Elderly Patient Surgery Case Study

Every nurse has the responsibility to safeguard their patients from harm and the NMC (2009a, p.14), states that “it is every adult’s right to live in safety and be free from fear and abuse”. There are a number of individuals who can be classed as a vulnerable person, these individuals can be either children or adults. A vulnerable adult is someone who is over 18 years old and meets any one of the following criteria: is receiving any form of healthcare or welfare service, needs assistance to carry out daily activities, unable to take care of him or herself and is unable to protect him or herself against harm. (DoH, 2009, Section 59)(DoH, 2000, p.8-9). Older people are generally regarded as vulnerable adults because of their general poor health and their high dependency on others to help with daily activities. In Peter’s case, he is not very young, is inclined to be forgetful and has mobility issues and therefore has the high probability of requiring help at home to help with his independence. All of these issues combined could have serious impacts on his health and safety which would mean that Peter could fit into each, if not all, of the mentioned categories and therefore he should be regarded as a vulnerable adult.

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The Independent Safeguarding Authority (ISA) is responsible for the vetting and barring of any individuals who may come into contact with or work with vulnerable individuals (ISA, 2009, p.3). The ISA have an Independent Barring Board who are responsible for maintaining two separate lists, one for the protection of children and the other for the protection of vulnerable adults, which contain the names of any person who has been referred to them for the harming of any vulnerable person (ISA, 2009, p.3). The harming of a vulnerable person, whether it be physical, verbal, psychological, emotional, financial or neglect, is regarded as abuse. Vulnerable adults may be abused by a wide range of people, including family members and abuse can be in the form of a single or a recurring act. As Peter’s daughter wants him to have the surgery the nurse will have to establish whether there is an underlying reason for this. Assessment of this situation would be essential because intimidation or coercion, which are both forms of psychological abuse, may cause Peter to be incapable of making his own decisions (DoH, 2000, p.11). As such, if this was assessed to be abusive behaviour, it would be important to remove Peter away from his daughter as the nurse has a duty of care to ensure that her patient remains safe at all times (NMC code??).

Nurses have a professional responsibility to their patients, are accountable for their actions when the patient is in their care and have a duty of care to ensure that the patient receives good quality care at all times (NMC code 1.4???). Every nurse must always ensure that they work within their abilities and should raise any concerns, to a senior member of staff, if they have been asked to perform any duties which they are not competent in performing and therefore may potentially cause harm to the patient (NMC, 2009b). Reasonable care must be taken to avoid acts or omissions which are likely to cause reasonably foreseeable harm to whomever a duty of care is owed (Dimond, 2008, p.40). If the nurse does not provide sufficient care to the patient and causes harm as a result, she will be held liable in the tort of negligence (Tingle & crib, p.92??), which is a civil wrong for the breach of duty to take reasonable care not to injure or harm a person. In order to be held liable in the tort of negligence it must first be proven that the nurse owed a duty of care to that patient, next the claimant must prove that there was a breach in this duty of care and then it must be proven that the damage being claimed for was caused by this breach of duty (Tingle???). The Bolam Test is the test which is used to determine a breach of duty and is concerned with how negligence should be established (Legal aspects??). It does this by testing the standard of care which should be given from a professional and comparing it to the standard of care which was actually given in the cases of the alleged negligence (????).

Accountability means being “responsible for something or to someone” (NMC, 2002, p10). According to Dimond (2008, p.5), registered nurses are held accountable to the patient, the public, their employer and their profession, and these are known as the four arenas of accountability. Where the registered nurse is accountable to the patient and the public, she is accountable to the law and accountability to her employer means she is responsible for keeping to her contract of employment and failing to do so may result in a hearing in front of the employment tribunal. Professional accountability assumes that the nurse is a member of the profession and that she has accepted the rights, status and responsibilities of the profession (foundations, p.473????). The NMC (2002, p.3) suggests that professional accountability involves using knowledge, skills, experience and professional judgement in order to make decisions which are in the best interests of the patient and should be able to justify the reasons for her decisions. This implies that nurses, as professionals, are competent in their area of practice, which allows the patient to gain trust in the nurse and enables the nurse to be able to act in the patient’s best interest (foundations, p.473??). Therefore, nurses have a duty of care to those they care for and as such, this implies that there is a right and a duty attached to professional accountability.

