CNA345: Comprehensive Report on Shared Transfer and SBNC Nursing Care

This report provides a comprehensive analysis of shared transfer of care and strengths-based nursing care (SBNC) principles, using a case study of Lars, a 70-year-old Dutch man. The report examines discharge planning, ethical considerations, cultural sensitivity, and practical applications of SBNC, including the importance of shared decision-making, patient documentation, and the involvement of healthcare professionals such as occupational therapists and counselors. The report emphasizes the need for a holistic, patient-centered approach that respects individual autonomy and cultural diversity, while also addressing the complex needs of both Lars and his wife, Isa. It highlights the importance of considering the patient's environment, financial status, and family dynamics to achieve positive health outcomes and well-being. The report also discusses the legal and ethical principles related to patient privacy and confidentiality, and stresses the need for a multidisciplinary approach to care that involves shared communication and documentation.

Running head: SHARED TRANSFER AND STRENGTHS BASED NURSING CARE
Introduction
According to ‘Primary Health Tasmania’ as well as the Australian Government, the healthcare
strategy of ‘Transfer of Care’ implies the transmission, sharing and shifting of an individual’s
healthcare needs and responsibilities across inter-disciplinary healthcare professionals,
healthcare service locations, healthcare service providers and levels (Primary Health Tasmania
2016). Patients often present not one, but a variety of complex, healthcare needs and concerns
which are not possible for management by a single specialty or healthcare provider (McAllister
et al. 2018). The following report, based on Lar’s case study, will discuss the principles of shared
transfer of care, strengths-based nursing care (SBNC) along with the cultural and ethical
concerns of communication, clinical decision-making and documentation.
Discussion
Case Overview
The following report will discuss the shared care transfer and SNBC principles in relation to the
case scenario of Lars – a 70-year-old Dutch man who, alongside his wife Isa, had migrated to
Australia in 1970. Lars was recently admitted to the emergency unit of a local healthcare
organisation in Tasmania after an event of carbon monoxide poisoning which resulted in his loss
of consciousness, hypotension and difficulty in breathing. He had presented with several
difficulties pertaining to limited movement, agitation and delirium during his hospital stay. He
had also suffered a fall a few days prior to his discharge, which resulted in a skin tear near his
left elbow. After discharge however, Lars has refused to communicate his diagnosis.
He has also refused residential care services for his as well as his wife, Isa. Isa at present,
inflicted with type 2 Diabetes, Chronic Obstructive Pulmonary Disorder (COPD), chronic
smoking and difficulty in movement (which began after her stillborn birth experience), and
whose care is supported full time by Lars himself.
Discharge Goals
1. Elderly individuals, due to the physiological effects of ageing, are prone to a range of
musculoskeletal issues pertaining to loss of muscle strength, bone density, increased
muscle cell atrophy, muscle wastage and reduced synovial fluid production resulting in
increased joint pain, swelling and loss of balance. Such changes increase the risk of falls
and fractures, as observed in the case of Lars, who recently encountered a fall when left

CNA345 Assignment task 2
alone in the healthcare organisation he was admitted in (Cox et al. 2018). Thus, one of
the key discharge goals for Lars’s discharge plan is to provide a supportive and
supervised environment for the purpose of reducing the risk of falls and harms
associated with the incidence of falls. Such a goal is largely associated with Principle 6
of a strengths-based nursing care (SBNC) which recognises the fact that an individual
demonstrates optimum strength and functioning within a ‘best fit’ or ‘goodness of fit’
environment (Gottlieb & Gottlieb 2017).
2. With ageing, reductions are observed with respect to the ability of the skin to encounter
cell growth, regeneration and repair resulting in increased risks for the elderly regarding
skin cuts, wounds, infections, dryness and flakiness, as observed in Lars large skin tear as
a result of his fall (Koyano et al. 2016). Thus, a key discharge goal would be to reduce
risks of incidences pertaining to skin tears for Lars post discharge.
