My placement was at a frailty ward with in the hospital which deals with the elderly who are experiencing an acute onset of a worsened disease conditions and neurological illness for example Parkinson`s, cerebral injury, tumours such as haemorrhage hypoxia and sub-arachnoid and are being referred by General practitioners, ambulance team and community nurses. The ward was also post-operative caring for patients who have received PEGs, RIGs and carotid endarterectomy. For this essay, I will be aiming on my personal experience and feeling on how I related with a patient Mrs Amanda (pseudonym) during my stay at a frailty ward with pain and End of Life management. To maintain privacy and confidentiality in line with the NMC Code of Professional Conduct (NMC, 2015), “As a nurse or midwife, you owe a duty of confidentiality to all those who are receiving care. This includes making sure that they are informed about their care and that information about them is shared appropriately”, pseudonyms will be used.
Throughout the essay l will reflect on how l provided holistic care to Mrs. Amanda until her last days on the ward which made me choose this experience due to the different aspects of care that will be explained in the essay that I learnt while she was on the ward. Care delivery, delegation and prioritisation will be explored along with team working, risk assessment and patient safety, taking into consideration my role as a supervised student nurse whilst analysing the roles and responsibilities of those supervising me and what influence this has on my practice. The discussion will comprise of the knowledge reinforcing practice and evidence base for the clinical skills that l learnt and validating them with the accessible literature. The essay will also include a reflection from my team work peer assessment during contributions in fixed team work and team based learning (see appendix 1).
I will be using the Gibbs (1998) reflective cycle as a model for this essay. The Gibbs (1998) reflective cycle which consists of six steps: Description, feelings, evaluation, analysis, conclusion and an action plan. In addition to the Gibbs (1998) models, there are several reflection models such as the Johns’ model of reflection (1995); Kolb’s Learning Cycle (1984), the Atkins and Murphy’s model of reflection (1994). But the Gibbs (1998) model prompts me to formulate an action plan which will enable me to look at my practice, observe what l would change in the future and how I would improve my practice. According to the RCNI 2015, “Effective reflection can allow professional practice to be enhanced and improved and is a process that can enable improvement to be achieved with ease, allow changes to be made, praise given where it is due, training or support needs identified, modifications made to practice and effective practice to be shared”.
When I arrived on the ward, my mentor Michael (pseudonym) briefed me about the patients on the ward. After, I took the opportunity to read each patient`s notes so that l had a better understanding about the patients and their illness. Under the NMC Code 2015, practise effectively for example communicating clearly by taking reasonable steps to meet people’s language and communication needs, when necessary aiding those who need help to communicate their own or other people’s needs. I introduced myself to the patients because it is important that the patients are aware of who l am and my status if l am to provide nursing care for them. During this placement, Mrs Amanda was admitted following a fall in her bathroom at home issues and was brought in by her family members. She had been also catheterised whilst on the ward because she had trouble of pass urine and had spent the last 8 weeks receiving holistic multidisciplinary care, for example nursing care, physiotherapy and occupational therapy and was due for rehab when medically fit for discharge. “The client is a holistic, autonomous being who has the right to make choices & decisions” (Ramont and Niedringhaus Page 34). Under the nursing ethics, autonomy is when a nurse must respect the client`s right to make decisions even when those choices are not in the client`s best interest. Under the supervision of my mentor while attending to other patients on the ward, Mrs. Amanda called out to me that she was in severe pain since she had been admitted with lower back pain. On approaching her I observed that she was in pain and once she had my attention she said she was in terrible pain and needed more pain killers. McCaffery,M, (1979, Page 11)
defines pain as “whatever the experiencing person says it is, existing whenever he/she says it does”. The most vital part of this definition is the care provider`s willingness to believe that the patient is experiencing pain and is the real authority about the pain.
I approached Mrs Amanda and introduced myself with the aim of establishing a pleasant nurse-patient relationship. I assured Mrs. Amanda that I will have a word with a qualified nurse and will be back. I walked up to Michael and asked that Mrs Amanda would need some pain killers as she is in severe pain. Michael then asked me where is Mrs. Amanda`s drug chart”? And instead of getting the pain killers for Mrs. Amanda, he asked me several questions. How do you know that she is in such severe pain as you have just described to me? Have you asked her with the trust policy of pain scale? (see appendix 2) What type of pain killers have been given to Mrs. Amanda and for how long ago were these given to her? He went on and on and I felt embarrassed and at the same time very eager to correct my mistakes. I was unable to answer any of the questions he asked and I presume I was overwhelmed with sympathy rather than empathy for the patient. I brought Mrs. Amanda’s drug chart and Michael explained to me that from her drug chart recordings, she is on PRN paracetamol and the last dosage was half an hour ago therefore she will need a review from the doctor to check whether she might need another route and dosage of the analgesic.
