Keywords: reflective nursing essay, colonoscopy medical essay
This essay aims to provide a reflective profile of the author's personal and professional experience of a patient being accepted for a colonoscopy. To achieve this, a style of reflection will be utilized and a rationale provided to aid this choice.
The main point of conversation is communication and advocacy. Advocacy is central to communication and part of the caring nurse-client romantic relationship (Arnold & Boggs, 2003). The author as a recently appointed nurse on the Endoscopy Unit, will reflect upon how they might have been an improved advocate for the patient in question. Honest and legalities will be reviewed. Finally implications for practice will be mentioned.
Using a style of representation allows the nurse to re-appraise the care they have delivered to a patient/client and in doing so can measure the effectiveness of this good care (Basford & Slevin 1995), thus with the goal of influencing future practice for the better. Prior to starting the reflection process it'll be more ideal for the professional to truly have a guideline or platform that to work from (Palmer, Uses up and Bulman 1994). Palmer et al (1994) view the procedure as something that is energetic and they suggest a cyclical style model using questions to give a format for reflection. It is for these reasons that the Gibbs Reflective Cycle has been chosen (Gibbs 1998) because of this essay.
In compliance with the Medical and Midwifery Council expectations on respecting confidentiality in practice, all labels and locations have been made anonymous (NMC 2008). As this is a reflective essay the writer will make reference to herself as "I" where appropriate.
The reflective circuit is divided into six sections each with the own key questions. They are:
Description: What occurred?
Feeling: What were you considering and being?
Evaluation: That which was good or bad concerning this experience?
Analysis: What sense is it possible to make of the problem?
Conclusion: What else would you have done?
Action Plan: If it arose again what will you do?
(Gibbs 1998)
These areas for representation provide the key topics for the rest of this project. When the practitioner is rolling out an action plan they may then return to the beginning of the cycle with the extra knowledge they have obtained from the first reflective experience (Gibbs 1998). It is here though with the information of the incident that the reflective cycle will start.
The following situation led me to question my actions when admitting an individual for a colonoscopy.
The patient a 43 year-old guy was known for a colonoscopy by his GP carrying out a three-week history of fresh rectal bleeding, anal itching (pruritus ani) and a change in bowel habit. Two weeks prior to the slated test, a pack containing a letter of session was delivered to the patient by the endoscopy supervision personnel. Enclosed were two sachets of Picolax bowel preparation, full instructions for consumption, highlighting the necessity to follow instructions accurately to ensure clearness of view and help diagnostic accuracy. Included with this load up was a pre-endoscopy questionnaire to enable the nurse to evaluate the patient's general state of health and identify any potential risk factors or difficulties, which may happen.
A booklet is at this pack detailing the procedure, reasons for the test, problems and risks and what to expect during the test. The booklet mentioned other available investigations to ensure that he could make the best decision and enable him to give educated consent for the test to just do it. The Medical and Midwifery Council (NMC) (2008) declare that before any treatment or good care is given to the individual, consent must be obtained. The BSG (2008) alert that consent issues are a significant way to obtain problems, sometimes leading to both issues and litigation throughout the NHS. Therefore valid and sturdy consenting is currently a required standard for the Endoscopy Global Ranking Size (GRS, 2009) which is a tool that permits endoscopy units to examine how well they offer a patient-centred service. Information in the booklet protected the choice of sedation and the necessity for appropriate after-care. A consent form was enclosed for him to signal at home, providing the patient possessed read, understood and agreed to under-go the task.
A morning session was made for the individual and he attained the machine by himself. He was greeted by myself, I checked out his personal details. This is in accordance with the BSG (2008) instruction for obtaining a valid consent for elective endoscopic steps as it says that identity assessments at key stages in the task are essential as some patients have even been recognized to undergo procedures intended for another scheduled to lack of autonomy and stress which can end result when entering the hospital. When these details was established he was made to feel safe in the preparation room.
