Reflection for Clinical Skill Improvement

Introduction

According to Oluwatoyin (2015), reflection involves critically paying attention to the theories and practical values that inform daily actions by evaluating practice reflexively and reflectively, leading to developmental insight. Therefore, reflection is a process by which practitioners can understand themselves better to be able to build on their existing strengths and take appropriate future action (Oluwatoyin, 2015). In healthcare, reflection is defined as the process of actively reviewing, analyzing, and evaluating experiences, drawing on previous learning or theoretical concepts to inform future action (White et al., 2014). In essence, reflection is the readiness to continually assess and review one's practice in light of new learning (Smith, 2016). Smith (2016) argues that reflection improves personal development by creating self-awareness. For instance, if a reflection centers around patient care improvement, it will help to develop and expand clinical skills and knowledge (Smith, 2016).

Description

For this paper, the author will reflect upon an incident in clinical practice, demonstrate a clinical understanding of effective communication with the public, patients and their relatives, and other practitioners. Consequently, the author will consider the alternative pathway options and provide a rationale for the choice of referral. The decision-making process and the professional role within the incident will also be discussed. Finally, this paper will include the clinical assessment and management of the patient. The reflective model by Gibbs (2001) will be used. Gibbs' reflective model is useful in making one think through all the phases of an activity or experience. The Gibbs model of reflection also encourages people to think about the stages of an event or experience (Scott, 2013). The author is also conversant with this model of reflection. The author will use the pseudonym James to identify the patient. The pseudonym will be used to comply with the Data Protection Act (2018) and the requirements of the Health & Care Professions Council (2017) to protect the confidentiality of the patient. For this assignment, I will reflect on the care I provided for a patient with lung cancer. I attended to James as a student paramedic during my clinical placement. The Gibbs model of reflection is systematic and follows various specific steps to be effective. The model is broken down into six stages with the description of an event being the first step. Therefore, I will start this reflection by describing my experience. This step explains the context of the experience and gives the fine details such as what happened, where the event occurred, and who was present when the event occurred (Forrest, 2014). At the time of this incident, I was working as part of an ambulance crew when we received an emergency call. The call was serious as the ambulance was needed at the scene within a target time of under eight minutes. The call was about a seventy-two-year-old man who was experiencing breathing difficulties. On our arrival, the patient’s daughter who had made the emergency call allowed us into the house. It appeared that James was in distress. I introduced myself and my colleagues. However, James did not respond. I asked James what the problem was. Again, he did not answer. James' daughter was present, and she informed us that James had recently been diagnosed with lung cancer. Lung carcinoma or lung cancer is a malignant tumor in the lungs that is characterized by uncontrolled growth of cells in the lungs (NHS, 2018). There are no symptoms or signs in the early stages of lung cancer but many people who suffer from the disease eventually develop symptoms that include persistent breathlessness, persistent cough, coughing up blood, unexplained tiredness and loss of weight, and pain when breathing or coughing (NHS, 2018). According to the NHS (2018), lung cancer mainly affects people who are older, is rare in people who are below forty years old, and the rates of the condition rise sharply with age. The disease is common in people who are aged between 70 and 74 (NHS, 2018). James’ daughter informed us that James had not experienced any cough since he had been diagnosed with lung cancer. However, he had been coughing since the previous night and complained about chest pains. James had difficulty communicating with us because of the breathlessness. The cough had been progressing since the last night and worsened about an hour before James started complaining about shortness of breath and breathing difficulties. The daughter also informed us that James had a fever the previous day. However, he was treated and discharged from the hospital on the same day. I used the ABCDE approach to conduct the medical assessment. ABCDE stands for Airway, Breathing, Circulation, Disability, and Exposure (Thim et al., 2015). This approach is a rapid assessment of a critically ill or deteriorating patient and is designed to offer the initial management of conditions that are life-threatening in order of priority (Thim et al., 2015). ABCDE uses a structured method to ensure that the patient is kept alive. This approach also ensures that a practitioner achieves the first steps to improvement instead of making a definitive diagnosis (Colbeck et al., 2018). According to Colbeck, et al., (2018), the ABCDE approach is applicable in all clinical emergencies for immediate medical assessment and treatment. This approach is widely accepted by professionals in emergency medicine and improves outcomes by ensuring that experts focus on the clinical problems that are most life-threatening (Thim et al., 2015). When I looked at James, I noted that he had no apparent bleeding or injuries. For the time we had been in his house, James had not opened his eyes. However, on placing my hand on his shoulder, he opened his eyes slightly. Patency was my primary concern when I was assessing James’ airway. I also noted that James had a self-maintaining patent airway. My next concern was to assess James' breathing. While a patient's history provides significant information for decision-making, a physical examination should not be underrated (Scott, 2013). Therefore, my physical examination focused on the respiratory system and other systems of the body that are affected by the respiratory system. This is critical as it may give clues as to the condition that caused James to have difficulty breathing and the severity of the condition. I applied the auscultation technique to assess the lung sounds of the patient using a stethoscope. James' lung sounds revealed wheezes in all fields of the lung and coarse rhonchi in the lower two-thirds of each of his lungs. I also decided to check for the patient’s radial pulse.

