CNA345: Strength-Based Nursing Approach for Joseph's Care Transition

This case study focuses on applying a strength-based nursing approach to the care transition of Joseph, a patient recently discharged from acute care. It outlines goals for improving Joseph's and his wife Sophia's well-being, including mental and domestic health services, disease awareness education, and culturally competent care. The care plan emphasizes respecting their autonomy and preferences, such as remaining at home rather than transitioning to residential care. The study considers legal and ethical principles, particularly autonomy and non-maleficence, and highlights the importance of culturally safe care. Available services in Tasmania, such as home and community care programs and mental health services, are integrated into the care plan. This assignment is available on Desklib, a platform offering a wide range of study resources, including past papers and solved assignments for nursing students.

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Executive Summary
The following report of the strength based nursing approach is based on the case study of
Joseph who has recently been discharged from acute-care settings of hospital. Both he and his
wife are not in favour of residential care. Thus the main goals for Joseph and his wife Sophia
will be to avail mental and domestic health service along with proper education for the
disease awareness in a culturally competent manner.

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Table of Contents
Introduction................................................................................................................................3
Transfer of Care.........................................................................................................................3
Legal and ethical principles for Decision Making.....................................................................6
Culturally Safe Care...................................................................................................................7
Conclusion..................................................................................................................................8
References..................................................................................................................................9

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Introduction
The following report is based on the case study of Joseph, who has recently been
discharged from hospital’s acute care settings. The report will mainly highlight the transition
of care under the parameter for the strength based nursing. The report will also highlight the
importance of the ethical, legal and cultural guidelines for a competent nursing care plan.
Transfer of Care
According to Enderlin et al. (2013), the principle of transfer of care refers to the
movement of people between the locations, providers or different levels of care as their
health care condition and the care needs changes. Enderlin et al. (2013) are of the opinion that
the movement facilitated by the transfer of care might cast an adverse or negative impact on
the people and their carers. The key principle of the transfer of care includes engagement of
the older person and their family members in the decision making process, medication
reconciliation which includes proper discharge planning and on-going management plan for
communication with the general practitioners (Enderlin et al. 2013). In case of Joseph, the
decision-making process for the health of Joseph will include his primary care giver along
with his wife. The primary care giver will be his children like in this case his daughter.
According to older adults are at high risk for gaps in the transition of care process and these
gaps might result in re-hospitalization. In order to successful transition of care, proper
education of the primary care givers about the patient’s individualized care needs like
cognitive needs, sensory needs and physiological needs are important.
As per the Joseph’s care study, the course of action will be improvement of the
overall health and well-being of Joseph and reducing the chances of the re-hospitalization. In
order to achieve the goals, health literacy will be given to Joseph’s primary care giver in

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order to educate them about Joseph’s immediate care needs. Joseph’s wife will also be
educated regarding why taking assistance or residential care support will be helpful for
Joseph and his wife keeping their age into consideration. The Primary Health Tasmania
provides a special aged care service. Under this service, the healthcare professionals educate
the older adults about the importance of the shared transfer care. The awareness is generated
by increasing the trust during the course of the awareness journey, health-related outcomes
and well-being (Primary Health Tasmania, 2019).
The objective set for the achievement of the goals is guided by the principle of the
strength-based nursing care (SBNC). The value 5 of SBNC is defined by the concept of self-
determination, which respects person’s self-knowledge and values choice, and thereby
increasing self-determination (Boswell and Cannon 2018). Joseph and his wife Sophia wish
to stay at their own home and does not wish to shift under the residential care support.
However, constant support will be crucial for the health and well-being of both Joseph and
Sophia taking their age into consideration. The education about the importance of constant
support for their health and well-being might be helpful for gaining their consent for availing
support services at home. The Department of the Health and Human Service of Tasmania
(2019), has a special Tasmanian Home and Community Care Program. Under this program,
the trained professionals provide per-time support to the aged individuals at their home. This
support might include help in taking mediation, taking nutritional food or performing other
daily activities and helping them to socialize at the community level. Proper education and
awareness about seeking help will help Joseph and Sophia to vouch for their value based
choice based on their self-knowledge. Availing support while at home will improve their
health condition and thereby helping to prevent the chances of hospital re-admission.
The second goal in relation to Joseph care will be taking assistance in order to
maintain a clean household and performing other daily activities like washing the dishes,

