Patient Discharge Process Reflection

Patient Discharge Process Reflection This reflective commentary will focus on a patients discharge planning liaison drawn from my experience in attending a Multidisciplinary team Meeting (MDT) held at my Elective Placement (Cardiology Ward) in the context of the dimensions of Interprofesssional Working (IPW) I will preliminary define in the introduction IP working; recognize policies; introduce patient scenario, identify the Reflection Model which I will use to evaluate and analyse the Dimensions of IPW. IPW refers to professionals with different training backgrounds (medical, surgical, counselling, psychotherapy, Occupational Therapist, physiotherapist) sharing common goals an objectives but who make a difference but complimentary contribution to the given client group in order to provide holistic care (Leathard, 2003). IPW has been highlighted by the United Kingdom (UK) government in a series of policies which shaped and continue to shape the way services and professionals work interprofesssionally. In 1998 The Department of Health (DoH) (1998) encouraged joint working through integrated provision. In 1999 papers such as DoH (1999) re-enforced that the effective care is the product of interagency working, promoting NHS to move towards interagency collaborative working or IPW in a shift from institutional to community-based care. The DoH (2000) a ten year programme of redevelopment practice to design and promotes a patient centered service and promote IP and Holistic care. One of the areas the DOH (2000) considered needed improving was the older generation patient discharge. To combat this, standard two of The Single Assessment Process (SAP) and Intermediate care services (ICS) was introduced by the National Service Framework for Older People by DoH (2001a) and this required services and professiona ls to work together in a co-ordinated assessment of needs for patients. From this, House of Commons Health Committee (2002) called for a number of key changes, one of them being a named Care Manager to coordinate all stages of the patient journey through hospital, up to and beyond discharge. And this coordination liaison could take the form of an MDT discharge planning meeting (DP). New ways of working have to be found that cross professional boundaries, in order to allow a more flexible approach to care delivery (DoH, 2002). To achieve this, the Government introduced Interprofesssional Education (IPE) in pre-registered students modules and their aim was to integrate IPE into their curriculum, enabling students to develop transferable skills that will facilitate communication and collaboration in the future (Barr, et al., 2005). Rattay and Mehanna (2008) suggest that as students should make an effort to attend MDT meetings to develop IP. I have used pseudonyms throughout my reflective commentary, to protect confidentiality in accordance with the Data Protection Act (1998) and the Nursing and Midwifery Council (NMC) (2009). I will refer to the patient as Sam. Sam is a 74 year old lady who lives alone in a ground floor flat. Sam has no family living locally however her neighbour visits regularly. Sam suffers from Chronic Heart Failure (CHF). Prior to admission Sam was fully independent at house cooping with her Activities of Daily living (ADLs) with slight difficulty due to breathing and poor balance (which Sam reported to suffering from for years). Sam was originally brought into hospital via accident and emergency by her neighbour as her breathing became progressively worse. There are many potential models of reflection. I will use Gibbs (1988) Model of Reflection (Appendix 1) as I find it more straightforward due to being depicted as a cycle, encouraging critical evaluation and analysis of the incident. Cyclical models are suggested by Ghaye (1998) to deepen awareness and increase knowledge and skilfulness from repeated movements around them. Reflection will able me to learn from the experience and identify my learning needs in areas which solicit improvements (Allen, et al., 2008). As suggested by Price (2006) Reflection makes a connection between theory, policies and practice required to develop evidence-based practice, professional and academic growth throughout my career; important in the development of lifelong learning (NMC (2009). Description The MDT meeting was held at the sisters office. The MDT consisted of a Ward Nurse (who was there intermittently due to staff levels), a Heart Failure Nurse Specialist (HFNS). Care Manager (Social Worker), Physiotherapist, Occupational Therapist, Doctor (Cardiologist Register) and myself. The meeting was led by the Doctor who gave an introductory overview of the Sams social situation and medical condition. The Doctor recommended that Sam was medically fit