CASE STUDY 1

Leadership and management in complex care: a case study of a patient from practice

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Introduction

Caring for patients often involves managing a complex area of professional practice,

legal requirements, legislation and codes of conduct, and legal and ethical considerations.

This complexity increases further when they are faced with people with multiple needs. For

the purpose of maintaining patient anonymity, this essay will refer the patient to Mrs A, a 65-

year-old female sufferer of diabetes mellitus and early-stage dementia, on top of the regular

ageing symptoms. Mrs A's journey highlights the inherent challenges of modern healthcare:

the fine art of balancing the consumption of her meals and physical activity, the ever-present

threat of being re-admitted, and the significant issues of how the power of decision-making

belongs to her. This paper explores various aspects of Mrs A, including applying

professional(code), legal and regulatory perspectives, and ethical principles. It analyzes the

Care experience of an individual identified as A. The essay will carefully analyze how and by

which the nurse took the leading position in her management, explore the interdisciplinary

team's cooperation (IDT), and consider the factors that cannot but affect the quality of the

care in accordance with the delivery. Lastly, this pursuit will expose directions toward the

person-centred Individualized approach to care and lessons from Mrs A. Making a stand out

is quite a challenging experience in the system.

Professional, Regulatory, Legal, and Ethical Considerations in Care

Professional Standards and Communication Challenges

According to (Shaban et al., 2024), this professional practice primarily focuses on the

patient, efficient practice, safety, and etiquette. However, it was established in Mrs A's case

that failures in communication among the healthcare givers impeded the provision of

competent care. For instance, a critical admission was delayed due to confusion as to the

patient medication examination, followed by a missed insulin dose. So, it is important for the

discussion seen in this incident that communication is a significant component of safe patient
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care (Shaban et al., 2024). According to De Micco et al. (2022), a breakdown of

communication that is expected, especially at the critical transition points, greatly raises the

odds of a negative outcome (De Micco et al., 2022). On the other hand, there was typical

professional behaviour when nurses offered emotional support to Mrs A. Being a patient

advocate for A's family helped them understand and embrace her care plan and respond to

their concerns politely. This is in line with the NMC Code highlighted by Mainey et al.

(2024) on communication and advocacy (Mainey et al., 2024). The empowered professional

involvement of rating staff should not overlook the all-important regularity of conjoint

sessions with other members of the interdisciplinary team; their collaborative discussions

remain the key to continuity of care.

Regulatory Frameworks and Compliance

Levels of compliance with geographically specific legislation were variable, and

formal care guidance, such as NICE guidelines regarding appropriate diabetes care and

treatment, was not always followed. For instance, Mrs It was reported that she significantly

experienced delays in receiving required Diabetic foot assessments. She suggested that

offering patients specialized diabetes care and implementing screening standards as

recommended by NICE (2021) can help avoid complications (Shaukat et al., 2021). The

persistence of delayed access to dietetic services also ultimately worsens her glycemic

control, indicating resource utilization. Consequently, the Gold Standards Framework (GSF)

seeks the timely anticipation of end-of-life care as well as cross-organizational cooperation

(Rao et al., 2021). However, Mrs A had a weak ACP; her family was not certain of her

wishes during key decisions, hence inadequate care for A. This lack of regulation may

explain why structured ACP discussions are called for.

Ethical Dilemmas in Decision-Making

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The primary concepts applied in medical practice, which define compassionate and

fair treatment of patients, are called medical ethics. Such principles as autonomy,

beneficence, non-maleficence, and justice are the principles commonly used by the healthcare

profession and assist in solving some of the complex matters of nature(Anthology, 2021) .

These principles applied to Mrs A's care and the decisions that were made, seeing through the

lens of ethical principles.

Autonomy

The autonomy principle, therefore, refers to a patient's choice-making ability

concerning their treatment regime, given that the patient can decide questions. However, in

the case of Mrs. A, her diagnosis of dementia raised contradictions of how this principle can

be upheld fully. Dementia often affects cognition, making patients less able to comprehend

the information they need to make decisions for themselves. As much as one had to take into

consideration the right to make her decision, her decision-making capability was put into

question and doubt because one wondered whether she comprehended the outcomes

associated with the choices she was making or not. As stated by the Mental Capacity Act

(2005), health practitioners have to evaluate their patients' mental capacity to make decisions

on their own before making their own decisions (Fard and Oberai, 2022) . In the case that the

patient no longer possesses the capacity to make decisions, a lot of consideration should be

given to engaging the patient in the decision-making process.

