This assignment is about an aspect of nursing care and how nursing theories, models, and knowledge affected the way this care has been delivered to patients and how it has been communicated to others, which I could observe while on placement. The aspect selected is pressure area care and nursing models, knowledge, and theories necessary to deliver care when assessing the risk of developing pressure ulcer will be discussed. In accord with NMC Code (2008), confidentiality will be maintained and names have been changed.
The placement happened in an acute medical ward, with a wide range of medical problems; where many patients were elderly people and people who need to be bed rest due their condition, while in hospital. Both types of patients are in high risk of developing pressure ulcer, and I could observe and help the nurse called Claire in the assessment of patients in risk of development of pressure ulcer and in the care of which have already developed it.
In order to choose the appropriated care, nurses need to assess the patients. Assessment is a vital part of nursing process, which is a ‘professional approach for selecting, organizing, and delivering appropriate nursing care to a patient’ (Potter and Perry, 2007). Nursing process it is a continuous patient-centred process and can be change in accordance with patient needs. It involves five stages: assess, diagnose, planning, implementation and evaluation (Kozier et al, 2008). To help in the nursing process, nurses will use nursing models.
Nursing models aim to help the nursing process work. It is a way of represent the nursing process, telling what nurses do to assess and gain information about patient, providing guidance when planning and delivering care (Aggleton and Chalmers, 2000). In this ward, nurses use the model developed by Roper, Logan, and Tierney in the 1970s.
This model is based in 12 activities of living ( appendix 1) which are linked with biological, social, or psychological needs required for health (Kozier et al, 2008). It is a way of identify and evaluate the care needs of the patient. The nurse’s interventions are based in the prevention, resolution, and management of actual or potential problems related with the activities of living, not forgetting that the activities of living may me influenced by biological, psychological, socio-cultural, environmental, and politico-economic factors to some degree (Alexander, Fawcett and Runciman, 2007).
The assessment using this model will include collecting information about the person, reviewing the collected information, identifying the problems and identifying priorities among problems; and supplementary information can be added later. It involves two types of information: the first, which is called by Roper, Logan and Tierney the patient’s biographical and health data; provide information for nurses to start look after the patient. The second one is called the Activities of Living data, which is focused on the patient’s abilities to carry out the activities of living, routines, and current problems (Roper, Logan and Tierney, 1996).
The use of this model helps nurses in that ward to identify patients that are in risk of developing pressure ulcer, as when assessing a patient’s activities of living nurses will find out about patient’s diet and fluid intakes, mobility, any existing medical condition, any medication that is being used, mental state and any other risk factors that may help on the development of the pressure ulcer. Also, the nurse will know if these factors are a usual pattern in patient’s life or they are actual/potential problems, which can be affected by life spam, dependence/independence continuum, and other factors that can influence the activities of life and have been mentioned before. The nurses also used Waterlow Pressure Sore Prevention tool as complementary assessment. This tool helps the nurses to assess some activities of living, like eating and drinking, mobilizing, eliminating, based in the actual patient’s condition and identify the risk of development of pressure ulcer.
In order to deliver care, nurses need to be competent and to have knowledge. We can develop knowledge from education, clinical or life experience, intuition, and nurses need to develop and use relevant ways of knowing that improve patient care (Bailey, 2004). Carper (1978) identified four types of nursing knowledge: empirical, aesthetic, personal and ethical (Basford and Slevin, 2003).
Empirical knowledge is the science knowledge of nursing. It includes theoretical knowledge from books, journals and conferences and draws on traditional ideas of science (Edwards, 2002), and research will support practice. When assessing the patient, Claire used her empirical knowledge to identify the risk of developing pressure sore demonstrating knowledge about what may cause pressure ulcer, anatomy of skin, risk factors for development of pressure ulcer, nutrition; and when the patient had already developed pressure ulcer, she could prove her scientific knowledge in wound healing, required interventions, dressing and aseptic technique.