The patient was evidently anxious. He was looking down a great deal and he previously his forearms folded. He spoke rapidly and with a quiver in his tone of voice one of the first things he thought to me was, "please knock me out for this". I told the patient that although we're able to give him some sedation which would make him feel more laid back, he would be awake as it might be unsafe to "knock him out" for the test. The sedation used for all endoscopic procedures is "conscious sedation". It has been thought as:
"A technique in which the use of any medication or drugs produces circumstances of depression of the central nervous system permitting treatment to be carried out, but where verbal connection with the individual is maintained throughout the period of sedation. The drug and techniques used to provide mindful sedation should bring a margin of protection vast enough to render loss of consciousness unlikely". BSG (2003, p3).
He explained that he noticed on the consent form that sedation would be offered and he interpreted this to be a general anaesthetic. I further explained to him that although the patient may feel sleepy, he'd be mindful throughout the ensure that you he would have the ability to speak to us. Cotton and Williams (2003) recognize, believing that the desired aftereffect of the sedation on the individual is sleepy, relaxed but rouse able. The patient clearly portrayed a desire for sedation and it was proven that the patient's wife could collect him after his technique and would stay with him over another 24 hours. It really is a need that any patient going through an operation with sedation should be followed home by a responsible adult who will continue to be with them for 24 hours as sedative effects are recognized to remain in your body system for this period of time (Royal College of Cosmetic surgeons, 1993).
At this point, I as a newly appointed personnel nurse on the machine was unsure if the consent form that the patient had authorized was valid as he at first thought that he was going to have a general anaesthetic when he previously signed the form. I have been been trained in taking consent which is noted in my e-portfolio in regards to the countrywide GIN training programme (Gastrointestinal in Nursing Training Program), but was doubtful what to do in this situation as I had never experienced the situation before. My original thought was that is was not valid as the individual possessed a different conception of the test. I told the patient that we was just going to get some advice from my colleague (who experienced worked well in the endoscopy device for quite some time) as regards the validity of his consent form. I said that I would need to make clear the problem to my colleague and he agreed to this joking that we didn't both need to get into trouble from the headmaster and get a detention. I said that I'd only be a couple of minutes and left the room to find advice.
I explained the problem to the nurse who was sat in restoration. The nurse said that the Endoscopist executing the procedure would go over consent again in the task room and not to worry about it. I expressed concern at this because I knew that consent must never be obtained in the task room. Guidelines readily available in relation to consent include British Contemporary society of Gastroenterology recommendations (BSG) (2008) and the Joint Advisory Group Rules (JAG) (2001). Booth agree that consent shouldn't be taken in the task room. Help with good practice in consent implies that all patients must have had satisfactory time to absorb and reflect upon new information. This is not achieved if consent is obtained at the last possible moment which is at the procedure room itself.
The nurse was dismissive and made unpleasant reviews regarding men in general. There was a brief distance between your nurse and the prep room where in fact the patient was so that it is probable that the patient heard her remarks. I did so not comment at this time even though I sensed her remarks to be improper. Fortunately this gentleman was the first patient on the morning's list and therefore, no other patients were in recovery to here the feedback. The nurse found the patients records and knocked on the prep room door. I thought i had better view too as the nurse searched ready for a challenge.
The nurse was very brusque in manner and asked the individual if he had browse the booklet which the unit has delivered for the ensure that you the section regarding sedation. The individual said that he had read the booklet and indeed the section regarding sedation but there is no point out that he would be awake after he had been given the sedative and assumed therefore that he would be asleep. The nurse then acquired a copy of the booklet. As she was flicking through looking for the webpage with the relevant sedation home elevators, she said "it obviously states in the booklet that if sedation is given, the patient will be awake throughout the test". However, when she got to the web page regarding sedation there is no mention of this. It just explained that sedation would be offered prior to the colonoscopy if the patient decided to have sedation that it was essential that someone was available to stay escort the individual home and stay with them right away. The nurse went scarlet, but did not apologise to the individual and said that she was going to "have words" with the administration staff and remaining the task room.
