The aim of this assignment is to analyse the legal and professional issues involved within a critical incident observed whilst in clinical practice and to discuss the interprofessional workings of the professionals involved. A critical incident is an event which has left either a negative or positive impact on the observer or participant, this information can then be used to inform future practice (Flanagan 1954). This assignment will first describe the critical incident witnessed, the legal and professional issues will be briefly discussed and advocacy explored in depth. Interprofessional working surrounding the incident will be discussed focusing on the importance of interprofessional working, interprofessional education and what makes an effective interprofessional team and barriers to its success. The critical incident occurred whilst on clinical placement on a high dependency ward, a patient was requesting more pain relief because they felt that their current medication was no longer beneficial.
This was making it difficult for the patient to mobilise and was felt to be detrimental to his rehabilitation. Both the nurse and the physiotherapist agreed that the patient’s pain medication should be reviewed and during the ward round discussed this with the doctor involved in the patients care. The doctor’s opinion was that once the patient had begun to mobilise he would review the pain relief and would not alter the medication until this occurred. The patient tried to explain the pain that he felt on moving to which the doctor replied that he wanted to wait and see what happened before altering the dose. The nurse and physiotherapist stepped in to explain to the doctor that the patient would not mobilise until his pain was under control but the doctor would not change his mind and left the bedside. The nurse then discussed the incident with the nurse in charge who spoke to the doctor and agreed to alter the medication. McCaffrey (p14, 1979) defines pain as ‘Pain is whatever the experiencing patient says it is, existing whenever he says it does,’ by stating that the medication would not be altered the doctor was dismissing this theory.
The General Medical Code (2006) requires doctors’ to respect their patients’ right to be fully involved in decisions about their care, listen to their concerns and respond appropriately which in this case did not occur. The moral principle in this case first and foremost is autonomy, the patient had made a choice and the requirement is for the doctor to respect that choice. By stepping in and explaining the reason why the patient required a review of his analgesia, the nurse took on the role of advocacy. Advocacy has a crucial role within nursing (Rumbold 2000), The Nurse and Midwifery Council (2008) promotes patient advocacy within the code of conduct by stating that the care of patients should be a nurses first concern. The International Council of Nurses codes of ethics (2006) also states that nurses have a responsibility to provide care which ensures the patient’s rights are met and the importance of advocacy.
Despite this finding a definition and explanation of advocacy is difficult (Bu and Jezewski 2007, Baldwin 2003, Zomorodi and Foley 2009), O’Connor and Kelly (2005), suggest that this lack of definition could make it difficult to implement within practice because nurses are unsure how and when to advocate for their patients. Authors have attempted to define advocacy placing it within a moral context rather than legal (MacDonald 2007), Hank (2010) believes it is acting on behalf of another, Malik (1997a) expands on this by stating that it is the act of arguing in favour of and the practice of supporting the patient to make their voice heard. Bennett (1999) reflects that many definitions encompass the nurses desire to care for a vulnerable individual rather than intervening because they have been asked to, suggesting that nurses’ do not need to be invited to advocate for others.
Nurses care for patients when they are vulnerable, this can be caused by the illness itself but also by the hospital environment and often in these times of vulnerability the nurse is required to be an advocate for their patient (Mallik 1997a, Baldwin 2003). Hewitt (2002) argues this is not true, writing that patients are now powerful with an increasing knowledge of medical science and their rights, therefore they demand that the nurse takes on the role of advocate O’Connor and Kelly (2005) agree that there is some evidence that patients are more aware of their rights within health care but believe they are not in a position to defend those rights. Despite this disagreement on vulnerability and power both Mallik (1997a) and Hewitt (2002) agree that for the nurse to advocate for their patient there needs to be a nurse/patient relationship. Mahlin (2010) writes that during the development of a therapeutic nurse/patient relationship patient advocacy will be encouraged, because of the intimate and sustained contact whereby the nurse gains unique knowledge of the patient and their needs.
Alongside knowledge of the patient the nurse also should be self aware to ensure that they are acting on the patient’s beliefs and needs instead of their own (Baldwin 2003, Bennett 1999). This self awareness helps to ensure that actions are not paternalistic; Zomorodi and Foley (2009) argue that there is a thin line between advocacy and paternalism and by ensuring patient autonomy and beneficence it will be easy to clarify the difference between advocacy and paternalism. The challenge with advocacy is to promote patient empowerment whereby there is a professional responsibility rather than autonomous choices which are made by the patient without the risk of paternalism (Vaartio et al 2006). Paternalism is more likely to occur when a patient is unable to communicate or is unknown to the nurse (Zomorodi and Foley 2009), although in the incident used within this assignment paternalism did not occur because the patient asked for an analgesia review and had developed a relationship with both the nurse and physiotherapist.