As a nurse it is important to use critical thinking to resolve problems related to direct patient care and as a student nurse, I asked for additional help since l did not know what else was happening to Mrs. Amanda because she said she was feeling very exhausted. Compassion is central to the care we provide and respond with humanity and kindness to each person’s pain, distress, anxiety or need (NHS Constitution 2015). Following discussion with Michael, I felt that Mrs. Amanda was uncomfortable, in pain and one of the healthcare assistants mentioned that Mrs. Amanda`s vital signs were between eight and nine, respiratory rate 28, oxygen saturations 89-91% and inspired oxygen 14-15 litres via face mask. To preserve safety under the NMC code 2015, I made a referral to Michael so that we worked towards the best interests of Mrs. Amanda as this was a concern to me. This is where my time management skills came in place, I made a timely report to the doctors who reacted appropriately since her oxygen levels and blood pressure were low. To my understanding, blood pressure and heart rate are very important to know the patient`s wellbeing to avoid cardiac arrest. The multi-disciplinary team members obtained information that clarifies the nature of the problem while suggesting possible solutions.
To practice commitment to safety and quality of the patient`s care, doctors take prompt action if they think that patient safety, dignity or comfort is being compromised. After re-assessment by the doctors that responded to the call, the doctor prescribed 48 meropenem for her since she had history of cystic fibrosis an inherited condition that causes sticky mucus to build up in the lungs and digestive system. I had the competency in medicine administration but on this occasion l was observed by two qualified nurses including Michael who talked me through the procedure while asking me questions about cystic fibrosis which l answered but he gave me feedback that I had insufficient information about the disease but I turned this into a positive feedback and read about it. Mrs. Amanda’s target oxygen saturations were meant to be 94% and above according to the doctor but Mrs. Amanda was deterioting. The ward sister discussed with the doctor that Mrs. Amanda may benefit from Opti flow and the team agreed for Opti flow trial. An Opti flow is a non-invasive device that warms and humidifies high flow nasal cannula air or oxygen which are delivered to the patient. Doctors recognise and work within the limits of their competence through making the care of their patient their first concern. The doctor called the critical care outreach team to provide the Opti-flow but Mrs. Amanda was feeling tired. “Decision making is a critical thinking process for choosing the best actions to meet a desired goal” (Ramont and Niedringhaus Page 39). For example, one of the nurse showed her courage and commitment to patient care by explaining to the doctor that it was not appropriate to continue the Opti flow due to exhaustion and poor improvement of Mrs. Amanda.
The doctor listened to the nurse`s concern and responded by later requesting for continuous positive airway pressure which is used as a treatment for obstructive sleep apnoea. Since Mrs. Amanda had capacity, the doctors and consultant explained to her and the family members that some of her organs were failing to function and among the roles of a doctor is to maintain trust by being honest, open and act with integrity. Mrs. Amanda was then placed on End of life Pathway (see appendix 3 for End of life pathway for acute hospitals) with her consent, transferred in a side room for privacy and referred to the palliative team. “Informed consent is an agreement by a client to accept a course of treatment or a procedure after complete information has been provided by a health care provider” (Ramont and Niedringhaus Page 25). A nurse is expected to provide safe and competent care so that harm such as physical, psychological or material to the recipient of the service is prevented. End of life definition from the General Medical Council 2010 states that “Patients who are approaching the end of their life need high-quality treatment and care that support them to live as well as possible until they die, and to die with dignity”.
While End of life as a patient, she was now nil by mouth because she had difficulty in swallowing and to prevent more discomfort, the doctors and nurses agreed to switch her to humidified oxygen for comfort. While on humidified oxygen, Mrs. Amanda was sweaty and getting exhausted when me and one of the sisters were changing her. The ward sister then explained to the family that she was getting exhausted so they should limit making her talk.
Relating Mrs. Amanda’s pain to my bioscience lecture while at University, pain is divided into acute and chronic pain based on its period. Acute pain is of short or limited duration usually associated with traumatic tissue injuries, whereas chronic pain is a pain or discomfort persisting for about 3 to 6 months and may persist beyond the healing period. Chronic pain despite therapeutic interventions for example medications, nursing care, physio and occupational therapists is classified as intractable pain which Mrs. Amanda was experiencing. Pain can be influenced among other things by culture, previous pain experience, mood, ability to cope or even belief and individuals should be treated differently. different.
Initially when I learnt that Mrs. Amanda was now on end of life management, I was interested to find out more about the patient and their condition but also sad to know that she will soon be a last office. When I met the patient, I felt sympathy towards her and the family and upon discussion she expressed herself that she felt like ‘giving up’ and ‘ending it all’. Looking at Mrs. Amanda l had a mixture of emotions, although I could understand why she would want to give up and the only reason was due to the pain she was starting to experience all over her body rather than just the back pain. I was quite confident at problem solving however this was a period where l was faced with a situation where l could identify the problem but was not able to come up with a solution due to the lack of experience in end of life management of patients. On reflection it was a positive experience as it allowed me to see how people cope differently with terminal conditions, and the impact it has on the family and carers
This being my first encounter of meeting a patient with acute pain and end of life management, I learnt so much and gain information especially about acute pain management having asked several questions and establish a good patient-nurse relationship. During this experience, the nursing team had built a good professional relationship with the patient and their family. The patient had plenty of time to discuss any concerns or issues that she had for example how she felt was important and her needs to be taken into consideration. Therefore, I used the trust`s pain scale tool to monitor the progression of her pain. I found the tool to be beneficial for effective management of pain because it was a good indicator as to when we would need to adjust her analgesia to ensure the patient was in the least amount of pain.