3. Ageing paves the way for a range of debilitating neurological changes such as sensory
impairment, neuronal atrophy and resultant loss of cognitive abilities, reduced ability to
engage in logical reasoning and decision-making as well as an increased risk of
neurological disorders like dementia, delirium and Alzheimer’s. Along with these
changes, loss of functional capacity associated with ageing also increases the risk of
mental health concerns in the elderly (Dajak et al. 2016). This can be observed in the
Lars’s episode of depression, aggression and delirium during his stay in the healthcare
organization as well as after the departure of Finn and losses in his business. Thus, a key
goal of discharge would be to ensure positive mental health outcomes and wellbeing
in Lars, with compliance to this personal and family needs. Such a person-centred
goal demonstrates compliance to SNBC principle 1 which necessitates the need to
consider an individual holistically (such as Lars’s mental health and family history),
rather than his or her parts (such as his physiological issues) (Gottlieb and Gottlieb 2017).
4. Lars’s healthcare is largely integrated with the chronic healthcare needs of his wife as
well as her linguistic needs considering her Dutch background. Additionally, there is also
a need to consider his financial status and ability to engage in medical services. Thus, a
key goal of the discharge plan must be to collectively address Lars’s condition using
a family centered approach, which will consider Isa’s health, their financial crisis
after their Finn’s engagement in gambling and departure from the family as well as
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the sense of unity amongst members. This will demonstrate adherence to SNBC
Principle 6 which necessitates the relationship between an individual’s health and
surrounding environment (Gottlieb & Gottlieb 2017).
5. Lastly, it must be noted that Lars refuses to participate in respite care services. The goal
of the discharge plan then would be to incorporate at-home clinical services, based on
the healthcare needs of Lars and his wife as well as including his own views in the
decision-making process. Such a goal demonstrates compliance to SNBC Principle 5 of
self-determination which recognizes the need to respect an individual’s competency and
desire for autonomy (Gottlieb &Gottlieb 2017).
Course of Action and Strengths-based Nursing
A key course of action would be the inclusion of an occupational therapist – a healthcare
professional specialising in improving an individual’s balance, strength and range of motion
(Cockayne et al. 2018). Since Lars does not wish to engage in respite, referrals can be arranged
for healthcare organisations providing in-home occupational therapy sessions in Tasmania,
which will comprise of a therapist engaging Lars as well as his wife in physical exercise,
stretching and physiotherapy. Such occupational interventions have been evidenced to improve
individuals’ strength, balance and thus prevent falls (McIntyre, Mackenzie & Harvey
2019).Inclusion of in-home, patient and family centred services will also demonstrate SNBC
Principle 5 which allows Lars to determine his healthcare needs in the comfort of his home
(McIntyre, Mackenzie & Harvey 2019; Gottlieb & Gottlieb 2017; Tasmania Government 2020).
Additionally, the collaboration of the occupational therapist with Lars regarding the need to
remove obstacles or include supports in his home as per ‘Stay on your Feet’ resources may assist
in the inclusion of a supportive and protective environment for Lars (Tasmania Government
2020). Such interventions complies with SNBC Principle 6 of ensuring a best fit environment for
the individual (Gottlieb & Gottlieb 2017; Tasmania Government 2020). Inclusion of in-home
counselling services in Tasmania where a counsellor can visit Lars and Isa at home, will allow
for the practice of behavioural interventions like ‘Talk Therapy’ or ‘Cognitive Behavioural
Therapy’ as well as compliance to SNBC Principle 1 of holism. Such interventions have been
evidenced to assist individuals in identifying and regulating their negative thoughts (Department
of Health and Human Services 2020; Gottlieb & Gottlieb 2017; Unwin et al. 2016).
