NU1505
Health, Society and Care Provision
The aim of the assignment is to perform a patient case study that will focus on the appraisal of the nursing model used in practice, culturally specific components of care, health education and promotion, and the multidisciplinary approaches to care provision.
All names in the case study have been changed to protect the patients’ identity, to conform with The Code (2008) and Data Protection Act (1998).
Edna is an 87 year old female, has a good quality of life and is busy socially. She lives alone and has been widowed for ten years, yet has plenty of family and friends close by. She is self sufficient, does her own cooking and cleaning, and drives to see her friends. Edna’s previous occupation was a dinner lady at the local school where she served for over 30 years. She is a devout Roman Catholic and goes to Church every Sunday.
Edna has previous medical history of hypertension, angina and arthritis, all of which are controlled with medication. More recently she had urinary problems and was suffering from incontinence. She was referred to the urology consultant and after tests, he discovered a blockage in her bladder that would require an operation for its removal. She was then seen by the specialist urology nurse who explained the procedure and went through the pre-operation checklist with her.
Edna was admitted onto the ward in good health as a planned surgery case to undergo a transuretheral resection of a bladder tumor. The ward is a mixed adult ward taking mainly planned surgical patients for urology and ear, nose and throat. The ward also had orthopaedic patients awaiting surgery, and any patients requiring surgery from accident and emergency. The admission process is done through a pack, which contains wristbands, waterlow score, nutritional score, bed rails assessment, Clexane assessment, drug board, patient notes, early warning score, Roper, Logan and Tierney model, and a disclaimer for property. This pack is used routinely for all patients and is to be filled in with patient present.
The nursing model used in the packs was the Roper, Logan and Tierney model of nursing. Newton (1991), states that the model seems practical, approachable and functional, and if used correctly enhances care. Roper (1976), explains that the complexity and specialization of nursing requires a simple frame work such as the Roper, Logan and Tierney, so that the elements of nursing are finally identified and understood. Hannah & Alimo (1989) discuss how this framework provides an explicit focus for nursing assessment and actions. They explain how emphasis is placed on independence and individual perception, and this encourages patient-centered care, stating that the model is useful, logical and holistic. They state that the model is for “Real nurses nursing real patients”. I think that the model met most of Edna’s needs, but a nurse needs to use the model as a guideline and concentrate on the patient. For example Edna is an elderly lady who is used to respect and autonomy. She is quite set in her ways as to when she likes to eat her meals and what she will eat, and although this is included in the model cannot be changed in the hospital environment. While it has been identified that she likes to rise at 6.30am and have her breakfast, then go back to sleep before rising again at 9am to have a bath, this is not feasible in the ward environment. This is because hospital meals are only delivered to the ward after 8am, and the ward does not have a bath, only two shower rooms.
I will now consider Dorothea Orem’s model of nursing, also recognized as the ‘Self Care Model’. This model promotes specific goals of the autonomy and patient self care. The aspects of the model require input and control from the patient, so would be unsuitable for a patient that is not mentally able. The nurse or healthcare professional is to supplement any deficit in the patients care, therefore supporting them instead of controlling their care. Deynes (1988) says that the model contains several propositions important to health promotion, and Orem (2001) states that adults in our modern society are expected to be self reliant and responsible for themselves. Therefore self help is a desirable activity and must be considered most important when caring for and teaching our patients. If we considered using this model for the patients care, we would allow Edna to define what activities of living she can perform without help, and then support her by filling in the ‘deficits’. As an independent lady, this model may help Edna herself identify any areas when she may require help or assistance and avoid any unnecessary doing from the nurse.
