Reflection on Care Interventions and Decision Making

Reflection on C atomic number 18 Interventions and Decision devisingReflective evaluation of pity interventions and clinical determination making.IntroductionThis search is a ruminative examination of a complaint episode in the domain of rational comfortablyness treat, in relation to the processes of nursing decision making, clinical savvying, and processes associated with enduring bursting charge think and management. The criticism on elements or aspects of apprehension, or on specific clinical experiences, is an classic part of obligate organic evolution and on going professional practice (Rolfe, 2005). Reflection is to a greater extent(prenominal)(prenominal) than manifestly bulge outanceing back at experiences and incidents, it is a process of making smell step forward of them, understanding all the dimensions of an experience, and using data, evaluation and analysis to meliorate future(a) practice (Hargreaves, 2004). It is, at that wanderfore, ab t urn out schooling from experiences, as much as learning about experiences (Gibbs, 1988 Kolb, 1984). Although reflection is k flatn to be, at times, an imperfect means of critiqueing practice, because in that location is always the possibility of biased reflection, or poor memory (J unitarys, 1995), it is a means of allowing student nurses and qualified nurses to ask questions about their practice and look at it in the light of touchledge and evidence.Using reflection, this essay pull up stakes attempt to examine the carefulness of an older grownup with dementia, in aver to examine the elements of clinical decision making and clinical reasoning in relation to their care and the management of care for them in the longer term. As such(prenominal), it get out withal look at elements of care planning for this patient, and the processes which meet a key clinical decision, which is about place of care for the designated patient, who will be described below. The essay will be b ased inside the framework of Gibbs (1988) cycle of reflection, which leaves a structure and guideline for constructive reflection and allows practitioners to develop action plans for future practice improvement (see Appendix). The essay will present the look history and summary of the clients clinical/ health precondition, and thence will follow the structure of the Gibbs (1988) reflective cycle. It will conclude with the action plan and a brief conclusion of the arguments unquestionable finishedout the essay.Case History/SummaryThe patient, whose name has been changed to protect confidentiality, is Arthur, a 69 year old man who was admitted to a general medical examination ward three weeks ago with pneumonia. Arthur is married to Anne, who is also 69, and both are retired teachers. Arthur was diagnosed with vascular dementia three years ago, and his health, and in particular, his symptoms of dementia, take over been steadily worsening since that time. Anne is his chief car er, and gets regular support and help from their two children, a daughter, who is a full time clerical worker, and a son, who is married and lives an seconds drive away from his parents. Anne and Arthur live in their own headquarters, where they aim lived since they were married 47 years ago.Arthurs symptoms are memory want and dysfunction, apathy, fatigue, withdrawal, fixation on routines, communication difficulties, and wandering. Arthur is accustomed to regular friendly activities at the local Home Guard club, some of which Anne attends with him, and also to going into the local shopping area most days to buy a paper. Anne has to help him with the majority of his activities of effortless living. His appetite has decreased, and he needs care with dressing, hygiene and other self-care activities. Anne helps him manage his medication. He has a history of indispensable hypertension, which is managed with anti-hypertensive medication.Arthur developed pneumonia following a vira l infection, and was admitted with dyspnoea, pyrexia and increased confusion, on base dehydration. He was treated on a medical ward, and during this time was reviewed by an occupational therapist, kind work liaison, and by the mental health aggroup, as well as his medical team. His pneumonia responded well to antibiotic therapy, and he true nutritional supplements and assistance with some of his activities of daily living.ReflectionDescription What HappenedArthurs physical health improved sufficiently for the medical team to get hold that he was ready for discharge from the medical ward. Initially, the discharge plan was straightforward, and had been commenced on admission, and finalised by the nursing team looking after Arthur, under the leading of his named nurse. Arthur was to be discharge domicile to his own internal, with community nursing involvement. However, because of his degenerative condition, and his real put forward of health and welfare, one of the nurses on the team objected to this plan, and persistent that it qualification be time to consider the best place of care for Arthur in the longer term. In the light of her referral to the medical consultant, and to the elementary care nurse consultant, a full fiber conference and multidisciplinary review was called to review the discharge plan. A execute of professionals were present occupational therapy, a social worker, his named nurse, the nurse who had instigated the case conference, the Nurse Practitioner, a representative of the mental health team, and the author, along with Arthurs Registrar and SHO.Each professional presented their case, and discussed Arthurs modern state of health, and the support, care and input he needed. Because of his increasing debilitation, reports of his wandering behaviours on the ward, and his increasing dependence on carers, it was decided that Arthur should non be discharged home, only instead a place should be found in an EMI nursing home, wher e he could receive the level of support believed to be inevitable for him. It was agreed that a nursing home close to his own home would be chosen, so that his married womanhood would be able to visit him, but the home found for him was s tear down miles away from their home, and when his wife was informed of his place of care after discharge, she was upset. She cute Arthur