Transfer of Care

The following report is based on the case study of Joseph, who has recently been discharged from hospital’s acute care settings. The report will mainly highlight the transition of care under the parameter for the strength based nursing. The report will also highlight the importance of the ethical, legal and cultural guidelines for a competent nursing care plan.

According to Enderlin et al. (2013), the principle of transfer of care refers to the movement of people between the locations, providers or different levels of care as their health care condition and the care needs changes. Enderlin et al. (2013) are of the opinion that the movement facilitated by the transfer of care might cast an adverse or negative impact on the people and their carers. The key principle of the transfer of care includes engagement of the older person and their family members in the decision making process, medication reconciliation which includes proper discharge planning and on-going management plan for communication with the general practitioners (Enderlin et al. 2013). In case of Joseph, the decision-making process for the health of Joseph will include his primary care giver along with his wife. The primary care giver will be his children like in this case his daughter. According to older adults are at high risk for gaps in the transition of care process and these gaps might result in re-hospitalization. In order to successful transition of care, proper education of the primary care givers about the patient’s individualized care needs like cognitive needs, sensory needs and physiological needs are important.

As per the Joseph’s care study, the course of action will be improvement of the overall health and well-being of Joseph and reducing the chances of the re-hospitalization. In order to achieve the goals, health literacy will be given to Joseph’s primary care giver in order to educate them about Joseph’s immediate care needs. Joseph’s wife will also be educated regarding why taking assistance or residential care support will be helpful for Joseph and his wife keeping their age into consideration. The Primary Health Tasmania provides a special aged care service. Under this service, the healthcare professionals educate the older adults about the importance of the shared transfer care. The awareness is generated by increasing the trust during the course of the awareness journey, health-related outcomes and well-being (Primary Health Tasmania, 2019).

The objective set for the achievement of the goals is guided by the principle of the strength-based nursing care (SBNC). The value 5 of SBNC is defined by the concept of self-determination, which respects person’s self-knowledge and values choice, and thereby increasing self-determination (Boswell and Cannon 2018). Joseph and his wife Sophia wish to stay at their own home and does not wish to shift under the residential care support. However, constant support will be crucial for the health and well-being of both Joseph and Sophia taking their age into consideration. The education about the importance of constant support for their health and well-being might be helpful for gaining their consent for availing support services at home. The Department of the Health and Human Service of Tasmania (2019), has a special Tasmanian Home and Community Care Program. Under this program, the trained professionals provide per-time support to the aged individuals at their home. This support might include help in taking mediation, taking nutritional food or performing other daily activities and helping them to socialize at the community level. Proper education and awareness about seeking help will help Joseph and Sophia to vouch for their value based choice based on their self-knowledge. Availing support while at home will improve their health condition and thereby helping to prevent the chances of hospital re-admission.

Improving Physical Health

The second goal in relation to Joseph care will be taking assistance in order to maintain a clean household and performing other daily activities like washing the dishes, cleaning of clothes and floors and the outside garden area. This goal will be achieved via taking consent for Joseph and his wife about availing domestic help service by making them understand its importance towards healthy living. Moran et al. (2014) are of the opinion that maintenance of the clean surroundings is a mandatory requirement for the patients who are recently discharged from the hospital. Moran et al. (2014) stated that geriatric patients, upon return to home after long-term stay at the hospital suffer from immune deficiency and thus are prone to infection. Maintenance of clear surrounding will help to reduce the chances of cross-infection and improving physical well-being. Maintenance of clean surroundings also helps to improve the emotional well-being. The value 6 for SBNC mainly emphasize for person and environment are integral. According to Boswell and Cannon (2018) value 6 highlights the environment affects that person and family. Having a clean environment helps to improve the health and well-being of the people via increased the quotient of the “goodness of fit”. Boswell and Cannon (2018) further stated that having a clean environment helps to increase their strength and self-determination for self-driven approach for healing and healthy thriving. Mowbray in Tasmania has special domestic and personal care support which helps to manage everyday activities under a safe secure and healthy home environment. The major activities include dishwashing, house cleaning, ironing, unaccompanied grocery shopping, helping with the meal preparation (The District Nurses Tasmania 2019).

Additional goals for Joseph and his wife Sophia will be mental health counseling. Kamiya et al. (2013) are of the opinion that the older adults who suffer from health related alignments, mainly remain mentally depressed and refuse to socialize. This mental depression and social isolation increases complication of their physical health. Taking help from the mental health professionals and attending counseling process might prove to be helpful for them. This approach is again guided by the provision 5 for the SBNC as it increases the sense of self-determination of the service users. Statewide Mental Health Services by Tasmanian Government (2019) has a special Adult Community Mental Health Services, which provides domestic family based mental counseling help and support to the older adults.

Goals	Measures to Accomplish the Goal	Services Available
Goal 1: Improving physical health	Educating about the importance of taking services while at home	Home-based health care assistance by Department of the Health and Human Service of Tasmania
Goals 2: Maintaining a clean environment	Taking assistance for personal and domestic care	Domestic and personal care by The District Nurses Tasmania
Goal 3: Improving mental health	Taking support from home-based mental health counselling	Adult Community Mental Health Services

 

The legal principle for the decision making process in nursing is guided by the rules and the regulation of the Australian Human Rights Commission. As per the Tasmania Charter of Rights, it is the right of every human to get equitable service and availing the provision to vouch final consent for themselves.  This concept is again guided by the ethical principle of autonomy. According to the Nursing and Midwifery Board of Australia (NMBA) (2018), a nurses must help patients in the decision making process through informed consent and this helps to respect the patient’s autonomy and patient’s own right for decision making. The professional code of conduct for the nurses and the midwives also vouches that proper protection to privacy and confidentiality must be given to the service users (NMBA 2018).

