CID1418 Patient Safety and Quality Improvement

Introduction       

In this essay, I am going to reflect about a case on patient safety and improvement brought about in the patient by rendering quality care. I am a nursing associate student working on older acute mental health and mental health of in patients. The patient whom I am going to talk about is a 38-year old male who was admitted to hospital by his mother and sister with a history of having Psychosis. He was characterised by having distorted perceptions and thinking, emotions, sense of self, language and overall behavior. Sometime the man used to become harmful, trying to harm himself. He also tried to ill-treat his mother and sister sometimes, when he was not within himself consciously and thus the safety of both the patient and the patient party was compromised. Having acquired a chronic illness, the patient was admitted to hospital before also but there was no sign of quality improvement seen in the patient.

Incident

To stick to the Nursing and Midwifery Council Code of Conduct for maintaining confidentiality (NMC, 2022), I have taken the pseudonym of Jackie for the client. Jackie was diagnosed with “psychosis”. One of the incidents of hallucinations that took place while he was admitted in the in-patient ward was that he suddenly woke up from his sleep at the middle of the night shouting in a very loud voice. When I and a few other nurses approached to him, we found that he was standing out of his bed with a bottle in his hand. As soon as Joseph saw us, he threw the bottle at us. It missed one of us by chance but this action of his could have been injurious. We tried to calm him down but that was almost impossible at that moment. He said that he heard a loud banging on the door of his ward along with someone shouting out his name and telling that he would be killed.

Assessment

When Jackie first came with his mother and sister at the psychiatry unit of the hospital, he complained of hearing various voices in form of hallucination for the last 10 months along with loss of apatite. Jackie complained that he sometimes became abusive to his mother and sister which made them feel unsafe and anxious. Moreover, he also complained of receiving death threats from unknown number, which were all a part of his hallucination. When the patient experienced auditory hallucinations, he engaged in third-person conversation which involved both a man and a woman. Jackie also felt uneasy and suspicious of people around him and thus he claimed that his safety was at risk.

After the admission of the patient, I and my team has rendered patient-centred care to the patient and his family by following the principles of rendering physical comfort, proper knowledge of the course of treatment, respecting their values and preferences, providing absolute support and waiving off fear and anxiety from their minds with an assurance of continuity and transition of quality care even after the discharge. In this reflective essay, I will be demonstrating skills, attitude and knowledge followed by assessment on the risk of harms along with proper observation. After having communicated with the team, I will implement the safety measure to render quality care to the patient. In the end, there will be evaluation on the outcomes for signifying safe practice rendered to the patient.

After thoroughly assessing Jackie, we found that his physical status was quite good. However, there was some degree of aggressiveness and rudeness in his behavior with the staff in the hospital. Emotionally he was quite unstable as he felt someone wanted to kill him and always had a fear in his life. The patient was showing symptoms of paranoia which also made us understand that there were some paranormal and spiritual trauma that he was associated with. I understood this at an instance, where I was made to stay at the patient’s ward one night. Jackie was completely unable to sleep as he was not able to trust me and felt that I could harm him. Jackie even started showing impulses where he was compelling me to leave the room by shouting loud. He was then brought under control with the help of tranquilizers. Throughout the process of treatment, it was very important to maintain a proper flow of communication which enabled us to perform accurate and consistent work of treatment that was consistent and ensured satisfaction to the family of the patient along with protection of the health professionals.

Auditory hallucinations are a serious matter at the time of Psychosis where the patient hears someone talking to them or asking them to do things. The voices which patients hear may be neutral, angry, excited or warm. Other types of auditory hallucinations might include hearing of sounds like people walking into the attic or clicking or tapping of noises. Hugdahl and Sommer (2018) stated that conviction of perceiving a voice in the absence any corresponding input of auditory stimulus is one of the most perplexing phenomenon of the human mind. This is known as “auditory verbal hallucination (AVH)” and it is one of the profound characteristic of Psychosis.