for discharge with a referral for HFNS community visits, as further health education was necessary. The physiotherapist suggested Sam was regaining confidence in her mobility but recommended further input to improve Sams balance and posture. The ward Nurse suggested Sams Nursing needs were stable and no input was required on discharged, upon this, I respectively argued that Sam discussed with myself earlier in the shift that she felt she was not coping at home and would feel more confident if she had minimal assistance with her ADLs at home. The Doctor re-directed the question to the HFNS, who re-directed the question to the Ward Nurse, both dismissing my input. At this point I respectfully assured the MDT that what I was advocating, it was also documented in Sam care plan. Subsequently, The HFNS requested Sams discharge planning to be discussed in a second meeting.. Following to this, The Occupational Therapist recommended she would liaise with Sam regarding any house equipment that would facilitate Sams ADLs. The social worker (Care manager) who would be coordinating all stages of Sams journey through hospital, up to and beyond discharge, organise possible (i) care (ii) meals on wheels. The Doctor summarised the MDT plan and rescheduled the meeting for 2 days to allow professionals to liaise with Sam in order to evaluate the discharge planning in partnership with Sam. Doctor was reluctant to reschedule and to change Sams expected day of discharge (EDD), it seemed. In the follow up MDT meeting, Sam was medical ly fit for discharge, her it seemed, had improved, as had her slightly her confidence but she could still benefit from further rehabilitation; therefore, Sam was referred to Intermediate Care Services (ICS) (Appendix 2) for further rehabilitation in the community, with out-patient medical follow up and HFNS home visits. Feelings When I asked my Mentor to attend the MDT meeting, I was excited as I was going to be able to see how the IPW provides a positive outcome for the patients. Slightly anxious but ready to be a Patient advocate. Soon it dawned on me when I was introduced to other professionals and given opportunities to work with them and I felt slightly insecure at the thought of having to expose myself to the criticisms of others. When Discussing Sams DP I commented on her behalf the feeling of slight insecurity was soon overpowered by a feeling of achievement as I was in a position to be her advocate appropriately and contribute in making a difference to her life for better. This feeling overpowered the shuttled frustration I felt when the Doctors dismissed initially my input but understandable due to my still pre-reg position, he needed reassurance as this input was going to change Sam EDD. As the meeting was lead by the Doctor I had inadvertently imposed a sense of hierarchy upon the group. I soon f elt that the hierarchy, even after the incident above, was not actually evident once a patient DP was being discussed as every professional was having a say and all professional seemed to understand each others responsibilities, roles and the documentation used involved all MDT input. I felt that through the discussions each professionals identify was gain and respect was given accordingly, although, I considered there was possibility of gaining a professional personality stereotypes and therefore ultimately a hierarchy may develop in future group meetings. By the end of it, I still felt slightly daunted to be in a MDT meeting working with professionals who knew so much (i) HFNS who developed their careers to a point of extreme knowledge, it overwhelmed me, that I am still just in the beginning of an extraordinary journey. Evaluation In accordance to Holland, et al. (2005) and Gonseth, et al. (2004) Heart Failure Nurse Specialist (HFNS) input was fundamental as HF patients as Sam require close clinical management and encouragement to manage their symptoms in order to remain in the community (James and Sarah, 2008). Furthermore, Blue, at al. (2001) randomised controlled trial suggested that HFN have the ability to focus not only on the clinical needs of the patient, but the educational and supportive needs as well as establishing effective liaison between health and social care. Although HFNS is important in the provision of Sams Good Health in the community, without front line staff (i) ward nurse to document appropriately and report to the appropriate professional and act as an advocate for patients in meeting such this, the provision of IP working and Safe Discharge Planning would be compromised (Atwal and Caldwel (2006). Record keeping was to be commended as the Discharge planning Form (DPF) (Appendix 3) was filled in from admission and updated regularly by Sams Multidisciplinary team regarding assessment, planning, and