NAD017-3 Leading Complex Care In Adult Nursing


Nurses possess the responsibility of making accurate clinical decisions after having recognized potential problems, observing changes in concerned patients and identification of immediate remedies for eradicating issues (Tinetti et al. 2019). Professional nurses invariably depend on acquiring evidence and knowledge for deciding on complications in patients, calling for modifications in care providers or deducing if formulated plans need revisions (Zaccagnini and Pechacek 2019). In this reflective account, I will demonstrate a clinical event which has made me observe the vitality of the crucial situation and mediate critical thinking to act rightfully in the patient’s favour. The study would make me analyse relevant information regarding the pertinent health issue, such as the patient’s clinical data findings, to evaluate content and review assumptions and create meaningful inferences. I have had to explore alternatives while considering ethical principles to make well-informed decisions for the patient, which would intend to enhance the speed of his recovery. The roles of a nurse in response to complex care and abiding by standards of the NMC code will be vitally highlighted.

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In my profession as a nursing practitioner, I had had to deal with multiple critical scenarios where I would assist doctors and envision the impeding amounts of stress in their work. As stated by McCuistion et al. (2021) Nurses are integrally responsible to apprehend the needs and requirements of the patients, utilize their learning about the concepts of inducing remedies and comfort, and proceed with donating good quality care. It so happened that we encountered a case of Mr. Smith, who was 67 years of age, was living with Dementia and had recently undergone a hip surgery for undergoing a huge fall at his house. He was in the hospital for long undergoing the administration of effective interventions and surgery in his recovery. The psychological disturbances were prominent as the patient had induced signs of depression, anxiety and he appeared to be a minimal conversationalist. The lack of social associations in his life had deprived him of a way at feeling productive, and he was also highly dis-engaged from his interests and hobbies (Courtin and Knapp 2017). He led a sedentary lifestyle, had congestive hear conditions, had a repetitive lifestyle pattern where he would somehow cater to his daily needs. He faced a huge fall from the stairs and was admitted to the hospital by a call from the house-help who had seen the master helplessly laying on the floor.

On diagnosis and assessment of his state, it was deciphered how his cognitive impairment affected his daily schedule and management. Signs of old age confirmed osteoporosis and calcium deficiency lead to the quick development of a pelvic fracture on facing the tragic fall (Kwan and Walsh, 2018).

The incidence of acute pain prevailed for the first one week after the admission of Mr. Smith. Computerized tomography scan had been conducted to help surgeons prepare for operation for noticing the position of everything concerning the break. Mr. Smith felt excruciating post-operative pain and was mostly on rest. The patient was peculiarly indifferent towards his state and he seemed to be aversive to having proper living standards. It was when I witnessed him lying supine in the bed with extended arms. On checking the draining device and the surgical wound, I traced how Mr. Smith winced whenever I placed my hand gently to palpate the incisions. Mr. Smith has also been diagnosed with diabetes and hypertensive episodes in the past.  A continuous procedure that was characterized by continual inquiry, open-mindedness, perseverance and a willingness to look uniquely at the situation was desirable. It would effectively determine if my identified assumptions could be relevant, true and applicable in these circumstances.

Individuals affected with Dementia have an increased risk of experiencing fractures for living in their own homes, being on antipsychotic medications and the deduced signs of osteoporosis evident with old age. Poor dietary intake, nutritional status and health of muscles were common for the patient (Groenendijk et al. 2020). According to Dennis et al. (2017) Mortality rates for people passing away from fracturing their hip with dementia remains about 12-33% in a year. As stated by Flikweert et al. (2018) complications for an older adult with dementia experiencing a hip fracture makes rehabilitation less likely to their previous functional levels.  They require ongoing facilities and also become less likely to receive pain medications adequately, thus having to rely on narcotic utilization for pain development. Dementia increases challenges to the process of recovery to the previous cognitive status. In addition, Mr. Smith also exhibited signs of delirium, where he would appear confused mostly and not be able to answer medication related queries. It significantly and uncharacteristically impaired his capability to speak coherently.

The review of nursing observations and the patient’s pain report confirmed the presence of pain as derived issue for operation. His reduced mobility appeared from intense pain and interventions based around pain reduction, and turning Mr Smith frequently in his bed for not letting infections aggravate from soreness.

