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This report will present the management of a moderately severe depressed patient while on practice placement at a Specialist Psychiatric Unit. The back ground of the unit will be introduced. It will present the collaborative working relationship between the inter-professionals that aim at promoting team working. The student nurse's involvement in the assessment process, referrals and periodic reviews to monitor and evaluate care provision that enhances quality of care will be presented. The management skills employed at the unit to provide effective patient care will be discussed. Recommendation for improvement in practice will be made, followed by learning that has been identified and how it will affects future practice. Confidentiality will be maintained as required by the Code of the Nursing and Midwifery Council (NMC, 2008). Pseudonyms will be used throughout this report.
Background of the Unit:
It is a specialist psychiatric unit that comprises a team of psychiatric nurses and approved mental health Practitioners (AMHP) and psychiatric doctors that:
Provide urgent brief assessment for patients who are deemed in crisis and require short term interventions.
Assess patients who are picked by the Police under section 136 of the Mental Health Act (MHA) 1983 for assessment and possible treatment.
Coordinate patient admissions, discharges and transfers to other wards.
Work closely with the Crisis resolution team and inpatient wards to ensure that the psychiatric hospital function effectively and safely.
Miss Pat Brown is a twenty-four year old British woman who was referred by her General Practitioner (GP) to the unit for further assessment and treatment of her depression.
Quality of care:
It is important that patient receive care in line with the National Standard Frameworks (NSFs). Quality of care can be enhanced through education, skills training programme and managers influencing staff behaviour to professional development by means of appraisal systems. The introduction of feed back from patient and patient satisfaction surveys can as well improve quality of care (Chambers, 2004). Having stated these, the cut in Budget spending of the NHS currently could hinder staff development which will seriously affect quality of care.
Clinical governance is an umbrella term for every thing that helps to maintain and improve high standards of patient care in the National Health Service (NHS). It covers a whole range of quality improvement activities that nurses are involved. For example clinical audit and practice development. It enables care to be measured in terms of effectiveness and quality. It helps all clinicians including nurses to improve quality and safe guard standards of care. National Institute for Health and Clinical Excellence (NICE) regularly carries out checks on new arrangements, develop new clinical guidelines, appraises new technologies and promote clinical audit. The Commission for Health Improvement (HCI) and the National Audit Office (NAO) conduct local and national reviews for implementation of NICE guidelines monitoring the quality of care through performance strategies and listening to patient experiences and ensuring their complaints are dealt with effectively (Kirby et al, 2004).
Inter and intra-professional working:
Intra-professional working is the collaborative working among colleagues who share a common education, values, identity and experience. It foster understanding of each other and thus promote quality care provision. Interprofessional working is collaboration between professionals who may not share a common professional education. It enables professional benefits, with reference to the sharing of knowledge. It offers opportunities to experience areas of work outside one's own remit. Professionals may have levels of improved job satisfaction and increased levels of confidence in dealing with difficult situations (DH, 2006). Interprofessional working promotes good practice as psychiatric nurse's work effectively with others to provide seamless care for the patient. It promotes interprofessional communication and maximum use of resources. One of it's disadvantage is that, interprofessional working creates communication difficulties as language differs from profession to profession which may leads to misunderstanding. For example, same words may have different meaning to people from different disciplines. It creates differing professional views which stem from differences in occupational culture in which each profession is socialised. This therefore prevents effective collaborative working (Norman and Ryre, 2004). The unit work as a team in reviewing challenging patient cases with the Psychiatric Consultant and the SHO twice weekly. Such meetings help team members to find solutions to their patient's problems and thus, patient care is improved. The student nurse is also given opportunity to present patient situations that seem challenging for discussion. This opportunity encourages appreciation and understanding of roles and responsibilities of other disciplines. The teamwork approach adopted to support each other at the unit encourages the whole team to work in partnership with their patients. The student nurse's exposure to members of the team from different disciplines is a good orientation toward other professionals.
Assessments are conducted at the unit by a team comprising a Senior House Officer (SHO), psychiatric nurses and an approved mental health practitioners. The assessment interviews are conducted in rooms very conducive that patients and their significant others feel safe to interact freely with the team. It was in such an atmosphere that Pat's interview was held. The student nurse took the initiative to arrange the interview room for the start of the interview. The mentor usually gains consent of the patient to allow student participation. In Pat's assessment like many others, the student nurse was allowed to listen, ask questions and take notes. The team discussed the interview to arrive at a clinical judgement and diagnosis. Each member of the team is allowed to share their views and observations.
Areas that were assessed: A comprehensive assessment included important areas such as:
a detail and precise description of the problems the patient is experiencing
a clear description of the patient's current symptoms,
description of patient's social, occupational and domestic circumstances
the support available and level of dependence.
a comprehensive risk assessment
Pat was diagnosed as suffering from moderately to severe depression and anxiety. (NICE, 2008). However, her risk factors were found to be low and did not require admission to hospital.
Management processes and procedures:
Management is the process of getting work done through others; thus, management entails working with others (Marquis and Huston, 2009). Management operates through various functions often classified as planning, organising, leading, coordinating and controlling. This contributes to the achievement of organisational goals. Planning as an aspect of management can be seen as deciding what to do in advance, how to do it, when to do it and who should do it (Du-Brin, 2003). Organizing is making optimum use of the resources available to carry out the plan while leading is the exhibition of skills to getting others to play an effective part in achieving what had been planned (Young and Cooke , 2002) Controlling is therefore the monitoring of progress against the plans which may need modification based on feedback (Wise, 2003).