Registered nurses must follow the guidelines within the Code of Professional Conduct and as such should be legally accountable for their work (NMC, 2009b) and will be brought in front of the Fitness to Practice Panel, and possibly removed from the register, for unprofessional behaviour that breaches the Code of Conduct (Brooker and Nicol, 2003, p.6). This is different for nursing students, as they are only accountable to their employer, in this case the university, and the law. It is not possible to hold students professionally accountable as their names have not yet been entered onto the professional register however the NMC states that students are still responsible for their actions (NMC, 2010, p.1). From this it must be said that it will be the registered nurse who is mentoring, or working with, the student that can be held accountable for the student’s actions or omissions as it is their responsibility to ensure that the student is working within their abilities (Brooker and Nicol, 2003, p.7).

Nurses are fundamentally responsible for the promotion and restoration of health, the prevention of illness and to ease suffering for their patients (Hendrick, p.76???), however nursing is not just about treating a patient’s illness; it’s about caring, teaching and supporting a patient at a time when they need it the most. This can be done if the nurse makes building a nurse-patient relationship with her patient a priority in the patients care. Communication is a necessary foundation for any nurse-patient relationship to be built appropriately and there are a number of ways in which people can communicate such as verbally, non-verbally, written or electronically. The nurse should always communicate with the patient at their level of understanding and should always avoid using medical jargon when speaking to the patient (NMC???). Effective communication is not just about talking, it involves active listening too and is an essential key in building a trusting relationship with the patient. Different communication techniques could be used between the nurse and the patient which include observing, listening, silence and open-ended questions (Brooker and Nicol, 2003, p.46). Without the appropriate use of these different communication techniques the relationship will not have a base to build on and if there is no relationship, the patient will not have the trust required for them to share their feelings, anxieties or wishes. In our scenario, Peter has opened up to the nurse by telling her how he is feeling and has put his trust in her to help him make the decision as to whether or not he should have the surgery. In this situation communication is the vital key as it is important that Peter is given open, honest, accurate and unbiased information about any procedures or assessments that will be carried out and the nurse must ensure that he fully understands the benefits, risks, side effects and consequences of these procedures (???). The patient should be consulted every step of the way which will enable them to remain autonomous.

All healthcare professionals should have a respect for their patient’s autonomy and should treat their patients as individuals, with rights, rather than objects of care (Hendrick, p.95??). Autonomy is the right of the person to make their own decisions and accepting their choices. One way in which a patient can exercise their autonomy is by giving consent and as such, autonomy is a requirement for consent (tingle & cribb, p.143??). Consent can be given in different forms such as expressed or implied. Expressed consent can be either written or verbal and this can be given by the means of a written and signed consent form or by word of mouth. Implied consent can be a simple gesture, such as holding their arm out for an injection or by arriving at the hospital for an operation. Each form of consent is as equally valid as the other however, consent is only legally valid if it is given voluntarily, based on clear and accurate information and if the patient is competent (tingle and mchale, p.100-105??). Gillan (Tingle and Cribb, 2007, p.140) defines consent as “a voluntary un-coerced decision made by a sufficiently autonomous person on the basis of adequate information to accept or reject some proposed course of action that will affect the patient”. This definition suggests that communication, autonomy and consent are intricately liked as effective communication is important because you must give adequate, open and honest information to the patient in order for the patient to fully understand and consider all the issues involved, which will enable the patient to be able to make an autonomous decision and ultimately be able to give consent. No other person is authorised to give consent, for any procedure or treatment, on behalf of another adult unless they are the legal power of attorney for the patient (legal aspects???).