at home with her, and insisted that she could cope with his care. She also explained that the care facility they proposed was non on an easily accessible pot route, and it would take two buses and a considerable amount of time to voyage from her home to visit him. Despite this, she was informed that the best place for him now was a nursing home, because his safety was at risk, and eventually, it was agreed that he be discharged to this nursing home as soon as a room became available.Feelings What Were You Thinking and Feeling.My find oneselfings were really much around empathy with Arthurs wife, who want ed Arthur discharged to his familiar home environment, but also a spirit of concern for Arthur, for his safety and wellbeing, and for the burden that his care was placing on his wife. However, I also snarl sort of strongly that she should have been included in the case conference. I also felt that Arthur should have been consulted about where he preferred to be discharged to. Although he had poor communication, there were times when he was able to appear at least aware of his surroundings and circumstances, and I felt that someone should have tried to get his thoughts and feelings on where he would go after discharge. I felt that the multidisciplinary team was working effectively, that they were communication openly and professionally about the care, but that they pipe down did non quite seem to see Arthur as a individual, a whole person, with a life, a family, and his own preferences. Instead, I felt that they saw him predominantly in terms of the problems he posed for ca re services. And I felt that this was non necessarily the best ethos to underpin such a strong, life-changing decision.Evaluation What Was best and Bad about the Experience.Positive aspects of the experience included the insight I gained into a multidisciplinary team case conference, in which all the professionals concerned were non only well prepared and well meaning, but eager to hark to each other, to listen to commonwealths experiences of caring for Arthur, and to debate the whys and wherefores of his case and the discharge decision. Attitudes towards Arthur were positive, in terms of direction on his wellbeing, safety, and prognosis, as well as focusing on the wellbeing of his wife and main carer.However, interdict aspects of this were chiefly the exclusion of Anne and Arthur from the case conference, and the lack of the presence of a penis of the community nursing team, or Arthurs GP, or anyone who actually still his home circumstances properly. It seemed to me that no one was able to really state with indisputablety what his home circumstances were like. I also felt that the team should have considered the effects on Anne of losing her husbands presence in her home, because this could have consequences for her emotional, social and even financial wellbeing. While Arthur is their primary concern, if they had seen him and his wife in terms of the realities of their lives together, this efficiency have affected their decision.Analysis What soul Can You Make of the Situation?Providing care for the older adult who has a diagnosis of dementia, whatever kind, is difficult and challenging, because the disorder affects so numerous aspects of their lives, not just their ability to take care of themselves. The NSF for older People (DoH, 2001) understandably states that all care for the older adult should be based on person-centred care principles, looking at the individual needs, and looking at the person in context of their social life and home li fe. However, because the older adult is more likely to have a number of con accredited health problems (Grabbe et al, 1997), providing care to meet all the needs of the patent pot be very challenging. The literary works suggests that despite the Governmental guidance, and the ongoing drive to improve care for the older population, standards of care for this sector are still not as good as they should be (Helme, 2007). This suggests that there are still considerable improvements to be make in the ways that such mess are cared for, and the kinds of decisions made and treatment choices offered for them (Redfern and Ross, 2001).Dementia is a difficult infirmity to plan care around, because it has so many manifestations, and for different reasons. It is a very prevalent disorder in the older population (DoH, 2001). According to Helme (2007) more than 50% of elderly people in nursing homes, and an equivalent number of elderly patients who are admitted to infirmarys, have dementia. Thi s poses a considerable burden on health and social care. But the NSF also argues that it is vital that older peoples dignity is preserved and prioritised in spite of appearance these health care services (DoH, 2001), and if this is the case, then the kinds of decisions made about their place of care, as in the case of Arthur, should be decisions that are about their dignity, and their self-reliance. It could be, in this case, that the balance between preserving Arthurs autonomy at home, and between protecting his dignity (he has been known to wander out of the house in his underwear, or get lost in town), has brought the team to their decision. If the team are practising patient centred care, or person-centred care, then Arthurs wellbeing would be the reason for the decision.However, this is not always the case, and it could be that the decision has been made based on what is likely to cause the least amount of sieve on the community health and social care services (Dellasega and Fisher, 2001). in that location is some evidence in the healthcare literature that many healthcare professionals continue to have innate prejudices or stereotypes of elderly patients (Gunderson et al, 2005). If this is the case, then Arthur may be being judged based on his diagnosis, and on preconceptions about his current clinical/mental state, rather than on a holistic demonstrate of his whole life and his social context. There are those who would argue that making this decision for Arthur is the wrong course of action, because he has been functioning well at home prior to hospital admission for a medical problem, and there is no reason why he could not carry on with the same level of support for the time being (Hoare, 2004). However, it might be that this