implementation and evaluation goals specific to each professional to establish safe discharge. Effective record keeping is the key factor to effective care and continuation of care of Patient; and a Code of Conduct requirement for excellence practice and care (NMC, 2009). The Community Rehabilitation/Intermediate Care Services (ICS) Appendix 3. Referral was suggested appropriately in order to meet Sams needs, in accordance with the DoH (2001a, 2001b) agrees that ICS establishes IP working and avoids duplication, enhances communication and allows each team member to view and check the patient notes at all times. Furthermore Godfrey, et al, (2005) suggests that it enhances Holistic care. According to Leathard and Cook (2009) Sams care could be considered Holistic as her physical, psychological, sociological, spiritual needs were addressed, and Sams views were considered alongside any recommendations offered by all the different multi-disciplinary teams in a mutual participation in a shared decision-making partnership. With changes in Nhs such as patient-centred care (DoH, 1998), and the establishment of sophisticated holistic approach to health and social care, one of the key features of Sams patient centred care is the development and  implementation of integrated care pathways (ii) collaborative care plans such ICS, providing Sam with a continuity of care. MDT meeting structure seemed to reflect The DoH (1998) in its drive for a first class service as staff seemed to clear understands of how their own roles fit with others in both the health and social care professions. Although, Role Clarity was predominant and significant, the Status caused distress within the MDT; it made some members feel their opinions are not as important as others (Robinson, et al., 2005). Furthermore, at certain points of the discussion the blurring of the boundaries of ones discipline Ward Nurse and (HFSN) (i) Doctor redirected the question about Sam to the HFSN first instead of the ward Nurse. I agree with Molyneux (2001) is a factor that may create a competitive atmosphere rather than a collaborative one. In addition to the group dynamics, the situation of Sam needing care set up also highlighted the tension between professionals and in a sense organizational aims and resources. Analysis The DoH (2000, 2006) stressed the need for team working to helping rove the quality of care to patients and encourage role development to meet the demands of IP working. (i) Registered nurse specialists are expanding their roles and skills in numerous clinical areas (DoH 1999, 2006) due to patients diversity of needs in todays society (Furlong and Smith, 2005). According to DoH (2000, 2003) and the National Institute of Clinical Excellence (NICE) (2003) Heart failure care and management is one of this areas which had an increase in nurse specialists (HFNS) in a broad evaluation by Patterden, et al., (2008) which showed that HFNS reduced (i) all-cause admissions by an average of 35 per cent an average saving of  £1,826 per patient is gained after the costs of the nurse have been deducted. Furthermore, a systematic review by Holland, et al., (2005) argues that HFNS management of HF associated with (reducing readmissions, improving patients quality of life, Like Sam and reducing finan cial costs is more efficient compared with medical management. In outcome, Hewison (2004) and Abbot, et al., (2005) agreed that although the development of roles and increased flexibility is usually a benefit to many  professions, it can be seen as a threat for their own interest and power status, generating a resistance to IP collaborations. Moreover according to Molyneux (2001) a tribalism sense. This is normally the professional at the top of the hierarchy (i) as when the doctor was resistant to move the EED. Furthermore, as far back as 1998 when (DoH, 1998) was published, Stapleton (1998) suggested that Collaborative working emphasis that demarcations and hierarchical relations between professions are neither sustainable nor appropriate. Although, in Sams MDT it was apparent in agreement with Hean (2006) my preliminary feelings of hierarchy are common and traditionally hierarchies place more power to the medical profession. The tension seemed in a way to be overcome through th e structured but open discussion regarding Sams needs which according to Freeth (2001) open discussion helps develop the team and recognise the benefits and the diversity and development of skills. Martin and Roger (2004) highlight that it is important to premise a clear understanding and appreciation not just for the roles but also for the pressures of other professionals (i) performance targets to meet. The Qualitative methodology questionnaire led interviews and focus group (18 cases studiers across Europe) by