Person Centred, Group Dynamics and Working in Teams: Assignment and Flow Chart

This report analyses care planning, MDT involvement, communication, implementation, monitoring and evaluation of person centred care, considering multi-agency working. It also discusses the process and stages of planning and delivering person centred care, and the importance of group dynamics and working in teams.

Assignment and Flow Chart
about Person Centred,Group
Dynamics and Working in
Teams

Table of Contents
INTRODUCTION...........................................................................................................................3
MAIN BODY...................................................................................................................................3
Task 1 ..............................................................................................................................................3
Care Planning...............................................................................................................................3
Implementation............................................................................................................................4
Monitoring...................................................................................................................................6
Evaluation....................................................................................................................................8
Task 2 ..............................................................................................................................................9
Process and stages of planning and delivering person centred care considering multi agency
working........................................................................................................................................9
CONCLUSION................................................................................................................................9
REFERENCES................................................................................................................................1

INTRODUCTION
Care planning is defined as the conversation between an individual or patient with the
healthcare professional about the improvement of health in their life (McMahan, Tellez and
et.al., 2021).
Therefore, the report will analyse that how the care planning for the patient is being done
indicating who are the individuals involved in the care planning process. The MDT involvement
and the goals being set will be analysed and evaluated. Also, along with this, importance of
communication will be analysed within the health and social care planning. Further,
implementation of the care plan which included interventions delivered in the care plan along
with the treatments and diagnosis will be examined. Moreover, monitoring will be done by
keeping in mind how the information of the patient regarding their care is being framed and
safeguarded. And finally evaluation of the patient's progress or deterioration and the plans for
discharge will be carried out will be done appropriately and who carry out these plans will also
be known.
MAIN BODY
Task 1
Care Planning
Care planing is defined as the care which is being provided to the patients and under the
nursing plan which is being analysed and is framed for them. The care planning is being done for
the patients who are in need and are unable to incur the services and care while living by
themselves. There are different categories of individuals who are involved within the care
planning and taking care of the patients and for the individuals who are in need (Jabbarian,
Zwakman and et.al., 2018). This involves the practitioners, health care professionals, doctors,
nurses, psychologists, physicians etc. These are some major individuals who are involved for
taking care of the patients at large scale and providing them adequate services and care which
they are in requirement of.
Apart from this, the MDT involvement is also there for taking care of the patients and
this helps in addressing the care planning to be done in an appropriate and adequate manner. The
involvement of MDT which is Multidisciplinary Team made for taking care of the patients and
the care users in appropriate manner (Kuusisto, Santavirta and et.al., 2020). MDT is the

involvement between and different specialized professionals for improving the health and taking
care of the patients appropriately such that the care users are not facing any difficulties and
issues while incurring the care facilities and services which are being provided to them. For
issuing and creating value of how effectively services and care is to be provided to the patients, it
is very important for the patients and health care professionals to understand the different aspects
of how the care is being provided by following some major legislations and laws such as Data
Protection Act and this is explained as -
The Data Protection Bill, 2021 is being framed for knowing and understanding the aspect
of what are the essential points which are to be followed within the health and social care system
and while taking care of the patients (Howard, Bernard and et.al., 2018). It is very important to
protect and safeguard the data of the patient or the care user so that the personal details of the
patients are not disclosed. The Data Protection Act specializes in addressing the aspect that
personal details and information of the patient is not to be disclosed. The bill is being passed for
considering the safety and protection of the details which the patients are considering at large
scale. The professionals are taking care of the details of the patients and the information and data
which is being addressed and is being evaluated.
It is also very important to have effective communication so that proper care and concern
of the patients is being taken into consideration and this helps in knowing that what are the
problems and issues which the patients are facing at large scale in their perspective of health.
With the help of effective communication, the care users and health care professionals are able to
address the aspects of how the care planing is being done in appropriate manner (Zwakman and
et.al., 2018). Proper framework of planning and schedules are framed which helps in delivering
the concerns which are related to providing medicines and services as per the schedules and on
time to the patients. Therefore, it is important that the communication is done in effective
manner so that the care is being provided to the patients by the health care professionals in by
keeping in mind their schedules and planning effectively and appropriately.
Implementation
There are certain interventions which are delivered as the part of the care plan for
ensuring that the care planning is being done in appropriate manner and this helps in creating
value for which aspects of how effectively care is being provided to the patients. It is very

