Integrated care pathways

Care pathways map out a process of patient-focused care which specifies key events, tests, interventions and assessments occurring in a timely fashion to produce the best prescribed outcomes, within the resources and activities available for an appropriate episode of care (Campbell 1998). In practice this describes, in advance, the care of patients within specific case types. The case type may be diagnostic such as hip replacement, procedural such as lumbar puncture or a condition such as pain.

Whatever the case type, there are common strands which are mapped out on the care pathway which is then used as a clinical guideline, with the practitioner using their clinical judgement on whether to follow the anticipated care on the care pathway or to deviate from that care. Decisions to deviate from the care may be based on a variety of causes such as:

Such deviations are recorded as part of the care pathway documentation, thus providing a facility by which care may be individualized as appropriate (Schriefer 1994). Such deviations are usually known as variances. It is these variances that make the difference between clinical guidelines, protocols or algorithms, none of which has the facility to actually record why the prescribed care was not given. Interventions may have much in common, but patients are different and the skill of the caregiver is to be able to differentiate and make clinical judgements about the appropriateness of the intervention. Care pathways allow clinical freedom in a way that clinical protocols do not. The care pathway has the advantage of being an audit tool. If the variances are completed correctly, then an audit of the pathways will show which particular components have the most variances and why. For example, if an item on the pathway is to record the patient’s blood pressure, there may be many reasons why this cannot be done. If other types of guideline/protocol are used, then the action is simply not taken.

A pathway of care should, wherever possible, be multidisciplinary, agreed between all professionals and used as a multidisciplinary record of care. This eliminates separate note keeping and has the added advantage that all carers know what interventions have taken place and when, and if they did not take place, why. A clear and stated hierarchy of evidence should support the items and the sources clearly stated. Each patient within an agreed diagnostic group will have exactly the same standard of care at the same time and will not rely on any member of staff having to remember what the care should be and when to provide it. Problems can occur when no evidence is available to underpin practice and it is recommended that ‘local best practice’ is used to underpin an intervention.

Research has recently showed that local best practice may be used as a generic term for the provision of care where no discussion on what this may be has taken place. If this method is to be used, then all disciplines should be involved in the decision making and a transparent process for deciding what an intervention should be and how it was arrived at must be documented.

A pathway may be time orientated – this is over a set period of time – or goal orientated where a particular goal or target has to be reached before the patient moves onto the next. For example, for an orthopaedic patient, it may state that a physiotherapist provide active care on the second postoperative day or it may state that when the patient is pain free then active care is provided.

The pathway must be tailored to each clinical area taking into account local resources, whilst never moving away from the underpinning evidence base. There are many different templates for care pathways and the reader is directed towards Pathways of Care for more details of these and much help in pathway design and writing.

Nursing process

The nursing process provides a framework for organizing individualized nursing care that focuses upon identifying and treating unique responses to actual or potential alterations in health. It consists of five steps: patient assessment, planning care, implementation of interventions and evaluation of the process and patient status:

The purpose of the nursing process is to document information for other members of staff, to initiate support and continue observations and measurements to ensure the effectiveness of interventions.

Observation of the patient

Nurses may not realize it but they begin to ‘assess’ and ‘make observations’ about patients from the very moment they set eyes upon them:

Observations are made not only of the patient’s physical condition but also of indicators of his/her psychological and emotional state too. An important point to stress is that observation depends not just on sight but also uses the senses of hearing, touch and smelling.

These observations will direct the nurse’s subsequent, more systematic approach to data collection which includes further observation of specific factors.

Interviewing the patient

The admission of a patient usually commences with an interview and it is from this structured discussion that a great deal of crucial information is obtained:

A good nursing assessment relies heavily upon the nurse’s skills in interviewing patients and nurses need to acquire a good interviewing technique. Observational skills also play a part in interviewing because information is forthcoming from patients’ ‘non-verbal communication’, in addition to what they actually say. Whether the non-verbal cues appear to support or contradict the verbal communication may be of importance. For example, a patient in the postoperative ward might say to the staff nurse ‘No, I do not have any pain’ but at the same time be showing facial expressions which indicate anxiety, uncertainty and obvious pain.

Nurses should not underestimate the importance of skilled verbal communication in interviewing. The nurse needs to learn to ask the right questions, to know how to encourage the patient to give information and, perhaps most important, to recognize non-verbal cues given by the patient.

Patient communication

Communication can be verbal and/or non-verbal, conscious or unconscious. It is an essential activity of living, which is as important as physical support. Patients often express dissatisfaction with communication during their hospital stay, which relates to the quality and amount of information received and to insufficient, confusing and contradictory information being given by different healthcare professionals.

Nurses, by giving active information, can speed up recovery and reduce the number of complications and the need for pain relief. In the acute care setting, the development of verbal skills, the giving of information and the additional use of listening skills are insufficient on their own. The nurse needs to increase his/her proficiency at monitoring and interpreting non-verbal cues from physically dependent patients who are unable to communicate verbally, due to speech loss or factors affecting speech, such as breathlessness or pain.

Non-verbal communication is the term used to describe all forms of human communication not controlled by speech and it can be used therapeutically by nurses. The non-verbal component of communication is five times more influential than the verbal aspect.

Stress can be actively reduced using relaxation and soothing techniques and caring can be conveyed through touch. Touch is a means of giving and gathering information but consideration should be given to the fact that people are individuals, so interpretation of tactile communication will differ from person to person.

The communication process comprises five elements:

When planning to meet patients’ communication needs there are six essential areas to include:

Resources, nursing actions and aids which can be used in connection with these six areas are suggested in Table 3.1.

