This case study will critically explore the person-centered, evidence-based care of the patient SJ and analyze an aspect of pain management with lower back pain to develop an appropriate plan of care that is safe, compassionate, effective, and holistic. The case study will also consider the most appropriate health promotion model for Mrs. SJ’s pain management, the use of guidance and policy to develop an evidence-based pain treatment plan that will facilitate the multidisciplinary team (MDT) to provide care. The case study will also cover the topic of nursing care, the importance of partnership with the patient to promote the patient’s self-care abilities, the nursing role in leading and managing care. During this case study, the rights of the patient are considered, and principles of confidentiality and anonymity will be used following the Nursing and Midwifery Council (NMC, 2018). All relevant names and locations will also be omitted.
The patient, Mrs. SJ, an 80-year-old female, was admitted to the day unit for a left lumbar facet joint medial branch block. Mrs. SJ feels pain which is worse in the left lower back with pain across the outer of the left hip, the left leg has spasms in the morning. She connects worsening of the pain since she tripped 11 months ago, following which she had osteopathy. Mrs. SJ has a past medical history of type 2 diabetes (diet control), hypertension, hypercholesterolemia, intermittent claudication for which she is taking relevant medication. She is on Pregabalin 150 mg, co-Codamol 30/500mg, simvastatin 40mg, Bendroflumethiazide 2.5mg, Ramipril 10mg, clopidogrel 75 mg.
On admission, Mrs. SJ’s mobility was significantly restricted, an X-ray showed moderate to degenerative changes affecting the lumbar spine endplate sclerosis and facet joint arthritis. Mrs. SJ was seen by a physiotherapist and osteopath, and the doctor increased pregabalin up to TDS. From anamnesis, Mrs. SJ had medial branch block to lumbar facets in 2017 when she had a lumbar epidural injection. MRI of the spine lumbosacral spine from November 2020 showed a broad-based disc bulge with moderate spinal canal stenosis at L4-L5, marked left-sided neutral exit foraminal narrowing at L4-L5, and L5-S1, more marked on the left with possible associated synovial cyst arising from degenerative facet joints. In the term of the back pain, the consultant and the doctor have agreed to try medial branch block to lumbar facet on the left. Mrs. SJ was informed about infection, bruising, possible increase pain, and a small incidence of nerve damage as probable complications from the procedure.
Applying the theories and strategies underpinning health promotion, protection and the prevention of ill health
Health promotion, protection, and prevention of ill health are central in people caring and planning their treatment. Chronic pain is a major issue of modern medicine as it impacts patients’ quality of life, condition, and level of life satisfaction. According to National Institute for Health and Care Excellence (2021), chronic pain, or long-term pain, or persistent pain, is one that lasts more than three months and can be divided into primary and secondary. Mrs. SJ has secondary pain as it is caused by an underlying condition and is connected to the pathological process in facet joints and spinal canal.
The main goal in the treatment plan should be the cure of the condition causing the pain and preventing further complications of the condition and possible relapses. Gatchel et al. (2014, p. 120) emphasize the significance of a multidisciplinary approach in pain management as the collaboration between health care providers can enhance the treatment outcomes. The authors see the major aspects of the tactic to be a mutual philosophy of rehabilitation, ongoing daily communication among physicians, and active patient involvement (Gatchel et al., 2014, p. 1221). Indeed, a patient-oriented strategy involving medical, psychological, psychical knowledge can lead to a new synergetic outcome of pain care.
Several studies prove the efficiency of cognitive functional therapy as one of the strategies for treating lower back pain (Gatchel et al., 2014; O’Sullivan et al., 2018). The mentioned theory has developed from an interdisciplinary approach of foundational behavioral psychology and neuroscience and influences modified factors causing pain (O’Sullivan et al., 2018, p. 420). Moreover, in this approach, pain and behavioral control strategies are used that help patients improve self-efficiency and return to their physiological state.
