A study of an elderly female patient receiving a DHS following traumatic fracture of the neck of femur.
77A care study of a 100 year old female patient receiving a Dynamic Hip Screw following traumatic fracture of the neck of femur.
SN. Daniel Bran Griffith RGN.
An edited version of this paper has been previously published in the Journal of Orthopaedic Nursing and the full reference for this work is Griffith D.B. (2007) A critical study of a 100-year-old patient receiving a dynamic hip screw. Journal of Orthopaedic Nursing. Vol.11. No.3-4. August-November 2007 p177-184.
doi:10.1016/j.joon.2007.08.001
Copyright © 2007 Elsevier Ltd All rights reserved.
Introduction
The objective of this paper is to review the care delivery of an individual female patient, admitted to the Trauma and Orthopaedic Directorate of a hospital within the Midlands. The patient in question received a traumatic musculo-skeletal injury, specifically an intertrochanteric fracture of the neck of femur following a fall. The author of this paper was directly involved in the care delivery of this patient. For reasons of confidentiality the name of this patient has obviously been changed.
To review the care delivery it will be necessary to provide a brief patient history, a description of the mode of injury and a diary of care. To examine the care delivery in more detail it will be necessary to discuss the choice of surgical procedure, the use of the particular nursing model used within the clinical area and the influence of relevant government policy. This paper shall end with some thoughts on the future of Trauma and Orthopaedic nursing.
Patient history
Emily Swiatek was born in the summer of 1904, making her 100 years young at the time of admission (2005). Our patient is of East European origin. Successfully avoiding the invading German army during the Second World War, Emily settled in England. Based on this information we can perhaps deduce that Emily possesses a certain determination.
At the time of admission the patients medical history was identified as; rheumatoid arthritis, type ii diabetes mellitus, an unspecified heart condition and mild confusion or dementia. Emily is of small stature and weighs 45kg.
The patients pre-admission medication as given by the residential home was; asprin 75mg mane´, enalapril, sodium docusate 100mg, Adcal D3 and "olanzapren."
We can deduce from this that the unspecified heart condition is atrial fibrillation and hypertension. It is noted that the residential home are unable to correctly identify one medication.
Mode of injury and day of admission
Emily was admitted via the accident and emergency department to the Trauma Assessment Unit of a nearby hospital. Arriving on the unit just before lunch time on a week day. The patient had fallen at the residential home and had been found that morning. Emily is not believed to have been left on the floor for any length of time. The patent had sustained injury to the right hip and a skin tear to the right forearm. Rather carelessly this was documented by the admitting nurse as left arm. This was however better than the medical notes, as the injury to the arm was not documented at all.
Medical assessment in A&E did confirm atrial fibrillation, hypertension, hallucinations, osteoporosis, anaemia, type ii diabetes mellitus, frequent falls and mild confusion. Emily was naturally sent for X-ray in A&E and her films identified a fractured neck of femur but no fracture to the forearm.
On admission to the unit the nursing assessment identified Emily as being occasionally doubly incontinent and as having red heels. Emily also had a skin break to her sacral region, to which Granuflex was applied. Emily's normal mobility was identified as independent with a walking frame. Emily was catheterised for retention later on the day of admission.
In hospital medication using a standard pre-printed fracture neck of femur drug chart plus one "general" blank chart was; paracetamol 1g QDS, codeine phosphate 15mg QDS, senna (ii) nocte, asprin 75mg manã´, enalapril 5mg at 0800 and 1800 hours, Adcal D3 (i) at 0800 and 1800.
The medication not identified by the nursing home was identified by the doctors as olanzapine. This is a drug usually used for the treatment of schizophrenia or mania. Emily was prescribed 2.5mg nocte.
PRN medication was prescribed and included morphine and cyclizine as subcutaneous injections, procholorperazine as an intramuscular injection and Lacri-lube and Hypermellose for the eyes. During her entire hospital stay Emily did not require any of these medications.
