Reflection

INTRODUCTION For this assignment I plan to reflect upon an incident that I have recently been involved in whilst working in clinical area. I plan to discuss my thoughts and feelings of the incident also the ethical issues that cropped up. For the protection of those involved, all names have been changed as per confidentiality guidelines determined by NMC (2008). The incident I shall reflect upon concerns the suprapubic catheterization of a deaf gentleman in chronic retention of urine, against recommendations of the consultant. Many legal and ethical issues arose, but due to the limitations within my word count I aim to focus upon autonomy and consent (and maybe paternalism) relating to my patient. Reflective practice provides health professionals with clear instructions on how to analyze situations and clinical experiences, the system is described as an internal examination of a said concern or experience. In order to effectively reflect upon the incident I describe I plan to structure it around Gibbs model (1988) of reflection. I chose this model as it a simple yet comprehensive framework for reflection. It follows a cyclical pattern suggesting that it is an ongoing process. What is reflection' Reflective practice can be described as a way to look at experiences with a view to improve the way in which we work, with greater confidence as a proactive practitioner. Fernandez (1997) suggests that reflection is an educational tool used to help bridge any gaps between theory and practice. Reid (1993) suggests reflection as a process of analyzing our own experiences of practice in order to make sense of it, explore more appropriate ways to approach it, and therefore inform learning about practice. Jasper (2003) believes that reflection enables us to identify our skills and limitations in order to understand and develop to become safe, competent practitioners. Our experiences are the starting point and reflecting upon them triggers learning. There are three fundamental constructs of reflection developed by Schon (1987), knowing-in-action, reflection-in-action, and reflection-on-action. Knowing-in-action is the unconscious, intuitive knowing or 'know how': 'When we have learned how to do something, we can execute smooth sequences of activity. Reflection-in-action happens when you can still make a difference to the situation by thinking in a focused manner whilst working, it's 'on-the-spot' reflection. Reflection-in-action has an important function, questioning the assumptions that underpin our knowing-inaction. It gives rise to on-the-spot experimentation because of our awareness and observation of new phenomena or things that occur in our practice. An example of this could be deciding the safest way to transfer a patient who usually mobilises with a frame to the bathroom should be followed with a chair because they seem less mobile at this time. However, Clinton (1998) debates whether reflection in action is obtainable given that in certain situations the need to react instantly and therefore reflecting in action would not be possible. Reflection-on-action is something that you do after the event. You think back about what you have done in order to discover how your knowledge used in practice (knowing-in-action) and your reflection in-action contributed to the outcome of your practice. Reflection-on-action has been widely applied in nursing practice through approaches, such as reflective writing (Holly, 1989), group reflection with nursing students (6etliffe, 1996), using art (Cruickshank, 1996) and critical incident analysis (Minghella and Benson, 1995). Jasper (2003) explains that during on action, it is presumed that the practice or event being reflected upon was underpinned by knowledge base and is therefore a cognitive process. Jasper (2003) also recognizes that reflection can be positive for future events such as a student’s clinical placement, by reflecting and anticipating what your learning needs could be and plan how to achieve them. Taylor (2000) also views reflection as a positive activity because of the potential ability to gain understanding and implement change if it’s required. There are disadvantages to reflection Atkins and Murphy (1993) illustrate; the need to reflect is often triggered by uncomfortable feelings, providing a negative connotation to the reflective process. Johns (2005) suggests that reflective models could be misused. Instead of using it as an aide memoire to create your own structure to reflect, incidents could be used to fit the model. In my opinion when introduced to the concept of reflection, it’s a negative connotation primarily displayed, some are defensive about how they perform at work or the way in which they deal with certain issues for fear of reprisal. I will use is Gibbs’ model of reflection (1988) for this assignment; I find it simple to follow and use to structure our reflection account. It is a cyclical model and encourages the notion that reflection never ends, it will continue throughout professional lives, each time a similar incident occurs our skills and knowledge should improve promoting the movement towards best practice. There are several models of reflection, such as John’s model of reflection (1994); Kolb’s learning cycle (1984) Although all these models intend to produce the same outcome in that you analyze and learn through your reflection, it’s about choosing one that works well for yourself. DESCRIPTION OF EVENT Whilst on clinical placement in an acute area we had an emergency admission via accident and emergency. A middle aged man, whom was profoundly deaf and was accompanied by an interpreter who could communicate with sign language for him. Upon assessment we found that the patient had a urethral stent that had dislodged and was protruding from the tip of his penis. As a result he was in retention of urine and had a bladder scan volume of 1300mls. During the nursing assessment the patient was extremely distressed as he couldn’t comprehend the questions I was asking him, possibly because of the stress of hospitilisation or pain, either way it raised issues of mental capacity. The doctor available upon