National Institute For Health And Clinical Excellence Nursing Essay

matter Institute For Health And Clinical justice Nursing EssayThis essay will critically appraise and evaluate the evidence that underpins tradeal Therapy blueprint at bottom a hospice setting and specifically an implemented interjection with reference to a trip ruminate. built-in at heart this will be a critical analysis for the rationale and clinical cerebrate in arrears employing that interposition, including the legislation and political drivers that govern and influence the intervention, the OT practice, and the setting, along with and in relation to the wider context of the service.The case claim focussed upon deep down this essay, surrounds Mrs A (pseudo name riding habitd), a lady in her early 60s, diagnosed with an inoperable knocker carcinoma with bone metastases. Initially Mrs A had heavyy accepting her deteriorating condition, resulting in her presenting with severe s help and loss of occupational identity and engagement in her disembodied spirit-long passion of drawing, despite trialling pharmaceutical treatments. This along with her low mood levels and favored aim to stay with her family in her business firm meant she was referred to community mitigatory financial aid OT (Appendix-slide 4, 5).The World Health makeup (WHO) (2012) defines palliative trade as the physical, psychosocial and spiritual approach that improves quality of life of the persevering and their families associated with a life limiting illness. This concept is re-iterated deep down palliative c atomic number 18 policies and a prominent piece of legislation within this specialist field is the End of demeanor C be Strategy (Great Britain. Department of Health (GB.DoH), 2008). Although published in 2008, it has developed from other integrated publications, such as the National Health Service (NHS) End of Life Care Programme (2007) and is the first issue and comprehensive framework aimed at promoting high quality attending for all separates that are approaching end of life. It also provides a basis for wellness and social care services to build upon and the core concepts of all health professionals duty of care whilst supporting patient and their carers.The school of thought of palliative care differs in focus from the medical present of health care, with its core focus on quality of life and purposefulness consequently it fits well aboard OT core principles and paradigms of holistic and patient centred practice (Lucey, 2012 Othero, 2010). Although OT intervention with patients with palliative care needs is non a new concept, there is little evidence that supports this landing field of practice (Ameri gouge Occupational Therapy Association (AOTA), 2008 Cooper, 2006). and the Improving Outcomes in Breast pubic louse document ack instantaneouslyledges the essential role and key concerns for OTs, assisting patients in sustaining their independence, autonomy and empowering the maintenance of control over own health decisi ons (NICE, 2002). to boot the Route to Success in End of Life Care Achieving Quality for Occupational Therapy (College of Occupational therapist (COT), 2011) and the National Service Framework for Older People (2001) provides a framework for OTs to work within. These are alongside other ethical and legal principles and professional codes of conduct, such as Code of Ethics and Professional lend (COT, 2010) and the Professional Standards for Occupational Therapy Practice (COT, 2007).Intrinsic within the core values of OT, are the concepts of the occupational constitution of individuals and that occupation has the cap skill to influence health, a key area within the care of Mrs A (Turner, hold dear and Johnson, 2002). Wilcock (2006) suggested that occupation is a basic human need found across the life span by dint of doing, universe, becoming and belonging, and the importance of occupational engagement in palliative care has been found in many research studies (Burkhardt et al, 2011 Lyons et al, 2002). Vrkljan and Miller-Polgar (2001) provided evidence for the value of breast cancer patients take part in meaningful occupations in score to enhance wellbeing at the end of life. In accordance to these principles Mrs A is experiencing occupational deprivation cod to her inability to engage in drawing, even so the age of this study restricts its application to todays contemporary practices. jibe to Ahlberg et al (2003) cancer-related fatigue (CRF) is the most commonly reported symptom associated with cancer and its treatment, preventing engagement in occupations, usual procedure and infringement on quality of life (Cooper, 2006). Classified as a distressing, subjective and persistent comprehend of exhaustion or tiredness, fatigue can be experienced during or after treatment by 70%-100% of cancer patients (Stone and Minton, 2008) (Appendix-slide 6). Only recognised as an official diagnosis by the International classification of Diseases (ICD-10) in 1998, its impacts on everyday occupations are subjective and no two individuals experience the CRF in the resembling way, making standardised assessments difficult. The impacts of fatigue outreach the individual concerned, increasing duties and responsibilities of carers, friends and family, therefore, it is an imperative OT role to assist, support and educate these individuals in the perplexity of fatigue in a way that is constructive to them (Kealey and McIntryre, 2005). These are evident points within the case