Emily was however prescribed cefuroxime 750mg TDS intravenously for three days. Starting from lunch time on the day of admission, Emily received seven doses running through the day of operation to the first day post operatively. Intravenous fluids were also begun pre-operatively as routine (normal saline and Hartmanns solution).
Emily's ECG was seen by the senior house officer on TAU that evening. Blood results from samples taken in A&E were; HB 8.2 Mg 0.81 K5. Although digoxin was originally planned this was now to be held back until post operation and further blood tests. A single unit of blood was prescribed pre-operatively.
Day of operation
One day after admission and within twenty fours hours of arrival on TAU, Emily underwent surgery. Receiving a dynamic hip screw under general anaesthetic. Specifically a four hole 135 DHS plate with an 85mm DHS lag screw. The wound was closed with 3/0 Monocryl and dressed with steripad. No drains were inserted.
One unit of blood had been given pre-operatively, followed by 20mg of frusimide. Emily's blood glucose pre-operatively was 3.5mmols (06.45 hrs) rising to 8.3 post operatively (11.00hrs). Intravenous dextrose saline had been administered during the operation.
The post operative plan given in the medical notes ran thus; deep vein thrombosis prophylaxis, blood samples (full blood count, urea and electrolytes), wound check in forty eight hours, mobilise fully weight bearing from day one, chest physiotherapy as tolerated and continuous antibiotic cover (cefuroxime 750mg TDS). These details were recorded in the patient's individualised care pathway. At the anaethetists suggestion the antibiotics were to be changed to oral forty eight hours post operation. From the recovery room Emily was transferred to the Extended Recovery Unit for overnight observation.
At this point some mention should be made of the two specialist units so far involved in the care of Emily. At the particular subject hospital the majority of trauma patients (those not destined for intensive care or high dependency), are admitted to the Trauma Assessment Unit. Here they are admitted and assessed by both medical and surgical staff prior to surgery. The ward of thirty beds is split (officially) into pre and post operative areas. Patients returning to TAU post operatively are expected to stay on the unit only two or three nights before transfer to an orthopaedic ward.
The Extended Recovery Unit will take patients post operatively, for usually no more than one overnight stay before transfer to an orthopaedic ward. Although primarily caring for the elective orthopaedic theatre lists, trauma is taken when necessary. The objective of both units is to provide specialist nursing care and close monitoring.
Post-operative diary of care
On the first day post-op Emily was seen by the medical team and prescribed 500mcg of Digoxin with a further 250mcg to follow six hours later. Emily was also transfused one unit of blood. That evening Emily was transferred from the recovery unit to a general ward via X-ray. An X-ray of the surgical area is generally required to confirm weight bearing status, prior to full mobilisation.
On the second day Emily was seen by the physiotherapists and sat out of bed. Her wound dressing had been changed (48 hour wound check) and redressed with a dry dressing for protection. Emily had her bowels well open. Unfortunately Emily's skin was judged to fragile to tolerate the usual anti-thromboembolism stockings.
On the third, forth and fifth days, Emily was now beginning to become more independent. Although still requiring full care with hygiene needs and wearing an incontinence pad. Emily was able to mobilise short distances with a walking frame. The skin tear to the right forearm was redressed on alternate days. The surgical incision was dry and left exposed on the forth day. The urinary catheter was removed on the fourth day. Emily's pressure areas although delicate were showing signs of improvement. Unfortunately the afternoon shift on the fifth day, documented her pressure areas as intact and blanching. This was an error picked up by the night shift and an incidence form was made out.
On the sixth day while washing the patient, a Healthcare Assistant observed that Emily's right arm appeared deformed and moved in an abnormal manner. This was brought to the attention of the author who was team leader on that occasion.
On checking the X-ray no fracture of either the radius or ulna was visible. However, the X-ray was only of the distal forearm. Suspecting a missed fracture this was reported by the author to the nurse in charge and on to the team. A second X-ray showed a fracture to the proximal ulna and Emily had a plaster of Paris backslab fitted later that day. Emily was provided with a "collar and cuff" for comfort and support.