I experienced guilty i had not challenged the nurse regarding her rude manner with the patient at the time but experienced intimidated and unable to voice my opinion, I also thought I needed failed in my own duty of treatment. I thought that the nurse had made a major deal when there is no need. I apologised unreservedly for my colleague's attitude and said that I would take steps to be sure that the booklet was clearer. Then i realised that my original question regarding the consent form hadn't even been answered. I asked the individual if it was alright if I asked another colleague their thoughts and opinions. The patient said yes but "not that do-lally nurse" and said that he would be making a problem regarding her frame of mind. Then i found the endoscopist who was actually heading to be undertaking the patient's ensure that you asked them about the consent issue. They said that the consent form was fine so long as I reiterated that the individual would be awake and that they fully understood the test. The Endoscpist said that they might discuss the consent form with the individual again before the method as this is normal practice.
I went back into the planning room and said that the consent form was not problems and that we would discuss it further. I spoke to the patient in a reassuring way, attempting to compensate from his previous treatment from my colleague. I asked the patient if he understood the test he was about to have and its own related risks. AFTER I felt like the individual experienced a clear knowledge of the procedure I asked him if he previously any questions about the procedure, the patient replied he had no further questions. He added that he was even more nervous now after the experience with the nurse but just sought it to be over as fast as possible. I began to clarify the procedure that he was going to undergo and asked if he recognized why the GP acquired referred him for this technique and relayed the benefits associated with viewing the bowel in this manner. The individual was happy that a identification might be forthcoming out of this test. I then reiterated the possible hazards of the task to the individual explaining that they were rare but never the less very real. The patient said that he grasped the risks involved but wanted to go ahead with the test to secure a examination of his problems.
I stated that if the patient would have sedation, then he should not drive or operate any machinery and should not hint any legally binding documents as the side results from the sedation would still have an effect on him for twenty four hours. I explained that the endoscopist would endeavour to complete the research however, if difficulties were to occur such as patient stress or poor bowel prep that the test would be left behind. Throughout a Gastrointestinal Endoscopy and Related Types of procedures Course at The University of Sheffield (Feb 2010, SNM 2215/3232) it was suggested that the guideline for up to date consent was signified by the acronym EMBRACE, Description of the task, Motive for the task, Benefits, Hazards, Alternatives, Problems and unwanted effects of the procedure. I think that these suggestions were completely complied.
Following the taking of the medical history and conclusion of an additional in-depth health check questionnaire to see any condition or reason to which sedation would be contraindicated such as elderly patients and also require significant co-morbidity and even in young patients, the existence of cardiovascular disease, cerebrovascular disease, lung disease, liver organ failure, anaemia, surprise and morbid overweight (BSG, 2003). It became visible that sedation would be a choice. I explained to the patient a nurse would be with him continuously throughout the task and would encourage him to inhale and exhale through any pain he might feel, or even to push a few of the air out of his lower part to alleviate any pain. The patient's blood pressure, pulse and saturations were taken and all were within appropriate limits. This provides a good baseline of the patient's observations for the task itself and can determine any changes that might occur because of this of the cardio or respiratory unhappiness which may be induced by sedation. Pascarelli (1996) claims that during the treatment, the nurse's most important responsibility is to screen the patients vital signs or symptoms along with communication with the endoscopist, supervision of medications and emotional support to the patient. Clarke (1994) warns that patients who undergo invasive procedures are usually stressed and their essential signs are generally elevated nevertheless the sedation lessens the anxiousness, and all of the vital signs cut down therapeutically to that patient's resting level.