In my opinion, the management could face extensive risks as standardized care routines would not suffice for Mr Smith. It required collaboration from medical experts and nursing practitioners to deduce functional interventions in improving care specific to nurturing Mr Smith’s health. Constant service revision and reassessment became strategically imminent as notable differences in Mr Smith’s condition would modify care plans accordingly. As opined by Urden et al. (2017) nurses working in crisis situations are expected to act quickly with the development of immediate patient issues. I learnt how critical thinking also lend me the ability to be the advocate or supporter for my patient and possibly improve desired health outcomes.

Not only were medical conditions prominent, but Mr Smith also had certain superficial beliefs where he declined to receive analgesia for pain recovery. It was found while being home he would often practice meditation amongst nonpharmacological intervention, which made him refuse analgesic treatment. It was imperative on my part to discuss the options available for pain control and how they would enhance relief, calmly addressing the options he would be comfortable ascertaining. 

The managerial techniques of the impeding complex situation required adherence to local and national policies. As stated by Ellis et al. (2017) 15 million individuals in England suffer from long-term conditions, having great healthcare needs, where their care and treatment considers 70% of primary and acute care budgets in the nation. According to Muth et al. (2019) barriers to people facing long term impacts of their condition include polypharmacy dangers and exclusion of holistic approaches. A generalist view would not incur positive effects while having lack of psychological support, informational continuity and planning consultation. Social services like employment, transport, housing benefits become fragmented for them. As stated by Jackson et al. (2019) NHS England utilizes the “House of Care” model as checklists for building high quality, coordinated person centered care. It relies on interrelated elements of commissioning, engagement of caregiversand informedindividuals, organization of clinical procedures, and healthcare professionals working in partnership (Phelan et al. 2017). At a personal level, it asks commissioners for planning discussions on selection of services and at the community level, the introduction of the whole system would cater to services beyond medications. As per Peters et al. (2019) treatable mental and physical health issues can be analyzed to co-exist with conceived conditions in patients. Care plans had been formulated based on prevention, aiding mobility, educating him, monitoring signs of circulatory overload, and transport precautions. It was necessary to include orthopedic patient transport having seat belts, brakes, and safe instructions of operations.

NICE (National Institute for health and care excellence) demonstrates guidance for utilizing evidence-based care in England concerning people with specific needs, and makes professionals gain ideas for preventing ill health (O’reilly et al. 2018). In our organization, NICE guidelines are implemented while making clinical decisions. It has helped in Mr Smith’s case for meeting “NHS Litigation Authority” standards of risk management to benefit from premiums and reduced claims. We have to abide by national priorities set by NHS England and DHS (Department of Health). According to Atkins et al. (2017) it could help in identifying ways for addressing nutritional requisites for Mr Smith, his home environment on rehabilitation, social interactions and peer support. It has ensured he had promptly available information regarding his condition, and made him access specialist support to manage his needs. It has respectfully promoted the upliftment of the patient’s dignity and trust.

National policies have a major role in safeguarding vulnerabilities in adults. According to Cameron et al. (2022) the mental capacity act of 2005 aids promoting equal rights for individuals while making lawful restraints only when it is under the best interest of the patient. As per Jonker et al. (2018) The CQC or Care quality commission is a governmental body responsible for regulating, inspecting and rating care providers. It effectively caters to improving performance efficiency of nurses and patient outcomes.