admission was junior, he wanted to fit a super pubic catheter, he was challenged by senior nursing staff that it wasn’t advisable and he therefore contacted the consultant that the patient was under for advice upon the immediate actions for managing the patient. The junior doctor was advised to prepare the patient for theatre and to aspirate what he could with a needle and syringe and instructed him not to attempt a super pubic catheter. The consultant was making his way to the hospital to operate on the stent. I chaperoned the doctor to the patient. Communication should not have been a problem as there are systems in place to support patients with advocacy issues due to lack of capacity. We had the lady to sign for us. The doctor approached the bed with no eye contact and told the patient what he was to do. I highlighted to the doctor that the patient was deaf and we had the lady to sign, I was ignored and the doctor proceeded to aspirate just 20mls from the bladder when he rudely ordered me to get him a super pubic catheter kit and lignocain quickly, I again highlighted that his instructions were to not do that. He totally shot me down and said “I’m the doctor, it’s my decision to make, not yours”. I left and approached my mentor to tell him what the doctor wanted and the reasons for why I was cautious. My mentor stated that it ultimately is a medical decision and all that we can do is hope it’s the right one for the patient, my mentor prepared the trolley and brought it to the bedside and left me with the patient. Again with no eye contact he said “I’m just going to numb the area, sharp scratch”, again I highlighted that he was deaf and could not hear him. I could see the lady franticly communicating to the patient, but the doctor didn’t acknowledge us. Without warning he thrust the catheter spike into the patient, expelling 1300mls into the bed where the patient lay very distressed. The doctor told me I better clean the sheets as the consultant would not be happy with me, at that point he turned to leave the bedside. He told the lady signing “that was a dangerous procedure your husband had, normally done under ultrasound guidance, but don’t tell him that, we don’t want him to worry” to which she replied “I’m not his husband, I am here to sigh for him, and I can’t not tell him anything, I have to tell him every word that is spoken”, the doctor left without a word. The consultant arrived on the ward almost immediately, took the patient to theatre where he spent over 11 hours repairing the internal damage. Feelings/ evaluation I have chosen to discuss this incident as it is an incident where I feel that I could have done so much more for my patient. There were many ethical and legal issues. No valid consent was obtained by the doctor for the procedure, poor practice and whistle blowing, the patient was not encouraged to be autonomous, advocacy, paternalism, bullying. For the purpose of this assignment I am going to concentrate on autonomy, advocacy and mental capacity. The second stage of Gibbs (1988) model of reflection is a discussion about my thoughts and feelings. I was terrified for the patient, I felt helpless in the sense that I knew the junior doctor was acting against the instructions of the consultant and not in the best interest of the patient, I had only witnessed this procedure once before and that suprapubic catheter was placed with intravenous sedation and local anesthetic. Contributing to my feeling of helplessness was the inferior emotions I felt as a student nurse. I was not supported by the staff on the ward until after the event, and I feel that my mentor should have been an active advocate for the patient. Reflecting upon my thoughts and feelings brought about the need to be able to overcome barriers, such as communication with the doctor and the patient and also to the nursing team, Heron (1990 cited in Jack and Smith 2007) highlights the value of reforming barriers in a positive manner to be able to progress. This incident had a huge effect on the way in which I internalize emotions; I felt that inferior feelings prevented me from using the knowledge I had to protect my patient. Should this arise again I feel I would be proactive in protecting them by showing maturity, self awareness and knowledge. Doctors are trained to follow the seeking patients consent: The ethical considerations’ (GMC 2009), offering all information, risks and providing a rational for why they wish to carry out a procedure or administer treatment. It suggests a process for obtaining valid informed consent. Informed consent in ethics comprises of the notion that the patient is fully aware of the potential benefits and risks involved. My patient was uninformed and not given the opportunity to reflect his own values or wishes. Valid consent can only be obtained from a fully informed person who has the mental capacity to understand, be it for themselves or by a person acting on their behalf with authority such as power of attorney. In the case of the patient I described above he had received no information, or explanation of the doctors proposed actions and certainly no time to internalize what was happening to him. The value of informed consent has a close relationship to autonomy. Beauchamp and Childress (2001) stated ‘Autonomy is the right of a rational person to self-rule and to generate personal decisions independently’ (cited by Butts and Rich 2005 pg 12). There are four ethical concepts contributing to autonomy, beneficence, non-maleficence and justice (Butts and Rich 2005). Autonomy is about a person being forthcoming in their self determination, For practice to be autonomous consent for treatment must be correctly obtained, There are many possible reasons why consent is not always gained in the appropriate manner, This could be due to paternalism, the nurses and doctors thinking that they know best and not including the patient in the decision, There are times when it is not possible to gain informed consent such as emergency situations, or when the nurse cannot be sure whether informed consent has been truly gained due to the patients mental health status or their ability