However, I was unable to find the radial pulse on his right arm, and I had to switch to his left arm. Since James’ radial pulse was difficult, I used a ball point to mark the radial pulse I had found on his left arm to make reassessment easier. The radial pulse helped me in assessing the patient's circulation. James' radial pulses were equal but weak. On the other hand, his respiratory rate was about 27 breaths per minute which can be considered to be abnormal. According to Cretikos, et al., (2013), the definition of abnormal respiratory rates in adults varies from over 14 to over 36 breaths per minute. Cretikos et al., (2013) add that if an adult had a respiratory rate of over 20 breaths per minute, he is probably unwell, and if a patient has a respiratory rate of over 24 breaths per minute, he is likely to be critically ill. Therefore, I was concerned about James’ respiratory rate. I placed the pulse oximeter probe on James' thumb to measure oxygen saturation. James had abnormal oxygen saturation levels as he had an oxygen saturation level of 75 percent. Normal oxygen saturation level should be between 95 and 100 percent (Nursing Times, 2016). I noticed that the patient had hypoxia because he had a cough and changes in the color of his skin. James had initially been in a reclined position, so I had to reposition him to an upright position with the help of my colleagues to help with breathing. After repositioning the patient, I noticed that he could now respond by shaking his head and raising his eyebrows. Since James was able to communicate non-verbally, I explained to him that I needed to examine his chest and that I needed his consent, to which he nodded to give consent. I began conducting respiratory assessment instantly. To address James' breathing difficulty, I set up a salbutamol nebulizer. I started with a single dose of 5mg. I requested for other observations from my colleagues which were reported as heart rate 113bpm, blood pressure 98/60, temperature 38.9oC, and 7.3mmols. I confirmed that James had no known allergies, and shortly after the single dose 5mg salbutamol nebulizer, James' oxygen saturation level increased to between 93 and 96 percent. After completing the initial assessment and addressing James' breathing problems, it was important to carry out an in-depth assessment. I performed a 12-lead electrocardiogram (ECG). An ECG is a reading that assesses the direction and magnitude of the heart's electrical currents and measures the repolarisation and depolarization of the cardiac muscle cells (Medani et al., 2018). The ECG indicated sinus tachycardia. Repeat observation was carried out which showed the respiratory rate at 25 breaths per minute, blood pressure 91/62, heart rate 110bpm, and oxygen saturation level at 96 percent after nebulizer. James' pupil size was 3.5, equal and reactive. Adults should have a normal pupil size that should vary between 2 and 4 mm in diameter in bright light and between 4 and 8 mm in the dark (Spector, 2013). The pupils are also generally equal. According to Spector (2013), pupil testing is a critical element of every comprehensive examination because of its potential to reveal serious neurologic, retinal, or other diseases and requires shrewd observation. Since James had difficulties communicating verbally, it was difficult to conduct A Glasgow Coma Scale (GCS) assessment.