of Mrs A as she felt she had lost ability to engage in her artistic passion (La Cour et al, 2007 Townsend and Polatajko, 2007). on base policies and legislation, the application of the compensatory frame of reference and the Model of Human Occupation (MOHO) informs and directs OT practice (Turpin and Iwama, 2011 Kielhofner, 2008). The compensatory frame of reference applies to Mrs A as it aims to maximise her independence and enhance her quality of life. This is achieved by foc using on the management of her symptoms quite an than the proactive treatment and cause, a notion that is synonymous with the values of palliative care. universe a functional approach it provides a basis for the fatigue management as it assists with the understanding of the concepts and an alternative method of participating in an activity, however this lack evidence (Duncan, 2011). Although the biomechanical frame of reference addresses occupational performance limitations through concepts of forcefulness and endurance, aspects such as energy conservation could also be team uped with the compensatory frame of reference as a method of increasing the applicability to Mrs As situation and minimising the impacts of her fatigue levels on her occupational engagement (Duncan, 2011 Curtin, Molineux and Supyk-Mellson, 2010) (Appendix-slide 12).Again, sympathetic to the philosophy of palliative care, the MOHO models holistic approach is centred on Mrs As needs (Kielhofner, 2008). Desp ite the MOHO model having an marvellous evidence base and reportedly being the most extensively applied occupation found model in OT practice, there is little evidence base for its application within palliative care and CRF (Lee et al, 2008). Additionally, the models oral communication can inhibit inter-professional working (IPW) within the multi-disciplinary team (MDT), therefore it was not applied in its total within the setting and the practice with Mrs A (Melton, Forsyth, Freeth, 2010). Further more(prenominal), MOHO lacks the idea of spirituality, a contemporary concept within both OT and palliative care literature (GB. DoH, 2010 Belcham, 2004), and an aspect that is important within the Canadian Model of Occupational carrying out and Engagement (Polatajko, Townsend and Craik, 2007). Nevertheless, the MOHO model provides understanding of Mrs As motivation for engagement in occupation (Lee et al, 2008) and according to Kielhofner (2008) it addresses Mrs As volition, habitua tion, performance capacity, values, roles, culture and her occupational identity. These are all key areas that her CRF had impacted on and it aided appellative of her difficulties and direction for intervention (Costa and Othero, 2012) (Appendix-slides 7-11).In order to assist Mrs A with her difficulties and implement an intervention, milieual and fatigue assessments were conducted indicating occupational imbalance, within her lack participation of drawing and finish of her occupational identity (Whiteford and Hocking, 2012 Mackenzie and OToole, 2011 Creek, 2003). Being non-standardised both assessments lacked the underpinning reasoning for the application and meant that outcome measures would be more difficult to certify the potentness of the intervention, in terms of its set up on Mrs As quality of life (McColl, 2010). However it enabled the practice to be patient centred, qualitative and more flexible with no formal structure, which is imperative within the nature of end of life care and ensures interventions are meaningful to Mrs A (Fawcett, 2007). Completion of the assessments also supported the formulation of her aims, which were to manage her fatigue level in order to regain engagement in her former self, and participate in drawing for her husbands Christmas present, therefore justifying the murder of fatigue management intervention (Appendix-slide 14).Due to the nature of the service, assessments and sign conversations needed to be completed within a short amount of time, yet were aided by the fact that they took place within her home environment with her family present. Research has supported this concept as it provides a in-personised and caring therapeutic environment (Meyers, 2010 Brazil et al, 2005), additionally achieving a patients preferred place of care has been highlighted as prominent need within national drivers. However in these circumstances interference from carers and family members or resistance to OT interventions as already i n preferred place of care periodically inhibited full engagement in intervention (AOTA, 2008).Lowrie (2006) and Halkett et al (2005) reported that fatigue management, compromising of energy saving, adaptation of role, activity planning and prioritising techniques, is a commonly recommended intervention for and sought after by cancer sufferers in order to maximise quality of life (Hawthorne, 2010 The National Comprehensive Cancer Network (NCCN), 2009). Although Saarik and Hartleys (2010) study comprised of a four week programme based in a hospice day care, as opposed to within the community, it concluded patients report decreased fatigue levels, increase ability to cope and improved functioning post receiving fatigue management.Furthermore the NCCN (2009) has recognised the importance of CRF management and has guidelines recommending that integrative non-pharmacological interventions, including fatigue management are implemented with all individuals undergoing cancer treatment, not only palliative patients. Though its importance is highly