Aesthetic knowledge is the art of nursing. It is the knowledge of doing nursing (Basford and Slevin, 2003). It is the nurse’s perception of what is important to the patient. This knowledge described as empathy, understanding and perception of the experience, needs and preferences of patients (Carper, 1978) and it could be observed when Claire showed empathy when communicating with the patient during the assessment, introducing herself and explain what she was doing. Also, she was always worried to maintain patient dignity and treat people as individuals.
Ethical knowledge is concerned with notions of right and wrong (Basford and Slevin, 2003). It is about moral knowledge, decision-making, and prioritising. It includes what is good, right and responsible, and involves confronting conflicting values (Edwards, 2002). It is part of every day work of nurses. As part of our ethical knowledge, we explained to the patients step by step what we were about to do, introducing ourselves and making sure they have understood the what was going on; and asked for patient’s consent before begin the treatment or care (NMC, 2008) as it is patient’s right to decline this treatment or care. And as part of her duty of care, Claire always ensures that all patients in risk of developing pressure ulcer have skin assessment done and incorporated in their care plan.
Personal knowledge it is concerned with self-awareness and includes experiential knowledge (from life and previous experience) and intuition, when nurses feel intuitively that something is wrong with a patient, but cannot express it in words (Edwards, 2002). Claire has been a qualified nurse since 2003, and has been working in the same ward for 4 years, and this gave her a wide-ranging experience in pressure area care, particularly in prevention and wound care. Due her personal knowledge she could excel in the assessment of patient, avoiding future development of pressure ulcers. Also, the fact that she has empirical knowledge of wound healing, she can apply her experience to assess how the patient’s wound is healing as she can recognize the normal aspects of wound healing.
The context where care is applied can affect the way on how the nurses applied their knowledge. The environment affects the individual’s health and the way the care is delivered. The ward has a ward manager, ward sister and a team mixed skills nurses and HCAs. Each bay has its own nursing team which includes a named registered nurse and health care assistants. This division gives the opportunity to become familiar with that group of patients and their individual needs. The named nurses lead and co-ordinate their nursing team, assess the patient’s needs, plan the care and implement and evaluate that care. They are also responsible for co-ordinating collaborative care planning involving appropriate members of multi-disciplinary team, and liaise with the patient and carer to ensure their wishes are being respected.
The care is delivered either by the named nurse and the health care assistants. The nurse delivers the specialized care and HCAs are responsible for the basic and personal care, with supervision of the named nurse. The HCAs could help the nurse with the assessment of patient’s skin while providing them with personal hygiene, and report it immediately to the nurse, which will come and do a more detail assessment. Although this is a very busy ward, the staff is very friendly and well organised, resulting in good deliver of care, with high levels of satisfaction of the patient and carers.
Communication between all health care professionals involved in care is another aspect that may influence the quality of care given. Communication is the heart of nursing and essential in conveying caring and applying nursing skills and knowledge as part of a health care team of patients, families and colleagues (Potter and Perry, 2007).
Claire has used written and verbal communication to make other ward staff or other health care professionals, which would be involved in that care, aware of patient’s needs.
Written communication involved patient records, assessments, interventions, documentation, nursing notes, risk assessment tools, care plans, discharge plan, diagnosis, fluid charts, nutrition charts, etc. All the written records about the patients’ health care are confidential and may be used as legal documentation. Information is recorded after each patient contact and is available to all health care team (Potter and Perry, 2007).
Each patient has two files, both available to all professionals involved with the patient’s care. The main file is kept on the nurses’ station and contains most of the information available about the patient. It is where all medical notes, nurses notes, interventions, care plans, tests and procedures, assessment tools (like Waterlow, moving and handling, admission assessment of activities of living), personal details about the patient, allergies and any other information for the daily care of the patient.
All patients on ward have a care plan, which is individualized, patient centred, and based on the needs identified on the assessment process. The care plans identify the actions required for that patient and the goals. It is revised every week by the named nurse of that patient. As all other patient records, the care plan should be factual, consistent and accurate, written in a way that the meaning is clear (NMC, 2007). The assessments are done by the nurses as well, revised weekly and kept on the main file, accessible to all multi disciplinary team. Patients identified as being at risk of developing pressure ulcer have a specific care plan, including prevention and treatment strategies.