Lefebvre et al. (2016), therefore proposes the application of the “Triple-Network Theory” which is used for a wide range of psychiatric disorders. Auditory hallucinations in Psychosis are considered to be evidence of power communication with powers that are divine and though undesirable, it is a sign of mental illness. This impairment carries a particular weightage in psychiatry and hence there is a clear requirement for clinicians to have an in-depth knowledge of various aspects of this phenomenon.  It has been found that the technique of voice dialoguing which occurs in psychotic AVH is based upon a dissociative model that portrays the problem as emotional representations which are disowned and can be engaged with the therapist in a manner which will instigate reconciliation and integration (McCarthy-Jones and Longden 2015).

Intervention

On a precise note, the knowledge of the experience of the patient is a necessary foundation (Škodlar and Henriksen 2019). As a team, we had to undertake a number of intervention methods for the patient which I would reflect upon in the order of priorities. The patient was initially subjected to psychotherapy along with medications such as tranquilizers. Psychotherapy was done with intention of normalizing the thought patterns. It also helped the patient cope with stress and to identify any early signs of relapse situation and thus help us to manage the illness better. The key interventions that we provided to the patient for reducing risks and harms included electroconvulsive therapy, rapid tranquilization along with psychotherapy. As a follow-up action, the patient was monitored regularly at fixed intervals. We asked him questions such as did he have hallucinations the last night or how did he feel after a series of medications. Some of the risk assessment tools were applied to assess the progress of the treatment process. To ensure that the patient did not harm himself at any time, one of the nurse from out team of nurses always stayed up in the room for 24 hours watching him constantly.

To enhance the strategies for providing optimum and quality care to the patient, we used various techniques. We collected data and analysed the outcomes of the patient. We induced techniques of relaxation involving mindfulness, inculcating deep breathing and relaxing muscles progressively.  We provided social support which was provided by the social worker in the team. The social worker always empathized with the patient and did not take their aggressive behavior personally. At the same time, the social worker dealt with the patient’s family member with a lot of compassion and patience by making them understand what they are supposed to do and how they shall deal with the patient post discharge.

There was a total of 7 healthcare professionals handling the case of Jackie. The team of health professionals who treated the patient suffering from Psychosis after his admission to the hospital were psychiatrists, mental health therapists, nurses, dietitian and social workers. Everyone played their role quite efficiently. The doctor did proper diagnosis and prescribed medications to the patient. Being a nursing student, I was only allowed to take care of the oral medications and other chores of the patient such as providing meals and medicines on time and helping him with his toilet and bathing. There were senior nurses who administered intravenous injections and some high dose medicines such as Diazepam and IM Haloperidol which were used as tranquilizers. However, when these medicines did not show effective results, a clinical pharmacists intervened and changed the prescribed medicine to IM Midazolam along with IM Haloperidol. Electroconvulsive therapy was provided by the doctor himself and there was a total of four cycles of this activity.

The role of the social worker was to enable the patient with daily life management along with the family members of Jackie to deal with insurance and income sources while the patient was admitted to the hospital.  The dietitian diligently prepared diet chart for the patient so that he could remain healthy. Me and the other nurses had assessed all the symptoms of the patient carefully and reported it to the doctor who then prescribed proper intervention for the patient. We also did thorough risk assessment of the patient with the usage of tools such as FACE, Brief Risk Assessment, Psychiatric Risk Assessment Scale, Clinical Risk Management Scale and The Social Performance Schedule. FACE as a tool is an efficient one as it assessed the current status of patient in terms of personal social as well as medical status and this tool consisted of three components.

With the use Brief Risk Assessment tool, which is an electronic tool, we assessed the presence or absence of any potential factor of risk for the patient. The approach of Risk Assessment Checklist was used for the patient as an integral part of the approach of care plan. There are two columns of the checklist where vertical columns have options have risk assessment outcome options such as catastrophic, minor, moderate, major and negligible. While the horizontal row consists of options which explains the probability of the risk that is being manifested. The options are rare, unlikely, possible, likely and almost certain (Ayhan and Üstün 2021). These tools helped us assess the risk factor of Jackie with quite effectiveness.

Evaluation

Psychotherapy as an intervention has been found to be very effective. It has resulted in improvement of emotions as well as behavior of the patient which could be linked with the positive changes in the body as well as the brain (Orfanos, Banks and Priebe 2015). I have found that when the patient was placed on cognitive behavioural therapy, we were able to modify the believe that the patient had and could lead to emotions that are negative. With the help of individual therapy, we could teach the patient and his family members the way in which people could deal with their thoughts and behavior.  