Gillan’s definition of consent states that consent can only be given by a sufficiently autonomous person. The DoH states that healthcare professionals must not make any assumptions that a person is incapable of making their own decisions, therefore they should carry out an assessment which would assess whether the individual is mentally capable of making these decisions for themselves. Autonomous decision making is therefore based on the matter of ‘capacity or incapacity’ (foundations p.500??). The term capacity is used to define the individual’s ability to make their own decisions about a particular matter at a particular time (Legal aspects???) and, as autonomy is the basic foundation for consent, if incapacity is suspected the individual is therefore not allowed to give consent until they are deemed competent.

The Mental Capacity Act 2005 states that healthcare professionals are required to assume that every person has the capacity to make their own decisions and that the healthcare professional has to prove that the individual has a lack of capacity and must then be deemed incompetent (tingle and crib, p.143??). Deciding whether a person has the capacity to make informed decisions for themselves is determined using the assessment tools defined in the Mental Capacity Act and cannot be established or judged by an individual’s age or appearance (The Mental Health Act section 2 and 3??). There are two basic concepts that underpin the Act these are: the concept of capacity and the concept of best interests (Legal aspects???). Both of these concepts link together and as such, if the patient lacks mental capacity actions can be taken or decisions can be made on their behalf and these must be made or taken in the best interests of that person. The assessment used to determine whether a patient is capable of making a treatment decision is split into two stages: the first stage is to determine whether the patient has any issues which prevent them from making a decision, and the second is to establish if this issue which prevents the patient from making a decision causes the patient any problems in communicating their decisions or wishes (Legal aspects???).

A person is not able to make their own decisions for themselves if they are not able to understand any of the information given to them, remember the information, utilise that information as part of the decision making process and are not able to convey or share their decision (Legal aspects???). However, if the information is not given to the patient in a way that is appropriate to his circumstances such as using simple words or visual aids, they are not to be judged as unable to understand that information (legal aspects, p.139???). Additionally, if the patient has a short memory span and can only retain information for a short period, they must not be classed as unable to make their own decisions, as this issue may not prevent them from being able to make the decision relevant to the treatment (legal aspects, p.139???). In such instances this decision must be made whilst the information is still held within the patient’s memory. From this is must be said that every person should be encouraged and enabled to make their own decisions or to participate as fully as possible in the decision-making, by being given the help and support they need to make and express a choice (NMC, 2008a).

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In this scenario it states that Peter has an inclination to be forgetful, because of this he must not automatically be deemed incompetent and it is vitally important that all the steps required to deem a person incompetent must be taken into account. One of the steps suggests that even though the Peter has a short memory span, it is vital to ensure that the information given is understood clearly and that the decision is made before the he forgets. This would enable Peter to give informed consent, however if he forgets this information and has not made an informed decision before his memory span lapses he must be deemed incompetent. From this we can establish that it is important to have the necessary mental capacity as it protects the individual’s right to make their own decisions (legal aspects??). If the individual is lacking in capacity then decisions need to be made on their behalf and these decisions that are made on behalf of someone else should be the decisions which limit the person’s basic rights and freedoms the least (legal aspects mc???).

The Human Rights Act 1998 ensures that individual’s rights are respected and that basic human rights such as the right to life, the right to not be discriminated against, the right to liberty, and the right to freedom from torture or degrading treatment and the right to respect for private and family life, home and correspondence are promoted (Human Rights Act 1998??). These rights can be promoted by providing high standard of care and treatment, respecting a patient’s privacy, dignity and confidentiality and by safeguarding the patients from harm. A person’s rights and freedoms are protected and promoted by the nurse when she acts as an advocate for them. Being an advocate for the patient is vitally important as it ensures that the patient’s choices and decisions are respected.

