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According to Eilbert Lafronza Partnerships comprise of a social system or individual based agreement between participating organizations to collaborate on a common goal in which benefits and risks, as well as resources and power are shared fairly. Patients and families cannot entirely be involved in the care decision process unless they have established a solid partnership between their health care providers i.e Doctors, Nurses, General practitioners etc . (McQueen :2000).2
Some of the way that patients and their families can be involved in the care decision process is by making informed decisions on:
Whether the patient wants treatment or not: Selinger (2009)3 states that the patient has every right to make an informed decision on the right to determine what investigations and treatments to undergo, and this decision must be respected by all doctors, nurses and caregivers.
Whether the patient wants to complete a Do Not Attempt Resuscitation (DNAR) form or not: Healthcare professionals have an important role in helping patients to participate in making appropriate plans for their future care in a sensitive but realistic manner, making clear whether or not attempted CPR could be successful. Helping patients to reach a clear decision about their wishes in respect of CPR should be regarded as a marker of good practice in any healthcare setting (British Medical Association (BMA), the Resuscitation Council (UK) and the Royal College of Nursing (RCN) : 2007)4
And finally, what right the patient has to be involved in decisions about their medication.
The National Collaborating Centre for Primary Care( 2009)5 states that patients have a right to be involved in decisions about medicines to the extent that they wish and it is the role of health professionals to facilitate and support patients in their involvement in decision-making and to support patients in taking medicine if the decision has been to prescribe.
Patient and family partnerships are very important in the care decision process because without them numerous problems may arise. Some of which are: self-discharge, readmission, deterioration of condition and death. (Smith and Hider: 2009)6
According to Gott et al. (2000)7 successful patient partnerships are those in which the patient and healthcare practitioner meet as equals with different expertise. The doctor or nurse has the medical knowledge and skill, but the patient has personal knowledge and skill. This is useful because it provides two different perspectives which in turn will provide the best outcome for both the patient and the healthcare provider. For the most part, patient and family involvement is beneficial to the care process because the patient knows their own condition the best and if we assume that they are close to their family and share their struggle with managing their condition/disease with them then they too know what the patient's condition well. Anderson and Funnell (2009)8 state that patient and family involvement in care decisions revolve mostly around decision making and empowerment.
Patient involvement in decision-making is now generally regarded as a feature of good quality health care. Many health professionals, institutes and government policies such as the Department of Health (2007)9 now advocate that patients should be involved in some way in decisions about their health care. According to the RCN (2003)10 empowering patients is a central element of nursing care, by forming a solid patient- nurse partnership, and encouraging the patient and their family to be part of the decision making process, this allows the patient to feel empowered and in control of various aspects concerning their health.
However according to a study carried out by Dickerson (2004)11 shows that although patient and family involvement is crucial in care decisions, various authors might argue that a lot of patients search for and find information/new treatments about their illness/ condition on non-credible sources such as the internet, magazines and social media and believe that whichever "fact" or new never trialled before treatment they read or hear about might be a diagnosis to their symptoms or a solution to their illness. The study showed that many patients (50%) relied on friends and family to navigate the Web, and most of patients reported that the information that they sought was unrelated to their clinical visit. This study shows that although patient and family partnerships are crucial to the care decision process, some patients and their family take the wrong path when seeking information about their condition, this is usually after a clinical encounter for diagnosis and/or reassurance or because of dissatisfaction with the amount of detailed information provided by the health professional during the encounter. (Kaimal AJ et al. :2008)12. According to McMullan (2005)13 Health professionals are reacting to the more "Internet informed" patient in some of the following ways: The health professional either feels threatened by the information the patient brings and responds defensively by asserting their 'expert opinion' (health professional-centred relationship). Or, the health professional and patient collaborate in obtaining and analysing the information (patient-centred relationship) (Pautler et al. : 2001)14. Although the health professional almost always comes to a decision to progress with the latter option, feeling threatened and being defensive about the internet based information being presented to them by the patient and their family is usually the health professionals' first reaction. An alternative approach would be for the health professional will guide patients to reliable health information websites. It is vital that health professionals acknowledge patients' search for knowledge, that they discuss the information obtained by patients and guide them to reliable and accurate health websites. It is suggested that courses, such as 'patient informatics' are incorporated in health professionals' education (Sommerhalder et al. : 2009)15.