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cleaning of clothes and floors and the outside garden area. This goal will be achieved via
taking consent for Joseph and his wife about availing domestic help service by making them
understand its importance towards healthy living. Moran et al. (2014) are of the opinion that
maintenance of the clean surroundings is a mandatory requirement for the patients who are
recently discharged from the hospital. Moran et al. (2014) stated that geriatric patients, upon
return to home after long-term stay at the hospital suffer from immune deficiency and thus
are prone to infection. Maintenance of clear surrounding will help to reduce the chances of
cross-infection and improving physical well-being. Maintenance of clean surroundings also
helps to improve the emotional well-being. The value 6 for SBNC mainly emphasize for
person and environment are integral. According to Boswell and Cannon (2018) value 6
highlights the environment affects that person and family. Having a clean environment helps
to improve the health and well-being of the people via increased the quotient of the
“goodness of fit”. Boswell and Cannon (2018) further stated that having a clean environment
helps to increase their strength and self-determination for self-driven approach for healing
and healthy thriving. Mowbray in Tasmania has special domestic and personal care support
which helps to manage everyday activities under a safe secure and healthy home
environment. The major activities include dishwashing, house cleaning, ironing,
unaccompanied grocery shopping, helping with the meal preparation (The District Nurses
Tasmania 2019).
Additional goals for Joseph and his wife Sophia will be mental health counseling.
Kamiya et al. (2013) are of the opinion that the older adults who suffer from health related
alignments, mainly remain mentally depressed and refuse to socialize. This mental depression
and social isolation increases complication of their physical health. Taking help from the
mental health professionals and attending counseling process might prove to be helpful for
them. This approach is again guided by the provision 5 for the SBNC as it increases the sense

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of self-determination of the service users. Statewide Mental Health Services by Tasmanian
Government (2019) has a special Adult Community Mental Health Services, which provides
domestic family based mental counseling help and support to the older adults.
Goals Measures to Accomplish the
Goal
Services Available
Goal 1: Improving physical
health
Educating about the
importance of taking services
while at home
Home-based health care
assistance by Department of
the Health and Human
Service of Tasmania
Goals 2: Maintaining a clean
environment
Taking assistance for
personal and domestic care
Domestic and personal care
by The District Nurses
Tasmania
Goal 3: Improving mental
health
Taking support from home-
based mental health
counselling
Adult Community Mental
Health Services
Legal and ethical principles for Decision Making
The legal principle for the decision making process in nursing is guided by the rules
and the regulation of the Australian Human Rights Commission. As per the Tasmania Charter
of Rights, it is the right of every human to get equitable service and availing the provision to
vouch final consent for themselves. This concept is again guided by the ethical principle of
autonomy. According to the Nursing and Midwifery Board of Australia (NMBA) (2018), a
nurses must help patients in the decision making process through informed consent and this
helps to respect the patient’s autonomy and patient’s own right for decision making. The

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professional code of conduct for the nurses and the midwives also vouches that proper
protection to privacy and confidentiality must be given to the service users (NMBA 2018).
The main ethical principle which must be considered in the decision making process
is guided by non-maleficience. The ethical principle of non-maleficience signifies non-
harming or inflicting less harm to the service users in order to achieve the beneficial
outcomes (Beauchamp, 2016).
Thus while assisting Joseph and his Sophia in the decision making process, proper
respect must be given to their autonomy. Like even after educating them about their health
concerns, they are unwilling move under residential care support program, their opinion
should be respected and domestic care support plan must be proposed as highlighted under
main goals of the care. This will help to protect the ethical principle of autonomy or the
human rights while giving importance of the ethical principle of non-maleficience. In the
health education process, privacy and confidentiality of both Joseph and Sophia must be
maintained.
Culturally Safe Care
According to Giger (2016) culturally safe care is guided by the principle of trans-
cultural nursing. The theory of trans-cultural nursing highlights that respect must be given to
the cultural thoughts and values of the health care service users. In doing so, the overall
quality of the care and the patient’s outcome can be increased via giving increasing patient’s
level of satisfaction and trust (Giger, 2016).
For example while arranging for the domestic help like cooking or unaccompanied
grocery shopping, it will be the duty of the attending nurses at that locality to inform the
domestic service users about the food preferences of Joseph and Sophia if any. This will help