Coxon (2005) suggestion that IP working promotes job satisfaction, improved team working, good communication and enhance co-operation with other agencies, and identifies IP difficulties to be due to organizational boundaries and financial limits. Additionally, Hubbard and Themessi-Huber (2005) used the same method as Coxon (2005) although he identified that a main difficulty to IP is managers focusing on policies and changes of services: arranging MDT meeting whilst front line staff, as ward nurses need to adapt to practicalities of the IP. Atwal, and Caldwell (2006) argues the importance of staff ratios as a barrier to nurses developing IP practices, furthermore a study carried by both with nineteen nurses in acute health care ward, it is spotted that in MDT meetings not all the professionals involved in the care of a patient are invited and that nurses did not regularly att end the meetings due to staff ratios. Another conclusion of this study is that nurses not always express their opinion for fear of being made a scapegoat, the result from the research show as well, that consultants and medical staff usually speak first and with more confidence on all issues. In divergence, Barrett and Keeping (2005) argues that collaborative working should minimise staff pressures from a ward level to community (primary and secondary setting) but research done within this Era of IPW still shows that at a nursing level in a 2005 survey by RCN (2006) found that 49% of nurses left the NHS due to stress/workload problems. Horder (2004) and Pullon and Fry (2005) goes further to suggest to overcome the work pressure, shared decision making is the ultimate hallmark of partnership and this requires distribution of power or the empowerment of all involved within the multidisciplinary professionals in a manner that would equalize the hierarchy through (i) through IPE. It is essential that health and social care professionals realise the important of IPW as it has now been recognised that a single profession can no longer deliver the complex patient care that is demanded nowadays, a holistic approach is required (CAIPE, 2007). Rattay and Mehanna, (2008) suggest in summary that structured MDT meeting provides the discharge process with a structure that is organised professionally and timely, allowing patients to return home earlier safely, consequently reducing the NHS cost, minimising the risk of hospital acquired infections, promoting independence and enabling patients to return back to their homes and community, like Sam. Lack of co-operation between agencies has led to a failure of service (Glasby, et al., 2004). Communication within the team is also an important issue to good collaborative working, developing ways to communicate and to work together is the key for successful IP working (Abbott, et al., 2005). The NMC (2004) advises that at the point of registration students should have the necessary skills to communicate effectively with colleagues and other departments to improve patient care. Cook, et al., (2004) identify that communication and decision making are very important for teams. Larking and Callaghan (2005) argue that teams who do not regularly hold meetings for policy making and resolutions of differences, should not be considered a team, these findings are also emphasized by Molyneux (2001) who states that communication is supported with weekly MDT meetings in order to evaluate and plan patient centred care delivery. Conclusion This reflective commentary allows me to connect policies, NMC requirements, theory and practice. It provided me with the assurance that the dimensions of IPW is complex but possible in practice IPE exists. It highlighted that different professionals have to deal with their own perceptions and adapt to changes. There is no doubt that IPW promotes a better and more holistic care and the documentation in place promotes further patient-centered care. The MDT gave me the opportunity to work closely with other professionals and understanding further their roles. This will help me to effectively work together in the future. Action Plan I will allocate the Action Plans in my professional portfolio to demonstrate achievement in clinical practice linked with theoretical knowledge. All my Action Plan are made SMART Specific, Measurable, Achievable, Realistic and Time (Drew and Bingham, 2004) 1. Inter-Professional To develop an awareness of the roles and services provided in the inter-professional team and identify examples of how this is appropriate in delivering appropriate patient/client focused care. 2. Enhance my knowledge about decision-making processes within care management 3. Continue to reflect in and on Practice therefore to participate in further process of reflection to establish my own learning needs (Appendix 4).