The Department of Health (2003)16 states an effective discharge as "A process and not an isolated event. It has to be planned for the earliest opportunity across primary, hospital and social services, ensuring that individuals and their carers understand and are able to contribute to care planning decisions as appropriate." Here we see the DOH (2003) describing an effective discharge as one that co-ordinates all of the services needed by the patient in order for the patient to have input on the discharge and for everything to be ready for the patients discharge. Nurses and other health care professionals recognise that planning for patients' hospital discharge during the inpatient stay sets the stage for effective and therefore successful self-care management at home. (Nosbusch et al.:2010)17.
According to the Wales NHS effective discharge policy document (:2009)18 an effective discharge constitutes of the following 6 principles:
Communication - when it comes to the transfer of care process, it is important that good communication consists of mutual understanding and having a common language between everyone involved. This requires effective dialogue and sharing of up to date information amongst patients, carers, providers and commissioners. Casey and Wallis (2011)19 state that Nurses and the nursing staff are at the core of the communication process: they "assess, record and report on treatment and care and handle information sensitively and confidentially" .To establish a healthy nurse- patient relationship, good communication is crucial. As a nurse, building a close rapport with your patient is one of the ways to make your patient feel listened to, understood and involved in their care. Good communication is vital in the process of decision making. Jonsdottir et al. (2004) 20 state that communication skills are one of the most imperative aspects of nursing, considering that nursing always is two-folded with both task-oriented and relational aspects. A nurse's communication skill is an essential requirement for patient participation in decision making. Communication discrepancies have been recognised as one of the major barriers to partnership building between nurses and patients (Keatinge et al. 2002)21. Good communication in the care decision process is vital In order to achieve a seamless discharge for the nurse, patient, the patients' family and all other healthcare practitioners/Multidisciplinary team (MDT) members involved. The NHS Trust Discharge policy (2010)22 states that before planning a discharge, the nurse and other healthcare practitioners must decide and inform the patient and their family on whether it is a simple discharge: one that involves minimal disruption to the patient's activities of daily living, does not prevent or hamper a return to their usual place of residence and will not require a substantial change in support offered to the patient or their carer in the community. Or whether it is a Complex Discharge: A discharge process that deviates from the simple discharge pathway and requires complex coordination of services to enable safe discharge. To ensure that the patient and their family is involved in the care decision process of discharge, the nurse and other clinicians must be certain that an effective and well-timed discharge plan is put in place. The main objectives of this will be to plan, inform, liaison and negotiate to ensure a smooth discharge for patients and their families. Supporting this is the need for an early establishment of what the discharge dates might be, including pre-admission planning, effective communication between individuals and across settings, good clinical management plans and the alignment of services to ensure continuity of care(DOH :2010)23. Assuming that it is a simple discharge, once the discharge plan has been put into place and is carefully explained to the patient and their family, the patient can then begin to contribute in the decision making process alongside the nurse and members of the MDT team.( Shepperd et al. :2010)24. Some of the ways a patient can contribute in the decision making process when it comes to discharge is to work alongside the nurse and members of the MDT team in order to inform and help them assess whether the patient can- Obtain and self-administer medications- the patient should inform the nurse and other clinicians (such as pharmacist) on what regular medication they take, what form they prefer their medication: liquidised, dosette boxes etc. How well the patient performs self-care activities, and does the patient eat an appropriate diet or otherwise manage nutritional needs and whether the patient is able to attend any follow-up outpatient appointments (Bull and Roberts: 2001)25. Atwal (:2002)26 states that ensuring that the patient and their family have full involvement in making the above decisions and steps to be discharged from the hospital will give the patient a sense of control and therefore empowerment and in turn guarantee an organized discharge as well as patient satisfaction and the nurse feeling confident that they have done their best for their patient and therefore feel fulfilled in their role as a nurse. It is prominent that a patient must be an active participant in his/her empowerment, signifying that Nurses cannot empower patients: the role is to facilitate and support the empowerment (Laverack :2005)27.