this fact was not taken into account during her mother’s care.
Should the staff have identified Freya’s learning disability and met her needs?
The staff should of course have identified Freya’s learning disability and the nature of her relationship with her mother. This would have enabled staff to appropriately locate Freya’s needs.
Case Study: Joan pg 674
- Joan’s care highlights some of the problems patients experience when they visit A&E, which the Keogh review aims to address. Identify these problems and reflect on how they could have been prevented.
The problems with Joan’s care were: poor initial assessment which did not include her daughter, nor take account of her particular needs; delay in accessing the evidence-based recommended care; delay in diagnosis; poor communication between the healthcare staff; poor communication between the healthcare staff and Freya; poor standards of care and delay in accessing the correct care pathway.
- What national standards should have guided Joan’s treatment and care?
Use of The National Stroke Strategy (2007–2017) – thus patients with a suspected stroke should receive an immediate clinical assessment from the right people (thus the practitioners must have the correct expertise). People requiring an urgent brain scan are scanned in the next scan slot within usual working hours and within 60 minutes of request out-of-hours, with skilled radiological and clinical interpretation being available 24 hours a day. Patients diagnosed with stroke receive early multidisciplinary assessment (swallow screening, identification of cognitive and perceptive problems) within 24 hours. All stroke patients have prompt access to an acute stroke unit and spend the majority of their time there. Hyper-acute stroke services provided as a minimum – 24 hours access to brain imaging, expert interpretation, the opinion of a consultant stroke specialist and thrombolysis is given to those who can benefit. Specialist neuro-intensive care is rapidly available and specialist nursing is available for monitoring patients.
The National Institute of Health and Clinical Excellence (NICE) (2010) quality standards for Stroke identify the necessity to establish a rapid diagnosis using FAST and ROSIER. Assess for the need for a brain scan and scan within the next available scan slot and administer thrombolysis if indicated, within 3 hours of the onset of symptoms.
Activity 42.1 pg 682
- Reflect upon your health beliefs, those of your family and those of the patients for whom you have cared.
- Are the majority of these based on scientific evidence, or past experience and long-held belief or tradition?
- How can you ensure that the care you deliver to a patient always respects their health beliefs?
There is no template answer for points one and two as these are an individual reflection.
You can ensure that the care you deliver to a patient always respects their health beliefs by asking the patient questions, listening to their views and developing their prescription for care based upon this. So, following an APIE approach;
- When Assessing a patient’s needs ask them about their health beliefs just as you would do if you wanted to find information about any other issue.
- When Planning a patient’s care involve them in deciding the goals they wish to achieve and how these are going to be achieved.
- When Implementing a patient’s care enable them to be an active partner in the process, so they are as fully involved as possible and understand all actions.
- When Evaluating a patient’s care ask the patient for their views upon how successful their prescription for care has been.
What’s the evidence? Pg 685
Student nurse perceptions of risk in relation to international placements
Morgan (2012) identifies the risks perceived by nursing students when undertaking an international placement.
Reflect upon the risks you would perceive when planning an international placement.
How could you reduce these risks?
Now read the article and consider whether your concerns were the same as the students’.
There is no template answer for the first and third points.
You can reduce the risks of an international placement by:
- Starting your planning early, so you have plenty of time to make arrangements
- Discussing your plans with your tutor
- Fully investigating the area you wish to visit and doing the same for the specific placement area
- Talking to people who know the area, live there or have visited it
- Finding out the local customs, especially relating to behaviour and clothing
- Carrying out a thorough risk assessment to identify any potential risks
- Ensuring you remove any unnecessary risks, especially those relating to health and safety
- Arranging appropriate health and travel insurance before you leave the UK
- Ensuring that there is a professionally qualified individual in your international placement area who is prepared to supervise you at all times and getting this agreement in writing
- Arranging your return travel plans and accommodation before you arrive in the area
- Arranging an emergency contact number so you can always talk to someone if you are concerned
- Taking money with you only to use in an emergency
- Keeping your passport and money safe at all times
- Not taking expensive items you do not want to lose with you
- Trusting your instincts, if you are concerned about your health or safety take the appropriate actions
- Arranging to make regular contact with someone in the UK at pre-arranged times throughout the whole of your visit
- Discussing all of your plans with someone you trust and carefully considering their views
Activity 42.2 pg 685
- What information should you familiarize yourself with before you leave for an international placement?
- What information sources would you need to consult in order to ascertain this information?
Before leaving for an international placement you need to know everything you possibly can about the general area and the specific placement area, how it will be acceptable for you to behave and dress whilst you are in the area, who you are going to be supervised by, how you are going to travel, how much money you will need, what you need to take with you and what the possible risks are – especially relating to your health and safety.
To ascertain this information you need to discuss your plans with your tutor (many universities have comprehensive information/guides to help students who wish to undertake an international placement), consult guidebooks, websites (such as Foreign and Commonwealth, World Health Organisation, Nursing and Midwifery Council), visit a travel clinic for health advice, talk to individuals who know the area and discuss your plans with someone you trust to ensure you haven’t forgotten anything.