Advocacy can be difficult to achieve due to the power of doctors and management (Mallik 1997a), Baldwin (2007) and Snowball (1995) write that part of the nurses role as advocate is to humanise the patient’s experiences of health care to those in power through a holistic approach. The nurse should act as a mediator between parties although this requires the nurse to be willing to intervene on the patient’s behalf (Baldwin 2007), MacDonald (2006) suggests that the dynamics within the healthcare team may influence the nurse’s decision whether to intervene. Being an advocate often brings the nurse into conflict with the doctor (Rumbold 2000), Rumbold (2000) continues stating that this is often ethical conflict whereby the nurse is respecting the patient’s autonomy and the doctor is being paternalistic and defining what is in the best interest for the patient, O’Connor and Kelly (2005), agree and write that nurses have fewer difficulties when advocating for patients to other members of the multidisciplinary team whom tend to be more open to advocacy, autonomy and a holistic approach.
Advocating for a patient has both benefits and risks, Mallik (1997b) describes the sense of anger and frustration that nurses may feel when their attempts to advocate are not successful and this was true with the incident, the nurse spoke of her frustration to the nurse in charge, who then spoke to the doctor and had the analgesia altered. Conflict with others may also affect the nurse’s confidence for advocating in future situations (O’Connor and Kelly 2005), more experienced nurses will develop methods to deal with this conflict, while less experienced nurses may weigh up the risk to themselves before speaking out future episodes of conflict. Mallik (1997b) suggests that unsuccessful attempts could be due to the doctors personality and the nurses status within the hierarchy, although in this case the nurse was a senior staff nurse and had been working with the doctor for a number of months and had what they considered a good working relationship. Snowball (1996) describes how being seen to advocate further enhances the nurse patient relationship because the patient feels that they have the nurses full support.
Baldwin (2003) agrees writing that patient autonomy is secured and the nurse will have job satisfaction and helps to achieve self actualisation. Successful patient advocacy can promote self esteem and confidence and help to ensure the nurses moral principles are up held (Bu and Jezewki 2006). As previously stated MacDonald (2007) highlights that the relationship between the nurse and multi-disciplinary team will affect whether the attempt to advocate is successful. For that reason the remainder of this assignment will look at interprofessional working and its context within the critical incident. Day (2006) defines Interprofessional working as individuals from a profession working together for the benefit of those in their care, although they state that this does not describe the complexity and levels of the term, Miers and Pollard (2009) states that interprofessional working differs from multiprofessional working because multiprofessionals are health care workers who do not necessarily work together.
The Nurse and Midwifery Council (2008) and General Medical Council (2006) state that nurses and doctors should work effectively as part of a multidisciplinary team and The Department of Health in 2007 launched the Creating an Interprofessional Workforce Programme which is designed to support integrated holistic care for patients and their carer’s. Interprofessional working has been proved to improve patient care, enhance patient safety, improve job satisfaction, streamline services and improve patient outcomes (Day 2006) and is necessary because health care has become more complex and patients now require specialised care from a variety of health care professionals with a range of skills and experience (Sargeant et al 2008). Interprofessional teams vary in makeup and size but there are several factors which will influence whether a team works effectively (Day 2006). Interprofessional working is not easy to achieve and there are many key elements and barriers to its success (Miers and Pollard 2009).
Interprofessional working requires commitment from the professionals involved whereby they share the same values and are motivated to provide high quality care (Day 2006). Doctors are often cited as lacking enthusiasm for interprofessional working, research suggests that this could be due to doctors receiving little training on the subject and lack knowledge on the roles of other professionals involved in patient care (Miller et al 2001, Baker et al 2011,) Miers and Pollard (2009) highlight that nurses are also sometimes unaware of other professional roles due to a lack of awareness of priorities and time frames. Effective team working takes time and is not a one off activity, time constraints within the acute care setting may affect the ability for professionals to commit, retention of staff particularly the rotation of junior and senior doctors may hinder the opportunity to form strong teams (Baker et al 2011,Day 2006).
The professionals involved in the incident all communicated with one another on a daily basis and were permanently based on the ward, this enabled them to spend time together, this was often small amounts of time but they were able to discuss the patients in their care, Sargeant et al (2008) believes that these small informal opportunities of interaction are crucial to good interprofessional working. Many authors have written about the importance of communication within an interprofessional team (Day 2006, Miller et al 2001, Sargeant et al 2008, Molyneux 2001). In the setting where the critical incident took place the team communicated during the ward round, ward rounds provide the opportunity for different team members to make contributions on patient care from different perspectives and are a positive method of interprofessional working, despite this the effectiveness of the team will depend upon the communication skills of the professionals (Day 2006).
Communication involves informing the other professionals of what has been achieved and is being planned, all information is passed on in an open and honest manner, and this enables the professionals to provide holistic and patient centred care (Day 2006). A fundamental aspect of communication is that the members of the team are able to be open to each other and free to raise issues about patients (Miller et al 2001). This relies on the members of the team respecting each other specific roles and knowledge, building on each other’s strengths (Day 2006). During the critical incident the doctor refused to listen to the nurse’s and physiotherapist’s opinion, this was detrimental to team working, when discussing their concerns, the doctor should have been receptive and supportive, trusting the expressed opinion (Miller et al 2001). Day (2006) and Baker et al (2011) suggest that this difference of opinion could result from professional socialisation, whereby professionals develop values, philosophies and perspectives of their profession, doctors value saving lives whereas nurses advocate humanism and physiotherapists will value improving quality of life.