Over the next few days Emily's pressure areas remained of concern. Duoderm was applied to her sacrum and a foam dressing to her left heel. A pressure relieving mattress had been in use from admission and Emily was not down-graded. Emily remained able to mobilise to the toilet but was occasionally doubly incontinent.
On the twelfth day post operation Emily had a complete lightweight cast fitted to her right forearm. Emily was discharged back to her residential home on the fourteenth day post operation.
Why a Dynamic Hip Screw?
Fractures of the femur neck are generally divided into two categories, intracapsular or extracapusular (Walsh 1997). Intracapsular fractures occur through the capsule at the base of the femur head. Extracapsular pass through either of the trochanters or the intertrochanteric area (Walsh 1997).
Tronchanteric fractures can be further divided into four types (Dandy and Edwards 2003).
1: Pertrochanteric in which the fracture passes through both trochanters.
2: Intertrochanteric in which the fracture passes between the trochanters.
3: Subtronchanteric in which the fracture is sustained below the trochanters and
4: Avulsion fractures of the trochanters.
Fractures to the intracapsular region are likely to damage the blood vessels supplying that region. So causing avascular necrosis (Schoen 2000a). This is particularly so if there is displacement and the choice of surgical intervention is hemiarthroplasty (Santy 2005a). With extracapsular fractures however, the viability of the blood supply to the femur head is not usually at issue (Walsh 1997) and the choice of fixation is either dynamic hip screw or an intrameddullary nail (Kunkler 2002).
Jenson and colleagues (1980) have concluded that with stable trochanteric fractures, the choice of implant does not necessarily effect results. However, past studies of the DHS in this area (Doppelt 1980) have put the reputation of the implant almost beyond question. Besides allowing early mobilisation the implant has good load bearing capability (Jacobs, McCain and Armstrong 1980).
Twenty five years later it is still the general consensus that the DHS is the implant of choice for stable trochanteric fractures (Harrington, Nihal, Singhania and Howell 2002, Lorich, Geller and Nielson 2004). This is considered to be particularly so in the elderly (Koval and Zuckerman 1998).
The choice of procedure with unstable fractures is broader, with the added choice of the short stem "gamma" nail or the longer intramedullary hip screw (Harrington et al 2002, Lorich et al 2004).
In her fall Emily sustained a closed and undisplaced intertrochanteric fracture of the proximal femur.
The nursing implications of a patient with a hip fracture
The diagnosis of a fracture is based on history, symptoms and on radiographic studies (Unwin and Jones 1995, Schoen 2000b).
The general opinion is that two views at right angles, are the minimum number required to evaluate a suspected fracture and that the X-rays should include the joints above and below (Kunkler 2002).
It should be observed that although it is not the role of the nurse to check an X-ray. A working knowledge of the fracture and the basic anatomical structures involved can provide guidance in care delivery. The first X-ray of Emily's right forearm was not from joint to joint and this is why the ulna fracture was originally not detected.
The implications of a fracture are many but the primary ones that can be identified here include; risk of compartment syndrome, risk of fat embolism syndrome, risk of deep vein thrombosis (Pellino, Preston, Bell, Newton and Hansen 2002), wound infection, chest infection, elimination difficulties, tissue breakdown, pain, the patient's psychological state and an adverse effect upon the ability to self-care (Santy 2005a).
The factor that many of these nursing issues have in common is the detrimental influence of immobility. Within orthopaedic nursing recovery is very often measured by the assistance a patient requires (Santy 2005a). The individual patient's self-care deficit. With mobility in particular, this comparison will be made with the patient's pre-fracture existence (Williams, Oberst and Bjorklyund 1994).
Under these circumstances the role of the orthopaedic nurse goes well beyond the prevention, detection and monitoring of any deterioration in a patient's condition. The role of the orthopaedic nurse includes active rehabilitation and the restoration of self-care wherever possible.
Nursing Models and the nursing process
To assess a patient and identify potential or actual problems some form of framework on which to base and develop the nursing process is required. Fawcett (1984) writes that concepts, theories and models are linked in a hierarchical structure with concepts as a base and models being the end result.