Taking into consideration the different styles and views of both models, I would find it hard to decide which would best suit the patient unless it was put into practice. I think that the Roper, Logan and Tierney model met Ednas needs for her stay at the hospital, as it was simple and helped the nurse to identify any particular requirements that Edna felt were necessary to her. I do however like the section of Dorothea Orems model that promotes normality. Normality is unique to us all, and so the promotion of normality would also be unique to the patient. As every nurses’ values, beliefs and opinions differ, so will the results of Edna’s care plan using either model. As Ellson (2008) quite rightly tell us, personal observations of the nurse using the model show us the naivety of its use, many nurses unaware of the complex nature of the model and the conflicts that can arise. She says there could be many reasons for different observation and usage of any model, stating time constraints, and prioritizing the patients’ most urgent needs. However, as nurses we must view and assess a patient holistically, and take in all of their beliefs and values, regardless of our own. I think that each model of nursing would suit a certain patient perfectly, but as all the models differ, so do our patients. So to conclude we need to use a model of nursing that best fits the majority of our patients, and train the staff of its correct use, as too many models on one ward would be very confusing.
Edna cultural needs were based on her age and the way she was brought up. As an elderly lady she was very well spoken, and socially she was a popular person and a leader figure in her family. Fox (2004), wrote the book Watching the English, and many of the traits she wrote about were of Edna’s generation. Some of these are common courtesy for others and manners, being uncomfortable in strange social environments, such as the hospital and being private about family life. Edna’s social needs were to be around her family and friends, and culturally, she wished for her business to be kept private and not to be a burden on anyone else.
Before discharge, Edna’s catheter was removed and she was taught to self catheterize by the urology nurse, then she returned to the ward. She went to the toilet and I found her crying. She explained that she was finding it painful and awkward to perform self catheterization due to arthritis in her neck, and was very embarrassed that she would have to do such a thing. Edna was terribly humiliated to be touching herself in the way self catheterization requires and felt that it was morally wrong. The nurse and I explained that an indwelling flip flow catheter would increase the risk of infection and might reduce the rate at which she could re-train her bladder to empty. Edna stated that she was not happy to self catheterize so a decision was made between the urology nurse and consultant to insert an indwelling catheter. Edna was happy and was not going against her morals and beliefs that her generation had embedded into her.
The history of nursing shows commitment to spiritual and cultural care, as it is essential in providing holistic care for the patient. Although as nursing care has become more technologically advanced, the spiritual and cultural components of care may be neglected on continued assessment. Literature tells us that there may be many reasons for this, Dossey and Keegan (2000) explaining one possibility being the nurses own perspective on spirituality. They state that nurses must identify their own spiritual requirements in order to provide competent spiritual care. The role of the nurse in maintaining the patient’s needs, is to support the patient in whatever they believe, regardless of their own beliefs. Nightingale (1996) believes that spiritual care is fundamental to our needs and is an essential part of the healing process. So if we take this into consideration, the spiritual and cultural components are of most importance in our patient care. Chung, Wong and Chan (2006) define holistic care as mind, body and spirit, helping us to understand that the mind and spirit are essential elements in the process of healing the person, and must not take a back seat to the medical needs of the body. We have learned that holistic care must mean just that, and take into consideration our patients needs on a spiritual and cultural level. As Dossey and Keegan (2000) have shown, this may mean that the nurses role is to examine her own spiritual and cultural beliefs before she can provide competent holistic care to ensure that the patients beliefs are maintained.
Health promotion and patient education, regardless of age can enhance health and motivate the individual. (Kelley and Abraham, 2007) Health promotion is a pro active section of nursing care that can provide the patient with the knowledge to manage their situation more effectively. It should be routinely offered to patients because if it was not, the prevalence of chronic health problems and demand on healthcare services would surely increase. (Department of Health, 2000) Wanless (2002) explains how patients must actively take responsibility for their own health, and to do so must have high quality health promotion and education advice available. As nurses provide the majority of care for patients, it is crucial that health promotion is part of nursing care. This is obvious, but problems occur when health promotion is integrated into the patient’s routine care. There are many constraints on a nurse’s time, but patient education and health promotion is essential to empower the patient and prevent any further unnecessary hospital stays. It is not only beneficial to the patient, but also to the health service.