In Mrs A's case, this process was not formally documented, which raised some ethical

questions. A pivotal concern regarding whether the healthcare team should go against the

patient's wishes in order to preserve her health, and vice versa, was when the team knew that

although the patient gave her informed consent, this decision was not in her best interest.

Beneficence and Non-Maleficence

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The concepts of beneficence and non-maleficence aim at doing well and doing no

harm. In Mrs. A's Nursing care, the nursing team embraces the principles. They stabilized her

blood sugar by giving her insulin and also managed her nutrition by educating her. These

actions were intended to enhance her health and avoid health complications, which are

common with diabetes. Nevertheless, the team faced challenges in their effort towards the

task. They mentioned one of the constraint dilemmas, for instance, inadequate staffing. This

sometimes caused a slow reaction to Mrs A's needs, which may have led to some

inconvenience. For example, a failure to give insulin when supposed to or to act on

symptoms of hypoglycemia may be very dangerous for her. Although the healthcare team

pursued the patient's best interest, encompassing beneficence and the principle of not harm,

the resulting organizational constraints occasionally prevented them from doing so.

Justice

The principle of justice is associated with equality in the treatment of patients in terms

of health. This means that each of the patients receives an equivalent treatment and service

delivery from the healthcare practitioners. Mrs A's challenges that currently affect the

healthcare system deprived Mrs A of justice. For instance, the long time it took to consult

endocrinology explained that Mrs A could not get to see a specialist at a time when the

condition required treatment or attention. This delay, besides reducing the quality of treating

her, affected issues of equitable access to health care.

Such systemic problems are not rare and further emphasize the fact that there have to

be changes for all patient populations, especially for those with chronic diseases like diabetes.

Solving these questions allows beginners in the medical field to work towards the goal of

delivering justice to patients.

Analyzing the principles of autonomy, beneficence, non-maleficence, and justice in

the context of Mrs A, one may get to appreciate the ethical issues that surround such workers.
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Such circumstances involve a delicate consideration of patient autonomy, benefits, and

constraints topped up with ethical and legal considerations about the subject.

Legal Obligations in Safeguarding and Documentation

Mrs A's care raises this legal aspect, MCA 2005 and safeguarding (Fard and Oberai,

2022). The early stage of dementia is quite serious, and it may lead to coercion from a family

member who demands to make treatment decisions on behalf of the patient. This shows why

it is compulsory to respect the power of attorney provisions and why the law must apply

measures to safeguard the interest of the patient. The lack of proper documentation made it

worse when it came to failure to implement proper documentation, which definitely

aggravated situations related to emergency care. Legal guidance has it that common respect

documentation related decisions should include the patient or the patient's representatives,

however, in the case of Mrs. A’s case, these were always disregarded, leading to creating a

lot of discomfort for her family at key times.

Evaluating Nursing Management and Interdisciplinary Collaboration

In healthcare, leadership, care management, and teamwork are becoming essential in

the delivery of quality healthcare to patients. Assessing such parameters in Mrs A's case

shows that the organization's strengths and weaknesses need to be worked on. In this regard,

some factors influenced her care.

Strengths and Weaknesses in Nursing Leadership

High-quality patient care is best driven by nursing leadership, but in the case of Mrs.

A, some constraints retrieved the nursing capacity. Of the problems identified, the most

serious was a lack of care planning. For instance, failure to follow through with her care plan

writing meant that some of the most vital parts of this patient’s life, including her diet, were

not met as required. Failure in thorough planning was also evidenced by her diabetes by

worsened diabetes, hence pointing towards a leadership gap.

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Effective leadership theories, such as transformational leadership, emphasize the

value of open communication, teamwork conflict anticipation and management (Sun, Chen

and Zhang, 2017). If these principles had been applied, there could have been an

improvement in the aspect of care coordination. Organizational transformational strategies

involve goal initiation, which means supporting the creation of goals within an organization;

provision of resources, which implies offering support and encouragement where it is

required; and finally, the provision of stimulation, which, in the case of Mrs A's care.