admission to hospital has been the frontmost time that such a boastfully team of healthcare professionals from different disciplines has had the opportunity to assess Arthurs current health status and healthcare needs, an d this is what has led to this decision (Fielo, 1998). It might be, for example, the first time the true impact of Arthurs condition on the activities of daily living has been observed (Farley et al, 2006). However, it is also important to remember that as a patient with Dementia, Arthur is likely to behave very differently in a hospital setting than he would in a familiar home environment, and so this judgment may not be based on how he usually manages his daily life (Zarit and Zarit, 2007). However, if the professionals voluminous believe that the complexity of Arthurs needs are such that the easiest place for Arthur to be cared for is within a nursing home environment (Miller et al, 1996), this might be the reason for the decision, perhaps in relation to an awareness of local resources and availability of certain support services for Arthur (Eloniemi-Sulkava et al, 2001).The process of discharge planning is one which still seems something of a mystery, despite the clear commun ication between the multidisciplinary team. It is apparent from the literature on the subject that discharge planning conferences can be difficult, and for many health professionals and patients, it can be hard to get your opinion across and make sure that this opinion, or observation, is taken seriously (Efraimsson et al, 2006). Certainly, I felt that I could not voice my opinion during this conference, and yet in hindsight I feel that I should have done so, because I really feel that the most important people were missing from the case conference. The voice of Arthur was not there, perhaps because the team believed he would not be able to broadcast effectively (Efraimsson et al, 2004), but Anne should definitely have been have-to doe with, as his wife and primary carer (DoH, 2001).The literature shows that lack of involvement in discharge planning, particularly when significant decisions are being made such as this, disempowers patients and their families and can have detriment al effects on health and wellbeing (Efraimsson et al, 2003). Leaving Anne out of this decision may have an impact on her health and wellbeing, including her mental and emotional health, and if she had been involved, she might have come to the same conclusions that the team had, rather than just having them make a rather paternalistic decision without consulting her (Redfern and Ross, 2001). end point What Else Could you Have Done?One conclusion that I have reached through examining this case, is that it is important to question care decisions and clinical decision making processes, even if you are in the minority (Daly, 1998). In this situation, I felt disempowered, and I am sure that it might have been the case that Anne would have felt quite challenged to be part of the conference, but it should have been opened up to include her and to give her a chance to voice her own thoughts and feelings, and provide the insight into Arthurs health, wellbeing and home life that was lacking fr om the conference. another(prenominal) conclusion I have reached is that while multidisciplinary conferences are important, there can still be underlying personal agendas, or prejudices, and so focusing on a person-centred model of care and discharge planning is important. Also, it might be that the label of dementia has been colouring everyones reactions and making them lean towards nursing home care because of what they know about dementia, rather than because of what they know about Arthur. I should have raised the questions that I had, and been more proactive.I also felt that they could have referred more explicitly to the available guidelines, such as the NSF (DoH, 2001), and the local policies and guidelines on discharge planning, and on social care planning. There should have been community nurses or Arthurs GP involved in the discharge conference. I should have raised these points, and perhaps referred to the divert guidance, or asked for it.Action Plan If it arose again, w hat would you do?I would ensure that the patient and their primary carers were included in the discharge planning conference, that their preferences, experiences and opinions were sought, and that these were incorporated into the clinical decision making process.I would insert together all available policies, guidance and governance documents relating to the case. I would also seek out and gather together as much of the evidence base as affirmable relating to the patients care, in order to make a more reasoned decision.I would make sure that the community health professionals who had been involved in Arthurs care up to the point of his admission to hospital were also involved in the discharge conference. This would mean that a more realistic picture of his needs was presented.I would include detailed information about an alternative plan of care and social support for Arthur, one which included realistic assessments of available resources and impact on current care provision.I wou ld make sure that the impact of this admission on Anne and her home situation was also considered in making the final decision. I would also attempt to ensure that the discharge plan included identification and militarisation of resources and support services for Anne as well as for Arthur.ConclusionIt would appear from this reflection that a significant decision making process such as this, even when many good principles are adhered to, is complex and difficult, and it is important to make sure that all aspects of the clients needs are being met, not just their safety and medical/social care needs. Decisions such as this cannot be made without the full picture and without considering alternatives to what might appear to be the easiest solution.References 213569Daly, W..M. (1998) Critical thinking as an outcome of nursing education. What is it? Why is it important to nursing practice? Journal of Advanced nursing 28 (2) 323-331.Department of health (2001) The National Service Frame work for Older People Available from www.dh.gov.uk. Accessed 10-11-08.Dellasega CA. 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