Patient Narrative Critical Appraisal

Introduction

Healthcare delivery is an important aspect of the health care system and requires close attention to achieve the results and outcomes desired by all the interested parties. Stedman (2007), defines health care as services which are offered to communities or people through health profession agents to restore, promote and maintain health. Health care delivery, therefore, constitutes a system of institutions and healthcare professionals keen to provide care services to patients. Central to this is person-centred care, which the Health Foundation (2014) defines as a practice of providing care to patients in a manner which could be valuable and meaningful to all the stakeholders such as patients, their families and healthcare professionals.

The assignment will include critical analysis of person-centred care by minutely analysing patient experience alongside 3 elements of care: Communication, Physical comfort and Emotional support by alleviating fear and anxiety. The analysis is undertaken through a narrative from a patient who spent two weeks in the cancer treatment ward. Hall and Powell (2011) point out that patient narrative can provide useful insight into their physical and psychological issues. Having such knowledge can help nurses to deliver better person-centred care. The patient was an 80-year-old male in a cancer ward. Informed consent was received from the patient as has been stipulated by Nursing and Midwifery Council (NMC, 2015). Furthermore, patient information has been treated with confidentiality and hence no single identifiable information has been used in this assignment.

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Communication

This section of the assignment will focus on the process communication. Communication is one of the most important factors in the discipline of Nursing; as the National Health Service (2013) indicates that it is critical in providing positive care experience and is at the heart of the NHS with working concepts such as compassion, competence, courage commitment and care (NMC, 2015). Communication determines the quality of care in nursing practices and can positively or negatively influence patient experience (Gault, Shapcott, Luthi et al., 2017). The Royal College of Nursing (2016) states that excellent communication is so important in nursing practices and helps the patient in different ways (for example, by making the patient feel at ease even in the wake of their medical condition). According to Kourkouta and Papathanasiou (2014), impressions of the patients regarding the services of the health care providers are based on how they relate and communicate with them and the impression they pass to them will influence the patient satisfaction and healthcare output.

It is evident from the narrative of the patient (see Appendix 1) that his first visit and treatment experience appeared to be fine. This is demonstrated by the patient’s narrative which was positive initially as he thought cancer was treatable from his previous experience. At this point, it is suggested that the nurses and doctors were proactive and communicating all of the required information. Good communication on the part of the healthcare team is important for both the patient and the healthcare team. When patients are given detailed information about their illness and treatment, they are more likely to follow a treatment regime and show greater satisfaction with the care provided (Negri, Brown, Hernández et al., 1997). Indeed, a lack of information regarding investigation results and treatment options is likely to create anxiety (Surbone, Zwitter, Rajer et al., 2014). From the team’s perspective, when they maintain effective communication with patients, they can identify the patients' needs, expectations and perceptions (Fong Ha and Longnecker, 2010). This is important because, in extreme conditions, where they believe that healthcare providers are not providing sufficient information about their condition, some patients may become aggressive (Surbone et al., 2014).

Although the initial patient narrative was positive, this deteriorated. The change appears to have been brought about by a ward transference. Indeed, the patient noted "I was transferred to another ward under circumstances which I did not understand". This suggests two things; firstly, a lack of communication (the importance of which has been explained previously), and secondly a resultant feeling of lack of control in the patient. This supports Berger’s (2013) conclusion that patients will always want to exercise control over their health affairs which can only be achieved with sufficient communication regarding their medical condition. In relation specifically to ward transference, the Society for Acute Medicine (2013, cited Lees, 2013) state that good communication should be promoted throughout, as patients could get anxious about being transferred and what to expect in the new ward. The link between communication and anxiety is clearly reflected here, and, as a result of poor communication, the patient was left anxious and with a feeling that he did not have full control on his health condition. In addition to anxiety, it could be suggested that the patient became frustrated to the extent where he tried to resist transfer to another ward. Alavi (2015) states when patients become frustrated it is crucial to identify and deal with the cause of the frustration. However, the patient does not say whether the cause of his frustration was identified and dealt with. The patient narrative suggests that, since the ward transfer was not properly explained, he felt his safety was not guaranteed. Certainly, effective communication is also important in maintaining and restoring a sense of safety in a patient (Riley, 2015). To support this, the patient should have been made aware of the purpose and destination of the transfer prior to this taking place, as this would have been more likely to have improved his compliance (Negri et al., 1997).

