Reflection on Care Interventions and Decision Making

Reflection on Care Interventions and Decision Making

This essay is a personal reflection on care interventions and decision making. Use it as a guide to create the perfect essay on interventions in healthcare and decision making.

Introduction to Reflection on Care Interventions and Decision Making Essay

What is reflection?

This article is a reflective analysis of a mental health nursing care incident in relation to nursing decision-making, clinical reasoning, and procedures related to patient care planning and management. Reflection on particular clinical experiences or features of care is an essential part of nurse growth and continuing professional practice (Rolfe, 2005). Reflection is more than just looking back on events and happenings; it’s a process of making sense of them, comprehending all of their aspects, and using knowledge, assessment, and analysis to better future practice (Hargreaves, 2004).

As a result, it’s as much about learning from events as it is about learning about them (Gibbs, 1988; Kolb, 1984). Although reflection is acknowledged to be an unsatisfactory form of examining practice because biased reflection or poor recall may occur (Jones, 1995), it provides a tool for student nurses and trained nurses to raise questions about their practice and examine it in the light of knowledge and evidence.

This essay will use reflection to look at the care of an older adult with dementia in order to look at the parts of clinical decision making and clinical reasoning in relation to their care and long-term care management. As a result, it will look at aspects of care planning for this patient, as well as the procedures that accompanied a significant clinical decision concerning the designated patient’s site of care, which will be explained below.

The essay will be structured around Gibbs’ (1988) cycle of reflection, which offers a framework for constructive reflection and helps practitioners to establish action plans for future practice development (see Appendix). The case history and overview of the client’s clinical/health state will be presented first, followed by the Gibbs (1988) reflective cycle structure. It will end with an action plan as well as a quick summary of the points presented throughout the essay.

Patient Health History

Arthur, a 69-year-old man who was taken to a general medical ward three weeks ago with pneumonia, has had his name altered to preserve his privacy. Arthur is 69 years old and married to Anne, who is also a retired teacher. Arthur was diagnosed with vascular dementia three years ago, and his health, particularly his dementia symptoms, has rapidly deteriorated since then. Anne is his primary caregiver, and their two children, a daughter who works full-time as a clerical assistant and a son who is married and lives an hour away from his parents, provide frequent support and assistance. Anne and Arthur have lived in their own house for 47 years, where they have raised their family.

Memory loss and malfunction, apathy, weariness, withdrawal, preoccupation with routines, communication problems, and ‘wandering’ are among Arthur’s symptoms. Arthur is used to attending frequent social events at the local Home Guard club, some of which Anne joins, as well as going into the nearby retail centre to purchase a newspaper on a daily basis. Anne must assist him with the bulk of his everyday chores. His appetite has waned, and he requires help with dressing, hygiene, and other self-care tasks. Anne assists him with his medication management. He has essential hypertension, which he treats with anti-hypertensive medicine.

Following a viral illness, Arthur developed pneumonia and was hospitalised with dyspnoea, pyrexia, increasing disorientation, as well as dehydration. He was treated in a medical ward and was evaluated by an occupational therapist, a social work liaison, the mental health team, and his medical team throughout this period. His pneumonia responded nicely to antibiotic treatment, and he was given nutritional supplements as well as help with some of his daily duties.

Reflection

Narration: What Took Place?

Arthur’s physical condition had improved to the point where the medical team decided he was ready to be discharged from the medical ward. Initially, Arthur’s discharge plan was uncomplicated, having been started upon admission and finalized by the nursing team caring for him, led by his designated nurse. Arthur was to be released to his own house with the help of community nurses. One of the nurses on the team, however, opposed this idea due to Arthur’s degenerative condition and present state of health and wellness and determined that it may be time to rethink Arthur’s long-term care options.

A complete case conference and multidisciplinary review was held to discuss the discharge plan in light of her referral to the medical consultant and the primary care nursing consultant. The occupational therapist, a social worker, his designated nurse, the nurse who had called the case meeting, the Nurse Practitioner, a member of the mental health team, and the author, as well as Arthur’s Registrar and SHO, were all there.

Each expert described their case and Arthur’s current state of health, as well as the assistance, care, and input he required. Because of his increasing debilitation, complaints of his wandering behaviour on the ward, and his growing reliance on caregivers, it was determined that Arthur would not be sent home, but rather would be placed in an EMI nursing home, where he could get the degree of care deemed required. It was agreed that a nursing home near to his house would be picked so that his wife could see him, but the institution that was located for him was seven miles away, and his wife was angry when she learned of his placement after discharge.