Table 3.1 Communication aids to meet patient needs (Manley & Bellman 2000)

It is important to remember that the information given through communication may not be remembered, especially by acutely ill patients whose drugs may interfere with information processing and storage; the patient may be unable to assign meaning to or organize the information at the time of exposure to it. This can lead to confusion and lack of memory with regard to the event.

Barriers to and interference with communication can occur at any point in the process. A summary of potential problems relating to the patient’s reception of messages from the nurse in acute hospital settings is provided in Box 3.1.

Autonomic nervous system

To determine the mental state (both physiological and psychological), it is necessary to have knowledge of the autonomic nervous system. The autonomic nervous system (ANS) has two subdivisions: the sympathetic and the parasympathetic nervous systems.

The sympathetic nervous system:

The parasympathetic nervous system:

These responses, under the control of the central nervous system, regulate other areas of the body to maintain homeostasis. An increase or decrease in either sympathetic or parasympathetic activity in the hospitalized person can often be reflected in other observations such as the blood pressure or heart rate. A general assessment of the patient’s ANS may alert the nurse to impending neurological overstimulation or deterioration.

The Glasgow Coma Scale

The Glasgow Coma Scale (GCS) assesses the ANS via two aspects of consciousness: arousal, which involves being aware of the environment, and cognition, which demonstrates an understanding of what the observer has said through an ability to perform tasks.

The GCS was designed to:

It focuses on the evaluation of three parameters: eye opening, motor response and verbal response (Table 3.2). The patient’s best achievement is recorded for each parameter. The scores are then added together to give an overall assessment of the patient’s neurological status. A score of 15 represents the most responsive while a score of 3 is the least responsive.

Table 3.2 The three modes of behaviour used in the GCS (Edwards, 2001)

Pupil size and reaction to light

Pupil size and reaction to light are tested by shining a torch onto the patient’s eye. It is important to note whether the patient has any pre-existing pupil irregularities which are normal for them, e.g. previous eye injury, cataracts, blindness in one eye. Check the following factors:

The pupil size (Fig. 3.1) – average pupil size is 2–5 mm.

The pupil reaction to light: brisk, sluggish or fixed.

The shape of the pupil – should be round.

If both pupils react equally to light and are equal in size.

Fig. 3.1 Pupil size observed during the Glasgow Coma Scale (GCS) assessment.

When undertaking the pupillary response the following should be observed:

The light should be shone into the patient’s eyes to see if they constrict.

The light should not be shone directly into the patient’s eyes; a torch should be shone from the side into the eye.

It is best to carry this out in dim lighting as one sees the eyes constrict better when light is shone on them. Protocols should exist to eliminate any inconsistencies in the patient’s score (e.g. discrepancies in dimming the light could occur during the night).

Progressive dilatation and loss of pupil reaction on one side occur as a result of pressure on the third cranial nerve on that side, indicating an enlarged intracranial mass (haematoma).

Progressive cerebral oedema eventually leads to compression of the third cranial nerve on the other side, so neither pupil then reacts to light (severe brain injury).

Some drugs, e.g. atropine, dilate the pupil; opiates, e.g. morphine, constrict the pupil.

Anxiety

A person’s response to anxiety is due to activation of the sympathetic nervous system, potentiated by adrenaline and noradrenaline from the adrenal medulla. There are many factors in everyday life that provoke anxiety and hospitalization is one of them. Anxiety is difficult to define, mainly because it is often explained as a vague, uneasy feeling, the source of which is often non-specific or unknown to the individual.

Anxiety may be both positive and negative: positive in relation to learning ability, as a high anxiety level may have a motivating function, negative in relation to particular experiences, e.g. hospitalization.

Coping with the anxiety of hospitalization can sometimes lead to aggressive behaviour as a result of anger and frustration. Alternatively, coping may take the form of escape from the anxiety-provoking situation, resulting in withdrawal, due to the person’s feelings of helplessness and the inability to gain control over events.

Anxiety is present in at least some hospitalized patients so there is a need for nurses to be able to make an accurate assessment. The assessment of anxiety relies on listening and talking to patients, questioning and discussion through interview, observation or the use of tools such as the:

Nurses may already be familiar with their use.

Stress

The concept of ‘stress’ is seen as an interaction process between the individual and his environment, rather than a single event or set of responses. Stressors make physical and psychological demands, which require individuals to assess and understand the situation and then to respond to it.

Situations where a person can understand and react to the circumstances in a satisfactory manner are less likely to be perceived as stressful by that individual. However, if the stressor demands new responses or ones which are undeveloped (e.g. illness) then it is likely that the experience will lead to stress.

Hence stress is taken to be the absence of or a deficiency in the individual’s ability to cope with current environmental demands. The resulting illness caused by stress is linked to increased sympathetic nervous system arousal. The body’s response to a stressor is reflected by a reaction which involves the whole body and generally consists of three distinct response phases:

The acutely ill individual in hospital is exposed to many stressors simultaneously. These act synergistically rather than cumulatively.

There are a number of events that make significant emotional demands upon the person while in hospital:

Therefore, the nurse caring for a patient in hospital needs to understand the relationship between the individual and his environment, life events and acute illness and as such take the following into consideration:

The ANS controls many other body functions and the physiological responses to stress can influence the measurements frequently undertaken by nurses during their daily work. The physiological responses to stress involve neuroendocrine activation and increased sympathetic activity, which stimulates the cardiovascular system and the adrenal medulla, resulting in the release of numerous substances into the circulation:

Under-management of pain