nursing

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Person centred care and interprofessioanl working

This assignment will focus on an incident experienced in the practice setting, whilst on placement in the maternity unit of an acute hospital site. In accordance with the NMC (Nursing & Midwifery Council) Code Of Professional Conduct (2004), confidentiality will be maintained throughout. Therefore hospital names and hospital trusts will not be mentioned, and pseudonyms will be used to protect the identities of those involved.

‘Susan’ was pregnant with her first child and as she was low risk, she planned to have a homebirth. One evening, at Term +5 gestation, she went into spontaneous labour at home. She coped very well with the early labour, and the community midwife (Janet) was called later that evening. Susan continued to labour well at home, until Janet could reach her. She arrived some time later, and on examining Susan, found her to be 3cm dilated. Janet stayed and continued to perform routine assessments throughout Susan’s labour - and it became apparent further into the labour, that the fetal heart rate dropped following most contractions, although it did recover each time. Janet monitored the fetal heart more regularly because of this and as time went on, it became apparent that the decelerations were not improving; and so the decision was made for Susan to go into the hospital.

On arriving at the hospital, Susan was still contracting strongly and when examined again, was found to be 5-6cm dilated. The fetal heart rate was continuously monitored with a CTG (Cardio-Toco Graph) monitor for around half an hour, and it was noted that the amount and duration of the decelerations were increasing. The consultant reviewed Susan’s case and the decision was made to perform a Caesarean Section for the indication of fetal distress. Her baby boy was born soon afterwards with the umbilical cord wrapped twice around his neck. He was otherwise in a healthy condition, requiring no resuscitation or respiratory assistance.

This particular scenario has been chosen for discussion because it encompasses the interprofessional collaboration of many different healthcare professionals; namely the community midwife, the hospital midwife, the student midwife, the consultant and the theatre staff.

As part of a team in the maternity unit, the healthcare professionals are working under policies and guidelines from many organisations, including the Nursing & Midwifery Council (NMC), the Department Of Health (DOH) and the National Institute for Health and Clinical Excellence (NICE). Although providing ‘person centred care’ has no policy or guideline of it’s own, it should still be an extremely important part of any healthcare practitioner’s work and responsibilities.

The concept of ‘person centred care’ began with the work of Carl Rogers (1951) and his ‘Client Centred Therapy’, and it has since been shown to improve outcomes of healthcare; including the satisfaction of both patients and healthcare practitioners (Tan, no date) .

It is described as care that is focused on the patient/client, that promotes independence by being non-controlling, and that provides a service that is reliable and flexible (Innes, Macpherson & McCabe, 2006).

Within the maternity setting, the notion of ‘person centred care’ is known more specifically as ‘woman centred care’, and it suggests that the central value of midwifery is to meet the individual needs of the woman, and to some extent, her family too (Page & Hutton, 2000). It emphasises the importance of informed choice, involvement of the woman in her own care, accessibility to services, and continuity of care (Royal College of Midwives, 2001). This requires a sound knowledge of resources and others expertise, so that further members of the interprofessional team can be called upon if required, in order to meet the individual needs of any woman (Fraser & Cooper, 2003).

The very nature of this particular scenario means that the ‘person’ (Susan) was possibly feeling vulnerable, frightened and maybe even distressed from the outset, as these are very common feelings that women can experience during labour and birth. Therefore it is part of a midwife’s role to recognise not only the physical aspects of labour and birth, but also the spiritual and emotional aspects, and consequently support the woman, provide comfort and help her through the experience (Page, 2003). It is essential that a midwife has a broad understanding of different needs, for example social and cultural needs, in order to provide the best care for each individual woman in any setting (Fraser & Cooper, 2003). On this occasion, Janet had been Susan’s community midwife from the beginning of her pregnancy and so she had become acquainted with Susan, was more aware of her individual needs as a ‘patient’ and could provide more personalised care for her. Furthermore, due to Susan receiving continuity of care, she also felt very comfortable with Janet and had a huge amount of trust in her as her midwife. As a result of these aspects, Janet was able to quickly recognise the abnormalities during Susan’s labour and was able to explain the situation to her and her husband, in a way in which she knew they could understand. Therefore, when Janet made the decision to take Susan to the hospital, Susan and her husband trusted her decision unconditionally.