To conclude this section, effective communication plays an important role in helping patients decrease anxiety, pain, disease symptoms and guilt. Moreover, communication can increase acceptance, cooperation with the medical team, patient satisfaction, compliance and improve functional and physiological status (Norouzinia et al., 2015). When communication is used well, it helps in the provision of accurate, clear and consistent nursing service, guaranteeing satisfaction and protection of the patients (Williams and Irurita, 2006). However, in the case of this patient, his experience on the respiratory ward demonstrates aspects of poor communication with specific negative outcomes. Furthermore, evidence shows that good communication between patients and nurses can lead to positive outcomes and experience for the patient. But, this must be done through a supportive approach where nurses understand and help their patients and pass any kind of message or information in a manner which could be acceptable, clear and understandable (Kourkouta and Papathanasiou, 2014).

Physical Comfort and Emotional Support by alleviating fear and anxiety

The physical comfort is referred to the feeling of being well which is brought through internal as well as environmental health conditions that are experienced as associated and agreeable with contentment and satisfaction (Zhou et al., 2016). The patients require experiencing physical comfort while accessing care from the nurses so that they feel they are being properly cared and mentally develop hope of their health improvement. However, in this given case, the patient did not receive physical comfort which is evident because he was continuously being shifted from place to place ignoring his health and his pain in the throat along with coughing which was not at all resolved. The physical comfort of the patients can be ensured by the nurses if proper treatment is offered to them along with person-centred care (TaghadosiMemarian and Ahmadi, 2015). Thus, the nurses by providing person-centred care to the patient in the scenario under consideration could have helped him to cope with pain and develop comfort to ensure he is being properly cared for. The physical comfort is related to emotional support because effective physical comfort of the patients helps them to become emotionally strong to cope with the disease. Thus, removal of physical disabilities and pain makes the patients feel they have successfully fought against the disease and would be able to be cured to live a normal life that boosts their mental health.

According to Wensley et al (2017) 19 studieshad explored what comfort means from the patients’ perspective in settings that include emergency departments, paediatric wards, Hospice Residential care for the elderly and surgical wards of a general hospital. They concluded that comfort involved several dimensions which had been experienced by patients as a sense of strength and positivity identified by not only the relief of physical discomfort but an integration of positive emotions which include feeling competent, confident, feeling cared for valued, safe, at ease and having a sense of personal control. According to Wensley et al. (2017) comfort should be considered by assessing social, psycho-spiritual and environmental needs so that adequate interventions can be formulated to achieve enhanced holistic physical comfort. Therefore, nurses should evaluate and adjust accordingly in order to meet patients’ physical comfort. As criticised by Chan et al. (2018), cancer patients, who seek physical and psychological comfort, do not always intend to fight cancer but they have the intention to become physically healthy. This is because they wish to be independent and avoid being a burden for others. In case of the mentioned patient, he is seeking physical comfort so that he can be emotionally strong to fight cancer. This is evident as he has informed that he feels depressed and feels that he is going to die with his increased physical deterioration. Thus, Chan’s study is reliable and credible because it informs data similar to the mentioned patient narrative that the cancer pateints do not always seek to fight against cancer but to feel physically healthy to feel better to execute their properly.