acknowledged there are multiple studies indicating that cancer patients are not receiving the fatigue management intervention in order to meet their needs (Purcell et al, 2010). A study conducted in the United Kingdom, supports this concept, as only 14% of the 1370 of the participants with mixed diagnosis reported receiving fatigue management (Stone et al, 2003). as well as in an American study of 814 participants, 23% suffering from CRF received management intervention (Henry et al, 2008). However extrapolation of the findings for this American studies small sample size would reduce its validity within the worldwide population and there whitethorn also be evidence of cultural norm differences.Attributable to its recent development, the intervention lacks clarity and a structured evidence base, which is fundamental in assuring a rationale and clinical reasoning for its use within practice (Lowrie, 2006 Wratton et al, 2004). Additionally there is insufficient robust evidence and investigation into the interventions efficiency however this does not certify the ineffectiveness of the intervention (Duncan, 2011). Alternatively the benefits of the fatigue management include that even token(prenominal) changes deliver validating impacts, its simple applicability and that it is highly patient centred, thus is tailored to Mrs As individual situation (Ream, Richardson and Alexander-Dann, 2006). Overall, literature, although limited, has found that fatigue management intervention has yielded positive outcomes for cancer patients where other conventional interventions arrive at failed, justifying its application with Mrs A. As with many contemporary interventions, yet research is mandatory in order to watertight effective clinical intervention and management of CRF (Mustian et al, 2007). This coincides with Bannigan et als (2008) statement of further development, which highlights research into the effective ness of OT interventions is now a priority for OTs.While it is a common opinion that traditional rehabilitation based interventions come back few improvements in physical functioning and suggested as an unethical intervention for palliative patients, research has shown that it is admit at many points during the disease trajectory, improving self-efficacy, control and identity, therefore applicable to Mrs A (Guo and Shin, 2005 Eva, 2001). Engagement in occupations reportedly assisting with an individuals ability to connect with the purpose in life and enhancing spiritual wellbeing, quality of life and ability to cope with their situation (AOTA, 2008 Prince-Paul, 2008 Jacques and Hasselkus, 2004). The role of OTs in palliative care rehabilitation has been supported through national guidelines and literature with NICE (2004) recommending and that all patients should receive a planned rehabilitation approach, including continuous assessment, goal-setting, care planning, intervention an d evaluation to prevent loss of identity and poor quality of life. Despite this there is little focus on how this is delivered in practice, resulting in settings lacking the right rehabilitation approach and consequently the case study setting displaying an absence of comprehensive evidence for its occurrence (Eva et al, 2009 National Council for lenitive Care (NCPC), 2006).Set within a community hospice setting the service provided to Mrs A was governed by the Care Quality Commission, equivalent to the NHS. However unlike the NHS, being an independent unselfishness the hospice has a short organisational hierarchy, therefore limited layers of bureaucracy mingled with the patients and their families, the health professionals and the leadership team. This means that the practice is not governed by such tight and mandatory restrictions and can be creative and adaptive to meet Mrs As needs. Although consequently, it is not so economically and fundamentally underwrite as a larger or ganisation like the NHS. Regardless of this it is imperative that service integration between the hospice and the NHS occurs and maintained to benefit Mrs As care.Furthermore, the small size of the organisation impacts upon its culture and enables opportunities for health professionals to undertake and be involved in service improvement and quality assurance activities, which attribute to both professional and personal achievements, furthering the quality of care provisions. Also, issues that are raised are rapidly and effectively examined by the directors with the patients needs central to all actions, instead of cost savings. Despite this, the importance of cost implications remain closely examined as being an independent charity, it is not funded by the NHS and crucial fundraising ensures availability of all resources, yet this can be difficult and precarious especially within todays economic climate.Due to the nature of Oncology and Palliative care being labyrinthian and demand ing, many health professionals from differing disciplines have to work collaboratively in order to combine expertise and create a service effectively integrated to resolve Mrs As key areas of need, whilst making resources go further (Atkinson, Jones and Lamont, 2007 NCPC, 2006). According to NICE (2002) an integrated MDT and the occurrence of effective IPW is imperative to ensure seamless continuity of care, supportive and seasonably response to patients needs (WHO, 2012). Although the MDT within the setting for the case study lacked a dietician, therefore this role was bout between all other