How does Stevenson explore duality in The Strange Case of Dr Jekyll and Mr Hyde? Essay

The idea of duality, in this case, of people displaying duality of character, being â€Å"two faced†, of showing contrasting sides to a person, was of much interest to people in the late 19th century, due to the way it reflected upon their society, and was a key concept of Gothic literature written at the time. In this essay, I shall see how Stevenson explores this, the techniques and methods he uses, and the way in which he shows us how duality is significant in Victorian society. The Strange Case of Dr Jekyll and Mr Hyde was one of the first novels to re-introduce the Gothic literary genre, and thus has several elements that are common to other Gothic novels, which I shall explore in this chapter. With Gothicism being a genre of horror fiction, almost all Gothic novels have some kind of monster as the antagonist. Mr Hyde, although generally regarded as human (a point which I will explore further later on), is quite obviously a monster in the original sense, that is, a being of pure evil and sadism. He is described as a repulsive, grotesque person, for example, by Mr Enfield: â€Å"There is something wrong with his appearance; something displeasing, something downright detestable †¦ he gives a strong feeling of deformity, although I couldn’t specify the point.† The fact that his features are not truly described, but only hinted on vaguely, is also important; it is common for Gothic literature to prey upon the fear of the unknown. Hyde as a monster is only ever witnessed through the eyes of others’, in other words, at no point in the novel do we get an explanation from his viewpoint. This is also another Gothic technique, designed to de-humanise the monster: if we could see things from it’s perspective, we could sympathise with it, therefore this is not allowed. In this novel, the idea of a monster is combined with another Gothic element: the double. The double is the idea of duality taken to an extreme, physical level: a character who has two different forms, often with one being good, the other evil. Common doubles in Gothic literature include werewolves, people who transform from regular humans into a wolf form, and vampires, people who, by night, become blood-sucking monsters. Hyde is the double of Jekyll; although he has a different form, he is not an entirely separate person, but is the evil side of Jekyll. By creating Hyde, Jekyll allows himself to express his innermost desires, without receiving the consequences, such as shame, guilt, or a loss of respect and reputation. This is part of one of the key themes of the book, which is exposing duality in Victorian society, that will be explored later. Finally, there is one thing that sets Jekyll and Hyde apart from other Gothic novels. Usually, they are set in very remote places, often in foreign, Catholic countries. This distances the reader from the often scary events happening, however, in Jekyll and Hyde, the fact that it is set in London makes the events seem much closer and real, and therefore scarier. Other than this minor point, however, it is easy to see how Stevenson uses the Gothic genre to explore duality in the book. Stevenson also uses a particular style of writing and a variety of techniques that help to explore duality, for example, the story is titled as â€Å"The Case of†¦Ã¢â‚¬ , which, as well as being a case as in a particular event, it is in some ways presented almost as a legal case. As the story unfolds, we see Mr Utterson on an investigation, with â€Å"evidence† in the form of accounts from Mr Enfield, the maid and others, as well as various letters and the will made by Dr Jekyll. At the end of the book, we get the full statements of the two main witnesses, Dr Jekyll and Dr Lanyon. As noted before, Mr Hyde’s recollection of the events is never known. By writing in this way, Stevenson clearly shows us contrast between the protagonist â€Å"prosecutor† and the antagonist â€Å"defendant† in the book, as well as involving the other characters as more neutral witnesses, but leaving it open to speculation whether they are in this case necessarily good or bad, exposing their duality, for example with Dr Jekyll, who, although he obviously hates Hyde for his crimes, still continues to crave becoming him for the purposes of expressing his desires. Another technique Stevenson uses is symbolism, mostly in the form of weather, for example, the city streets were filled with smog when Hyde was out, and in chapters 2 and 4, where Utterson and others are trying to find Mr Hyde, there is a thick early-morning fog. This, although common in London at the time, still had associations of secrecy and obscurity, as it was the domain of people like Jack the Ripper, and therefore the perfect setting for the crimes of Mr Hyde. As well as weather, Stevenson used the symbolism of doors and windows also as metaphors for secrecy. For instance, in Jekyll’s laboratory, it is always behind the closed cabinet door that he transforms into Hyde, and it is only when this door is broken down that the mystery is solved. Also, when Utterson and Enfield go to speak with Jekyll in Incident at the Window, the window serves as a barrier between Utterson and the truth that Jekyll hides. To understand how the book as a whole expresses duality, it is important to understand how contemporary readers would have viewed and reacted to the book. Obviously, at the time it was published, readers would have not suspected the idea of transforming into an evil doppelgà ¯Ã‚ ¿Ã‚ ½nger was the key to the mystery about Jekyll and Hyde. We should bear in mind that the most logical solutions are that Jekyll and Hyde were having a homosexual