Nursing models are not physical representations of an idea, concept or theory. They do not come in boxes marked "Airfix" nor are they assembled using glue. It can be argued that nursing models are conceptual in their own right (Riehl and Roy 1980) and that they are based upon a theory of nursing, such as self care (Orem 1971) or activities of living (Roper, Logan and Tierney 1980).
A nursing model is an abstract and conceptual framework from which we are able to assemble the nursing process. The patients condition is compared as it is now, with conditions before admission, allowing problems and goals to be identified. These factors are used to formulate a care plan and together they will form the nursing process.
The nursing process is often regarded as having distinct stages (Walsh 1997, Andrews and Smith 1992).
1. Assessment of the patient.
2. Identification or diagnosis of problems.
3. Establishment of goals and the writing of the care plan.
4. Implementation of the identified nursing care.
5. The ongoing evaluation and final conclusion of the care given.
These stages are in turn often summarised into four steps; assessment (which includes the identification of problems), planning (and the writing of the care plan), implementation and (ongoing) evaluation.
The Roper, Logan and Tierney model of care
The Roper, Logan and Tierney nursing model is used not only within the Trauma and Orthopaedic directorate of the hospital that Emily was admitted to. It is used in the majority of wards and departments of that particular trust. It is regarded as a general model, adaptable to many areas and needs.
The starting point for this model is the work of Abraham Maslow (1954) and his hierarchy of human needs, from the most basic to the most sophisticated. Maslow suggests that our basic biological requirements (such as nutrition) must be met, before we are able to satisfy higher psychological needs.
The RLT nursing model is based on the theory that people are best understood by the activities of their lives (Aggleton and Chalmers 2000), biological, social and cultural. Some activities are essential and primarily biological in nature, while others are non essential but enhance the quality of life. These needs are therefore primarily social and psychological. This is a holistic view of the person and represents a move away from the mechanistic perspective, of the traditional biologically centred medical model (Archibald 2000).
The twelve activities of living identified by this model are; maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and finally dying.
Added to this concept are three components of nursing care based upon a balance between dependence and independence (Kenworthy, Snowley and Gilling 1996). The first is the preventing component, here the object of nursing care is to prevent (or assist in preventing) a worsening of the patient's condition and the development of new problems. The second component is that of the comforting component, the object to provide and assist in physical, emotional and spiritual comfort. This component is difficult to define as it is highly individualised relying heavily on the nurses interpersonal skills. The third and final component is the dependent component, this component recognises that the patient will be dependent upon the nursing staff for aid and it is this component that represents the implementation of nursing care.
Care delivery using the Roper, Logan and Tierney model of care
Although intended as a framework for care delivery nursing models are often used as an assessment aid, with little influence on the later stages of the nursing process. The RLT model is popular with nurses and it is suggested this is partly because of its resemblance to the medical systems model (Archbald 2000). There is a danger that any model used mechanistically becomes mechanistic, as does eventual care delivery. This is directly opposite to the aim of any nursing model, which is to provide a framework for individualised patient care.
The RLT model is relevent to orthopaedic nursing as it recognises how injury can effect the patient's self-care ability (Santy 2005b) on top of the many serious medical complications.
How the RLT model influences care delivery, is best illustrated by a brief review of the care given. Like all the different areas of any model, the factors that they influence and are influenced by, are broad in concept and overlap.
Maintaining a safe environment: Due to Emily's mild and intermittent confusion, an awareness of potential dangers to her wellbeing is vital. Care was taken that Emily could manage a hot drink and was supervised when mobilising in the early stages of her stay. A falls risk assessment is carried out on all patients within this particular clinical area. Emily was judged to be of a high risk but was later reassessed as medium as her ability to mobilise competently increased.
This section however may include other factors, such as aseptic wound care and the administration of medication. Particularly the administration of antibiotics to prevent infection. The observation and prevention of surgical complications such as DVT may also be included in this section.
Communicating: A two way process in which the healthcare staff must identify Emily's needs using both verbal and non-verbal cues. Roper, Logan and Tierney place pain in this zone as the patient must express their discomfort. Therefore the alleviation of pain or the introduction of a coping mechanism, is a nursing issue. Emily's pain was well controlled during her stay with no particular complaints being made post-operation, even with an unidentified broken arm.