health professionals, occasionally causing some duplicated information or gaps within service provision, being potentially detrimental to Mrs As health and wellbeing (Infante, 2006).Central to the idea of effective IPW is communication and due to the nature of the community setting, this can be made more challenging, with many health professionals on visits when their input is needed (Infante , 2006). This is exaggerated by many of the health professionals within the team working part-time hours. In order to overcome this and instil effective and efficient practice each day, a mandatory multi-disciplinary meeting occurred for all health professionals to discuss patients within their care.Overall the OT presence within the MDT team was well respected, other health professionals identified and recognised the core OT philosophy, which is indicative with end of life care in literature, and replicated in the reasoning for Mrs As referral. This concept was also readily recognised by the directors and replicated within the OT budget. However, regardless of this the OT practice and patient service was restricted due to limited OT professional hours, with recent audits indicating that organisational OT targets were not being met and highlighting the increased need for more OT hours within the caseload. Conversely, despite receiving a late initial phone call, Mrs As level of care showed no evidence of this occurrence, although it could have severely impacted upon her if she required additional input. Furthermore there was evidence of professional tribalism, as some protective professional relationships were formed, limit effective IPW and efficiency of her care between the MDT (Armstrong, 2007).Improved quality of life and engagement in meaningful occupations are primary outcomes of all OT intervention within palliative care (AOTA, 2008). In summary, the outcome measures utilise within the setting were limited, non-standardised, and based on patient feedback (Appendix-slide 18). Yet qualitative and centred around Mrs As the fulfilment of her occupational need and aims, by completing a drawing for her husband and remaining within her home. In addition to this, the fatigue management techniques were found to be transferable to everyday activities, thus Mrs A reporting improvements in her overall occupational participation, quality of life and consequently he r wellbeing, therefore further justifying its use as an intervention (Cooper and Littlechild, 2004). Nevertheless within palliative care the importance of timeliness and an awareness of disease growth are crucial for both Mrs A and the OT, as it is evitable that Mrs A will develop further occupational deficits due to disease progression therefore outcomes are short term and future positive or negative outcomes may not be a direct cause of the intervention (COT-HIV/AIDs, Oncology and Palliative Care Education, 2004). This may be fundamental in terms of patient satisfaction as to whether these aims are achieved and then lost again, or not achieved at all. In line with the importance of timeliness, is the concept that precedent referral to OT services would have restricted the degree of fatigue that Mrs A presented with and also the greater the impact of the fatigue management could have had on her quality of life.McLaughlin and Kaluzny (2006) recognised that patient feedback as an o utcome measure is a fundamental part of quality and service improvements within care. Despite originally being a moot concept, patient feedback has now become so well acknowledged that it has formed an essential part of health planning documents (Darzi, 2008). However due to this, it does not conclusively show financial benefits of the OT service, yet presents the importance of patient choice, quality of life and patient led care. Therefore a standardised outcome measure that could have been implemented to provide structure and improve OT practice whilst acting as an assessment, is the Model of Human Occupation Screening Tool (MOHOST). Implementing this tool would also embed the MOHO model framework further into the OT practice (Kielhofner, 2008). Being observational it wouldnt require input from Mrs A, therefore will not exacerbate her fatigue levels, although only gives the OTs knowledge of her difficulties. Additionally the Quality of Life questionnaire and the Fatigue Impact S cale, although not OT specific, could be implemented to provide put across areas of focus and as an outcome measure, as these are key elements of the purpose of OT intervention and palliative care settings (Pearson, Todd and Futcher, 2007). Utilising these assessments tools within OT practice would demonstrate both the benefits and the cost effectiveness of the OT intervention, crucial elements within a charity run organisation.To conclude, the role of an OT within palliative care is diverse and challenging, although ideally positioned to assist Mrs A in maximizing her quality of life and achieving her aim of drawing her husbands Christmas present (Kealey and McIntyre, 2005 Vockins, 2004). Achievement of this surrounds addressing her fatigue difficulties in a holistic, ethical and patient centred way, whilst having specialist knowledge of disease related problems within contemporary evidence based practice (Berger, 2009 Steultjens et al, 2004), a notion that has been acknowledged b y both professional bodies and researchers (Oertli, 2007 National Breast Cancer Centre and National Cancer Control Intitiative, 2003).