Jackie, as a patient could learn more about his illness. There were several issues which the clinical pharmacists had raised at the time of admission which called for alternative medicines inducing faster tranquilization, along with proper investigation and documentation of the data obtained. The vitals of the patient was recorded with every details. Changing the medications brought some positive effects in the health outcome of the patient. Record-keeping of the missed doses of medication were also done properly. The medicinal interventions which were undertaken by our team including the pharmacists along with the psychiatrist and the nurses and social workers brought about a wonderful improvement in the health of the patient before discharge from the hospital.

Sound and ethical decision-making is absolutely important for compassionate and astute critical care of the patient. It is the responsibility of wise clinical practitioners to identify the ethical aspects of work (Noordsy 2016). We needed to consider certain legal and ethical frameworks while treating Jackie with Psychosis. Among the three primary duties and principles that have to be followed by a nurse, I had followed the three main principles with utmost seriousness and diligence. These are duties of autonomy, duties of maintaining confidentiality and the duty of care that can be rendered to the patients. I had kept the identity of the patient confidential and the details of the patient as well as the patient party was kept absolutely confidential. We used the pseudonym “Jackie” for the patient. These ethical duties are supplemented by a few principles such as the principles of beneficience. I made Jackie’s mother and sister join a support who extended support and care to psychotic patients. This would help them take care of Jackie even after discharge. One day, at hospital Jackie was having some hallucinations. I exhibited complete compassion along with veracity for him which helped him calm down slowly. Me and my team also avoided non-maleficence which meant to avoid any kind of harm for the patient.

Conclusion

It can be concluded that for people with Psychosis, a combination of psychosocial therapy along with psychopharmacological interventions bring out some effective and notable results. There are various psychosocial treatments which have shown efficacy. These treatments also include employment with support, intervention from the family’s end, assertive treatment from the community and cognitive behavioural therapy (Vita and Barlati 2018). As a nursing associate, I have understood that quality improvement in patient safety aims at preventing and reducing risks along with harm and error which might occur to patients at the time of health care provision. From the entire essay, I have gathered immense knowledge on teamwork and coordination. I have attained compassion and empathy towards patients and this shall enable me to flourish myself in my career in future.

Reference List

Ayhan, F. and Üstün, B., 2021, April. Examination of risk assessment tools developed to evaluate risks in mental health areas: A systematic review. In Nursing Forum (Vol. 56, No. 2, pp. 330-340).

Hugdahl, K. and Sommer, I.E., 2018. Auditory verbal hallucinations in Psychosis from a levels of explanation perspective. Psychosis bulletin, 44(2), pp.234-241.

Lefebvre, S., Demeulemeester, M., Leroy, A., Delmaire, C., Lopes, R., Pins, D., Thomas, P. and Jardri, R., 2016. Network dynamics during the different stages of hallucinations in Psychosis. Human brain mapping, 37(7), pp.2571-2586.

McCarthy-Jones, S. and Longden, E., 2015. Auditory verbal hallucinations in Psychosis and post-traumatic stress disorder: common phenomenology, common cause, common interventions?. Frontiers in Psychology, 6, p.1071.

NMC, 2022. The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates - The Nursing and Midwifery Council. [online] Nmc.org.uk. Available at: <https://www.nmc.org.uk/standards/code/> [Accessed 8 April 2022].

Noordsy, D.L., 2016. Ethical Issues in the Care of People With Psychosis. Focus, 14(3), pp.349-353.

Orfanos, S., Banks, C. and Priebe, S., 2015. Are group psychotherapeutic treatments effective for patients with Psychosis? A systematic review and meta-analysis. Psychotherapy and psychosomatics, 84(4), pp.241-249.

Škodlar, B. and Henriksen, M.G., 2019. Toward a phenomenological psychotherapy for Psychosis. Psychopathology, 52(2), pp.117-125.

Vita, A. and Barlati, S., 2018. Recovery from Psychosis: is it possible?. Current opinion in psychiatry, 31(3), pp.246-255.

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