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to increase the trust of Joseph and his family in the overall care plan and thereby increasing
the quality of care. Moreover, while educating about the importance of taking help, a
culturally competent nurse will help them to communicate freely. Douglas et al. (2014) are of
the opinion that the people who are not native to Australia might not communicate in English
fluently. For those non-native people in Australia, use of interpreter or a culturally competent
nurse prove to be effective.
Conclusion
Thus, from the above discussion, it can be said that three gaols are highlighted in
order to promote successful transition of care include culturally competent care plan through
education about the importance of taking seeking help under the residential settings and
managing domestic helps/personal care support and mental health counselling for Joseph and
his wife Sophia. The care plan must be given while giving respect to the service user’s
autonomy.

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References
Australian Human Rights Commission. 2019. Tasmania: Charter of Rights. Access date: 16th
Jan 2019. Retrieved from: https://www.humanrights.gov.au/tasmania-charter-rights
Beauchamp, T. L. 2016. Principlism in Bioethics. In Bioethical Decision Making and
Argumentation (pp. 1-16). Springer, Cham.
Boswell, C. and Cannon, S., 2018. Introduction to nursing research: Incorporating evidence-
based practice. Jones & Bartlett Publishers.
Department of the Health and Human Service of Tasmania. 2019. Tasmanian Home and
Community Care Program. Access date: 16th Jan 2019. Retrieved from:
https://www.dhhs.tas.gov.au/hacc
Douglas, M.K., Rosenkoetter, M., Pacquiao, D.F., Callister, L.C., Hattar-Pollara, M.,
Lauderdale, J., Milstead, J., Nardi, D. and Purnell, L., 2014. Guidelines for implementing
culturally competent nursing care. Journal of Transcultural Nursing, 25(2), pp.109-121.
Enderlin, C.A., McLeskey, N., Rooker, J.L., Steinhauser, C., D'avolio, D., Gusewelle, R. and
Ennen, K.A., 2013. Review of current conceptual models and frameworks to guide transitions
of care in older adults. Geriatric Nursing, 34(1), pp.47-52.
Enderlin, C.A., McLeskey, N., Rooker, J.L., Steinhauser, C., D'avolio, D., Gusewelle, R. and
Ennen, K.A., 2013. Review of current conceptual models and frameworks to guide transitions
of care in older adults. Geriatric Nursing, 34(1), pp.47-52.
Giger, J.N., 2016. Transcultural Nursing-E-Book: Assessment and Intervention. Elsevier
Health Sciences.

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Kamiya, Y., Doyle, M., Henretta, J.C. and Timonen, V., 2013. Depressive symptoms among
older adults: The impact of early and later life circumstances and marital status. Aging &
Mental Health, 17(3), pp.349-357.
Moran, M., Van Cauwenberg, J., Hercky-Linnewiel, R., Cerin, E., Deforche, B. and Plaut, P.,
2014. Understanding the relationships between the physical environment and physical
activity in older adults: a systematic review of qualitative studies. International journal of
behavioral nutrition and physical activity, 11(1), p.79.
Nursing and the Midwifery Board of Australia (NMBA) 2018. Code of Professional Conduct
for the Nurses and Midwives. Access date: 16th Jan 2019. Retrieved from:
https://www.nursingmidwiferyboard.gov.au/
Primary Health Tasmania. 2019. Shared Transfer of Care. Access date: 16th Jan 2019.
Retrieved from: https://www.primaryhealthtas.com.au/for-health-professionals/programs/
connecting-care/shared-transfer-care/
Statewide Mental Health Services by Tasmanian Government. 2019. Adult Community
Mental Health Services. Access date: 16th Jan 2019. Retrieved from:
https://www.dhhs.tas.gov.au/mentalhealth/mhs_tas/gvt_mhs/adult_community_mental_health
_services
The District Nurses Tasmania. 2019. Enabling you to manage everyday activities in a safe,
secure and healthy home environment. Access date: 16th Jan 2019. Retrieved from:
https://thedistrictnurses.org.au/services/domestic-assistance-home-help/