Maintaining a Clean Environment

The main ethical principle which must be considered in the decision making process is guided by non-maleficience. The ethical principle of non-maleficience signifies non-harming or inflicting less harm to the service users in order to achieve the beneficial outcomes (Beauchamp, 2016).

Thus while assisting Joseph and his Sophia in the decision making process, proper respect must be given to their autonomy. Like even after educating them about their health concerns, they are unwilling move under residential care support program, their opinion should be respected and domestic care support plan must be proposed as highlighted under main goals of the care. This will help to protect the ethical principle of autonomy or the human rights while giving importance of the ethical principle of non-maleficience. In the health education process, privacy and confidentiality of both Joseph and Sophia must be maintained.

According to Giger (2016) culturally safe care is guided by the principle of trans-cultural nursing. The theory of trans-cultural nursing highlights that respect must be given to the cultural thoughts and values of the health care service users. In doing so, the overall quality of the care and the patient’s outcome can be increased via giving increasing patient’s level of satisfaction and trust (Giger, 2016).

For example while arranging for the domestic help like cooking or unaccompanied grocery shopping, it will be the duty of the attending nurses at that locality to inform the domestic service users about the food preferences of Joseph and Sophia if any. This will help to increase the trust of Joseph and his family in the overall care plan and thereby increasing the quality of care. Moreover, while educating about the importance of taking help, a culturally competent nurse will help them to communicate freely. Douglas et al. (2014) are of the opinion that the people who are not native to Australia might not communicate in English fluently. For those non-native people in Australia, use of interpreter or a culturally competent nurse prove to be effective.

Conclusion

Thus, from the above discussion, it can be said that three gaols are highlighted in order to promote successful transition of care include culturally competent care plan through education about the importance of taking seeking help under the residential settings and managing domestic helps/personal care support and mental health counselling for Joseph and his wife Sophia. The care plan must be given while giving respect to the service user’s autonomy.

References

Australian Human Rights Commission. 2019. Tasmania: Charter of Rights. Access date: 16^th Jan 2019. Retrieved from: https://www.humanrights.gov.au/tasmania-charter-rights

Beauchamp, T. L. 2016. Principlism in Bioethics. In Bioethical Decision Making and Argumentation (pp. 1-16). Springer, Cham.

Boswell, C. and Cannon, S., 2018. Introduction to nursing research: Incorporating evidence-based practice. Jones & Bartlett Publishers.

Department of the Health and Human Service of Tasmania. 2019. Tasmanian Home and Community Care Program. Access date: 16^th Jan 2019. Retrieved from: https://www.dhhs.tas.gov.au/hacc

Douglas, M.K., Rosenkoetter, M., Pacquiao, D.F., Callister, L.C., Hattar-Pollara, M., Lauderdale, J., Milstead, J., Nardi, D. and Purnell, L., 2014. Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing, 25(2), pp.109-121.

Enderlin, C.A., McLeskey, N., Rooker, J.L., Steinhauser, C., D’avolio, D., Gusewelle, R. and Ennen, K.A., 2013. Review of current conceptual models and frameworks to guide transitions of care in older adults. Geriatric Nursing, 34(1), pp.47-52.

Enderlin, C.A., McLeskey, N., Rooker, J.L., Steinhauser, C., D’avolio, D., Gusewelle, R. and Ennen, K.A., 2013. Review of current conceptual models and frameworks to guide transitions of care in older adults. Geriatric Nursing, 34(1), pp.47-52.

Giger, J.N., 2016. Transcultural Nursing-E-Book: Assessment and Intervention. Elsevier Health Sciences.

Kamiya, Y., Doyle, M., Henretta, J.C. and Timonen, V., 2013. Depressive symptoms among older adults: The impact of early and later life circumstances and marital status. Aging & Mental Health, 17(3), pp.349-357.

Moran, M., Van Cauwenberg, J., Hercky-Linnewiel, R., Cerin, E., Deforche, B. and Plaut, P., 2014. Understanding the relationships between the physical environment and physical activity in older adults: a systematic review of qualitative studies. International journal of behavioral nutrition and physical activity, 11(1), p.79.

Nursing and the Midwifery Board of Australia (NMBA) 2018. Code of Professional Conduct for the Nurses and Midwives. Access date: 16^th Jan 2019. Retrieved from: https://www.nursingmidwiferyboard.gov.au/

Primary Health Tasmania. 2019. Shared Transfer of Care. Access date: 16^th Jan 2019. Retrieved from: https://www.primaryhealthtas.com.au/for-health-professionals/programs/connecting-care/shared-transfer-care/

Statewide Mental Health Services by Tasmanian Government. 2019. Adult Community Mental Health Services. Access date: 16^th Jan 2019. Retrieved from: https://www.dhhs.tas.gov.au/mentalhealth/mhs_tas/gvt_mhs/adult_community_mental_health_services

The District Nurses Tasmania. 2019. Enabling you to manage everyday activities in a safe, secure and healthy home environment. Access date: 16^th Jan 2019. Retrieved from: https://thedistrictnurses.org.au/services/domestic-assistance-home-help/