She insisted on having Arthur live with her at home and that she could handle his care. She also indicated that the care facility they recommended was not on a convenient bus route and that seeing him would need two buses and a significant amount of time from her house. Regardless, she was told that the best place for him now was a nursing home since his safety was in jeopardy, and it was finally decided that he would be sent to this nursing home as soon as a room became available.

Feelings: What Were You Thinking and Feeling?

My emotions were split between empathy for Arthur’s wife, who wanted him discharged to his familiar surroundings, and concern for Arthur, his safety and well-being, as well as the burden that his care was putting on his wife. However, I firmly believe she should have been invited to the case conference. Arthur should have also been asked where he wanted to be released, in my opinion. Despite his limited communication, there were occasions when he seemed to be aware of his surroundings and situations, and I believe that someone should have attempted to get his views and emotions about where he would go following discharge.

I thought the multidisciplinary team was doing a good job, speaking honestly and professionally about Arthur’s care, but they still didn’t appear to view him as a whole person with a life, a family, and his own preferences. Instead, I had the impression that they only regarded him in terms of the issues he brought to the care system. And I didn’t think this was the greatest mindset to base such a huge, life-altering choice on.

Evaluation: What Was Good and Bad about the Experience?

The insight I gained into a multidisciplinary team case conference, in which all of the professionals involved were not only well prepared and well-intentioned, but also eager to listen to each other, to hear people’s experiences caring for Arthur, and to debate the whys and wherefores of his case and the discharge decision, was a positive aspect of the experience. In terms of concentrating on Arthur’s well-being, safety, and prognosis, as well as the well-being of his wife and primary caregiver, attitudes toward him were good.

However, the exclusion of Anne and Arthur from the case conference, as well as the absence of a member of the community nursing team, Arthur’s GP, or anybody who really knew Arthur’s home situation, were the main drawbacks. No one appeared to be able to say with any clarity what his living conditions were like. I also believe the team should have examined the implications on Anne of her husband’s absence from her house since this might have ramifications for her emotional, social, and economical well-being. While Arthur is their major worry, they may have made a different choice if they had viewed him and his wife in terms of the reality of their existence together.

Analysis: What Sense Can You Make of the Situation?

Providing care for an older adult with dementia, regardless of the kind, is tough and difficult because the condition impacts so many facets of their life, not only their capacity to care for themselves. The National Service Framework for Older People (DoH, 2001) stipulates that all care for older adults should be based on person-centred care principles, which look at the individual’s requirements as well as the person’s social and home life. However, since older adults are more likely to have many health conditions at the same time (Grabbe et al, 1997), delivering treatment that meets all of the patient’s requirements may be difficult.

Despite government advice and continuous efforts to enhance care for the elderly, research reveals that standards of care in this sector are still not as high as they should be (Helme, 2007). This shows that there are still significant changes to be done in how such individuals are cared for, as well as the types of decisions and treatment options available to them (Redfern and Ross, 2001).

Dementia is a tough illness to plan care for since it manifests in so many ways and for so many causes. It is a highly common condition among the elderly (DoH, 2001). According to Helme (2007), dementia affects more than half of old adults in nursing homes and an equal percentage of senior patients admitted to hospitals. This places a significant strain on health and social services. However, the NSF also contends that it is critical that older people’s dignity be preserved and prioritized within these healthcare services (DoH, 2001), and that if this is the case, then the decisions made about their place of care, as in the case of Arthur, should be decisions about dignity and autonomy.

It’s possible that the team’s choice was influenced by the balance between keeping Arthur’s liberty at home and safeguarding his dignity (he’s been known to leave the house in his underpants or get lost in town). If the team were following patient-centred care or person-centred care, Arthur’s well-being would be the driving force behind the choice.

This isn’t always the case, and it’s possible that the choice was made based on what would put the least amount of demand on community health and social care services (Dellasega and Fisher, 2001). Many healthcare workers still have natural biases or assumptions about older patients, according to some evidence in the medical literature (Gunderson et al, 2005).

If this is the case, Arthur may be assessed only on the basis of his diagnosis and preconceived notions about his present clinical/mental condition, rather than a comprehensive view of his life and social circumstances. Some say that making this choice for Arthur is the incorrect course of action since he was working well at home before to being sent to the hospital for a medical ailment, and there is no reason why he couldn’t continue with the same amount of assistance for the time being (Hoare, 2004).