The physical comfort for the patients are important so they could be made physically active to execute personal duties without hindrance (Jim, Pustejovsky, Park et al., 2015). This helps in developing empowerment of the patients as their physical comfort drives them to feel they can accomplish all the tasks required for betterment of their health. The empowerment makes the patients feel mentally strong and this makes them able to take their own decisions and thus not become the burden on others which boosts their health conditions (Castro et al. 2016). This is because while being a burden on others, they could be often neglected which makes the patients lose meaning of their lives and get depressed. In the given scenario, it is seen that the patient is feeling physical discomfort which is evident because his coughing and issues with throat pain are not resolved properly by the nurses. This led the patient to experience further deterioration of health as he was unable to take regular meals which made him remain hungry and did not receive proper nutrition. According to Arthur, Delk, Demark-Wahnefried et al. (2016) lack of nutrition and improper intake of food amongst the patients lead to further deterioration in their health. This is because nutrition is required by the body to help the patient properly cope with the disease and respond positively to the treatment. It leads to further deterioration of health as seen in case of the patient from the patient narrative where he mentioned: "lack of proper intake of meal made him feel weak and forced the doctor to scold him as he showed weak response towards treatment”.

The physical comfort for the patient though usually relief them from pain and physical distress but it is also more than that where the patient can feel actually relaxed while being in the diseased state (Avoine-Blondin, Parent, Lahayeet al., 2017). However, the mentioned patient referred in the narrative that he has no feeling of comfort while accessing care in the hospital as he had to continuously change to new wards which led him to often face issues with getting accustomed with new environment. In this case, the nurses could have fixed a particular bed for the patient and could have shifted other patients in emergency to other rooms without making much physical discomfort for the mentioned patient. This is because it would have the made the patient feel comfortable as well as emotionally satisfied from the care given to him. Further, resolving coughing issues with the patient could have boosted him to feel physically better which could have helped him to develop emotional support that he can be cured.

Anxiety and fear due to illness can be so great that many patients may be destabilised and this can even lead to poor response to treatment (Owens and Antony, 2011). This is evident in case if the patient where the person was provided medication to resolve his throat pain but it failed to offer him support to resolve the issues. Thus, it informs that may be the medication did not show proper response to resolve the problem of the patient because he was mentally destabilised. This is because it is found that often the patients do not successfully respond to the treatment because they are mentally destabilised which results in hindered healthcare for the patients (Negri et al., 1997). Therefore, in this case the nurses could have been able to provide emotional support to the patient to overcome fear and anxiety regarding his disease of throat cancer then the response towards the medication could have been different. The patient could have resolved his throat pain and would be able to take proper meal to ensure better health outcomes.

Owens and Antony (2011) discuss the importance of understanding and overcoming health anxieties. Health anxieties can create a state of confusion in a patient’s life and might affect the whole care delivery process. Burke, Lowrance and Perczek (2003) state patients with anxiety, rate themselves as having more pain, more physical limitation, poorer physical functioning and lower self-perception of general health. This is evident from the narrative of the patient as he already informed that he was facing physical discomfort and frustration that is limiting him to feel satisfied with the care given to him by the nurses. Moreover, the patient did not get any form of emotional support from the nurses is true because he already informed that he is accessing mental support from the surrounding patients who are receiving care in the hospital to feel mentally stable. Further, the nurses do not even inform about his suicide attempt to the family of the patient or neither arranged any emotional support program for the patient to cope with the fear and anxiety of cancer that led to his greater frustrated and depressed state.

The nurses in the hospital in this case had given mental support to the patient regarding his diseased state the patient could have shown more positive response towards treatment. The patient could have avoided showing so much frustration and helplessness which could have assisted in thinking that he can be cured like before. This would have led him to cooperate with the nurses in getting treatment for resolving his throat cancer without showing much resentment. As stated by Geyer, Koch-Giesselmann and Noeres (2015) relapse of cancer often leads the individuals to feel distressed and lack of hope to live. This is because they think the disease is incurable and they can never be relieved from the health distress. It is also seen from the narrative of the patient who stated that "I was shocked and distressed with the relapse of my throat cancer and I think I can never recover.” However, proper intervention of the nurses in this situation by providing mental support to the patient by the nurses that they can be cured is able to change the thinking and develop zeal in them to live. However, in this case the patient was not offered any form of mental support from the nurses which led him to think the disease is incurable and feel depressed as well as frustrated. Thus, it informs that required mental support was not offered by the nurses to the patient in this condition which could have been vital in the improvement of the condition of the patient.