The nurse can act as an advocate in many different situations such as, offering an alternative explanation, or asking the other professionals to give the information again in basic terms, if the nurse feels that the patient has not been given clear, honest and adequate information. (NMC??). Another way for the nurse to act as an advocate is to try to adhere to the patient’s wishes if the patient was proved to be incompetent; if this is not possible then she must act in their best interests. As Peter has asked the nurse in this scenario to help him make the decision as to whether or not he should have the surgery, he is putting his trust in her and allowing her to become his advocate. However, until all the necessary steps have been taken to ensure whether Peter has understood what he has been told and once his mental capacity has been assessed, no other person can make this decision for him, unless he was deemed to be mentally incompetent. If he was deemed to be incompetent the decision as to whether he has the surgery or not will be made by the healthcare professionals, unless his daughter has lasting power of attorney, and will be based on his best interests. The decision that is likely to be made is that Peter will go ahead with the surgery, as this is in his best interests and will improve his quality of life. If Peter is deemed competent, then Peter should make the decision for himself and his decision will be final. If Peter decides not to go ahead with the surgery, then Peter’s home life would need to be assessed.

Inter-professional working is required in order to care for the patient holistically. Holistic care is primarily concerned with ensuring that the patient’s basic needs are met (NMC, 2009a, p.9) and making sure that any observations, medications and decisions are recorded accurately (NMC, 2008b, p.6). A nurse’s role also includes supporting and teaching the patient and their families about the illness or about improving their lifestyle to prevent the illness from re-occurring. It is extremely important that the nurse develops a close working relationship with these other multi-disciplinary professionals, as Peter will need support when he gets home whether or not he has had the surgery. The range of other professionals which may be involved in Peters care when he gets home include social workers, occupational therapists and physiotherapists. It may be possible that Peter’s daughter may be pushing for Peter to have the surgery as she may be his primary carer and might be feeling stressed or overworked and if this surgery can improve his mobility, this may offer her some form of relief. If this is the case, the nurse could arrange for a carer to help them within their home and that way Peter’s daughter may get some relief from the work involved in his care. In this case, the nurse can act as an advocate to ensure that the decisions are not being made for him or that he is under no undue pressure or being forced to make the decision.

Being an advocate for a patient implies that there should be a level of trust between the nurse and the patient and this level of trust can be built up through a therapeutic relationship. Therapeutic relationships are an intervention which is central to nursing and a nurse should have an essence of self-awareness and self-knowledge and have an awareness of the boundaries of the professional role in order to be able to establish a therapeutic relationship with their patient. Effective communication, trust, respect, genuineness, acceptance and empathy are key principles in establishing this relationship (Brooker and Nicol, 2003, p.45). When this relationship has been established the patient may feel at ease to share information and have a willingness to open up and share their feelings (Dossey and Keegan, 2008, p.370). Establishing and maintaining this nurse-patient relationship is vital to the holistic care of the patient and even though the nurse should develop a close relationship with the patient in order to open up communication barriers she must always keep and emotional distance from the patient and their families. It is the nurse’s responsibility to ensure that she never oversteps the professional boundaries throughout the care of the patient (NMC Code).

In conclusion it has been established that in order for a patient to be given high quality, safe care a nurse needs to have the appropriate skills and knowledge to be able to perform the even the simplest of tasks competently. This assignment has briefly looked at the importance of a therapeutic relationship with communication being one of the vital keys, as without using it effectively it will be difficult to bond and build a professional relationship with the patient. It has also been identified that every nurse has a duty to protect their patients, that they should safeguard their patients and promote their rights and autonomy. It is vitally important that the nurse has the confidence to speak up to other professionals if she feels that the information hasn’t been delivered to the patient honestly, accurately or clearly, otherwise she could be held accountable if something was to go wrong. The importance of the guidelines and codes issued by the NMC, have also been discussed, as they are in place to help protect, not only the patient, but also the professionals who are involved in the patient’s care. One of the guidelines which has been focused on, is for the nurse to make sure that the patient has given informed consent without any undue pressure and that the nurse, acting as the patient’s advocate, can help protect the patient. We have also looked at the importance of using assessment tools to assist in decision making process as this is used to identify whether the patient has the capacity to give consent or not. We have established that all health care professionals need to work together as a team and must communicate, not just with each other, but with the patient and his family to ensure patient’s needs are met and that every patient should be awarded the opportunity to live independently or be offered help and support from the necessary health care professionals to enable the patient to live as independently as possible.