Critically Evaluate Nursing Care for Complex Patients PDF

**Critically evaluate the nursing and clinical care of a patient with complex care needs** There is a wide range of perspectives and factors that need to be considered when delivering nursing care for a complex patient. The aim of this essay is to critically analyse the care needs for adults with c...

**Critically evaluate the nursing and clinical care of a patient with complex care needs** There is a wide range of perspectives and factors that need to be considered when delivering nursing care for a complex patient. The aim of this essay is to critically analyse the care needs for adults with complexity in their care to optimise their care and reduce reliance on medical professionals (Nicolaus et al. 2022). The case study focussed on in this essay is a homeless young man (Patient X) who self-presented to accident and emergency in his wheelchair. He stated that he was intense pain after falling out of his wheelchair earlier that day, making him unable to move without 10/10 pain. He had chronic hip problems and was on the 12 month long waiting list for a hip replacement at the hospital. The patient repeatedly asked for morphine and became extremely agitated when told he couldn't just be administered morphine, he would have to wait in the waiting room before being seen by the doctor and chose to self-discharge. He was very well known to Leeds Mental health services and Leeds Addiction Services and has a known opioid addiction. He presented to accident and emergency 7 times in the past 12 months with the same issue, each time asking for strong painkillers and refusing to comply with staff when explaining the analgesic ladder of pain management. The balance between controlling a patient's pain and managing their substance misuse issues is a complex dichotomy with several areas to consider such as alterative prescription considerations and the role of trauma informed care in treating vulnerable frequent service users holistically, and care for the patient safely. It is also important to consider external factors and the level of input from non-clinical specialist support in the provision of care for these most vulnerable adults, while being aware of and combatting systemic discrimination and othering within healthcare (Gilmer., et al.). A complex patient was defined in 2013 as the presence of "multiple chronic conditions in a patient" by Zulman et al. This definition is succinct but fails to understand the complexity that multimorbidity can bring and be influenced by, including socioeconomic factors, and a patients entire biopsychosocial and spiritual wellbeing. A more holistic definition was provided by Nicolaus et al in a 2022 literature review of patient complexity as a definition based on multiple chronic conditions, however various non-medical factors play a role in the complexity of the patient, such as biopsychological, cultural and environmental factors. Nicolaus et al recognised that holistic care for patients with complex needs may improve quality of care and help to reduce visits to accident and emergency (A&E) (Nicolaus et al. 2022.). It is clear that patient X has several non-medical factors influencing the complexity of the care of their physical health, and how the burden of chronic pain negatively affects their mental and socioeconomic wellbeing, that could be helped with alternative interventions and signposting to specialist services. Physiological needs are at the core of Maslow's hierarchy of needs, and prioritising the patients basic right to not be in pain is met allows for other needs to be fulfilled such as safety, love and belonging, self-esteem and self-actualisation (Fleury., et al. 2021.). Holistic assessments are an essential part of providing person centred care to complex pain patients. It is essential to comprehensively assess an individual's physiological and psychological health, as well as psychosocial factors that may influence their care. Using the above case study, biological factors identified are his chronic pain, and his addiction issues. His social care needs such as unemployment, support system and lack of secure housing can also greatly influence his experience of pain (Tracy. 2017.). Leeds Teaching Hospitals use the Adult Acute Pain Intensity Score, which asks patients to rate the severity of their pain from 0 to 3. This simple assessment can be easily understood by patients and can give healthcare providers a quick snapshot into the patients experience of their pain. Although self-reporting is a reliable way for a patient to communicate their experience with pain, their rating of the pain is extremely subjective and is influenced by several factors in their life, from their previous experiences with pain to their gender. (Adeboye, et al. 2021.). Functional pain scores go further into understanding how the pain is affecting the patient's day to day life. This is a comprehensive assessment that focussed on the patient's functionality to carry out their activities of daily living (ADLs), work, and communicate with others around them. The patient can rate their pain from hardly noticeable pain with no impact on ADLs all the way to severe pain leaving them "unable to do any ADLs, and unable to talk or sleep". (Adeboye, et al. 2021.). Functional pain scores could be used for patient X to identify how the pain affects his mobility, ability to socialise, and build up a support system to transition out of homelessness into secure housing, alongside securing sustainable and suitable work. A Care Act Assessment may also be relevant to patient X, to determine what tools can be offered to him to support his every day life, in line with the 2014 Care Act (Legislation.gov.uk. 2014.). There also several addiction assessment tools that can be used as part of a complete holistic assessment. This is relevant to the treatment of patient X as his dependency to opioid medications is heavily impacting his quality of life. A 2013 report by Trevino et al showed that people using narcotics 4 months after trauma had a large increase in 'pain, life interference, depression and anxiety' (Trevino., et al.). The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) was developed by the World Health Organisation (WHO) and can be used by healthcare professionals to identify vulnerable people who are experiencing problems with addiction (WHO. 2010.). The questionnaire allows for open channels of communication to be established between service user and provider, and appropriate interventions can be delivered such as access to specialist services and support from third party organisations such as support groups and online forums. These assessment tools can facilitate access to specialist occupational therapy and physiotherapy for pain management for patient X (Semmons. 