Population diversity finds old people to come from all sections of the society. Healthcare services should be accommodating and sensitive towards different religious, cultural or moral requirements. Older people lacking capacity and sensory control require modified techniques for medicine administration, to adjust to normal living standards (Osoba et al. 2019). As stated by Butts and Rich (2019), ethics are integrally significant in the nursing profession as it helps in ensuring proper patient care and determines their behavior in clinical settings. In making decisions for Mr Smith, I have had to apply the ethical principles of beneficence, autonomy and justice (Santos et al. 2017). It had been my responsibility along with that of colleagues for fulfilling Mr Smith’s lifelong desire of making decisions for him even if he was at the most vulnerable stage. He had the right to be well-informed about all information related to his health and developments, while not making it look too intimidating as that could have made him afraid. Although mostly indifferent about his progress, Mr. Smith would be polite to all of us in the ward, irrespective of any issues. We had pre-informed his farfetched relatives who were rarely concerned to ask about his health, but it was our duty to mediate the risks and benefits of the treatments that would be incurred on him. After the fracture, we needed to necessitate his approval in using a wheelchair when he would be rehabilitated (Lim and Kwek 2018). But it could be sensed that he was aversive to take his medications for superficial beliefs like relying n meditation or non-pharmacological remedies. In order to consider his wellbeing by making him experience contentment in his actions, I had to also find a way to inculcate in him the importance of regularized medicinal interventions. His memory disorder would make him understand content for brief periods of time, for which I had tactfully created records of whatever he mentioned and accepted in the ward. It is necessary to exhibit precision in caring, and honesty and simplicity can make efforts worthwhile (Ednell et al. 2017). As opined by Bester (2020) actions of healthcare practitioners can be deemed to be right only when suits patient interests and avoids negative consequences. As per Alagra et al. (2018) maintaining the privacy and confidentiality of the patients and their health records should strictly be adhered to. Falsification or leakage of documents can have severe legal consequences.

Nursing management requires characteristic skills and training as fundamental elements of driving team motivation, satisfaction and performance (Tinetti et al. 2019). As a nursing manager, I have had to focus on my leadership style to assess suitable measures of providing guidance and formulating effective methods of improving clinical productivity. I have explored the principles of transformational leadership in my personal nursing practices. In my opinion, a skillful nurse would be able to balance patient needs along with maintaining the technical demands of their job. According to Ibrahim et al (2017), medicine administration for patients needs utilization of knowledge, and cognitive ability for managing time and educating patients appropriately. As stated by Baileys et al (2018), nursing leaders have evolved to be noted as mentors, preceptors, educators, advocates, financial consultants, managers and researchers. Nursing as a role essentially demonstrates leadership as a responsibility to be displaying skills and competencies.

As stated by Yaslioglu and Selenay (2018), the transformational leadership style highlights collaboration, shared vision, inspiration and encouragement for facilitating change. Leaders enabling he transformational theory are often extroverted, open to experiences, secure in their potential and creativity and have visions for future development. I have always been patient and tolerant of errors and mistakes while encouraging innovative practices. In complex care, it is evident that one would possibly have to manipulate techniques to the evolving needs of the patient. For instance, if Mr. Smith required assistance with movement and was unable to find anybody immediately, a simple solution like the presence of a tapping bell could notify the nurse in the closest junction. Also I believe, an immediate emergency with Mr. Smith’s health could not have waited to rely on people to intervene with solutions, but would depend on the strategic actions of the nurses on spot. As per Nibbelink and Brewer (2018) it also promotes decision-making standards in nursing to concurrently utilize rationality along with evidence. My nursing role was also derived by the “hypothetico-deductive model” wherein I could take critical and immediate decisions for Mr. Smith. Nurses in this care are expected to thoroughly assess situations, use previous records of diagnosis, decide on actions and ultimately implement it (Ju et al. 2017). It can be obtained through intuitive reflection. Large changes or overall improvements can be directed by a unified guiding force. I have acknowledged how transformational leadership motivates people to think on their feet to find fitting solutions rather than simply following authorized instructions In cases of emergency, I have also excelled at conflict resolution by mobilizing individuals into group and raising the morale through efficient rapport. 

According to the theoretical underpinnings of Pinkert et al (2018), acute complex care environments can impose several challenges and risks for healthcare staff. The risks are often exacerbated when patients like Mr Smith possess a co-morbid mental illness. Pertinent issues like fear experience, poor literacy of mental health, overall pessimism and hopelessness of patients often create constraints for delivering care adequately. Immense support from peers and the organization is mandatory for initiating meaningful commands despite times of distress. Nurses tend to have demanding routines as shift timings are generated according to the availability of nurses (Fawaz et al 2018). If patients display extreme conditions, then we are bound to manipulate our timings for their welfare. As opined by Wooldridge et al. (2022) lack of synchronicity of nurses due to haphazard schedules and impeding pressure can deviate the focus from patient management. It is important for nurses to also maintain their mental peace and cohesively function as per patient needs. In Mr. Smith’s case, his memory impairment has caused major issues in dedicating measures for him. He would sometimes refrain from acting according to instructions, often unintentionally, but also for his untimely adamant belief in relying on what he thinks is best for him.