The sedation of choice in my office is intravenous Midazolam. Midazolam is a benzodiazepine reputedly well suited for used in endoscopy. It has an amnesic affect leading to a reduction in storage area recall. Clarke (1994) agrees saying that the goal of IV mindful sedation is some degree of amnesia. Patients will occasionally remember some parts for example, the initial launch of the colonoscope. It is for this reason clear written discharge instructions receive to the patient prior to release, with a contact telephone number in case of any problems which was explained to the patient. Sedation may be mentioned for many reasons. In the primary these may include allaying of anxieties regarding a procedure, and aspires to facilitate conformity with repeat steps as a result of the amnesic impacts induced. In many cases it assures co-operation and eases issues for the endoscopist and generally provides a rapid, safe return to the normal activities of daily living.
The patient was asked to undress from the stomach down and placed on the gown provided. When the patient was ready he was considered by myself in to the procedure room and introduced to the endoscopist and the appointed staff nurses where in fact the issues of consent and sedation would once again be talked about with the patient as it is the endoscopist's ultimate responsibility.
Throughout the experience, I experienced that a number of important issues have been highlighted. One issue is that of the booklet that is sent out to the patients prior to the test. I assume that individual patient's perspectives about the ramifications of sedation may vary greatly, from a light sedative to an over-all anaesthetic. I conclude this to derive from the individual interpretation of patient information received and relatives and friends providing a distorted image of their own experience because of the amnesic have an impact on of the sedation. I would advocate good effective communication skills are paramount in allaying misconceptions and fears and the giving of a realistic overview is therefore essential.
It was clear that there would have to be some improvement of the reason of conscious sedation as I felt that is merely skimmed the top explaining that the option of sedation was there and that there needed to be you to definitely escort the individual home and stick with them over night. I felt it would have to be clearer in the actual fact that it requires to say that the patient will not actually be anaesthetised and furthermore that amnesia is a common side effect from the sedation given. This has subsequently been talked about to the ward sister and the booklet has been up to date to clarify conscious sedation.
Perhaps one of the very most clear issues is that of the frame of mind of the other nurse. The BSG (2008) state that the patient should not be put under any pressure and have sufficient time and energy to digest the info in order for consent to be valid. I thought that the attitude of the nurse in question did put pressure on the patient and caused further stress for the individual. I noticed that the nurse spoke to the individual in a degrading way and revealed a lack of professionalism. The Medical and Midwifery Council (NMC 2008) state that nurses must treat people as individuals and value their dignity, must not discriminate and must treat people kindly and considerately. This was false in the aforementioned example.
The Equality and Individual Rights Percentage (2008) state that no matter your position you should be treated reasonably and with admiration when using professional medical services. The Team of Health (2008) cite the UK Human Rights Take action in their recommendations about human privileges in health care when they say that individuals have an absolute right never to be cured in a degrading way. Which means that it is unlawful for the NHS organisations to do something in a way that is incompatible with the human rights function. Endoscopy nurses and indeed all NHS personnel should be considering their practice and exactly how their response to a situation may impact on a patient or client's human being rights. If the patient acquired chosen to complain (as he said he would do) about the nurse's attitude towards him, then the nurse may have well been in trouble.
This experience has made me question my future practice as a rn and how I'd deal with an identical situation. Arnold and Boggs (2003) claim that an advocate is somebody who speaks out; promoting a person so that their views are listened to and their privileges are upheld, with the only real reason for maximising the patient's health. I had not been assertive as I did so not defend the individual and therefore didn't fulfil my responsibility of treatment by becoming an advocate for the individual, ensuring he was cared for with dignity and value. I was worried about what may happen easily challenged the nurse's practice. I have to develop my assertiveness and be able to speak confidently and effectively with both patients and healthcare professionals. It is rather easy for a nurse to be an advocate for the patient when there is absolutely no stress included but it can be quite difficult when it should go against other health professionals (Kendrick 1994). In this situation there was a conflict between your patient's best interest and my fear of challenging the nurse. EASILY had been a far more experienced nurse on the endoscopy product and known the nurse involved in this situation better, I believe I may have been able to foresee her reaction to the patient and perhaps might not have approached this specific nurse or used my communication skills as well as advocacy to diffuse the problem.