However, some shortcomings were identified in this study. Shining a positive light on the

nursing staff, the following organizational strengths were evident. They showed

understanding and flexibility, which they applied in emergencies, like instances when blood

glucose levels were high. They were quick to try and calm. Daily check on Mrs A's blood

glucose levels demonstrated compliance with evidence-based practice in managing diabetes

alongside patient education on self-management. All these efforts showed that the nursing

team wanted to enhance her health outcomes despite leadership and systems barriers.

Collaboration Within the Interdisciplinary Team

The management of complicated cases like those of Mrs A requires the effective

collaboration of the members of the Interdisciplinary Team. The team consisted of

community nurses, dietitians, and endocrinologists, and through collaboration, we achieved a

constructive change and significantly enhanced her glycemic control. For instance, regarding

dietary changes as well as insulin treatment, options were more precisely adjusted, referring

to her with cooperation. Still, the efficiency of implementing a team approach in these large-

scale projects was not very brilliant, and the cause of that was poor communication.

A major challenge that has emerged over time with respect to the policy is the Case of

Mrs A's hospital-to-home transfer case, where mixed orders regarding her insulin schedule

were given, creating confusion around her caregivers. Such types of breakdowns do not only
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impact continuity of care and delivery but also bring anxiety to her caregivers. This situation

calls for enhanced methods with regard to discharge planning, as these ought to incorporate

comprehensive instructions and plans for follow-up.

A number of issues can be discussed by referring to the interdisciplinary team and

applying the Tuckman model, which divides the work of the team into four stages: forming,

storming, norming and performing (Sokman et al., 2023). In Mrs. A's case, the team was

mostly in the "storming" phase most of the time. This stage involves role confusion, and this

creates many problems and decreases the effectiveness of the team. For example, uncertainty

in identifying who was supposed to be in charge of discharge planning made it cumbersome

in terms of performance. Transitioning to 'norming and 'performing' is preceded by

intentional management measures that focus on developing clear roles, communication and

building trust in the team.

Systematic and Organizational Influences

Psychological and sociopolitical systems, in addition to organizational factors, impact

the work setting (Young et al., 2022). Environmental resources and organizational culture,

therefore, influenced Mrs. A's care. With regard to the evaluation of the practice, one of the

critical concerns was a lack of access to specific training for caregivers, including those

focused-on dementia care. Some of the staff members themselves were not knowledgeable

and skilled enough to meet her cognitive needs, which probably undermined the rest of her

needs. Also, high turnover staff rates were observed to interfere with the continuity of patient

care. This instability is a familiar issue in healthcare environments and has been reported

frequently in the literature. The volatility of the workforce is an undesirable phenomenon

because it leads to more mistakes and decreased quality of care (Cernega et al., 2024). In Mrs

A's case, she was transferred multiple times within the facility, generating a high turnover
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rate of her caregiving team, and the nursing team rarely knew her previous medical history to

facilitate smooth care.

These issues demonstrate a need for staff development, a focus on retention measures,

and a positive work environment. Solving these problems is critical for guaranteeing that all

patients like Mrs A. Generally, Analyzing the best practices of leadership in nursing and the

role of interdisciplinary and systemic characteristics in managing the specific situation with

Mrs A's care. Such ideas are useful in teaching the administrators and staff in any health

facility how to better manage care coordination, communication, and leadership.

Person-Centered Care and Proposals for Improvement

Person-centred care is a strategy that involves making a healthcare intervention that

responds to the needs, wants, and beliefs of the recipient. In the case of Mrs A, attempts to

engage her in decision-making autonomously were done in a rather uneven manner. This was

probably occasioned by the fact that it was believed she had poor mental health; hence,

sometimes, decisions were made without involving her fully.

The person-centred approach developed by Carl Rogers highlights three key

principles: recognition of empathy, client-centred model and nonjudgmental acceptance

(Kumari, 2024) . These principles allow patients to trust doctors and other healthcare workers

steadily by incorporating patients' opinions, being sincere, and embracing them. Despite their

use in averting the issues that may be raised during diabetes self-management education

sessions, the principles are not reliably and consistently executed by the staff of the hospital

where Mrs A was receiving care. Such a gap reduced the use of the person-centred approach

and decreased the chances of tailoring the care to her needs.

Proposals for Improvement

To address the issues, intervention strategies need to be developed that will enhance

person-centred care. The strategies include:

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 Strengthening Communication

Precise communication among Interdisciplinary team members and with Mrs A's

family. She should also be able to get all the necessary care information from everybody

involved in her care. In addition to this, Health education has to take place to help all the

involved parties ensure proper caregiving. Techniques like the SBAR approach (Situation,

Background, Assessment, Recommendation) can be used to organize.

