This essay will focus on an event from clinical practice where it

This essay will focus on an event from clinical practice where it was necessary to make a collaborative care decision and analyse the decision-making process that was taken. It will take into consideration the perspectives of both the patient and the multidisciplinary team and apply professional and legal principles to the situation. The names used within this essay are pseudonyms to comply with the NMC Code (2015) and protect the confidentiality of the individuals being discussed. During a night shift on a critical care unit a student nurse witnessed a consultant inform the nurse in charge that a patient on a general ward had suffered a cardiac arrest and required observations and clinical interventions that could only be provided and managed safely on the critical care ward however, at that time there was no bed space available. Because of this, the consultant, nurse in charge and the doctor on duty performed a ward round to discuss the condition of the patients with the nurses on the ward so that they could determine if any of the patients on the critical care ward were stable enough to be “stepped down” to the ward to make space for the critically unwell patient.A definition provided by the hospitals transfer policy of a critically ill patient is that it is at risk of deterioration or is already deteriorating and as such requires a transfer to an area that can provide a higher level of care. These patients are to be categorised as level two or three patients and those who have been identified and accepted for transfer by the consultant should be transferred appropriately within one hour of the decision to admit to a critical care unit (LD).On the ward was 65-year-old Mary, who at the beginning of the shift was documented as being a level two patient which suggested that she required more detailed observation or intervention than can be safely provided on a general ward. However, reviewing her history, clinical observations and treatment plan the consultant and the nursing team felt that Mary was better identified as a level one patient, which meant she was stable enough to be treated safely and effectively on the ward. Mary was woken to be told that she was being moved out of the critical care unit to the ward as the bed space was needed for someone else, however this made her extremely distressed and Mary refused to be moved, as she felt that not only was she was not well enough, but that her needs were being put second to the patient who was to receive her bed space. Because of the nature of the situation the hospital management team was consulted who after speaking with the consultant, sister in charge, nurse and patient, decided that despite Mary’s anxiety, the best decision was to step her down to the ward and that this should be done immediately as not to increase the risk of harm to the patient who had suffered a cardiac arrest by delaying treatment.The “person” acronym demonstrates the importance of respecting patients as individuals with specific needs and treating them with dignity and respect when providing their care. Each letter focuses on a specific area of practice for example; patient centred care, evidence-based care, risks assessed and managed, safe and effective delivery of care, outcomes of care benefit the patient, and the nursing strengths and weaknesses. Together these create a complete and thorough summary of the most important aspects of decision making as well as representing key sections of the NMC code, which makes it an ideal template to use when evaluating nursing decisions in practice. (book)By working together to facilitate the patients transfer to the critical care unit the care team were demonstrating that they were able to provide a patient centred care approach that was both evidences based and reduced the risk of harm to the patient. For example, to provide care that is person centred nurses must treat each patient as an as individual and work with the relevant members of the multidisciplinary team to provide all-inclusive care (NMC code 2015). In the scenario this was demonstrated by the involvement of the multidisciplinary team members responsible for the care of the critically unwell patients such as the consultant, the doctor on shift, the sister in charge and the nurse directly responsible for the care of each patient were involved in the decision on who to move to the ward.Furthermore, the NMC code describes evidence-based care as relating to a nurse’s professional responsibility to keep their skills and knowledge up to date to provide safe and effective practice (nmc code). The most up to date guidelines produced by the resus council states that patients who suffer from a cardiac arrest should be transferred to the highest care area for continued treatment and monitoring (reference) and this is supported by an analysis performed by (reference) which determined that post-cardiac arrest care performed in a critical care unit improved the outcome for those patients. However, as mentioned above the hospital’s policy states that when a patient has been identified and accepted for transfer to a critical care unit by a consultant they should be transferred a within one hour (LD) which was not followed through in this scenario due to unavailability of beds. Therefore, although by transferring the patient to the critical care ward the care team were demonstrating evidence-based practice, for future practices it should be ensured that patients are able to be transferred within the proposed time to ensure best practice.Furthermore, when considering the effect of the decision an evaluation into its effect on Mary should also be explored. For example, the Kings fund states that it is our commitment to patients as nurses to only move them based on their needs, and that once a patient has reached a ward after assessment in the acute medical unit, they should not move again, unless there are exceptional circumstances (kings fund) Additionally, findings of an analysis completed by the Lancet found that compared to during the day, patients transferred at night are at a significantly higher risk of further deterioration as the decision to transfer is often premature due to the lack of senior staff available for consult during night shifts compared to during the day. However, the implication that patients who are fit for transfer should remain in critical care can be considered impractical due to the unpredictable nature of a hospital environment, such as the event of an emergency admission from theatre, the emergency department or general ward and must also take into consideration the reality that many hospitals have insufficient critical care beds (lancet). Similarly, a systematic review investigating the effect of out of hour transfers from critical care units to general wards found that there within the United Kingdom 9%-27% of patients who died on a general ward have been prematurely discharged from a critical care unit, and suggests that mortality rates could be reduced by 39% by allowing patients to remain in critical care for an extra forty eight hours after being identified as medically fit. However, the study acknowledges that a further 16% of beds would be required in care units for this to be practical in a busy hospital setting and so instead suggests using a discharge triage model to aid doctors and nurses in identifying patients who are at risk from premature and inappropriate discharge from intensive care, and as a result can help doctors make an informed decision of who to discharge to make room for a patient in the even that an urgent admission to the unit is required (ncib 2). Furthermore, the NMC code also states that nurses have a professional and moral obligation to their patients to provide care that has the most benefit and causes the least harm, which is described by beneficence with non-maleficence. Beneficence to nurses relates to their obligation to act in a way that benefits their patients, while non-maleficence means to do no harm. To achieve this, nurses must not only ensure to