However, as mentioned earlier he was communicating by raising his eyebrows and shaking his head. According to Carter & Thompson (2015), what can be visualized by a paramedic such the location, posture, and response level of the patient can provide many clues as to the severity of the patient’s condition. I also reassured and communicated with James in soothing tones and explained everything I was doing. There were no visual cues that could indicate that James was in pain. I also tried to obtain as much information as I could by asking James' daughter about the events that led to this incident, other symptoms that James may have experienced, and questions about James' past medical history. I was informed that James had been previously admitted to a local hospital with pleural effusion. He had been discharged four weeks earlier. Pleural effusion can be described as excess fluid in the pleural cavity, generally as a result of an imbalance in the regular rate of pleural fluid absorption or production, or both (Bhatnagar & Maskell, 2015). Sometimes fluid build up between the rib cage and the lungs in patients with lung cancer making it hard to breathe (NICE, 2018). Besides the lung cancer, James had been diagnosed with Chronic Obstructive Pulmonary Disease (COPD) in 2015 and two myocardial infarctions. While I continued to take the history of the patient, I asked about his daughter about his social history. James lived alone but had carers who visited his home four times a day to assist him with basic daily tasks such as washing. However, James' daughter lived nearby and visited him daily and prepared his dinner every day. Although James had been diagnosed with COPD, he was a non-smoker and never drank alcohol or abused any drugs. James' family wanted him to be admitted to the hospital because James was still strong and could perform most daily tasks with little assistance. As I continued assessing James, his son arrived. I explained my concerns about James' current condition. James' family was also concerned and wanted James to be admitted to a hospital to receive proper medical care. James' son told me that he has been close to his father and had conversations with him about his lung cancer and that he would have wished to be admitted to a hospital to receive proper medical care. As a team, deciding to take James to a hospital was easy because his family had consented. I asked James if he was comfortable with the decision to admit him to a hospital and he slightly raised his eyebrows to consent. However, I could not be sure whether James accurately comprehended my question. I explained the situation to a general practitioner. I also contacted the hospital whose care James was under for further advice and they adviced that they would receive James for admission. It was essential to reach the hospital because they were familiar with James and his family. After, the hospital whose care James was under adviced that we should take him there, we took him to the hospital. Shortly after, James' son and daughter arrived at the hospital. After a comprehensive discussion, it was decided that the most likely diagnosis was pleural effusion given our examination, and admission would be appropriate as it was also his wishes. The doctors agreed that they use pleurodesis to treat James. Pleurodesis is a process through which doctors may try to stop the fluid build up. Pleurodesis involves draining away the fluid and then injecting sterile talcum powder into the pleural space between the two chest lining layers, causing the two layers to stick together so that fluid cannot build up again in the pleural space (Saguil, et al., 2014).

Feelings

The second step of the Gibbs model of reflection encourages the author to explore their feelings and thoughts about the experience or at the time of the event. According to Koshy, et al., (2017), reflecting about one's feelings can be a useful tool of stress management as feelings that might have been suppressed can be reflected on deliberately, openly, and consciously. Writing about one's thoughts also provides an opportunity to learn from experience, and if done correctly, it can improve the skills of a health care provider (Koshy et al., 2017). Ferguson (2018) asserts that a worker should be able to understand and acknowledge their emotional states to be in touch with the feelings of those to whom they provide services, and the potential for their experience and emotions to trigger emotional reactions in the practitioner. Therefore, it is critical for a healthcare practitioner to write about their feelings for the benefit of both the patients and themselves. Writing about one's feelings is vital because it provides an opportunity to identify weaknesses and strengths (Koshy et al., 2017). Although the benefits of describing one's thoughts and feelings about an event or experience are clear, many health care professionals ignore it (Koshy et al., 2017). When we received the emergency call, I was worried because this was my first time dealing with a senior with breathing difficulties, and I did not know what to expect. However, I knew that we would reach James' home in the shortest time because James lived nearby. I knew about breathing difficulties in the United Kingdom, and that most emergency calls are about breathing difficulties. According to the National Health Service (2018), breathing difficulty or sudden shortness of breath is the most common reason for visiting hospital emergency and accident departments. Breathing difficulty is also one of the most frequent reasons people call for an ambulance (National Health Service, 2018). On entering James’ house, I realized that his breathing difficulty was so severe that he could not communicate with us. At that moment I felt nervous because as I mentioned earlier, this was my first time dealing with an elderly patient with breathing difficulty. I also panicked because severe breathing problems are usually a symptom of severe underlying medical problems. However, I relaxed and was ready to help James having remembered that breathing difficulties are prevalent in older adults. According to Johnson et al., (2017), estimations for breathlessness prevalence in the general population vary between 9 and 59 percent, with higher prevalence in women and older populations. As I was helping James, I felt sorry for James’ daughter and son because breathless in older adults often precedes their death. Johnson et al., (2017) write that restricting breathlessness increases in elderly population in the months that precedes their death from any cause, and given that James had lung cancer, I feared that his survival rates were reduced. Age is one of the significant prognostic factors that affect survival in patients that have lung cancer (Tas et al., 2013). As I obtained more information from James' daughter, I became low-spirited because, before his diagnosis of lung cancer, James was an active and happy person. The condition restricted him, and he was not as happy as he used to be. Also, being unable to communicate with James verbally, I felt that I would not truly understand his needs. Although I made every effort to make him comfortable, I thought that I was not giving him the targeted care that he might have wished. When I learned that James had also been diagnosed with COPD in 2015 besides lung cancer, I felt that a severe underlying problem caused his breathing difficulty. However, I was happy that the hospital that James was under was willing and ready to receive him. Given that the hospital was familiar with James and his family, I knew that he would receive appropriate medical attention. Additionally, I was not able to conduct the GCS assessment because James was not able to communicate verbally. I was worried that our decision making as a team would be negatively affected without the GCS assessment.