to understand and retain that information. The Nursing and Midwifery Council (2008) stipulates that patients have the right to make their own decisions regarding their care, and as nurses we should treat each patient as an individual, respect their dignity and the choices they make. Reflecting upon this incident highlights the importance of addressing any issues with my personality, and to be able to speak up and ask for support in situations where I feel out of .my depth. Evaluation is the third stage of Gibbs (1988) stage/ process of the reflective cycle. In my patients situation the whole process was not an example of holistic care, and change within me on a personal level may have improved the outcome for the patient. I needed to be more self aware and an active advocate for the patient. Things that didn’t go well was the communication to the patient and to provide the support that he deserved, had he had an effective advocate then he wouldn’t have had to endure 11 hours of reconstructive surgery, the patient was left feeling confused and anxious because he wasn’t made aware of the procedure. The patient wasn’t given the chance option to be moved to a treatment room, he was treated on the bed in a bay full of patients. No dignity or privacy respected not to mention infection control. The doctor may have felt he was acting in the best interest of his patient. Things that went well were the discipline of the junior doctor, supported by the team. Having reflected upon the incident I described I feel the same as I did when I reflected in-action, the nurses didn’t carry out their duty of care by promoting advocacy to the best of their ability for fear of accountability for poor practice, without the doctor present the patient utilized the interpreter to communicate with myself and my mentor, that opportunity could have been used to inform the patient what the doctors plans for treatment was and how the patient felt about it. Reflection is a useful learning tool that has helped me become aware of my emotional learning needs and self awareness. Advocacy In accordance with the NMC (2009) guidelines ‘as a registered nurse you must act always in such a manner as to promote and safeguard the interest and well-being of patients and clients’. Gates (1994) suggests consequences for the nurse’s emotional wellbeing. There is the potential to harm your own health by worrying and getting stressed because of the responsibility. This highlights the need for good support networks, within the team we work in. other problems that could potentially arise are disruptions with your relationship within the team due to lengthly meetings etc. conflict of interests as a professional nurse and the wishes of the patient (Reeves and Orford 2002). The nurse that should have been advocating for the patient appeared to be using avoidance to distance himself from any accountability from the incident which to me is a clear breech of the NMC guidelines (2009) In common law ‘best interests’ refers to the treatment which is the best option that can be provided to someone taking into account all relevant factors, including medical, welfare, emotional and psychological well being (Butts and Rich 2005). Self-awareness is a key skill in all interpersonal interventions, it requires continuous practice. It can be described as a process of “getting to know our feelings, attitudes and values, it is a process that can develop and mature each day” (Wondrak 1998 p97). To become self aware is not a simple task, it can be a daunting responsibility, that said a self-aware individual is better able to benefit from the ability to change rather than remain attentive and institutionalized. Mental capacity To fully comprehend proposed treatment or care decisions capacity is essential in order to fully understand the information presented to the patient to be able to ascertain autonomous informed consent. The NMC (2008) enforces the requirement of knowledge for the nurses regarding the legislation surrounding mental capacity with the view of safeguarding patients by keeping patients at the centre of decision making. When assessing an individuals capacity it is important to not make a judgement based upon the patients presenting apperiance or behavior as it does not impact upon the ability to comprehend the information they are supplied with. In the case of the patient I have discussed it would be wrong to assume that because he had a hearing impairment he would not be able to internalize the information, he had an interpreter to communicate with to overcome that barrier. It was his anxixety and inability to to respond to questions during assessment that provided the need to assess his mental capacity. The patient could not make a decision to simple questions such as “when did you last eat and drink'”. The mental capacity act would support the assessment for lack of capacity to consent due to his reaction in the decision making process that required consent. He was unable to communicate effectively through talking, writing or through the medium of sign language. A formal assessment should be arranged in cases where it is questionable if they have the capacity to consent to the proposed procedure or element of care. Should it then be agreed that the patient does not have the capacity to make the decision relevant to that aspect of care that does not automatically mean they don’t have capacity to make any other decisions regarding their care (WAG 2008) The Mental Capacity Act 2005 provides a framework to protect patients with capacity concerns. The act supports the assumption that a person has the capacity to make their own decisions unless it is indicated that the probability is that they do not due to a recognized or diagnosed disturbance of the mind or brain or an impairment, whether it be permanent or temporary, the principles are the same. Prior to the act the decision fo acting in the best interest of the patient was a responsibility of the health professionals in charge of the patients care, that system left no provision for outside input meaning nobody else could consent for the patient limiting decision making to health