Upon arrival at the hospital, the first act of interprofessional collaboration occurred when Janet introduced Susan and her husband to the midwife (‘Elaine’) and student midwife that would be caring for her, and the handover of care was given. The time was taken to ensure that Susan’s history and current situation were discussed in her presence and that both her and her husband were involved in the conversation. A poor example of person centred care would be if this handover was undertaken on a ward where others could overhear it, as this would violate Susan’s privacy. Or alternatively, if the handover had occurred in Susan’s presence, but she was completely ignored and not at all involved in the communication.

As it was, it took place in a private labour room, and having Susan involved in the process meant that she did not feel ignored and felt more like a person rather than a ‘case’. She was also able to put forward her feelings and wishes regarding her care, for the healthcare practitioners to take into account, and was able to ask questions for her own benefit.

Elaine’s responsibility as the new caregiver (along with her student), was now to gather all the relevant information from Janet, ensure the safety of Susan and her baby via monitoring, and collaborate with other members of her team regarding the plan of care.

A number of studies have shown that during the labour and birth experience, women wish to be treated with support, kindness and respect, as well as receiving adequate information and explanations regarding the events (DOH, 2004). During this early period at the hospital, Susan was kept informed of what was happening and was never left to feel abandoned or unimportant. She was understandably anxious as she had been expecting a straightforward homebirth and was now in a high risk unit with potential problems. Elaine’s skills as a midwife meant that she was able to help to reduce some of Susan’s anxiety and consistently took into account her wishes, feelings and needs.

Susan also had the benefit of a student midwife helping to care for her. Working under the guidance of Elaine, ‘Alice’ was a first year student midwife and although students in the healthcare sector are officially supernumerary, they are still able to provide high levels of care, and can often prove to be a huge benefit to the person/woman receiving their care. It is widely believed that having a student participating in the care, can result in the patient receiving more attention and possibly more one to one care. This is partly because the qualified midwife usually has to explain procedures and assessments to the student, and so the patient/woman (and whoever else is present) will also hear that explanation and will further understand the process and the reasons for it. Also, qualified healthcare professionals are usually very busy due to looking after, and being responsible for, more than one patient at a time. However as someone who is supernumerary, a student has more time to spend with individual patients, and it has been shown that woman do appreciate the care and support of a student midwife (Modasia, 2007). Therefore, this was also beneficial in the provision of woman centred care for Susan.

Elaine had some concerns regarding the fetal heart trace from the CTG monitor, as she could see that the decelerations that Janet had noted were not improving. Consequently, the second act of interprofessional collaboration occurred when Elaine decided to contact a consultant obstetrician to review Susan’s case. Sterk (2002) states that when the birthing process deviates from the norm, a responsible caregiver should use their best judgement in order to avert any further complications, and Elaine did this in enlisting the help of the consultant. Healthcare practitioners working in a hospital are often part of a hierarchically structured team, and doctors are frequently thought to be the main controllers of the medical profession (Sterk, 2002). Although a midwife is an autonomous practitioner, it is still important to know when it is necessary to seek help from other professionals, regardless of their position in the ‘hierarchy’, in order to provide the best care.

When the consultant (‘John’) arrived, once again the discussion about Susan and her situation took place in the room with her and her husband, and they were involved in the conversation. As now the most senior of Susan’s care-givers, it is Johns responsibility to identify the seriousness of the case, and make an appropriate plan of care to reflect his findings. He involved Susan as much as possible in his ‘review’, and made sure to ascertain her wishes and feelings regarding her circumstances and her future care plan. It could be assumed that as midwifery is a female dominated profession, midwives are naturally more ‘woman centred’ than male doctors (Page, 1993). However John was clearly a very ‘person/patient centred’ practitioner, and so this skill was easily able to be transferred to be ‘woman-centred’ for the maternity setting.

He echoed Elaine’s concerns regarding the fetal heart trace, and explained to Susan and her husband his feelings that a caesarean section would be the best option for the safe delivery of their baby. It is important that some form of explanation is given as to why a procedure such as this is necessary, and that the explanation is understood (Gee & Glynn, 1997). Although they were clearly disappointed, their anxiety and concerns for their unborn child were more dominant. The careful and considerate explanations of the situation and the procedure, from both Elaine and John, were able to help Susan and her husband to understand the need for the intervention, ask questions and prepare themselves.