The nurses could have taken a more person-centred approach to resolve the mental stress of the patient. This is because in person-centred approach the patient is the key focus where the needs and demands of the person are identified and measures are developed to meet them (Gyllensten, Koinberg, Carlstrom et al., 2018). Thus, person-centred care could have helped the nurses to understand the importance of mental support required by the patient to make him feel comfortable and fight with cancer to have a better and healthy life. According to Faller et al. (2016), mental support for cancer patients from the nurses and doctors are required to help the patients have the zeal to live life. This is because cancer in itself a fatal disease which raises fear of death amongst the patients . It also leads to frustration among few patients because they can no more find meaning for living life. This emotional turmoil may lead the cancer patients to cause self-harm or great resentment to take medication that results in deterioration of their health (Lloyd-Williams et al. 2014). It is evident from the scenario of the patient where he mentioned that he has lost hope to be cured from cancer and has already attempted suicide. Moreover, he informed the family that he is going to die and so they need not to take anymore care for him. Thus, it informs that lack of mental support has led the patient to become emotionally weak to lose the zeal to live. In case the nurses had emotionally supported him, he would have never attempted suicide and would think of life to be more meaningful. This would have made the patient to show better response towards the treatment procedure to develop better physical health to live effectively by fighting against cancer.

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Conclusion

Care delivery management is quite broad with a lot of factors in play. From the patient narrative, patient-centred care prominently features, with the key principles that can either improve or hinder the patient experience. The three principles, such as communication, physical comfort and emotional support by alleviating fear and anxiety discussed in this paper came out to be more significant in enhancing patient care and in almost all cases they are interdependent. At a glance, it is always easy to assume that care is basically providing treatment to a patient, but without applying the key principles of care and in this case patient-centred care, no health care professional has a chance of success. The patient narrative has clearly demonstrated that communication is the most outstanding principle of patient-centred care and must be given the attention it deserves. Throughout his stay in the hospital, the patient highlights many cases where communication was not properly done and that affected his experience negatively to a large extent. Communication was largely the biggest factor throughout the two weeks in the hospital. This demonstrates how effective the use of patient narrative can be in helping the nurses’ to take informed decisions in relation to person-centred care.

The assignment also discusses emotional support and physical comfort, which by far also affect the overall experience of the patient. It is therefore not enough to just provide treatment but to create a feeling of attachment with the patient. Patients will most likely respond positively to treatment when they have emotional connection with the staff. Although physical comfort did not feature a lot in the patient narrative, it comes out as an important factor that can create a positive experience in a patient. The environment must have a home-like feeling. Person-centred care, therefore, needs to be offered, based on the principles discussed above to significantly influence patient experience. Moreover, the physical comfort is seen to drive emotional comfort which in case have been given to the patient he would have never thought of attempting self-harm. This is because physical comfort alleviates physical pain that is seen as symptom by the patient that they have the ability to fight against the disease.

Overall, I am aware of how important patient narratives are in planning, in order to provide holistic care and in helping nurses meet the NMC guidelines, so I will incorporate the learned information in future practice.

References

  • Lloyd-Williams, M., Payne, S., Reeve, J. and Dona, R.K., 2014. Thoughts of self-harm and depression as prognostic factors in palliative care patients. Journal of affective disorders, 166, pp.324-329.
  • Faller, H., Weis, J., Koch, U., Brähler, E., Härter, M., Keller, M., Schulz, H., Wegscheider, K., Boehncke, A., Hund, B. and Reuter, K., 2016. Perceived need for psychosocial support depending on emotional distress and mental comorbidity in men and women with cancer. Journal of psychosomatic research, 81, pp.24-30.
  • Castro, E.M., Van Regenmortel, T., Vanhaecht, K., Sermeus, W. and Van Hecke, A., 2016. Patient empowerment, patient participation and patient-centeredness in hospital care: a concept analysis based on a literature review. Patient education and counseling, 99(12), pp.1923-1939.
  • Chan, E.A., Wong, F., Cheung, M.Y. and Lam, W., 2018. Patients' perceptions of their experiences with nurse-patient communication in oncology settings: A focused ethnographic study. PloS one, 13(6), p.e0199183.