act within their professional capacity but as well as respect patient autonomy as what constitutes benefit for one patient may be harm for another (book 2). For example, although transferring beds would benefit the cardiac arrest patient it could potentially cause harm to Mary and therefore the care team would need to compare the potential risk of harm to Mary by transferring her out of the critical care unit against the potential risk to the cardiac arrest patient by delaying his admission to the unit. For example, comparing the results from two studies conducted on post critical care mortality and the effect of post cardiac care being performed in a critical care area shows that while the observed hospital mortality of patients in general wards was 56%, the mortality of patients placed within critical care units was 45% (ncib 1). Therefore, when considering the percentage risk to of harm to the cardiac arrest patient is 56%, while the risk of harm to Mary from premature discharge is a maximum of 27% it can be concluded by risk to the cardiac arrest patient is much higher and therefore is the appropriate decision. An important aspect of decision making is a nurse’s ability to remain professionally accountable for their actions in practice and be able to justify the decision made using appropriate evidence. The NMC writes professional accountability to be a nurse’s responsibility to remain answerable for their acts and omissions in practice and to be able to justify their decisions. In this scenario the care team would be achieve this by using the evidence discussed as it supports the outcome of the decision. However, in the event that there was not appropriate evidence and Mary or the cardiac arrest patient had suffered avoidable harm as a result of the decision, thus meaning the care team were unable to justify their decision (or lack of one) they could face disciplinary action from their professional regulatory body and the hospital that includes but is not limited to; an order to undertake mediation, a suspension order, conditions of practice order, “striking off” from the professional registrar (nmc sanctions). Furthermore, if a compliant is considered to include criminal misconduct then an appeal on a point of law can be made to the high court for criminal prosecution. (legal)As mentioned above to be suitable for an admission to a critical care unit within the local hospital a patient must be of level two or three, meaning that they require more thorough observation or intervention, such as that which are used to support a single failing organ system, extended postoperative care, or those stepping down from level 3 care. Level three patients are those who require advance respiratory support such as mechanical ventilation, or support for the failing of two or more organ systems (LD). At the time of the decision making scenario Mary was documented as being a level two patient however, when her history, clinical observations and treatment plan was reviewed by the consultant it was felt that she was better identified as level one, as she was not receiving any support that could not be provided on a ward, and was responding well to her treatment which was reflected in her clinical observations being stable and within normal parameters. Mary being re-identified as a level one patient poses the question as to how long she had been clinically fit for discharge from the critical care unit, and whether or not the decision making process at that time could have been avoided had the management staff identified her as being medically fit sooner, which would have allowed for her to stay in critical care for the full forty eight hour window as to reduce the risk of deterioration upon discharge, as well as allowing Mary to contribute to the care decision, and provide the bed management team within the hospital time to find a bed space that is suited to Mary’s need and allow her to be transported at an appropriate time. The NMC standards for competency identify the provision of leadership in managing adult nursing care as a key value, and states that nurses must understand and be able to coordinate interprofessional care when needed by liaising with specialist teams. Furthermore, nurses must be both adaptable and flexible and be able both through ability, knowledge and confidence to take the lead in acting upon the needs of people of all ages in a variety of circumstances including those where immediate or emergency care is required (nmc competency) In the scenario, when approached by the consultant the nurse in charge instinctively worked within her capacity to aid the decision making process as well as discussing each patient with the nurse in charge of their care. This demonstrates both leadership abilities and the nurse ability to work as part of a team and work with different teams to ensure a positive outcome for the patients in her care. Furthermore, it was identified in the scenario that Mary expressed feeling as though her needs were not as important as those of the cardiac arrest patient, this could be a result of the consultant using the phrase “the bed space is needed for someone else”. Giving that it is necessary and appropriate, when patients are transferred to the general ward from a critical care area they should be given information regarding their condition and reason for transfer, as well as being encouraged to participate in decisions that relate to their carer (NICE) This is reflected in the hospitals policy as it states that the senior nurse responsible for the patient’s care should, if possible, gain agreement from the patient and document this in the nursing notes (LD). Therefore, from a management perspective the consultant who discussed the transfer with Mary should have ensured he was using appropriate communication skills, not only explaining the reason for the transfer but how it relates to Mary and her needs so that she felt that her needs were the primary focus and consideration. In conclusion, The NMC code as it defines risk management as a nurse’s ability to take the necessary steps to reduce the risk of deterioration or harm to the patient, as well as themselves, the public and their colleagues (NMC code 2018). Therefore, when considering this following the “person” centred approach for evaluation of the overall decision and how it was made, by implementing the recommendations given by the evidences provided the care team were actively risk managing and were delivering safe and effective care which reduced the overall risk of harm to the patients, which is their obligation by through their professional responsibility and the law.At the time of the decision being made I felt that the decision to move a patient from critical care against their choice was unfair and unprofessional as it opposed what I knew as a student nurse which was that patients should consent to every decision, and nurses working with patients who are unable to make an informed decision should act as advocates to ensure the best outcome for their patients. However, I realise now that as at the time I did not have the knowledge and understanding to make an informed decision that considered the bigger picture, as I did not take into consideration the risk of harm to the patient who suffered a cardiac arrest if he did not receive the correct care. I believe that the reason I did initially consider the needs of the cardiac arrest patient is because he was not a patient on my ward and was set in caring for the patients who I had direct contact with, this situation has identified the importance of remaining open and considering the care of patients who although I may not have direct contact with, require my care of professional input. Lastly, the decision-making scenario discussed has aided in me in improving my knowledge regarding the standard of my practice that is set out by my professional regulator- the NMC- and has taught me the significance of effective management, leadership and team working skills on improving the outcome of care for my future patients.

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