The principle of upholding professionalism under the NMC code 2015 is supporting appropriate service and care environments by raising concerns when issues arise that could compromise quality, safety and experience. “Professionalism is characterised by the autonomous evidence-based decision making by members of an occupation who share the same values and education. Professionalism in nursing and midwifery is realised through purposeful relationships and underpinned by environments that facilitate professional practice. Professional nurses and midwives demonstrate and embrace accountability for their actions” (NMC 2015). Michael confirmed to me that Mrs. Amanda may need a new review by the palliative team to reassess her pain. I went to inform Mrs. Amanda of this. On getting to her, I introduced myself with the aim of continuing our nurse-patient professional relationship and to obtain consent. I informed her that she will need a reassessment by the palliative team to change her pain killer or if there is need to increase the dose and that the doctor has been notified of this. This seemed to calm her down a little as I explained and listened empathically to her. Nursing is the art of caring and we must listen empathically to what service users and patients want so that we can deliver the care they deserve.
Under the trust`s local policy, “palliative care team seek to improve the patient`s quality of life when they are facing problems associated with life-limiting illnesses and their aims are to prevent and relieve suffering by identifying their need for high level assessment and treatment of pain and other problems which can be physical, emotional, social or spiritual”. When one of the palliative team member came on the ward, she told the doctor to prescribe PRN midazolam 2.5mg which was given to her via intravenous and Mrs. Amanda was very complaint with her medication. “The use of high-strength midazolam should be considered in palliative care and other situations where a higher strength may be more appropriate to administer the prescribed dose, and where the risk of over dosage has been risk assessed.” BNF NICE Drugs 2018.
According to the Mental Capacity Code 2005, “Having mental capacity means that a person can make their own decisions. The Mental Capacity Act says that a person is unable to make a decision if they cannot do one or more of the following, understand information given to them, retain that information long enough to be able to make the decision, weigh up the information available to make the decision, communicate their decision – this could be by talking, using sign language or even simple muscle movements such as blinking an eye or squeezing a hand.” But Mrs. Amanda had capacity and the multi-disciplinary team made sure that she was involved in her care. Patients may specify that they wish to have life-sustaining measures withdrawn for example treatment but there`s no ethical or legal distinction between the withholding or withdrawing of treatments but usually more troubling for health care professionals to withdraw a treatment than to decide initially not to begin it “Nurses must understand that a decision to withdraw treatment is not a decision to withdraw care” (Ramont and Niedringhaus page 33). As the primary caregivers, nurses must ensure that sensitive care and comfort measures are given as the client`s illness progresses.
There is a lack of evidence of catheters at end of life/ palliative care. (Fainsinger & Bruera, 1991). The relaxation of the urethral sphincters of the bladder causing urinary incontinence can indicate approaching death (WHO 2003). Using a range of verbal and non-verbal communication methods, and consider cultural sensitivities, to better understand and respond to people’s personal and health needs is important under the NMC Code 2015. With consent from Mrs. Amanda, I informed her that the catheter is to be removed for her comfort and an absorbent pad will be provided which she accepted.
“The rate of urinary tract infection in women is about 20% yearly compared with a rare of 0.1% in men” (Ramont and Niedringhaus page 413). Urinary tract infection accounts for 40% of all nosocomial infections because they are caused by Escherichia coli a common bacterium to the intestinal environment. Particularly women are at risk of urinary tract infection due to the short urethra and its closeness to the anal and vaginal areas. Nurses provide information and instruction in hygiene and diet to help prevent recurrences of urinary infection for example increasing the fluid intake for patients. As a student nurse, I pledged to commit my responsibility to all patients and their families or carers treating them with respect and dignity always whilst delivering the best care possible putting into consideration the team effort and abiding by the NMC 6C`s of nursing. So, l made sure l played my role as an advocate for Mrs. Amanda making sure that her comfort rounds were done and that she was comfortable before her last offices on the ward. (See appendix 4 for comfort round)
In addition to caring for Mrs. Amanda, I was given the opportunity to be involved in meeting with the palliative care team for the hospital which enhanced the importance of good communication skills and accurate record keeping ensuring that all participants in Mrs. Amanda’s care knew exactly what was happening. In terms of communication I felt I was gaining confidence especially with the family members as I had built up a relationship which was both professional whilst being friendly and trusting.