Appendix 1: Patient Narrative

“About a year ago, I was diagnosed with throat cancer. I went through a successful operation to cure it. The Doctors conducted further tests, which were all negative, and hence I was given a clean bill of health and discharged. However, after six months I again started feeling pain in my throat, had lost appetite, started to lose weight and experienced persistent coughs. I decided to go back to hospital. I was admitted to the hospital where several tests were conducted. I was shocked to learn that I had cancer again and even worse of it that it had spread from my neck to other parts of the body”

“At first, I thought I cannot be cured because it has relapsed in such a bad manner. However, following my previous experience with cancer, I tried to think that it is mat be treatable and therefore remained slightly positive even in my communications with friends and family. I, therefore, assumed that this would be over soon, and I will get the opportunity to get back to normal and go about my businesses"

“After 4 days, I was transferred to the oncology ward as I began to receive my cancer treatment. I got a confirmation here that indeed I had cancer but was optimistic about receiving quicker treatment. During my time at the oncology ward, I met patients with similar conditions shared our stories. I still held believe that just like them I would be cancer free as soon as my treatment began. During my stay at the oncology ward, the nurses did not show much concern about communicating what to be done next for effective treatment. Moreover, during my stay at the ward, I felt pain in my throat while having solid food and often coughed violently thus I informed the nurses about the condition. They gave me medication for it but it was ineffective as my coughing was not entirelyeased and the pain was so much that I could not take regular meals. However, the nurses did not show any concern to look after the matter so that the pain can be eased.

“I spent around three days in the same bed after which a nurse came to my bedside and explained to me that there was a needy patient (very poor) who had to use my bed and hence I have to be transferred to another ward. I was therefore moved to another ward with patients who had breathing problems, a totally new environment for me even after establishing a good relationship with my fellow patients at the other ward. This led me to get frustrated because my pain was not being eased and the nurses wish me to move to another bed with new patients around me. However, I avoided arguing and accepted the matter”

“My frustration increasing about yet another bed move (this was the third under one week), I found it so difficult to keep changing beds especially after meeting people that I could share my feelings. I even tried to resist this transfer, but the nurse did not understand my point. She was surprised by my attitude. I even thought that she did not consider my cancer treatment as important as other conditions” “I spent a couple of days in the respiratory ward, still keeping my hopes of receiving better treatment until after a week when I noticed a nurse with an “end of life” badge walking through and it immediately hit me that I was actually in a ward featuring patients with incurable conditions. This became the lowest point of my stay in the hospital and given that no one cared to let me know that my cancer had reached a point where it could not be treated. I also had to share this information with my family and hard to prepare them to understand that my condition was incurable. Thus, I finally realised that what I thought at the first was true that relapse of my throat cancer is fatal and incurable. This thought leads me to attempt cutting my wrist as I can no more feel meaning for my life but somehow the nurses saved me and I was scolded for the act.”

“My overall experience was horrible and I always felt unsatisfied, frustrated, ignored and feared with my health and surrounding in the hospital. No one cared to explain to me the results of the tests conducted. I had to literally make personal enquiries to get information from the Hospital staff. I mostly discovered a lot through the actions observed rather than the communications I received. The lack of transparency, the transfers from bed to bed and lack of genuine commitment to helping me receive treatment and care was really frustrating. The activities of the nurses also made me feel helpless. Moreover, the nurses did not even informed my family that I attempted suicide and I ignored informing it to my family because I think it is meaningless in my life to say or do anything. I told my family members that I am going to die anyway and so they need to stop worrying about me.”


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