Interprofessional working will not be successful unless these difficulties are overcome; interprofessional education is a method considered to provide a solution for improving communication (Robson and Kitchen 2007). Interprofessional education is considered one of the most important precursors to successful interprofessional working (Petri 2010) and is endorsed internationally and nationally (World Health Organisation 2006, Department of Health 2007). Creating an Interprofessional Workplace (Department of Health 2007) was launched after several high profile cases of bad care were reported, these cases revealed that health and social care services were still not collaborating effectively (Day 2006).
The learning should take place either in a classroom setting or on the job training and provides guidance for those planning and implementing interprofessional education (DOH 2007) Robson and Kitchen (2007) suggest that interprofessional learning is more beneficial when conducted within the clinical setting rather than the classroom because professionals tend to forget how to transfers the skills that they have acquired into practice. Exposure to interprofessional education fosters understanding of other professionals and helps to develop respect for their individual roles (Petri 2010). Baker et al (2011) state that doctors often devalued the benefit of interprofessional education, were reluctant to participate and saw it as a threat to their professional status, the reason for this lack of interest could be due to a lack of evidence for its implementation. Other health professionals although more willing to be involved still maintained traditional hierarchy values whereby the doctor had the final decision regarding care (Baker et al 2011).
Best practice depends upon each professional understanding the contribution of other professionals to the team (Atwal and Caldwell 2006), despite this many professionals still gravitate towards traditional hierarchy roles (Petri 2010). The concept of interprofessional working implies that all professional are equal, care and power is shared amongst the team (Petri 2010), Sargeant et al (2008) suggests that doctors will often assume the role of leader and decision maker. The reasoning for this could be due to the doctor feeling liable for any wrong decisions concerning the patient and their view of being the decision maker resulting from the number of years spent studying (Baker et al 2011). Robson and Kitchen (2007) however state that despite the doctor taking the role of leader the team can still work together collaboratively as long as the doctor is open to the opinions of the others within the team, Miller et al (2001) agrees writing that being the leader doesn’t necessarily make the individual the decision maker.
Baker et al (2011) continues stating that nurses and other professionals will also endorse the doctor’s hierarchy by deferring to the doctors when making decisions, but believe this often due to the pressure and time constraints within the clinical environment. During the critical incident discussed the doctor took the role of leader, the nurses and physiotherapist were working together in the best interest of the patient, the doctor disregarded the views of both the other professionals therefore leaving them feeling frustrated and devalued which is a common result of unsuccessful interprofessional working ( Baker et al 2011). Nurses are in an ideal position to play a pivotal role in interprofessional working because they aim to provide holistic care, spend large amounts of time with patients and their carers’ and have a wide range of generic skill (Miers and Pollard 2009).
Other professionals also agree with the nurses important role are believe that nurses are there to advocate for the patient (Miers and Pollard 2009).Kenny (2002) reminds us that the debate about interprofessional working and whether it is successful can result in the loss of focus on the patient involved, the most beneficial relationship between any individuals will include the patient being care for. An effective interprofessional team will have a clear achievable goal, respect for each other, communicate well and understand each other’s roles (Day 2006). During the critical incident both the physiotherapist and nurse worked as a team considering the needs of the patient, demonstrating an incident of good interprofessional working, whereas the doctor was dismissive of the opinions of the physiotherapist and nurse and took lead of the situation although did not explain the reasons why he would not alter the medication this demonstrates an incident of poor interprofessional working.
Effective team members are able to resolve conflict and not let situations affect future opportunities for collaborative working (Day 2006), poor interactions can affect interprofessional relationships which may become strained (Robson and Kitchen 2007).Despite the disagreement the doctor and nurse were able to continue a professional working relationship focusing on patient care rather than letting the incident become personal, therefore demonstrating elements of effective interprofessional working (Day 2006). Writing this assignment has provided me with an opportunity to research the area of advocacy, it has shown me the importance of advocating for a patient in my care and the barriers which I may face. The factor of self awareness when advocating for another was something I have never considered and will influence my future practice.
I have also become more aware of the importance of the nurse patient relationship and have started looking at how more experienced and senior nurses communicate with their patients for guidance which I can implement into my practice. The practice of more experienced nurses is also an area I have observed for interprofessional working and as a student often feel that I am unheard when putting my opinions across when discussing patients in my care. The skills necessary for advocating for patients and interprofessional working will take time to develop and when newly qualified I will have a steep learning curve when I am responsible for my own patients, however this assignment has provided my with the knowledge to influence my clinical practice.
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