It is rare to discuss management without including the concept of leadership. Leadership is portrayed as a process that involves influencing individuals who have a common goal (Heller, 1998). Leaders set the direction, clarify the big picture and develop strategies needed to achieve organisational goals. Leaders do this by communicating the vision to the team, motivating, inspiring and empowering individual team members through differing leadership styles (North house, 2001).
The nature of nursing follows this problem solving approach. Nurses assess their patients, formulate plans for their care, implement and evaluate their progress. Problem solving involves interpersonal communication skills, open mindedness, flexibility and the realisation that problems occur as normal part of life and finding ways to solve them is a skill that can be learned and practiced. Patient progress need to be reviewed, identify potential barriers to further progress and address how these may be overcome. For example redefining the problem or reducing the goal into smaller or more easily accomplished components. For effective patient management strategy, it is important to develop a therapeutic collaborative working relationship with the patient and their significant others (Nelson-Jones, 1990).
Wallace (2001) defined communication as a vehicle by which human relations are developed and maintained. He likened nursing care as a building whose foundation is based on sound knowledge and skills of communication which are essential components of clinical competences. The team's engagement with Pat conveyed respect, warmth and genuineness. Discussions were held with Pat concerning her possible nursing interventions so she could make an informed choice. Communication and passing information from one person to the other is essential for effective teamwork. Communication failures can seriously compromise a patient's quality of care. The team including the student nurse employed effective interpersonal communication to illicit the necessary information that helped it to make a good clinical judgment, diagnosis and treatment plan.
Delegation of duty is the transferring to a competent individual the authority to perform a selected task in a particular situation (Daft, 2003). Delegation is a skill worth building, for the advantages it holds. It make work load become more manageable. It provides professional development opportunities to junior staff by relinquishing task that will challenge them. As a student nurse, delegation practice gave a clearer picture of nursing roles and the scope of nursing practice. However, the delegation of tasks and responsibility should be within the skills and experience of the delegate. After interviewing Pat, the student nurse was delegated to document Pat's care in her nursing notes and send fax to her GP, notifying him of her treatment plan. Pat's referral forms were sent to the psychology department by the student nurse.
Prioritizing patient care is an integral component of decision making process that nurses goes through when caring for their patients. Preferential order for nursing action is established using notions of urgency through priority setting (Benner, 2000). During priority setting, problems are conveniently classified as high, medium or low. This must be done in line with the treatment guidelines and consideration of the patient's views. It is important to negotiate with the patient on some issues when providing care, by thus the patient's view are solicited and respected. Their preferences need to be considered so as to avoid coercing them to accept any care contrary to their view. Pat's treatment for her depression and anxiety were prioritised by the team giving consideration to the treatment of depression as a priority (NICE, 2004). The team held discussion with her on treatment options and her prescribed medication with its possible side effects. She was informed that the therapeutic effect of the medication will be seen in four to six weeks.
Diagnosis: moderate to severe depression with anxiety.
Short term: treatment with SSRI (Selective Serotonin Reuptake Inhibitor).
She has been referred to the Psychologist for Psychotherapy sessions.
20mg Citalopram (anti depressant)
7.5mg Zopiclone (PRN)
Female patients with depression who are below the age of thirty have the tendency of committing suicide by taking overdose (Semple et.al, 2007). Even though her risk level is low she had been given medication that will last for only seven days. Pat's treatment was reviewed after seven days and she has been given a repeat prescription for another two weeks. At the last review her mood state had not improved much so her Citalopram dosage had been increased to 40mg. Pat is to attend another review in three weeks.
Pat will be discharged from the Specialist Psychiatric unit when there is an improvement in her depression.
She will take her repeat prescription from her GP when she is discharged.
She will be referred to the Community Mental Health Team (CMHT) who will manage her care in the community.
Lessons learnt: The caring attitude that the team demonstrated in Pat's care delivery is worth noting. Cross fertilization of ideas and skills within the team fostered the holistic and individualized care that Pat received at the Unit.
Conclusion: In conclusion, a report has been presented on a patient suffering from moderately to severe depression. The collaborative working relationship of the interprofessional has been highlighted. The management skills employed in patient care have been discussed. The student nurse's involvement in the assessment and review meetings has been presented.
1) Nursing care delivery involves management and leadership skills which nurses are expected to carry out to enhance quality care delivery. However, there are no management studies in nursing education; neither is there any staff development programme in management skills for their counterparts in practice. Nurses have good clinical skills but under developed management abilities. Student nurses as well as practicing nurses urgently require management skill training if team management and patient care is to be improved.
2) Inter-professional working has advantages, one of which is the integrated seamless care it offer. Though it has been in practice for some time, there are working difficulties such as occupational culture, communication difficulties and professional identity. These affect collaborative working and need to be tackled.
3) Education and training is essential. Interprofessional education where undergraduate student's in medicine; physiotherapy; occupationaltherapy and nursing learn core skills together will encourage appreciation and understanding of roles and responsibilities. It will impact on service provision and patients will benefit from higher level of care delivery.