Physical presence of nurses is imperative for patients like this who have faced an injury, possess co-morbid conditions as well as decreased mental capacity (Fallahnezhad et al. 2021). It was quite challenging to strictly stay in close proximity to him as he could casually fall from the nursing bed as well. We were obligated to play our part in monitoring his activities. Deciding on medications which would not have co-reactivity with other conditions was crucial. Due to the patient’s vulnerability in accessing help, we would have to constantly question him in advance, maintain written records and understand if he has actually taken the medicine that was offered to him. Timing differences in medicine administration could be highly problematic as that would disperse the effects of other medications (Heikman et al. 2017). There were also numerous physical demands like lifting the patient, repositioning him, carrying heavy objects and equipment, and standing for long intervals without breaks. Experiencing traumatic scenarios is evidently not comforting for nursing professionals. A minimal error could cause fatality for Mr. Smith. It is a highly emotionally taxing profession if one does not seek adequate support from others.

The “Nursing and Midwifery council” aims to set guidelines for registered nurses in the UK for justified implementation in healthcare (Weeks et al. 2017). It sets out standards of behavior and conduct, where nurses can exercise their professional judgement (McKenna and Copnell 2020). We should work in boundaries of our competencies as it can significantly influence public protection.

As per the standards of the code, I had to prioritize and put patient interests as a primary concern. It was imperative of me to refer to his preferences while mediating interventions. I had to empower and encourage Mr. Smith and other nurses to have shared decisions in treatment options. I was expected to pay special attention to assess and upheld the physical and psychological needs of the patient, while acting as an advocate in his welfare, whenever necessary.

The practices had to be aligned to best evidence available. Effective communication is essential in understanding the patient’s language needs, using multiple gestures in times of difficulty for checking if the information has been assimilated by the patient (Dithole et al. 2017). An ability to handle teams and cooperatively work with colleagues could be shown through aligning contributions and sharing decisions. Proper teamwork is expected in this profession. As per Belbins team-roles I have found myself to be a coordinator. I have provided effective leadership to promote the wellbeing of the concerned patient while improving their experience in healthcare. Inducing communication and teamwork abilities can also enhance my future development as a practitioner. As opined by Wood et al. (2019) a nurse can reflect on their practices through gathering feedback from various sources to enhance nursing performance. It is also essential for nurses to maintain accurate records that gain relevance to their practices. It could also help in identifying potential threats and risks. On abiding by the NMC code, nurses also have the role of preserving safety while exerting their duty of candour (Morgan and Parry 2017). Concerns could be immediately raised on coming across scenarios in which the patient safety falls at risk. Honesty should be maintained in across all aspects of treatment, even if errors have taken place. It is imperative for nurses to act without any delay when it comes to safety of patients or protection of public in the workplace (Scott and Scott 2021). Mr. Smith needed quick implementation of necessary interventions. I have had to explore my role in advising, prescribing and dispensing medicines within my limits of competence, training, law and associated policies. Awareness and reduction of risks can potentially decrease occurrence of harmful events. According to Nash (2017) the NMC code also guides us to display commitment to the standards while upholding the reputation of our profession as a nursing associate, midwife or registered nurse. I have also dutifully cooperated with audits and investigations during my tenure.


Complex care seeks to promote enhancement of wellbeing and health of individuals with multiple health conditions by reshaping and coordinating care delivery. As observed in the case of Mr Smith who was diagnosed with various ailments, he required efficient nursing interventions to improve his state. It is foreseen how undergoing a surgery for a fracture can be difficult for dementia patients. Identification of his co-morbidities needed careful assessment, disciplined approaches, and sound managerial practices. I had to utilize my decision-making, communication and teamwork abilities to supply justified recommendations and leadership. The guidance of the NMC code has substantially helped me understand my role as a registered nurse and made me cohesively upheld the rights of the patient.


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