2022.). Initial assessments allow healthcare professional to identify alternative treatment pathways for patient X, as well as education for professionals leading to greater awareness of the patient's needs, for example awareness and education surrounding non-opioid pain medications such as non-steroidal anti-inflammatory drugs (NSAIDs) for prescribers. Working in partnership to try alternative forms of pain management is essential, and forming a strong relationship based on trust between patient X and the healthcare professional is essential as the professional supports the patient in managing their condition. Holistic assessment tools are especially important to use in the case of Patient X to make sure all of his needs are being met, and work to ensure he doesn't feel unsupported or neglected in the healthcare system. Patient X is an individual with severe and multiple disadvantage (SMD). He experiences two out of the three disadvantage domains, categorised into homelessness, substance misuse and offending by the 2015 LanKelly Chase Hard Edges Report. Patient X is at a severe disadvantage due to the stigma and "dislocation from societal norms" these intersections represent (LanKelly Chase. 2015.). The higher the prevalence of these overlapping health conditions, the lower the health outcomes are for this group. This is a combination of structural and systemic factors within the healthcare and education system, as well as personal factors. This may lead to individual barriers for patient X, including feelings of shame, embarrassment or stigma for needing access to specialist addiction or social services (Parkma., et al. 2017.). Othering, discrimination and clinical bias in healthcare has negative consequences to the quality of care being delivered to patient X. In a 2020 qualitative study into how people experiencing homelessness feel they have been treated when attending accident and emergency, felt prejudged by clinicians when they disclosed their housing status. (Gilmer., et al.). This is clear in the case of patient X, as nurses and doctors in accident and emergency labelled him as a drug seeker, leading to poor trust between the clinician and the patient, and poor care given as a result. By being aware of bias and stigma within healthcare is essential for working with vulnerable adults such as patient X, and recognising the lack of trust homeless people may feel and being aware of homeless people's perspectives on the barriers to receiving high quality care. Stigma and othering within a&e may co-occur in healthcare workers with compassion fatigue. This can impact a caregiver's ability to engage and sympathise with patients, leading to poor care outcomes. A 2018 research paper into compassion fatigue among nurses can be lessened by the provision of formal and informal peer support, as well as systemic changes within the organisation to improve working conditions and work life balance for staff members in all fields of healthcare (Steinheiser. 2018.). NICE have developed guidelines for "improving integrated health and social care services for people who experience homelessness" (NICE. 2022.). These guidelines emphasise the need for provision of housing, as well as the importance of multidisciplinary service provision. Specialist services must be designed and integrated into care to support frequent attenders to emergency departments, in order to decrease the pressure on primary care services. The money saved from reducing frequent attenders could be redirected to specialist services for vulnerable frequent users such as those with multiple long term conditions, or behavioural risk factors that negatively impact their care usage (NHS England. 2022.). Proactive personalised care can be delivered by care coordinators, social prescribing and link nurses to create reactive care for vulnerable people with unmet needs. Several regions around the UK have these services in place for frequent service users called HIU services. Lord Darzi's 2024 investigation into NHS England as a whole clearly highlighted the need for more funding and investment for community services. In a 2022 NHS budget report it was found the budget spent for hospitals has risen to 58%, leaving massive gaps in community care, and forcing patients to attend A&E, with 40% of patients waiting over 4 hours for care (Darzi, A. 2024.) (Office for National Statistics. 2021). Despite the positive changes hat these specialist services have been proven to facilitate for frequent attenders to accident and emergency providing this service may not be effective for Patient X as he appears disengaged with services due to his complicated circumstances. The service can only be successful if the patient is willing to engage with the work, so nurses, social workers and other healthcare professionals must work to "actively support re-engagement". (NICE. 2022.). One of the ways this could be achieved is through the use of trauma informed and recovery oriented language, making sure the information is easy to read and avoiding jargon, in order to make it accessible for people with all language and literacy levels (NICE. 2018.) (ThinkLocalActPersonal.org.uk. 2013.). Housing is a significant determinant of health and impacts the way an individual is able to function with and heal from a physical health condition (Onapa., et al. 2021.). Crisis.org stated in 2016 that poor physical health is both a driver and consequence of homelessness (crisis.org. 2016.). A recent study found that homeless people are 17 more likely to be a victim of violence than the general population (crisis.org. 2016.). The housing first model enforces the idea that if you give a homeless person access to secure accommodation, it can become the foundation to allow other needs to be addressed and become apparent, and recovery can begin (London Assembly Housing Committee, 2019.).. Housing first projects can significantly improve health and wellbeing outcomes for homeless people. A housing first participant review in London found that the percent of participants reporting 'very bad or bad' health fell from 43% to 28% after a year of using housing first (London Assembly Housing Committee, 2019.). When housing is provided in combination with psychological support and physical health checkups, advice and guidance, there is significant improvements in their overall wellbeing. In conclusion, there are numerous ways his mental, physical and social wellbeing can be improved, with support from a wide range of None of these things can exist or work in a vacuum Disparity Hierarchy of needs HOLISTIC Person centred care !! support system Social (Love and belonging) Support systems Wholeism social needs, self esteem Power differentials Beneficence REFERENCES. **** ****.. RESEARCH **Hard Edges** Mapping severe and multiple disadvantage Exploring high intensity use of Accident and Emergency services Understanding the health care needs of people with multiple health conditions Managing Vulnerable Frequent Service Users North Tyneside Care requirements WHO analgesic ladder Untreated addiction is a barrier to chronic pain management What does a patient want vs what do they need Street entrenced Diss also?? https://pmc.ncbi.nlm.nih.gov/articles/PMC7059226/