important that the nurses need a roadmap for planning care schedules which are framed for the
patients and taking care of them by providing quality care and services effectively. There are
some nursing interventions based on doctors orders, nurse practitioners can also develop orders
using principles of evidence based practice. There are certain common examples of nursing
interventions which include -
 Administration of medication.
 Post-partum support (Zhou, Wang and et.al., 2022).
 Feeding assistance.
 Bedside assistance and care.
 Monitoring of vitals and recovery progress.
There are certain implementations which are related to nursing in the evidence based practice
and this helps in ensuring the aspects as to how effectively and in appropriate manner certain
services are being analysed for providing care to the patients effectively. Along with this, person
centred approach is being used and this indicates that there are certain ways in which different
concerns along with care and services are delivered appropriately (Rogers, Goldsmith and et.al.,
2020). There are three major components of evidence- based practice which are being analysed
and identified in the manner which helps in curing the patients from having any type of illness
which is related to their health and social care. These three major components are – utilizing the
best external evidence, drawing an individual clinical expertise, considering the values and
expectations of patients. This helps in creating and analysing the improvement in the process of
implementing the care planning in effective manner.
There are certain aspects which are delivered and are analysed to ensure that the care
planning is being implemented to ensure the safe and security of the patients so that the patients
are creating value in analysing the concerns which are related to interventions within the care
system and planning (Lum, Brungardt and et.al., 2019). There are also advantages within the
care planning which helps in ensuring that how effectively care planning is being done. These
advantages within the evidence based practice are – improvement in the patient outcomes
through superior care, it helps in maximizing the providers time and helps in reducing cost,
further, it adds new contributions to the science of nursing. There are certain evidence based
practice examples in nursing which is related to how effectively and in appropriate manner there

are concerns which are related to delivering the care to the patients. Examples of evidence based
practice are -
 Giving oxygen to patients with COPD.
 Measuring blood pressure in children.
 Improving infection control practices.
 Recognition of the alarm fatigue.
There are also certain treatments and procedures which are carried out and this helps in ensuring
that how the care is being taken of the patients. The intervention usually includes the following
steps which are -
 Making a plan.
 Gathering information.
 Formation of the intervention team (O'Hanlon and et.al., 2018).
 Deciding on specific consequences.
 Holding the intervention meeting.
 Following up.
This is how the treatments and procedures are framed and are followed up which helps in
indicating and analysing the aspects of how effectively the implementation of the care planning
is being done appropriately and in adequate manner. By providing special care and treatment to
the patients, the patients are able to analyse what type of care they are being provided and this
helps in ensuring concerns which are related to effects of providing proper care and services to
patients.
Monitoring
Health monitoring is defined as the assessment of physical, functional and cognitive
status which helps in detecting the changes which helps in indicating the health problems and
facilitates the appropriate interventions. The care of the patient is being monitored for ensuring
that there are certain aspects which are being considered and are analysed for ensuring the
concerns which helps in facilitating the care to be provided to the patients who are not able to
take care by themselves. Monitoring is the performance of planned serial measurements of
certain parameters at regular intervals (Gilissen, Pivodic and et.al., 2018). It is very important
that how effectively the care plan is being framed which helps in ensuring the concerns which