 Advance Care Planning

Advance care planning discussions can help introduce structure to address concerns

and document and ensure the goals for Mrs A's preferences for her care. It will be good to

engage her and her family in order to have a chance at creating a care plan, bearing in mind

her preferences even when her capacity is impaired, which is an important matter to consider.

 Training and Education

Organizational training with respect to staff attending to Mrs A may help them gain

knowledge on what should be done for people living with dementia. Meet cognition needs

specifically for her. This would involve measures of communication and behavioural

challenges that may be present and ways of engaging the patient despite deficits in these

areas.

 Cultural Sensitivity

Accepting and utilizing the roles played by Mrs A's cultural and spiritual beliefs in

her care plan yields a big positive impact on her. For instance, aspects such as her eating

habits, religion, or family structure would show the therapist a particular aspect about her

that, in turn, would make the trusting intervention a success.

Implementation Plan

To operationalize these improvements, the following steps are proposed:

Introduce Regular Interdisciplinary Case Reviews:

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The efficiency of care delivery can be evaluated by conducting case conferences with

the interdisciplinary teams on a regular basis, and this can lead to the discovery of any issues

that need to be addressed. Such reviews are an opportunity to heat the discussion on the

problems, work on them together, and make sure that Mrs A is receiving the care and remains

based on person-centred principles.

Utilize Patient Activation Measures

Using tools like Patient Activation Measures can evaluate Mrs A's level of

involvement in her care. Consequently, the obtained information may be used to create

tailored interventions that can effectively engage her in the promoted approaches to managing

illnesses.

Leverage Technology for Care Coordination

It is easier to document Electronic Health Records EHRs and use them to improve

care team communication. Tools like integrated care plans and automated notification

features can enhance continuity, avoid gaps and omissions in clinical care and increase the

likelihood that they will be incorporated into the next phases of Mrs A's likes and dislikes and

are communicated to everyone who has to attend to her needs.

In general, these strategies, as well as the action steps, bring the healthcare team

closer to achieving person-centred care for Mrs A. These initiatives will not only recognize

deficits but also yield a care experience that is integrated and, more so, honouring her needs

and beliefs.

Conclusion

Mrs. A's case reveals the difficulties in providing care to patients with extensive needs

for complex care interventions to which professional knowledge and their application, legal

requirements, and ethical standards all have to be applied. There were positive practices, like

work done to manage her blood sugar levels; nonetheless, there were communication, lack of
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proactive care planning, and teamwork factors that affected the chances of the best results.

Sometimes, there was some inconsistency in interdisciplinary relationships and role

confusion impaired care coordination. There was also a lack of staff knowledge and cultural

competence in dementia care, thus limiting the effectiveness of interventions. To overcome

these threats, a personalized, person-centred, recovery-focused care approach that caters for

patients' needs and preferences is necessary.

Thus, advanced structuring in care management, effective tools of communication,

and specific materials of the educational setting can contribute to improving compliance with

identified patient values, as well as developing a more patient-oriented and significant

atmosphere. Furthermore, system-level intervention, including staff supply, staff retention

and autonomy in the delivery of targeted and recovery services, will help build a strong and

effective care model. Regarding collaboration, sustainable education, and strong-layered

support, healthcare teams can provide better results to the patient, such as Mrs A so that their

care meets the patient's needs as well as professional and ethical requirements.
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References

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Appendix

SBAR for Mrs. A

Situation Mrs. A, aged 65, has been diagnosed with diabetes mellitus

type 2 and early dementia, which manifested in her frequent

hospitalizations because of hypoglycemia and intense reports

of cognitive disturbances.

Background  Uncontrolled diabetes Mellitus type 2.

 Currently, less than one year from diagnosis

with early dementia, which has affected their

capacity to make decisions regarding her

treatment and medication compliance.

Assessment  Regular instances of high blood sugar levels.

 Lack of compliance with Type II diabetes self-care.

 Lack of competency to engage in decision-making on

aspects relating to care planning is an implication of a

learning disability.

Recommendation  The interdisciplinary team should come up with a list

s of actions that will be good for the care plan.

 Start advance care planning conversations.

 Develop dementia care training for the staff in the

centre.

 Discharge planning as an intervention should be

stepped up so that there can be better transitions from

one setting to another.

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