Including this approach is essential to the patient’s care as oftentimes, pain is causing anxiety and other psychological conditions worsening the treatment results. Fighting the mental side of the issue can help improve the results. A study by Gardea and Gatchel (2000, p. 22) proved that among four levels of pain management centers, interdisciplinary team centers show the most efficiency. Mrs. SJ has been having lower back pain for 11 months, and entering the hospital the last time, she was more nervous and irritated than previous times. According to NMC (2018, p. 7), it is essential to respond to people’s psychological, social, and physical needs. A multidisciplinary approach corresponds to this statement and will help to shorten the treatment period.
Applying the underpinning knowledge and skills required to undertake holistic assessments
From the physiological point of view, a patient, according to MRI results from 8th November 2020 report about spinal canal stenosis and left-sided neural exit foraminal narrowing on the level L4-L5 and L5-S1 are more likely to be caused by the synovial cyst. The straightest way to treat pain would be the operation on the spine with targeting the main reason causing the lower back pain and solving it. However, an 80-year-old patient with diabetes mellitus, hypertension, hypercholesterolemia, intermittent claudication that refers to atherosclerosis, and highly possible heart insufficiency night meet a higher level of risk while managing the operation or postoperative period. Protrusion, prolapse, hernia, cyst, and other reasons that could be causing back pain should be primarily treated conservatively to avoid exuberant surgical intervention (National Institute for Health and Care Excellence, 2020, p. 4). According to the guidelines of low back pain and sciatica (National Institute for Health and Care Excellence, 2020, p. 7), the tactic should involve injection and surgical treatment if the pain persists. According to the current state and anamnesis gathering, the pain of Mrs. SJ persists within 11 months. The patient suffers from a lack of sleep and progressive numbness of the left leg area. In this case, considering the nerve root injection might be rational for the patient’s condition. Choosing this tactic will correspond with NMC’s professional standards (2018, p. 9) providing efficient and appropriate treatment to the patient without delay using the best of physicians’ abilities. From the psychological side, the patient should get cognitive functional therapy previously mentioned. The emotional and spiritual condition of the patient is mostly depending on the nursing personnel as they are the ones that interconnect with patients the most. A nurse can interact as the patient’s case manager, monitor his or her responsiveness to the treatment, and provide useful data to other healthcare professionals to enhance the presentation of the current patient’s condition. Maintaining applicable interaction with colleagues is one of the principles of a co-operative working atmosphere advised by NMC (2018, p. 10). Nursing plans of care should include assisting the physician, providing help for the injection procedure, maintaining efficient communication with the treatment team, attending formal interdisciplinary treatment team meetings to review patients’ progress, and evaluating and monitoring patient’s curing outcomes.
Evidence-based, safe, compassionate care and work in partnership with people, families and carers
It is essential to demonstrate patient-centered, safe, compassionate care to the patient and his family. Mrs. SJ has a daughter that was coming to the hospital to get to know about the progress of the treatment and the current condition of her mother. Relatives oftentimes are worried about the state of their close people, and cooperating with them, involving them in the treatment plans is important. Sometimes, the family is facing the harsh decision about the further cure method by signing papers and allowing healthcare personnel to act. Most of the time, the patient is without consciousness or was declared legally incapable. Providing care and attention to the relatives can also bring a positive outcome to further treatment planning.
The initiative for communication with relatives should be taken by all the healthcare personnel as the physicians, and the nurses can emphasize various aspects and details. Nurses cooperate with patients’ families and have the ability to show sympathy, attention, and care. Nurses’ work with the patient is a mutual process that can provide mitigating risk, optimizing recovery and well-being of the patient (Kitson, 2018, p. 100). Focus on practical acts of caring in the working process of nurses plays a central role in providing effective care. Helping Mrs. SJ managing fundamental care needs such as personal hygiene, mobility, sleep, rest, comfort, feeling safe, being respected, and having the possibility to make a choice. The chosen aspect of care was safe, efficient, compassionate, and provided the patient with the most needed help throughout the day and night. In nursing practice, it is important to remember patients’ feelings and psychological conditions. The permanent pain can develop anxiety and depression, and providing care, paying attention to such contingent of patients is essential for their adaptation to the hospital atmosphere, accepting treatment plans, and participating in their care. Identifying, observing, and evaluating the features of a normal patient’s condition and worsening of his or her state is one of the responsibilities of a nurse (NMC, 2018, p. 13). A nurse participates in a multidisciplinary approach, and the nurse’s actions can lead to a faster enhancement of the patient’s condition. That is why following the guidelines for nursing care, implementing in their treatment principles of morality and ethics is essential for modern medicine and healthcare outcomes.
