Safe and Quality Care includes Holism

Written by Professor Kirby

My Director of Nursing (DON) accepted Mr. W. as a scheduled admission to our skilled nursing facility on a Friday evening. She did not inform the nursing staff he was a high risk for falling or allocate additional staff to monitor this patient. When the nursing staff did receive reports from the hospital, they discovered he was a high fall risk. However, it was too late to discuss the plan of care for this potential admission or if he was an appropriate admission for our setting because the DON left for the day. Unfortunately, this patient was admitted on Friday and fell five times over the weekend.

Although, none of the falls resulted in an injury but the weekend staff was overwhelmed. They made multiple phone calls to the DON in reference to their inability to safely care for Mr. W. The DON informed the staff that she needed to fill the empty beds and as a result, she had to accept this high-risk admission. Then, she instructed the nursing supervisor not to document the resident’s incidents as falls, but a purposeful change in the plane. The nursing supervisor felt this was the wrong thing to do because the resident’s cognition was intact, and he had the ability to ambulate. Her assessment was that the patient clearly fell as a result of his hallucinations. However, she followed through as instructed.

This resident’s cognition was intact, and he had the ability to ambulate.  When the management team returned on Monday, we met with Mr. W. to discuss his plan of care.  He explained he knew when he was hallucinating.  He recognized some of his ideas were not the best choice, but he would proceed with them.  He continued to fall multiple times after the first weekend, and every morning management discussed his care or lack thereof because our staff patterns did not allow for one on one nursing staff to monitor Mr. W. and we’re a restraint free facility.  Therefore, Mr. W. was placed on every 15-minute checks ongoing daily.  Also, a new policy was implemented to perform checks every fifteen minutes on every new resident for the first week on night shift only.  These two interventions produced a safer environment for Mr. W. and future new admissions.

What could we have done differently to promote a safer environment at this skilled nursing home? Or better yet, how could holistic care been implemented? First, the DON view of the patient was number or census driven admission and not person driven admission. If the DON and the nursing team, seen Mr. W. as a person and considered his needs as a whole being fall prevention would have been a priority. They DON was not mindful of the patient’s needs. According to Philbrick (2015), mindfulness is purposefully focusing on or giving your attention to a specific person or thing. Mindfulness was not implemented initially for Mr. W. during the admission process. But, later, mindfulness became a routine part of everyone’s daily routine care to ensure Mr. W’s safety. Consequently, holistic values such as standards were not instinctively initiated by nursing. Dossey and Keegan (2016) defines holistic nursing as person-centered care which involves purposeful and attentive care which aligns with both the American Nurses Association and Relationship Based Care principals, as well. Initially we failed to establish a meaningful relationship with Mr. W., and he was a number on our census. Patient-centered and relationship-based care was developed much later. Unfortunately, it was a forced relationship due to the numerous incidents of falls. However, holistic nurses recognize the physical ailment of the disease as only one aspect of the human need and therefore, the nurse strives to meet both the seen and unseen needs of the patient. The art of caring for the whole person produces hope and gives a better an outlook on life.

References
Dossey, B. M., & Keegan, L. (2016). Holistic Nursing: A handbook for practice. (7th edition ed.). Burlington, MA: Jones and Bartlett Learning.

Philbrick, G. (2015). Using mindfulness to enhance nursing practice. Kai Tiaki Nursing New Zealand, 21(5), 32-33.