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To address Lars’s skin tears, in home dermatological services residing in Tasmania can be
included, to demonstrate emollient therapy as per Lars’s needs at home. Emollient therapy has
been evidenced as beneficial for treating skin conditions of dryness and flaking and thus prevent
skin tears as in the case of Lars (Idensohn et al. 2019).
Lastly there is a need to include in-home family counselling services who can communicate to
Lars’s family regarding the prevalence of unity as a protective factor during times of distress,
and in turn, demonstrate compliance to SNBC Principle 6 of individual and environmental
connectedness (Mutchler 2017; Gottlieb & Gottlieb 2017). Care has to be taken to include an
interpreter who may collaborate with Isa, Lars as well the identified healthcare professionals in a
culturally competent manner. Demonstrating respect for a client’s ethnic diversity paves the way
for consideration of a community and cultural strengths approach where he or she feels that his
or her linguistic identity is not a liability but rather an asset to be respected (Pérez 2019).
Shared decision making
1. The healthcare interventions agreed upon by the above team, must be in congruence to
patient centred and family centred principles, to ensure that Lars and his family’s
opinions are prioritised in the decision-making process.
2. The interventions and clinical decisions to meet the needs of Lars and his family must not
only be shared but must also be evidenced based.
3. Provisions must continue to ensure that the chosen interventions are financially
accessible f or Lars’s family.
4. The care plan must be based on SNBC Principles 1, 5 and 6 as previously identified, and
must include interventions which are coordinated across team members and also
multidisciplinary in nature (Primary Health Tasmania 2016).
Patient Documentation
As evidenced by Primary Health Tasmania, some of the key principles underlying effective
practice of shared transfer of care, are the need to engage in shared communication and
documentation between patients and the multidisciplinary care team as well as across the
members of the multidisciplinary care team (Primary Health Tasmania 2016). This implies that
not only must the chosen inter-disciplinary professionals actively involve Lars in the clinical
decision- making process in a timely manner, each member of the team must also engage in
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common patient assessments and collectively share the responsibility of documentation of Lars’s
health. This can be done via collective adherence to the ‘ISOBAR SHARED Planning Checklist’
developed by Primary Health Tasmania – as a part of shared documentation to be collaborated
across members of Lars’s healthcare team. The ISOBAR checklist is comprised of: Identify,
Situation, Observations, Background, Assessment and Recommendation (Beament et al. 2018).
Adhering to the components of the SHARED section of this checklist, enables healthcare
professionals to identify the nature of support required to transfer Lars with safety across
healthcare providers, listen to his concerns and relate it to the identified care plan needs. This
checklist also prompts healthcare professionals to involve his family (Isa, Hannah), communicate
assessment results to Lars in a patient centred manner and identify the prevalence of adequate
safety measures in chosen healthcare destination where Lars may be sent to. It must be ensured
however, that Lars is actively included in the shared documentation process to engage in patient
centred shared transfer of care as well as Principle 6 of enabling Lars to self-determine his
healthcare needs (Primary Health Tasmania 2016).
Legal and Ethical Principles
While sharing documentation and assessment results across healthcare professionals, there is
often a risk to patient privacy, confidentiality and safety, especially when the personal data of the
patient are being shared or transferred across healthcare professionals (Slomski 2017). Thus,
while patient documentation must be shared to patients as well as to members of the healthcare
team, there is a need to adhere to ethical principles of patient privacy and confidentiality
(Primary Health Tasmania 2016). This can be done by replacing Lars’s name with a code or
different name, labelling patient documentation records as ‘non-disclosure’ and restricting the
access to patient documentation to authorised personnel only (Edwards et al. 2018).
Conclusion
This paper has highlighted the key approaches to take for Lars’s and his family’s t which are
met using a strengths-based approach and principles of shared transfer of care. Shared transfer of
care must not only be multidisciplinary in nature but must also be shared across team members in
terms of documentation and communication. In addition to practising family and person-centred
approaches, shared transfer of documentation must be done in a confidential, safe and secure
manner.
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