The use of aids such as spectacles and hearing aids are covered by communicating. Emily does use spectacles but her use of them could just as easily be covered by maintaining a safe environment.
Breathing: This also includes the cardiovascular system as a whole. Several of Emily's medical conditions are covered by this area, including hypertension, atrial fibrillation, anaemia and diabetes. The necessity of close observation is clearly required in the early stages of care to prevent complications developing.
Eating and drinking: Emily had no particular needs in this area with regard to appetite or surprisingly fluid intake. However Emily is a type ii diabetic and therefore the choice of correct menu was required. Her diabetes was remarkably stable post-operation.
Eliminating: Emily is occasionally incontinent, sometimes doubly. Prior to her operation Emily did require catheterisation but this was removed on the fourth day post-operation and incontinence pads provided. Emily was by this time mobilising to the toilet with a walking frame and the catheters removal gave Emily greater independence.
Personal cleansing and dressing: Due to her advanced age and her injury Emily required assistance. Over a few short days however, she was able to progress to washing her upper body with less help. When assisting a patient with hygiene healthcare staff are in a privileged position of intimacy, raising many issues regarding privacy and dignity. This time also affords an opportunity to inspect the patient's skin integrity. It was whilst assisting Emily with her morning wash, that a Health Care Assistant first became suspicious of the injury to Emily's right forearm.
Controlling body temperature: Emily is capable of expressing her needs with regard to body temperature and generally only required assistance with the choice of appropriate clothing. There is always a risk of potential infection following an operation and monitoring of the patient's temperature is necessary. Emily also received a blood transfusion peri-operatively and therefore required close monitoring at that time.
Mobilising: Emily was able to mobilise on the second day post-operation. Her walking distance and independence increased until she was able to walk to the toilet without assistance. Although Emily could not get in or out of bed or raise herself from a sitting position without aid. This increased mobility is desirable, as it will lessen the risk of complications such as thromboembolism episodes and aid the recovery of Emily's pressure areas.
Working and playing: Emily's leisure interests centred around reading and watching television. Her family who visited daily, provided books and newspapers as necessary to relieve the boredom of her hospital stay.
Expressing sexuality: The use of the word sexuality within this area causes much confusion. In reality this zone includes both sexuality and gender issues relating to hygiene, self-image and self-awareness. The patient's need to express their individual and self perceived needs relating to hair, make up, washing and shaving (facial if male and lower limb if female). Emily does not normally wear make up but she does like to have her hair looking presentable. One Health Care Assistant after bathing Emily, put her hair in curlers.
Sleeping: Lack of sleep and sleeping in a strange environment can have detrimental effects upon an individuals mental state. Promoting good quality sleep and rest in hospital is difficult. The wards are always busy and very often noisy. Limiting the number of visitors to each bedside and monitoring noise levels can help. Providing comfortable and the right number of pillows may also help. Unfortunately there are still difficulties and although necessary from a health and safety position, ward night lights do not promote rest.
Dying: People die everyday but an individual does not. However, a patient and his or her relatives may have concerns about the possible worsening of an illness. Patients with a terminal illness or the elderly, may "live with the prospect of death" and the nurse should handle these concerns with care. On a practical front the documentation of who to contact if the need arises should be made. If living alone the patient may have pets that need to be cared for. In dealing with anxiety, the nurse may need to contact distant friends, a spiritual advisor or even a neighbour.
The suitability of the Roper, Logan and Tierney model within orthopaedics
It can be argued that many nursing models are unnecessarily complicated. Yet the RLT nursing model may be regarded by some nurses as being simplistic. This is a mistaken view. The RLT model has depth that will only become apparent with regular use by the practitioner. This is particularly true when exploring the component factors related to dependency. Here it is for the practitioner to use their own judgement, as to when to step back and allow the patient to do more for his or herself.