Claire writes the daily nurse notes based on the care plan, which makes easy for other professionals understand how the implementation of care is progressing, however, not all nurses or HCAs do the same, and sometimes the notes are confused and not clear, with lots of abbreviations. NMC (2007) standard for record keeping says that records should not include abbreviations, be recorded using terms that the patient or client can easily understand, be recorded clearly and in such a manner that the text cannot be erased or deleted without a record of change. Nurses and HCAs can write in the nurse notes, and other professionals will write on the medical notes.
The second file is kept by the patient’s bed, and contains the MEWT chart, fluid/food charts, nutrition chart, and drug chart. It is also easily accessible to multi disciplinary team and to the patient. This file is filled by the nurses or HCAs.
Verbal communication occurs all the time in the ward. The most common situation where verbal communication occurs is when doctors are doing ward round and during handovers. It also occurs when nurses are delegating work to HCAs, when nurses are being part of multi disciplinary team meetings, and when communicating with family and patients.
Claire tried as much as she could to be together with the patient when doctors teams were around, as she sees this as an opportunity to discuss with then the patient’s needs, progress and interventions, and to keep the patient informed. However, it wasn’t possible all the times, and she used to talk most of time with the doctors team over the phone and document the any instruction gave by them in the nurses notes stating the date, time and name of the person with she spoke with. Other situation where verbal communication is important is during MDT meeting, where nurses are required to do an oral report of the patient’s condition and progress. Oral reports also happen when there is a need of exchange patient’s information between members of the health care team and when patients are being transferred from the ward. Usually, the reports when patient is transferred occur over the phone.
Handovers between the ward staff involved both written and verbal communications. Patient handover process explores care and information given will promote the continuing of patient’s care. It is a way of update your knowledge about individual patient and care process, enabling nurses to take over the care of patients and to deliver high-quality care specific to individual patients based on actual and perceived needs (Davies and Priestly, 2006).
The handover of patients was responsibility of the registered nurse in charge of the ward on the beginning of each shift. Before the handover take place, the named nurses give a verbal report of their patients’ conditions, interventions and progress to the nurse in charge. This nurse prepares the handover sheet, which contains the patient’s name, bed or room number, consultant, past and current medical history, reasons for admission in the ward and in the hospital, possible date for discharge, care update and actions to be taken; and pass the information to the staff , nurses and HCAs, who will be working in the oncoming shift. The information given in the handover sheet was clear and objective, with good details about the patient and their needs, helping the staff to take over the care of the patients. However the handover process takes too long and the nurses don’t go to all points of the handover sheet and make vague and simple comments about the patient, so it is up to the staff to read through the handover sheet to find out what needs to be done in that shift.
The relationship between patient and nurse is created by the nurse involving care and skills, and communication strengths this relationship established with the professional role (Potter and Perry, 2007). Effective communication includes professional appearance and courtesy. All staff on the ward was well presented, reflecting friendliness and competence. Claire and most of the staff always introduced themselves to the patient; however some HCAs didn’t, making the patient unsure about their professional status. Also, Claire always makes sure that the patient knows what she is planning to do and get consent before any action. Other important aspect of communication with patient is about patient expectations, and listening to these expectations, Claire reduces patient’s anxiety and provides individualized care as the treatment of pressure ulcer is usually very long.
During my experience on this placement I could observe that the ward follows Roper, Logan and Tierney model of nursing to delivery all types of care. The assessment sheets are based in the activities of living and care is delivered based in the patient needs. The nurse, who I worked with, Claire, is very person-centred and she tried always to make the patients feel better in all aspects while they were in hospital. She can demonstrate clearly that she has a good knowledge and experience about pressure area care, and can apply it in her work every day with confidence and share her experience with colleagues.
The fact that the ward is a very busy environment didn’t affect the quality of care given by the staff, and care plans were constantly updated in accordance with the patients needs. The communication between the staff were relatively effective, however handovers can be improved. The written communication in the nurse notes also needs to be improved, as it contains many abbreviations and the fact that the notes are note clear may lead to mistakes.