Person-centred Practice in emergency care: what are the challenges?

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Person-centred Practice in emergency care: what are the challenges?. Vidar Melby & Donna McConnell University of Ulster. Personcentredness:a prehospital emergency care perspective. - PowerPoint PPT Presentation

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REACH Project A Clinical Careers Framework for Nurses

Person-centred Practice in emergency care: what are the challenges?Vidar Melby & Donna McConnellUniversity of Ulster Personcentredness:a prehospital emergency care perspective

Dr Vidar Melby, UU, Joint Research and Writing with Mats Holmberg, PhD-StudentKarolinska Institute, Stockholm, and Professor BO Suserud, Prehospital Research Institute, Bors, Sweden

Patient experience stressful, injured or ill, awaiting ambulance clinicians, or strapped to chair or trolley, unfamiliar environment, limited space in ambulance. Care is often urgent. Limited research focus on core caring concepts in prehospital emergency care.

Melby V. et al. 2012. Patient comfort in pre-hospital emergency care: a challenge to clinicians. Journal of Paramedic Practice, 4, 7, pp 389 - 399

Existing knowledge

Prehospital emergency care services are vital components of the health service, with responsibility for immediate assessment and treatment during the most acute stage of the journey for acutely ill and injured patients. Such care has always had a focus on immediate life support and management of trauma and medical emergencies. The process encompasses the emergency call and dispatch, a race to the scene of the incident, accessing the patient at any potential location during any weather condition, triage and emergency management, and finally transporting the patient to the nearest emergency department (ED) or trauma centre as quickly and safely as possible. Within the United Kingdom (UK), the Department of Health has set specific time targets for ambulance clinicians (paramedics and technicians) to reach the scene of the incident. This is normally close to eight minutes.The patient experience of this journey can be stressful, strapped into in a chair or onto a trolley within an unfamiliar environment in an ambulance with limited space. This journey is a rapid one, guided by the Golden Hour rule that suggests that patients should be transported to the ED within one hour of the incident to maximise survival and minimise complications. In 2006 the patient experience was listed as one of nine ambulance design challenges that was listed for improvement in the design of future ambulances (Hignett et al. 2009). The principal concerns were focused on patient safety, response times, dignity, modesty and carers. Furthermore, the authors reported that within one of the other identified design challenges (space and layout), patient care and comfort were specified as central concerns. The comfort, warmth, feelings of safety and preservation of dignity of patients during the prehospital journey is important. The patient covering forms a central part of this. Cotton blankets are used as standard throughout the health service to retain body heat and prevent draft, thus enhancing comfort. Furthermore the blanket is essential in maintaining patients dignity by providing body cover. Temperature regulation can be critical in patients who have experienced trauma, as hypothermia impacts negatively the metabolic and haemostatic mechanisms: a 0.9C drop in core body temperature can cause a slowing of the coagulation processes and thus accelerate haemorrhage (Watts et al. 1999) and worsens prognosis in trauma patients (Armstrong-Brown and Yee 2001). Signs of hypothermia may indeed go unrecognised in pre-hospital settings (Shah 2004). In their study, Watts et al. (1999) concluded that traditional methods such as blankets were of little clinical benefit. Indeed a majority of patients who have experienced trauma arrive hypothermic to EDs (Owen and Castle 2008). To date the published studies that evaluate patient coverings are normally limited to assessment of thermal efficiency ( Watts et al. 1999, Jalan et al. 1999, Cohen et al. 2002, Henriksson et al. 2009, Thomassen et al. 2011), maintaining body temperature during surgery (Kabbara et al. 2002), heat transfer in forced-air warming with upper body blankets in intra-operative patients (Bruer et al. 2003, Perl et al. 2003), bacterial count in warming blankets (Sharp et al. 2002), cooling by waterflow blankets (Creechan et al. 2001) and warming blankets to promote comfort in hospitalised older patients (Robinson and Benton 2002). While Kabbara et al. (2002) compared hospital blankets with commercial blankets in surgical patients the focus was on forced air warming with both types of products. Some research has focused on technical aspects of the patient journey, for example the commonly used spinal back-board employed to immobilise the spine (Edlich et al. 2011). In their small experimental study of healthy volunteers, testing an inflatable air mattress and spinal stabilization apparatus, the authors reported enhanced comfort and reduced risk of pressure sores for participants who used the apparatus. Most of this research is laboratory based, or the researchers have used manikins or healthy volunteers.No studies to date have examined the views of ambulance clinicians regarding patient coverings in relation to comfort, warmth, perceptions of safety and preservation of dignity, or explored issues in relation to accessibility during transport and or transfer times. Backlund & Hagiwara (2007) undertook a study in Sweden that examined the comfort of patients during the ambulance journey, investigating the views of ambulance clinicians of the patients experience using traditional blankets (Fig 1) and patients who were wrapped in an all-enclosed TelesPro Rescue Covering (Fig 2). Comfort is a fundamental concept in nursing care, even though the concept is not uniformly defined within nursing (Tutton and Seers 2003). While there is limited research exploring this concept in emergency care, Backlund & Hagiwara (2007) in their review of literature noted that comfort invariably is associated with pain relief, nurses competence, warm blankets, effective communication and emotional support. Very little research has been carried out in the prehospital emergency care on non-medical topics such as comfort, safety and dignity associated with the patient experience. In nursing, the concepts have been explored normally as separate entities or associated with other areas such as quality of life or care of the dying patient. Four papers were found in the nursing literature that discussed all three concepts together. Tang (2000) found that comfort, safety and dignity were important for Chinese patients in Taiwan who were dying at home, Kane (2001) contested that all three were important for quality of life in long term care in the United States and Klager et al. (2008) highlighted the importance of all three as central end of life needs for people who have Huntingtons Disease. The closest to prehospital care where all three concepts were mentioned was in a discussion paper by Mark (1994) who proposed that nurses should advise flight crews on in-flight emergencies associated with passengers who had medical needs, further suggesting that dignity, safety and comfort would be improved. While there is a scarcity of empirical evidence, nursing literature suggests that all three concepts are important in the patient experience. It is posited therefore that the experience of feelings of safety, dignity and comfort are strongly interrelated. While this is probably the case for most care environments, in pre-hospital care such experiences may be poignantly symbolised in experiences and perceptions of the patient covering or blanket (See Fig 3).