However, it’s possible that Arthur’s admittance to the hospital was the first time a big group of healthcare specialists from several disciplines had the chance to analyze his current health state and healthcare requirements, and that this is what prompted this decision (Fielo, 1998). It might be the first time, for example, that the real effect of Arthur’s illness on everyday activities has been seen (Farley et al, 2006).

Even so, it’s vital to keep in mind that, as a Dementia patient, Arthur is likely to act considerably differently in a hospital setting than he would at home, so this evaluation may not be based on how he normally conducts his everyday life (Zarit and Zarit, 2007). If the professionals involved believe that Arthur’s needs are so complex that the best place for him to be cared for is in a nursing home (Miller et al, 1996), this could be the driving force behind the decision, perhaps due to a lack of awareness of local resources and the availability of certain support services for Arthur (Eloniemi-Sulkava et al, 2001).

Despite excellent communication across the interdisciplinary team, the discharge planning process still seems to be a bit of a mystery. According to the literature on the issue, discharge planning conferences may be tough, and it can be difficult for many health professionals and patients to get their point of view through and ensure that their point of view, or observation, is taken seriously (Efraimsson et al, 2006).

Certainly, I did not feel able to express myself at this conference, but in retrospect, I believe I should have since I believe the most essential persons were absent from the case meeting. Arthur’s voice was missing, maybe because the researchers assumed he wouldn’t be able to speak effectively (Efraimsson et al, 2004), but Anne, as his wife and major caregiver, should have been included (DoH, 2001).

The research suggests that patients and their families are disempowered when it comes to discharge planning, especially when major choices are being made, and that this may have negative consequences for their health and well-being (Efraimsson et al, 2003). Leaving Anne out of this decision could have a negative impact on her health and well-being, including her mental and emotional well-being, and if she had been involved, she might have reached the same conclusions as the team, rather than having them make a paternalistic decision without consulting her (Redfern and Ross, 2001).

Conclusion: What Else Could you Have Done?

 Decision Making
Reflection on Care Interventions and Decision Making

Examining this case has led me to the conclusion that it is critical to challenge care choices and clinical decision-making procedures, even if you are in the minority (Daly, 1998). I felt disempowered in this situation, and I’m sure Anne felt similarly challenged to be a part of the conference, but it should have been opened up to include her and give her a chance to express her own thoughts and feelings, as well as provide the insight into Arthur’s health, wellbeing, and home life that the conference lacked.

Another conclusion I’ve come to is that, although interdisciplinary conferences are necessary, there may still be underlying personal agendas or biases, so emphasizing a person-centred model of care and discharge planning is critical. Also, it’s possible that the diagnosis of dementia has coloured everyone’s attitudes and caused them to lean toward nursing facility care rather than Arthur due to what they know about dementia. I should have asked the questions I had and taken a more aggressive approach.

They may have also alluded to the existing recommendations, such as the NSF (DoH, 2001), as well as local policies and guidelines on discharge planning and social care planning, more specifically. The discharge discussion should have included community nurses or Arthur’s primary care physician. I should have expressed these concerns and, if necessary, referred to or requested appropriate advice.

Action Plan: If it arose again, what would you do?

  • I would make certain that the patient and their main caregivers were invited to the discharge planning meeting, and that their preferences, experiences, and views were explored and included in the clinical decision-making process.
  • I would collect all relevant policies, instructions, and governance papers. In order to make a better-informed judgment, I would also seek out and collect as much evidence as possible relevant to the patient’s treatment.
  • I’d make sure that the community health experts who had been engaged in Arthur’s care up to his hospitalization were present at the discharge discussion. This would imply that a more accurate picture of his requirements was conveyed.
  • I’d offer specific details regarding an alternate plan of care and social support for Arthur, one that includes realistic assessments of available resources and their influence on existing care.
  • I’d make certain that the consequences of Anne’s admittance on her family status were included in the ultimate conclusion. I’d also make an effort to make sure that the discharge plan includes locating and mobilizing resources and support services for both Anne and Arthur.

Conclusion

This reflection suggests that a large decision-making process like this is complicated and challenging, even when many excellent principles are followed, and it is critical to ensure that all parts of the client’s requirements are satisfied, not just their safety and medical/social care needs. Such decisions cannot be made without having a complete picture and examining alternatives to what may seem to be the simplest answer.