are related to creating safety and security of the patients. There are certain aspects which are
concerned in monitoring and ensuring that proper care and services are provided to the patients
appropriately. There are certain aspects which requires monitoring and this includes -
 Patients' health status which is important concern and is to be monitored at regular
intervals.
 Progress of the illness including effect of treatment on the illness (Cortezzo and et.al.,
2020).
 There are side effects of therapy or any operation which the patient has undertaken or is
undergoing during time.
With regard to illness or any type of treatment which the patient is undergoing, there are aspects
which helps in considering and knowing the basis as to how the change is done for better or
worse. The treatment or care which is provided to the patient is undertaken to ensure the aspects
to be considered appropriately and taking in concern the aspects which helps in knowing that
how effectively the care is being provided to the patients. Monitoring helps in ensuring the
favourable outcome which helps in rectifying the measures which are creating hindrance in
providing health and social care facilities to the patients (Haaksma and et.al., 2020). There is
also frequency of monitoring which analysis the extreme and low measure of the care being
provided to the care patients. There are measurements within the monitoring of the care and
these are made in regular intervals . The frequency of measurements depends on -
 Nature of parameter and availability of measurement technology.
 Desirability, efficiency and cost effectiveness.
Remote patient monitoring devices are the major source through which monitoring of te4h
patients and care is being done and these devices must be electronically connected which is
accomplished via Bluetooth and cellular networking.
The information of the patient is recorded which helps in ensuring that the data and
information are safely kept to the devices handled by the health care professionals at large scale
within the health and social care system. There are three major ways to track and maintain the
patients records and information and these are -
 Integrating patients records (Artingstall and et.al., 2019).
 Recording medical prescriptions which is done electronically.
 Archiving the patients records on cloud.

Apart from this, a computer – based patient record (CPR) is an electronic patient record of
information which resides in system specifically helping the support users by providing the
accessibility to complete and accurate data, clinical decision support system and these are linked
to medical knowledge and support aids. This helps in providing the concerns which are related to
ensuring that how the care is being monitored and this helps in initiating to know the information
which is being gathered appropriately.
Evaluation
Evaluation of patients progress is being done when patient undergoes proper monitoring
with the care plan being framed appropriately. Evaluation is the process of integrating of all the
information regarding the patient which is followed by the determination of the conformance
which is initiated and is done in the care plan. This also includes the effectiveness in the
treatment, the potential risk followed by the alternatives which are being followed for the course
of action which is preferred next (Spacey and et.al., 2021). There are some important decisions
which are taken into consideration and this helps in providing the concerns which are necessary
for the care plan. Success or failure of patient is based on the diagnosis which should be correct
and this helps in measuring the aspects which are being considered in appropriate manner. With
the help of evaluation the care providers are indicative of the accuracy of the diagnosis. There is
proper evaluation of the diagnosis which is being monitored through which the health of the
patient is being taken care of. If the diagnosis is certain the evaluation helps in indicating the care
plan is to be designed or chosen. The alternative care plan has been framed and this helps in
indicating that the plan is being framed for analysing and creating the aspects of how the care
planning is being done appropriately.
Evaluation is the result of how the care planning is being done in appropriate manner.
Value of parameters monitored, findings at progress helps in reviewing the concerns which are
related to how effectively and in appropriate manner the evaluation of the care planning is being
done effectively. The patients are discharged when they are provided with adequate care and are
provided with proper care and services at large scale (Nouri and et.al., 2020). The evaluation is
concerned with the final outcome which helps in indicating and knowing the concerns which are
related to how effectively the care planning is done and what are the improvements in the health
which are observed at large scale. The patient is discharged when they are recovered fully. There

is proper planning which is done for carrying out the process of discharge of the patient and this
is carried out by the health care professionals, doctors, nurses etc. The discharge plans are being
carried out in proper manner which helps in understanding that the patients details and
information are not to be disclosed and are kept for safeguarding them appropriately. The
discharging of the patient is done when the doctor and other healthcare professionals are satisfied
with the treatments and have observed the improvement in the health of the patient. The
discharging of the patient is done when the doctors and healthcare professionals are satisfied
with the health of the patient and the care which is being provided to them (Kezirian and et.al.,
2018).
Therefore, the discharge planning is done to ensure that how effectively care and services
are being provided to the patient in appropriate manner. This helps in knowing and
understanding the aspects of care plan being framed so that the patient is also able to deliver the
concerns which are related to ensuring the importance of framework of care plan. The
discharging of the patient is analysed by how effectively the care planning is being done and the
treatment which is provided to the patient.
Task 2
Process and stages of planning and delivering person centred care considering multi agency
working
The process of delivering the person centred care flowchart is framed below -