There is no ideal nursing model and in practice, the nurse may subconsciously use a combination of models. Each nurse (in the opinion of the author) may carry their own nursing theory or philosophy, in their head. However, it may not necessarily be the right one.
The RLT model has the balance of being relatively easy to allow familiarisation, together with the depth to allow adaptation in variable settings. The model itself is certainly not the worst in existence but it may not necessarily be the best.
Taking mobility as the central focus within orthopaedic nursing, can the above model be improved? Balcombe (1994) has attempted to answer this question by placing the patient's desired health state at the centre of nursing care. Giving eleven areas for consideration within the assessment criteria; mental state, diet, self concept, sleep and rest, breathing (and cardiovascular state), home environment, pain, movement (and mobility), behaviour, hygiene and aspirations.
Davis (2005a) takes this one step further by adapting the activities of living model (Roper, Logan and Tierney 1990) to orthopaedics. By centralising mobilising the "Davis model" shares some characteristics of the Balcombe model. Incorporated into the Davis model are the activities of living from Roper, Logan and Tierney. Together with the lifespan and the dependence-independence concepts from the same model.
The possible advantage of the Davis model is that it recognises the value of other models and builds upon them. Added to the above is a self-empowerment framework, an area representing individualised nursing that includes assessment and finally an "other" category. This area called "factors influencing" is the framework for factors not necessarily covered by the others.
An unfortunate disadvantage of the RLT model is the placing of pain under communication. Based on the view that the patient must express and therefore communicate their experience.
The question is does pain really fit within communication? The impression given is that the communication area is something of a catch all. Balcombe has the advantage of recognising the importance of pain as a factor in its own right and not merely as a sub-factor. Davis is honest enough to actually have an "other" category.
One possible way of combining all that is best from the above models would be the continued use and development of integrated care pathways. Care pathways are documentation and care planning tools, following agreed guidelines and protocols while based upon evidence based practice (National Electronic Library for Health 2004, Santy 2005b). Care can be documented and any deviations recorded as a variance (Bayliss and Salter 2004).
The UK government has identified the use of the integrated care pathway as having significant benefits to patient care (Davis 2005b). However, less than fifty percent of trusts actually use them (House of Commons 2004).
Each care pathway should be tailored around the unique needs of each clinical area (Bayliss and Salter 2004). So recognising their inherent speciality. A key feature of the Davis model (in being different from the Balcombe model) is the recognition that orthopaedic nursing is a speciality and therefore deserves a specialised nursing model."'
Government policy
There is today a wide spread professional and government support for the concept of patient centred care (Price 2004). Current thinking has a focus on benchmarking and clinical governance. The aim is to provide a structured approach to the comparison and improvement of clinical practice (Bayliss and Salter 2004, Burton 2004).
Government policy directives provide the structure for future planning in healthcare (Martin 2001). There are a number that influence current thinking, including The NHS Plan (DOH 2000), various National Service Frameworks and The Essence of Care (Parkin and Bullock 2005). The influence of government policy may be based on the principle that "he who pays the piper calls the tune."
The National Service Framework for Older People
It is generally accepted by many that age discrimination can and does exist within the National Health Service (DOH/SNMAC 2001, Coombes 2001 and Kmeitowicz 2001). There is however some difference of opinion as to whether age discrimination is endemic or an aberration from normal practice. Forster (1993) quoted Eric Midwinter the former director of the Centre for Policy on Ageing as saying, "Discrimination by age is as vicious as discrimination by race or sex and is not borne out by medical evidence." The suggestion is made that discrimination may be unintentional and that health care professionals are unaware that the older person can benefit from many procedures.
The National Service Framework for Older People (DOH 2001) has been interpreted as a plan to end age discrimination within the National Health Service (Kmietowicz 2001). The policy document itself gives precedent to the subject of age discrimination. The declared aim of Standard One being, "To ensure that older people are never unfairly discriminated against in accessing NHS or social care services as a result of their age." This statement is reinforced by Standard Two whose declared aim is, "To ensure that older people are treated as individuals and they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries." The objective of the NSF is to guarantee fair and equal care for the older person.