When the time came for the caesarean section to take place, more interprofessional collaboration occurred between the obstetric team (Elaine and John), and the Theatre staff. Again, all conversations took place in the presence of Susan, and all staff were made aware of her particular case and the reason for the procedure. Because everyone had this knowledge, they were able to adapt their care and their practice to fit Susan’s individual circumstances, therefore making it more ‘woman/person centred’.

During the procedure, Susan and her husbands feelings and wishes were consistently taken into consideration and a member of the Theatre staff stood next to them and spoke to them throughout; talking them through the procedure and answering any questions. This helped Susan to feel more in control, and helped them both to feel less anxious.

Soon afterwards, their baby boy was born and as there were no serious threats to his health, Susan’s original wishes to hold her baby as soon as possible after delivery were upheld.

It could be assumed that Susan and her husband would have negative feelings about the caesarean delivery, and possibly feel that it was unnecessary as their baby was born in a healthy condition. However, due to the excellent person centred care they received throughout the labour and birth, they understood the concerns of the healthcare professionals and the need for that particular method of delivery. Therefore there was no negativity and they were altogether happy with all aspects of the care they received..

The benefits of interprofessional collaboration are clear to see in this particular scenario. Relatively often, hospital midwives work collaboratively with obstetric consultants. Frequent collaboration such as this result in a higher level of ‘team knowledge’ (Miller, Freeman & Ross, 2001). This means that the team members have a wider understanding of each others roles and ability’s, and therefore there are no conflicting messages being given to the patient about their care or diagnosis.

Within a team, there is often a central goal; which in the healthcare setting, is usually promoting the health of the patient. Decisions about the diagnosis and care plan can be based upon a wider knowledge base, when being made by more than one professional. This aspect also means that broader care plans can be considered, as joint strategies can be implemented (Miller, Freeman & Ross, 2001).

There is often a lot of negative press about staff shortages within the healthcare sector, with Britain’s ‘Maternity Crisis’ being a main feature. Aspects such as staff shortages could hinder the delivery of person centred care; not only because the staff to patient ratio will be much lower, but also because the act of interprofessional learning and collaboration will be more difficult, and therefore reduced.

Communication is also a highly integral part of person centred care; both between practitioners, and between practitioners and patients.

Between professionals, it is important because one persons perception of a situation can be different from another’s (Ramsden, 2000). Different practitioners also have different levels of experience and expertise. Therefore this communication enables all caregivers involved, to have the same knowledge about the particular case and effectively discuss it and devise a plan together.

With the patient, communication is an important factor as it means that they do not feel excluded, and can be more involved in their own care. Patients appreciate simply being informed of what is occurring, and what their plan of care is, etc. It is also important that this communication is clear and useful to the patients, without using language and medical terms that the patient will not understand (Sanghavi, 2006). Effective communication can help the patient to feel more in control, which as we have heard, is one of the main factors of person centred care.

‘Person centred care’ is often more of an ideology that is rarely achieved. Factors such as staff shortages, lack of time, and low morale amongst staff, are often used as excuses for the lack of person centred care that is delivered. As stated by various studies, person centred approaches can take more time and the demanding nature of institutions such as hospitals, do not allow for this.

There may also be some professional issues when working collaboratively with other members of a team; such as competitiveness, conflicting views, professional self interest and differences in skills (Leathard, 2003). As we have seen that interprofessional collaboration is such an advantage to the delivery of person centred care, problems such as these would be a huge hindrance to both the dynamics and effectiveness of the team, and the standard of care being given.

It is also sometimes thought, that practitioners do not like working with a person centred approach, because they may feel a loss of professional status or power when having to hand more control over to the patient.

Comparatively, and in conclusion, it can be said with confidence that Susan’s case was an extremely good example of person/woman centred care. She clearly benefited from the process of interprofessional collaboration, and also from the excellent communication throughout her experience. And although she could not fully control her care as the situation was out of her hands, the professionals involved still helped her to feel more in control by taking her wishes and feelings into account at all times, and keeping her fully informed throughout. Coupled with the sheer professionalism and dedication from the practitioners involved, Susan and her family were extremely happy with the standard of her ‘person centred’ care.


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