There are also different stages in person centred care which is described through the flowchart –
Process of Person Centred Care
Exploring
what matters
to the person
Identifying
the best
treatment
Providing care
and support
Supporting the
health care
professionals to
set goals.
Thinking and
framing about
actions to reach
the patients.
Stages of
Person
Centred Care
Empathy (patient’s point
of view is understood by
the counsellor)
Congruency (counsellor
being the genuine
individual)
Unconditional positive regard (the
counsellor is being non –
judgemental)

CONCLUSION
Thus, it is concluded from the above report that care planning for the patient was being
done appropriately which helped in indicating who are the individuals involved in the care
planning process. The MDT involvement and the goals being set were analysed and evaluated.
Also, along with this, importance of communication was also being analysed within the health
and social care planning. Further, implementation of the care plan which included interventions
delivered in the care plan along with the treatments and diagnosis was examined appropriately.
Moreover, monitoring was done by keeping in mind how the information of the patient regarding
their care is being framed and safeguarded. And finally evaluation of the patient's progress or
deterioration and the plans for discharge are being carried out was done appropriately and who
carry out these plans was also analysed.

REFERENCES
Books and Journals
Artingstall, J. and et.al., 2019. 122 Communication of advance care planning decisions. BMJ
Supportive & Palliative Care. 9(Suppl 1). p.A53.
Cortezzo, D.E. and et.al., 2020. Perinatal palliative care birth planning as advance care
planning. Frontiers in Pediatrics. 8. p.556.
Gilissen, J., Pivodic, L. and et.al., 2018. How to achieve the desired outcomes of advance care
planning in nursing homes: a theory of change. BMC geriatrics. 18(1). pp.1-14.
Haaksma, M.L. and et.al., 2020. Survival time tool to guide care planning in people with
dementia. Neurology. 94(5). pp.e538-e548.
Howard, M., Bernard, C. and et.al., 2018. Barriers to and enablers of advance care planning with
patients in primary care: survey of health care providers. Canadian Family Physician.
64(4). pp.e190-e198.
Jabbarian, L.J., Zwakman, M. and et.al., 2018. Advance care planning for patients with chronic
respiratory diseases: a systematic review of preferences and practices. Thorax. 73(3).
pp.222-230.
Kezirian, A.C. and et.al., 2018. Advance care planning in the nursing home setting: a practice
improvement evaluation. Journal of social work in end-of-life & palliative care. 14(4).
pp.328-345.
Kuusisto, A., Santavirta, J. and et.al., 2020. Advance care planning for patients with cancer in
palliative care: A scoping review from a professional perspective. Journal of Clinical
Nursing. 29(13-14). pp.2069-2082.
Lum, H.D., Brungardt, A. and et.al., 2019. Design and implementation of patient portal–based
advance care planning tools. Journal of pain and symptom management. 57(1). pp.112-
117.
McMahan, R.D., Tellez, I. and et.al., 2021. Deconstructing the complexities of advance care
planning outcomes: what do we know and where do we go? A scoping review. Journal
of the American Geriatrics Society. 69(1). pp.234-244.
Nouri, S. and et.al., 2020. Evaluation of neighborhood socioeconomic characteristics and
advance care planning among older adults. JAMA Network Open. 3(12). pp.e2029063-
e2029063.
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O'Hanlon, C.E. and et.al., 2018. A framework to guide economic analysis of advance care
planning. Journal of Palliative Medicine. 21(10). pp.1480-1485.
Rogers, J., Goldsmith, C. and et.al., 2020. The advance care planning nurse facilitator: describing
the role and identifying factors associated with successful implementation. Australian
journal of primary health. 25(6). pp.564-569.
Spacey, A. and et.al., 2021. A critical realist evaluation of advance care planning in care
homes. Journal of Advanced Nursing. 77(6). pp.2774-2784.
Zhou, Y., Wang, A. and et.al., 2022. Mechanisms and contextual influences on the
implementation of advance care planning for older people in long-term care facilities: A
realist review. International Journal of Nursing Studies. p.104277.
Zwakman, M. and et.al., 2018. Advance care planning: a systematic review about experiences of
patients with a life-threatening or life-limiting illness. Palliative medicine. 32(8).
pp.1305-1321.
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