Concerns as to the differences in care across the country were summed up by Bowling (1999), who wrote of evidence of age being used as a factor in health care provision and in the invitation of joining screening programmes.
In an ideal world people are and should be treated equally. Treating people equally is not treating all people in exactly the same manner. It is instead giving equal consideration to their individual needs, so as to avoid discrimination. All patients have the right to be treated with dignity and respect (Williams, Shannon and Catalano 1999) and this includes the right to privacy. However, we do not live in an ideal world. If people were treated with equal consideration there would be no necessity for anti-discrimination policies.
Standard six of the NSF is of relevance within the sphere of orthopaedic nursing, as it highlights preventative measures regarding falls. Research suggests that the strongest predictor of having an osteoporotic fracture, is having had a previous one (Minns, Dodd, Gardner, Bamford and Nabhani 2004). Although it is important to prevent the first fall, we must regognise that once a fall has taken place, prevention of further falls is equally important.
The Essence of Care
Although it may be tempting to think that where the above NSF ends, The Essence of Care (DOH 2001) begins. This is not strictly true. For example, both publications share the same original year of publication.
Furthermore, the various National Service Frameworks (of which there are now several) deal with issues within specific client groups. Besides the National Service Framework for Older People, there are frameworks specifically for diabetes and mental health.
Originally The Essence of Care consisted of eight core aspects considered crucial to the quality of the patient's experience of care (Bayliss and Salter 2004). A ninth aspect was later added focusing on communication (Burton 2004, Modernisation Agency/DOH 2003).
The nine patient focused benchmarks are;
*Continence, bladder and bowel care
*Personal and oral hygiene
*Food and nutrition
*Pressure ulcers
*Privacy and dignity
*Record keeping
*Safety of patients with mental health needs in acute mental health and general hospital settings
*Principles of self-care
*Communication between patients, carers and healthcare personnel
The influence of government policy on care delivery
The National Service Framework for Older People was set up at least in part to counter ageism. Age simply should not be the major over riding factor in (although it may still influence) the choice of care.
The Essence of Care is a more generalist document, applicable to all fields of nursing. Laying down as it does, specific guidelines to form a foundation for the future delivery of nursing care.
Emily at 100 years young may have been expected to live less than five years, even before surgery. That however is not the point. The decision to carry out surgery is based on the relief of pain and the restoration of function. By undergoing surgery for her hip fracture, quality of life for Emily will be improved. Emily will it is hoped, spend her last years pain free and mobile with a walking frame.
Although Emily is something of a success story and her nursing care can be judged as being of a more than acceptably high standard. Based upon the current benchmarking thinking, it cannot be necessarily judged as excellent in its entirety.
Emily was well cared for. She made a remarkable recovery and was discharged, pain free and mobile. However, two factors detract from this otherwise great success. First of all the quality of the documentation and secondly, the missed fracture of the right ulna.
Pressure areas documented as being intact and blanching by one shift, were identified by another as patently not being intact. The fracture to the ulna was not identified until the sixth post operative day. It will be remembered that although the injured area was identified by the admitting nurse. It was documented as the wrong forearm. If during care delivery healthcare staff cannot get the basics right, how can improvement be implemented?
Final thoughts and the future of orthopaedic nursing
The nine Essence of Care core aspects are in the opinion of the author, comparable with the activities of living concepts advocated by Roper, Logan and Tierney. It recognises several fundamental requirements necessary to maintaining the wellbeing of a patient. Including nutrition, pressure area care and certain psychological aspects within communication and self-care. However, as with any nursing model, if not actually used as a guide during care delivery then its use is of limited value.
The Roper, Logan and Tierney model is a good all round general purpose nursing model, suitable for adaptation and modification within variable clinical settings. Even so, there is an argument that in certain specialist areas, such as trauma and orthopaedics, different approach using either another model or a modified version of the RLT model, may now be necessary.
The introduction of a change of emphasis, such as a greater focus on mobility within the framework of care delivery, coupled with the clearly set standards of the Essence of Care, may prove to be beneficial to our patients. The time has come for orthopaedic nursing to have its own nursing model.
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