relationship, that Hyde was the illegitimate son of Jekyll, or that Jekyll was somehow being intimidated and controlled by Hyde, possibly via blackmail or debt; contemporary readers would probably have guessed that one of those was the most likely to be the case. It is also important to understand how readers would have viewed Hyde. In the late 19th century, many post-Darwinist theories about evolution and creationism were being discussed and debated, and people were beginning to accept the idea that humans were descended from apes. From this came the idea that people who were socially unacceptable, that is, anyone who did not confirm to the Victorian ideals of etiquette and manners, could be regarded as less evolved, and in a way sub-human. This is highly evident with Mr Hyde, who is described as being very short, deformed and ape-like. There is, however, a final point about the readers of the book, which I regard as one of the most important, and it is what made the book so shocking and controversial at the time. This is the way in which the book exposes the duality that was present in Victorian society, which is displayed by the important characters in the book. Society and culture at the time were based highly on etiquette and conformity, and of appearing the best as possible in public. Any person’s vices were kept behind closed doors, even with close friends and family, and thus, this lead to people leading very separate public and private lives. In Jekyll and Hyde, Stevenson shows this to some extent with all of the major characters, the most significant of which I shall explore further. Mr Utterson seems to be the most single-track, sincere character, however, he does display moral ambivalence as a lawyer. In his own words, â€Å"I let my brother go to the Devil in his own way†. At first, it seems that it is good of him, as a lawyer, to not judge people at all, however, although this seems helpful, it can also be bad, for example it means that he will not step in to help someone who is â€Å"going to the Devil†, but rather let them sort things out in their own way. He only seems to change this at the end of the book, and that is only because Poole suspects that Hyde has murdered Dr Jekyll. Mr Carew, an MP, is clearly shown as being a well-mannered gentlemanly figure, but because of this, we can not help but wonder why he is out in a shady district of London at night, and what he said to anger Mr Hyde so much (if anything). This shows once again the idea of having a private life, kept hidden and separate from your public life, which is what Carew appears to be doing. Finally, there is Dr Jekyll. Throughout the book he is described as a good man, who was respectable, admired by his friends, as someone seen as nearly perfect by Victorian standards. However, beneath the public face we can see that his fascination with Mr Hyde is not purely scientific. Once he has experienced what it is like to be in Hyde’s body, he begins to crave it more, this is because, through Hyde, he can do things that are completely unacceptable, even by modern standards. The book suggests that, as well as murder, he practised many sexual perversions, and similar acts. This shows how a man can fall and become a lesser human, as noted before, and that this is achieved by science. At the time, people believed in the idea that humanity could reach a peak level, and then devolve, becoming ape-like once again, Jekyll and Hyde could be seen as a metaphor for this. As you can see, Stevenson uses these characters effectively as well a wide variety of literary techniques and in the style of a Gothic novel to explore duality and how it relates to society at the time.

Case Analysis International Business Law - 4792 Words

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The Problem of Feminism in Female Art Essay - 2249 Words

The Problem of Feminism in Female Art A review of the world’s great artists conjures familiar images: Michelangelo’s Sistine Chapel; Vincent Van Gogh’s Starry Night; Pablo Picasso’s The Tragedy. There are many more, of course: Monet, Moya, Warhol, Rembrandt, Kandinsky. What is immediately noticeable, however, upon any brief study of art, is the significant absence of women as heralded artists—not only in our ancient pasts, but even today, amongst valiant efforts for gender equality. The question â€Å"Why have there been no great women artists?† has been debated since the 1970’s, when historian Linda Nochlin released her book of a similar name. In the decades that have followed, the number of women pursuing education and†¦show more content†¦The goal for feminist artists all along has been the gender-blind interpretation of art, allowing women equal opportunity for success. Feminists have long cried for museum curators and art collectors to see more than just â€Å"male† or â€Å"female† in a work. However, politics tend to get in the way, and it may be argued that, by clamoring for equality, women have isolated themselves further, making female art a socially-conscious fad rather than a respectable institution. In Women, Art and Society, Whitney Chadwick elaborates: â€Å"Feminist critics remain sensitive to the dangers of confusing tokenism with equal representation† (1990). Fear of such tokenism, and perhaps too much emphasis placed on inequalities, has made feminism somewhat of a â€Å"dirty word† to some artists today. The question of â€Å"why feminism?† has been presented to a number of female artists who deal with strong constructions of gender in their work. The answer, overwhelmingly, has been the desire to modify stereotypes about women that have prevailed in male-dominated art history. 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