3Having Sympathetic Presence Ambulance patients perspectivesA development from being lonely to being cared for.A temporary presence.A caring presence.After the presence ends back into a lonely struggle despite being under hospital care.Holmberg,M., Forslund, K., Wahlberg, A.C. and Fagerberg, I. (2013) To surrender in dependence of another; the relationship with the ambulance clinicians as experienced by patients (Submitted)Quotation: Then something happens and people come to help you and open up themselves. They talked and cared as I was a family memberYou get very warm and happy from that. I got that feeling.

Providing Holistic Care Ambulance Nurses PerspectivesEncounter the person as unique and in a unique situation.The patients feel that the whole caring encounter is managed by the clinicians.Assessments are based on physical, psychological and social perspectives.Quotation:that the doors are locked and the oven is switched off if the patient is alone in the apartment. You always have in mind if there are pets, younger people or children in the apartment.Holmberg, M. and Fagerberg, I. (2010) The encounter with the unknown: Nurses lived experiences of their responsibility for the care of the patient in the Swedish ambulance service. Int. J. Qualitative Stud Health Well-being 5 (2) DOI: 10.3402/qhw.v5i2.5098

Engagement Ambulance Nurses and Patients PerspectivesAmbulance Nurses

To inform and prepare.Understand the patients experiences.Encounter without pre-made assumptions.

Quotation:In a practical way I try to tell the patients what my thoughts are. What will happen next. So that not a lot of things happens that the patient doesnt understand. (Nurse)

Ambulance Patients

Being involved.Being respected and acknowledged.Being important.

Quotation:They talked directly to me they really did. They asked me where I had pain and if they should get the stretcher. They talked in a daily manner and I felt immediately a relief (Patient)

Challenges in the Prehospital Emergency Care Context?The balance between medical treatment based on set protocols and personcentred care. Maintaining Core Caring Concepts while effecting Evidence Based Emergency Interventions. Shared Decision Making are patients happy to relinquish autonomy? Effective Communication collaboration in care. Innovative Working Culture freedom to be innovative working within strict medically based protocols.