Applying the principles of leading and managing nursing/midwifery care and collaborating within the interdisciplinary team
The principles of leading and managing nursing care are essential in collaboration with an interdisciplinary team. Nurses should represent high professionalism and reliance that will eventually underpin trust, gratefulness, and appreciation from the patients and colleagues. A nurse has always been a symbol of sympathy, goodness, and help. Managing nursing activity created order and a better functioning system. A doctor relies on a nurse as the latter is his right hand and assists during most of the manipulations, operations above the patient. A nurse is a significant chain between a doctor and a patient, a patient and his treatment, and a patient and his relatives. Providing leadership is major in nursing care as it provides protection of people’s well-being and improves their experiences in the healthcare system (NMC, 2018, p. 22). A true leader learns to identify priorities, manage staff, timing, and recourses efficiently caring about healthcare quality service, the satisfaction of patients, and delivering them decent medical aid.
Leadership also involves supporting colleagues by following the Code by helping them in decision-making and showing a personal example (NMC, 2018, p. 22). Checking the amount of knowledge, skills, the competence of nurses is essential for their safe and efficient practice. When the Code is broken, a leader should be ready to gather the staff, raise the issue, and discuss the possible ways of solving the issue. The manner of the true leader should be making a good impression, being the example to the staff, not frightening them or talking with a commanding tone.
While taking care of Mrs. SJ, staff was making several mistakes in providing healthcare. One of the colleagues could not interpret the patient needed help stand up and go to the bathroom. Sometimes, it is not easy to state a patient’s condition and concerns. A professional nurse learns throughout the working practice and gains the experience that allows understanding patients better and providing them proper medical help. This comprehension and experience come within years, but the main task of a leader is to help staff improve their skills and cooperate with a patient with no misunderstandings.
Mrs. SJ did not say her intention out loud; however, feeling the one a nurse takes care of is an essential skill that follows a professional nurse and distinguishes him or her from other colleagues. Trying to be a decent leader, I came into the patient room and helped the nurse and Mrs. SJ to stand up from bed. Mrs. SJ has trouble with active movement because of pain despite the prescribed painkillers. That is why such a patient needs special attention to smoothen the edges of troubles caused by a new disability.
Frameworks, legislation and regulations for clinical governance and quality improvement
Healthcare quality is influenced by clinical governance that is a special framework through which medical organizations are taking responsibility to constantly improve their service quality and provide protection for their patients. Implemented in 1999, the Health Care Act postulated the legitimate level of quality every healthcare organization should aim to (Macfarlane, 2019, p. 174). All the clinical governance frameworks are aiming for delivering patient-centered, safe, and efficient care to every individual in the United Kingdom. Apart from that, there are standards for every direction and condition in medicine that help doctors plan their treatment plan according to the clinical protocols. This can prevent errors and provide the patient with high-quality care. Standards of treatment are developed by the National Institute of Clinical Excellence (NICE) mentioned previously multiple times (Zahir, 2001, p. 2). Minimizing and managing risk factors can identify the issues in safe patients’ care, and if medical organizations have a transparent, honest reporting system, it can prevent recurrences.
Reporting an incident is also essential when providing healthcare as it may report about damaging a patient’s health. All the serious cases in the United Kingdom are reported via National Reporting and Learning System (NRLS) (Macfarlane, 2019, p. 174). Mrs. SJ, before agreeing on nerve root injection, was informed about possible complications from the manipulation, such as inflammation, bruising, pain intensification, nerve damage, and COVID infection. Mrs. SJ signed the form agreeing to the procedure and acknowledging the fact of being informed of possible outcomes. If the patient ends with a severe worsening of the condition due to the doctor’s decision or manipulation that can be proved to be irrational, then the guilt is on the doctor’s side.