Gates (1994) states advocacy is one of the key duties nurses have; it is part of interacting on behalf of the individual and/or their own families, operating as a mediator to express their needs and experience. In healthcare, communication is fundamental to promoting the effective and safe health care of patients. The Office of Health Knowledge and Skills Framework (KSF) (DoH 2004) is a competence construction to aid professional development and career development through the NHS and is approximately lifelong learning. It offers core dimensions necessary to providing quality health care. Core sizing 1 (level 4) is concerned with communication. It expresses that the goal of communication may include 'advocating with respect to others'. For me to progress as a nurse on the endoscopy device I need to be familiar with and work within the KSF and other suggestions.
On reflection, Personally i think that I did so communicate with the individual well. Smith (1995) proposes that reflection does not automatically entail an event that was remarkable or negative; it could easily be something positive a person discovers they obtain valuable learning experience from. Communication with the patient has to be one of the most crucial aspects of nursing care. An integral part of this technique is just how a nurse should use and understand body language (Wilkinson 1991). It really is as vital a part of the communication process as speaking and should be treated consequently. Body gestures can present all human thoughts either consciously or not and can show a persons true feelings regardless of what they may have said (Pease 1984). I possibly could tell incidentally that the patient was connecting non-verbally that he was restless. His facial expressions and good posture showed the classic signals of someone being troubled (Teasdale 1995). Finding this, perhaps I should have explained to the nurse beforehand that the patient was anxious so that she may have acted with a bit more admiration towards the individual. It really is clear that good clear communication skills can improve patient satisfaction and conformity, thus reducing nervousness.
I think that through the admitting process with the patient I did positively discuss the procedure with the patient. I felt that we gave the individual opportunity to ask questions and allay any anxieties he was harbouring. I sat next to the patient and spoke to him about the task in an casual and pleasant manner, presenting him possibility to tone of voice any concerns that he previously. I believe the patient is at their most vulnerable and anxious upon getting into the endoscopy unit and some motivating reassurance makes the patient's experience less of an ordeal. It is my opinion an assessment of your patient's personality and level of understanding regarding consent and sedation enables the development of a communication strategy consequently thus providing a acoustics understanding of the test, sedation offered and for that reason prepared consent.
This article has allowed me to echo upon my own practice and exactly how I will have acted in a different way by standing up for the patient at the time, not allowing my very own lack of confidence to avoid this. I understand that the health care of the patient is my first concern and that I have to work with others as a team to protect and promote the health and wellbeing of those in my treatment (NMC 2008). Perhaps with this understanding, I am less troubled about felling inferior around other pros. I will articulate my professional judgement given a similar situation, using what I have been taught which is best evidence based practice to rationalise my known reasons for questioning their practice. I'll try to develop my assertiveness (as I understand that assertiveness does not come naturally to me) to speak out in the interests of the individual, whatever the problem. I am going to develop my capacity to communicate with both patients and other professionals to offer them the chance to rationalise their own care delivery and mirror upon it. I really believe these activities will improve my professionalism and promote best practice, in the interest of the individual.
I acquired chosen to concentrate on communication and advocacy as they are areas where I feel I need to focus on. Gibbs (1998) reflective pattern was used in this assignment because it is a familiar tool that I've found to be useful and uncomplicated. Learning from an experience and then reflecting on that experience is an excellent way of bettering the skills in my chosen vocation (Kolb 1984). From my own personal perspective, I proceeded to go into this task with some extent of mental imbalance for the actual fact that I did not speak out for the individual but now Personally i think that I have gained in a number of areas. I feel my reflective skills have increased and with it my self-assurance regarding tackling such situations again. Also Personally i think more calm with the thought of reflecting unpleasant incidences because I can see the benefits in doing this.