Exploring Person-Centredness in the Emergency Department

Donna McConnell PhD StudentProf Tanya McCanceDr Vidar MelbyDr Paul Slater (adviser)8Its a war zone, people were crying in pain, ED patient, Belfast Telegraph, 23.03.12the current ED system in NI is de-humanising and patients are not getting the quality of care they deserve or that nurses want to provide (RCN 2012) Pensioner dies alone on hospital trolley U105fm, 2012 I saw a nurse just standing there in tears, ED patient, Belfast Telegraph, 23.03.12We pay lip service to providing services that are patient and client focused RCN spokesperson 2012Were at breaking point, warns Northern Ireland director of nursing , Belfast Telegraph 20129Person-centred practice has shown to transform practices for patients...increased choice and involvement in decision makingimproved quality of nurse/patient engagements staff taking time to get to know the person in a more meaningful way staff were more person-centred, in their language and team-work a reduction in ritual and routine

10....and staffa shift in values to appreciate caring over the technical aspects of nursing care increased effectiveness of teamwork and workload management improved staff relationships with more effective collaborative workingincreased personal and professional job satisfaction - less intention to leave postsa more effective use of resourcesMcCormack et al (2010)

11Themes from the literatureOutcomes for patient and relatives what they want vs. what they receivedOutcomes for staff- Aggression and violence Staffs values and beliefs- a culture of worthiness - medical tasks and technology valued over caringStaffs role in managing the service 12What the literature said patients and relatives wanted in EDCompetence of staffWaiting timesPain controlledProvision of information and explanation tailored to needsSmall actions which gave physical comfortA family presence

Developed interpersonal skills - nurses taking care of the patient and engaging in active listening- being present and fully engaged with them in the momentTo be near their relatives and touch or talk to them and know what was happening to them

13Literature - patients experiencedNon-urgent patients received a series of fragmented courtesy encounters and found it difficult to make themselves seen or heard. They projected their dissatisfaction elsewhere and tried to maintain relationships with staff by being good patients (Nystrm et al 2003, Nyden et al 2003, Elmqvist et al (2011) A feeling of not being considered as an individual and a lack of caring as predominant features (Nystrm et al 2003)..abandoned, exposed, vulnerable, ashamed, ignored, insecure, frightened forgotten or unwelcome (Kihlgren et al 2004, Gordon et al 2010, Mller et al 2010, Elmqvist et al 2011).

14Literature - staff experienced aggression and violencePain, anxiety, lengthy waiting times, alcohol and substance misuse, overcrowding, lack of informationOne nurse described a feeling as if the whole waiting room hated them and stated it just wrecks my spirit (Hislop and Melby 2003)Negative consequences include powerlessness, frustration, isolation and vulnerability, anger, anxiety, fear, worry, decreased job satisfactionAll experienced ED nurses understood the term eat our young (Baumberger-Henry 2012) it felt like being kicked in the teeth (Pich et al 2011) At times staff may inadvertently contribute to violence by being overtly authoritative, being judgemental and confrontational, rude and condescending (Ferns 2005, Lau et al 2012, Pich et al 2011)

OUTCOMESSatisfaction with careInvolvement with care Feeling of well-being Creating a therapeutic culture

15Literature - staff values and beliefs- a culture of worthinessStaff experienced frustration with frequent fliers and regulars (Bergman 2012, Muntlin et al 2010)Patients who arrived with trivial conditions, prior expectations of treatment and expectations of preferential treatment breached cultural beliefs (Fry 2012).You have a positive bag sign, when I see the ambulance pull up and the bags on the trolley. I just immediately think, right, youre in the waiting room (Fry 2012)

Staff held a collective belief system beliefs of what was considered true, right and good (Fry 2012)Sbaih (2002) states this is a reflection of staffs desire to keep the department running smoothly rather than a moral judgement of worth. 16Literature - staff values and beliefs - medical tasks and technology valued over caringInteractions with patients were only initiated when undertaking doctors instructions. These nurses defined good trauma care by good technical care (Winman and Wikblad 2004)Medical treatment is highly valued while nursing care is undervaluedED nurses are socialised by the social authority and status of medicine (Nystrm 2002)

our patients do not need nursing care, they are just waiting for a medical examination (Nystrm et al 2003a) We are not good at giving nursing care. We are trained in acu...

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