Patient education played a large part in Edna’s case as we quickly and efficiently had to show her how to use a flip flow catheter and its attachments, and how to effectively clean the area. As Richardson (2008) explains, it is of upmost importance to maintain high standards of personal hygiene to prevent urinary tract infections. The health education was delivered in a private treatment room by myself and the registered nurse. We explained the procedure of cleaning the area, and she was happy with this. We then showed Edna how to use the flip flow and let her practice emptying the catheter herself. When she was comfortable doing this we introduced the day and night urine bags and demonstrated how to attach them. Edna did this a few times and felt that she could manage it herself at home. The nurse’s role in health education is to deliver the knowledge at the correct level for the patient and to ensure the patient fully understands. I think the method of delivery was perfect as we could actually watch the patient perform the procedure and decide on her competency.
The multidisciplinary team includes everyone who has input in a patients care including the patient themselves. A patients needs cannot be met by one professional alone, so we must work together to provide the best care to our patients. This is achieved by effective communication between all members of the team and ensuring all patient records are kept up to date and relevant. The role of the nurse is to act as an advocate for the patient and get them the help they require, especially when specialist nurses or doctors are required. This leads to better quality decisions made for the patient and increased professional satisfaction for the nurse. When a multidisciplinary approach to care provision is used correctly, it can benefit the patient and the whole team. The patient is satisfied, it increases their compliance with treatment and decreases reason for readmission. The benefit to the multidisciplinary team is sharing of responsibilities, complimentary strengths and mutual support. Literature tells us that there are many benefits to inter and multidisciplinary team approaches to care provision. Carter, Garside and Black (2003) say the patient feels more confident knowing a full team are involved in their care rather than just one clinician, and the continuity of care is easier to provide with more ‘hands on deck’. Team working within the NHS also provides each member with a sense of purpose and gives the opportunity for friendship and support. Communication between members of the team also enhances the quality of care for all patients, each team member gaining knowledge that they would not have if working alone.
Many of the multidisciplinary team were involved in Edna’s care from the specialist urology nurse at pre-op, to the consultant who performed the operation. The students, healthcare assistants and nurses who cared for Edna on the ward also had a large input in Edna’s care. Literature has proved that the multidisciplinary approach to care provision is best to deliver high quality care for our patients.
On discharge Edna felt comfortable with the health education she received and felt confident in her own ability to care for herself. We made her an appointment for the catheter to be changed, and also gave her telephone numbers for the ward and the specialist nurse if she was ever to become unstuck. I think the friendly nature of all members of the team caring for Edna made her feel more at ease, and I think with the advice and support she was given, she would be more likely to call if she required any help. The level of the knowledge and the method that it is delivered must suit the patients needs, otherwise we may confuse our patients, by using ‘medical jargon’ that they cannot understand and therefore would not find useful.
To conclude, I think a nursing model should be based holistically on a particular patient, however the need for a different model for every patient is not viable in clinical practice. The Roper, Logan and Tierney model is an excellent model to use, and is probably the main model utilized in the NHS in the UK, because it is easy to use and simple to understand. The model identifies any important deficits in the patients care, and seeks to provide alternatives. The professional taking the details from the patient however needs to realize the limitations of the model and use their knowledge and common sense.
We have discussed the cultural components of Edna’s care and why these and spiritual components are essential to our care provision. To repeat, we as nurses need to look at our own beliefs and spirituality before we can give effective spiritual care. Only when we discover how important spirituality is to ourselves will we realize the importance it plays in our patients lives.
Health education and promotion within the multidisciplinary team is vital, not only to the patient but also to ourselves as healthcare professionals. Giving good advice and support can make a huge difference to the outcome of a patients health and only by working as a team can we achieve this.
Carter, S., Garside, P., & Black, A. (2003) Multidisciplinary team working, clinical networks and chambers; opportunities to work differently in the NHS. Available at URL: . Last accessed 12 December 2008.
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