professionals meant a possibility of cohersion and paternalism by the medical proffesion. The approach that the mental capacity act (2005) took contributed to holistis care by allowing input from others who know the wishes of the patient. There are four legal systems in place: Lasting powers of attorney (LPAs), Court appointed deputies, a new Court of Protection and a new Public Guardian. These all aim to support the patient’s best interest (Dimond 2005). In situations where the patient maybe unconscious and therefore does not have the mental capacity to consent to treatment then health professionals may perform medical interventions in order to protect the patient (Dimond 2005). In british law, nobody else is able to give consent or refuse treatment on behalf of another adult whom is unable to do so for themself (DoH, 2001 p5). On occasions where lasting power of attorney (LPA)has been previously assitained in accordance with the Mental Capacity Act 2005, it allows the election of another to act upon and make decisions on behalf of the said patient, empowering the patient to maintain there views and wishes in situation where it isn’t possible for them to do so themselves. The LPA is a legal document discussed and produced when the client is in full possession of capacity and able to make full informed decisions (www.direct.gov.uk. 2009). In the situation of my patient there was nobody with lasting powers of attorney and therefore would not have been considered elligable by the health professionals to provide consent to treatment on his behalf due to the instructions of the Human Rights Act (1998), it protects the patient’s rights (DoH, 2001). Human Rights Act (1998) came into force in Britain on the 2nd October 2000 and incorporated some of the European Human Act concepts into British law. Although the Human Rights Act (1998) does not contain any specific articles on consent it does contain articles that are relevant to consent. These current guidelines exist to provide guidance to health professionals on the law and professional practice, as protecting the patients and their rights (Stauch et al, 2002). There maybe occasions where a legal representative could be acting for the patients with alteriour motives, in instances where this is believed to be the case or it is suspected that the allocated advocate is acting otherwise than in accordance with the patients best interests there is a process that they can initiate. The decision of the appointed patient can be challenged in a court of law to resolve any concernes raised Griffith (2006). In conclusion to my research of determining mental capacity and the surrounding litigation, my understanding is that the act supports best practice and provides a system to which supports the decision making for patients who are unable to do so themselves due to lack of capacity. It suggests views and possible interventions during times of of incapacity. It is important to plan for such occasions when the patient is lucid and in possession of there capacity to consent. Any decisions made and/or views expressed need to be clearly and concisely documented within the patients medical records so they are accessable should they need to be utilized in times of incapacity. The conditions of the act consider the probability of the patient regaining capacity questioning would it be best to wait for that period of lucidity, allowing the person to make that decision for themselves Griffith (2006). No treatment can be administered whilst working under the act unless there is an agreed consensus for best interest, but if a valid and applicable advanced decision has been made when the person was assessed to be lucid at the time the decision was made in direct referral to the proposed treatment relevant to the presenting situation. Action plan My action plan should this situation crop up in the future would be to expand my knowledge base for both theory and practice. I did not feel confident when faced with this situation but reflecting upon the feelings of the patient puts it in perspective of his emotional ordeal. Having a greated knowledge base will stand me well in providing holistic, evidence based care for patients with complex health needs partnered with some mental health issues. With knowledge comes understanding of the issues that impact upon the behavior of the patient and identify methods of communicating with them, confusion and anxiety can be easily resolved with an active advocate who is there for the patient and enfourses the need for communication within the team involved with the patient ie the doctor and nurses with direct patient contact, and referring to the wider team when further assistance is needed such as in capacity issues. The use of critical reflection on practice has increased my awareness ten fold, I now realize the importance as a developing practitioner the value of reflection. I believe the process has made me aware of issues that need addressing and I now feel that I could contribute to better care resulting in a better out come for the patient reducing the stress and impact upon myself. Conclusion of assignment This essay discussed the importance and value that reflection has. I chose to use Gibbs (1988) model of reflection, I reflected on-action of an incident I had been involved in whilst on clinical placement. I followed it in the order he stated. It is a responsibility of the health professionals to ensure that human rights and the dignity of the patient are upheld as a pressing priority. Reflection upon this event has highlighted the importance of ensuring informed consent is obtained and the option for informed refusal clearly given. This experience showed me hopefully rare practice and poor team cohesion; I hope that my research and reflective internalization will have a positive impact upon future patient contact. Every patient is individual in the sense they have their own health needs, feelings, views and values, even though several people may need the same procedure it doesn’t mean they will react the same as the next person; without considering these effectively holistic care will not be administered.