Frequently Asked Questions (FAQs)

1. What is the meaning of reflection on practice?

Reflection on particular clinical experiences or features of care is an essential part of nurse growth and continuing professional practice (Rolfe, 2005). Reflection is more than just looking back on events and happenings; it’s a process of making sense of them, comprehending all of their aspects, and using knowledge, assessment, and analysis to better future practice (Hargreaves, 2004).

2. What is the importance of reflection to you as a student?

Although reflection is acknowledged to be an unsatisfactory form of examining practice because biased reflection or poor recall may occur (Jones, 1995), it provides a tool for student nurses and trained nurses to raise questions about their practice and examine it in the light of knowledge and evidence.

3. What are the very early signs of dementia?

Memory loss and malfunction, apathy, weariness, withdrawal, preoccupation with routines, communication problems, and ‘wandering’ are among Arthur’s symptoms

Gibbs' (1988) cycle of reflection
Reflection on Care Interventions and Decision Making

References

Daly, 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 Framework for Older People Available from www.dh.gov.uk. Accessed 16-03-22.

Dellasega CA. Fisher KM (2001) Posthospital home care for frail older adults in rural locations. Journal of Community Health Nursing. 18(4): 247-60.

Draper, B. & Low, L. (2005). What is the effectiveness of acute hospital treatment of older people with mental disorders? International Psychogeriatrics, 17, 539-555

Efraimsson, E., Sandman, P. Hyden, L-C., and Rasmussen, B.H. (2006). How to get one’s voice heard: the problems of the discharge planning conference. Journal of Advanced Nursing 53 (6) 646-655.

Efraimsson, E., Rasmussen, B.H., Gilje, F. and Sandman, P. (2003) Expressions of power and powerlessness in discharge planning: a case study of an older woman on her way home. Journal of Clinical Nursing 12 707-716.

Efraimsson, E., Sandman, P. Hyden, L-C., and Rasmussen, B.H. (2004). Discharge planning: ‘fooling ourselves?’ – patient participation in conferences. Journal of Clinical Nursing 13 562-570.

Eloniemi-Sulkava, U., Notkola I.L., Hentinen, M. et al (2001) Effects of supporting community-living demented patients and their caregivers: a randomized trial. Journal of the American Geriatric Society 49(10):1282-7.

Farley, A., McLafferty, E. and Hendry, C. (2006) The physiological effects of ageing on the activities of living. Nursing Standard 20(45) 46-52.

Fielo, S. B. (1998) Discharge Planning for the Elderly: A Guide for Nurses. Nursing and Health Care Perspectives Volume 19(2) 94-95.

Gibbs, G. (1988) Learning by Doing. A Guide to Teaching and Learning Methods Further Education Unit, Oxford Polytechnic, Oxford

Gould, D., Berridge, E-J. And Kelly, D. (2007) The National Health Service Knowledge and Skills Framework and its implications for continuing professional development within nursing. Nurse Education Today 27 26-34.

Grabbe, L., Demi, A., Camann, M.A. and Potter, L. (1997) The health status of elderly persons in the last year of life: a comparison of deaths by suicide, injury and natural causes. American Journal of Public Health 87 (3) 434-437.

Gunderson, A., Tomkowiak, J., Menachemi, N. and Brooks, M.D. (2005) Rural physicians’ attitudes toward the elderly: evidence of ageism? Quality Management in Health Care 14 (3) 167-176.

Hargreaves, J. (2004) “So how do you feel about that? Assessing reflective practice.” Nurse Education Today 24 (3) 196-201.

Hoare K. (2004) Care home placement: can admission direct from acute hospital be justified? Nursing Older People. 16(6): 14-17.

Jones, P.R. (1995) Hindsight bias in reflective practice: an empirical investigation. Journal of Advanced Nursing 21 (4) 783–788.

Kolb, D. A. (1984). Experiential Learning London: Prentice-Hall.

Miller, J., Neelon, V., Dalton. J. et al (1996) The assessment of discomfort in elderly confused patients: a preliminary study. Journal of Neuroscience Nursing 28 (3) 175-182.

Redfern, S.J. and Ross, F.M. (2001) Nursing Older People. Third edition. Edinburgh: Churchill Livingstone.

Rolfe, G. (2005) The deconstructing angel: nursing, reflection and evidence-based practice Nursing Inquiry 12 (2), 78–86.

Zarit, S.H. and Zarit, J. M. (2007) Mental disorders in older adultsfundamentals of assessment and treatment. New York: The Guildford Press.

Reflection on Care Interventions and Decision Making

 

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