Morbidity and Mortality (M&M) meetings can be effective to further prevention of negative outcomes, knowledge spreading, and fostering discussion. Such gathering should help in the friendly atmosphere, involving physicians from various fields, a so-called multidisciplinary approach. Being critical and judging colleagues is a feature of non-professionalism and breaks ethical principles. A human factor might lead anyone to make a mistake, and learning from others saving respect towards them is a sign of professionalism and honor. Colleagues should support each other and cooperate in providing decent care to the patients and improve as specialists.
Clinical governance outside of the healthcare companies can be monitored by the Commission for Health Improvement (CHI) that has a program of visits to each healthcare organization to check if all the activity is corresponding the quality of care (Zahir, 2001, p. 4). Monitoring clinical governance helps improve the efficiency of hospitals and the quality of their services.
The nurse’s or midwife’s role in coordinating, leading and managing the complex needs of people across organisations and settings
Nursing care coordination actions can be divided into three categories: those relevant to the patient, their family, and colleagues; those targeting care and social teams; and those uniting patients and healthcare professionals. An implemented team-based approach of care coordination between a social employee and a nurse gives them a possibility to assess a patient together (Karam et al., 2021, p. 2). This model improved the interconnection between medical organizations and social services and enhanced the complicated patients’ care outcomes. Nurse care coordination has also put a positive impact on improving treatment appropriacy, clinical results, quality of care, interconnections between the personnel, and decreasing the unplanned patients’ returns into the hospitals (Karam et al., 2021, p. 3). Depending on the hospital’s needs and resources, nurses can be working as coordinators of healthcare activities, be responsible for team management, and work with clinical practice.
Collaboration between nurses and doctors can provide the healthcare professional a wider evaluation of the patient’s health, and condition as the nurse spends more time with a patient and is able to notice more details. The organizational and communication skills of nurses facilitate the implementation of the interdisciplinary health care approach; they can unite the team and spread empathy. Reporting the condition of Mrs. SJ daily, the nurse kept the treatment of the patient up-to-date and essential for all healthcare providers. Raising the topic of psychological insufficiency can help insert a multidisciplinary approach and involve other specialists in the treatment plan.
This case study analyzed the treatment plan of the patient with secondary chronic pain and specified the nursing care involvement in it. The treatment plan provided for Mrs. SJ is patient-centered, safe, and holistic as it assesses the patient’s current condition and risks and aims for a multidisciplinary approach. Involving cognitive functional therapy to prevent anxiety and depression is helpful in long-term outcomes. The nerve root injection can decrease the pain in the lower back and left leg and be an initial step towards the improvement of the patient’s condition. The importance of nurses in the patient treatment, medical coordination, interrelation with his or her family must not be underestimated. Within this practice, I realized being a leader of nursing staff is not easy and requires vast knowledge and self-development. I aim to enhance my leadership skills to be a decent example for colleagues to follow the Code, be attentive and patient with those who need medical aid, and encourage nurses to provide high-quality treatment and create a friendly working atmosphere.
Gardea, M. A. and Gatchel, R. J. (2000) ‘Interdisciplinary treatment of chronic pain’, Current Review of Pain, 4(1), pp. 18–23.
Gatchel, R. J., McGeary, D. D., McGeary, C. A. and Lippe, B. (2014) ‘Interdisciplinary chronic pain management: past, present, and future’, American Psychologist, 69(2), pp. 119–130.
Karam, M et al. (2021) ‘Nursing care coordination for patients with complex needs in primary healthcare: a scoping review’, International Journal of Integrated Care, 21(1), pp. 1-21.
Kitson, A. L. (2018) ‘The fundamentals of care framework as a point-of-care nursing theory’, Nursing Research, 67(2), pp. 99–107.
Macfarlane, A. J. R. (2019) ‘What is clinical governance?’, BJA Education, 19(6), pp. 174-175.
National Institute for Health and Care Excellence. (2021) Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain.
National Institute for Health and Care Excellence. (2020) Low back pain and sciatica in over 16s: assessment and management.
Nursing & Midwifery Council. (2018) The code: professional standards of practice and behaviour for nurses, midwives and nursing associates. London: Nursing & Midwifery Council.
O’Sullivan P. B. et al. (2018) ‘Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain’, Physical Therapy, 98(5), pp. 408-423.
Zahir, K. (2001) Clinical governance in the UK NHS.