When James son arrived, I realized how crucial it is for a health care expert to effectively communicate with the relatives of the patient. I was able to explain to James’ son about his father's condition and the appropriate action to take. Deciding on admitting James to the hospital was easy as a result. Carter & Thompson (2015) argue that effective communication skills in healthcare have a positive impact on the quality of healthcare output. Effective communication also helped in the seamless handover of the patient to other medical practitioners. Generally, I felt that we had made all the effort to provide the best care despite the challenges that we encountered. I felt happy as James' breathing improved after the nebulizer, and I had a feeling that he would receive the best medical care at the hospital and be back with his family soon. At the end of the job, I felt stressed because the experience was intense and required prompt actions and decision making. Writing about my feelings enabled me to deal with the stress.

Evaluation

Evaluation is the next step in the Gibbs reflection model that an author should write about. Evaluation entails the assessment of the strengths and weaknesses of the experience or event (Pianpeng & Koraneekij, 2016). Jayatilleke & Mackie (2012) add that the evaluation element of the Gibbs cycle describes what was right and not so good about the experience. In this regard, the event revealed that a paramedic must always be prepared for challenges. James’ inability to communicate was a positive experience. The positivity stemmed from being able to get an opportunity to learn from new challenges and new experiences. As I mentioned previously, this was my first time dealing with an elderly patient. Besides, the patient was unable to communicate verbally, and it required me to interpret his nonverbal cues. This provided a learning opportunity. Patients’ nonverbal communication can contain critical information about the patient’s illness (Cousin & Mast, 2016). Also, James being unable to communicate verbally, I thought it was best to try to communicate with him nonverbally by nodding and smiling. Research has also shown that nonverbal communication by healthcare providers can predict many important patient outcomes (Cousin & Mast, 2016). The most notable negative experience about the experience was that despite James’ cough having started the previous night, no medical attention was given until the emergency call. The hospital under which James was should have been more involved in his entire pathway. They should have been able to provide care holistically to ensure that all James' needs were addressed and that they could be easily reached if there were any signs of deterioration in his condition.

Analysis

In this situation, I was required to conduct a primary assessment, initiate immediate treatment to ensure relief, carry out a comprehensive clinical assessment using a medical model, obtain information from different sources, and use clinical reasoning and decision making to develop a plan of care to ensure the selection of a suitable pathway. According to Evans et al., (2017), only 10 percent of emergency calls are life-threatening, and paramedics have the potential to use their skills to reduce or eliminate the demand for emergency departments. Therefore, as stipulated by HCPC (2017), paramedics should be able to practice autonomously and exercise their professional judgment. I had to assess the situation, determine the nature and severity of James’ problem, and make appropriate decisions to deal with the situation accordingly. For this situation, I will use the decision-making model suggested by Marquis & Huston (2009). Marquis & Huston (2009) suggested that decision-making has seven elements. The elements include, identification of the problem, gathering data and analyzing causes and consequences, exploring alternatives, selecting an appropriate solution, implementing the solution, and evaluating results. This model of decision-making allows a health professional to think logically, and avoid emotions in situations that are distressing and could cloud judgment (Blaber, 2012). After my initial assessment, I began to conduct a secondary survey. According to Wardrope & Mackenzie (2012), any further clinical evaluation should be guided by clinical suspicion and history. Then a differential diagnosis can be reached, and decisions regarding treatment, definitive care, and transportation can be made. It was essential to conduct respiratory assessment because James had breathing difficulty. James' daughter informed me that he had been coughing since the previous night. I applied the auscultation technique to assess James’ using a stethoscope. His lung sounds revealed wheezes in all fields of the lung and coarse rhonchi in the lower two-thirds of each of his lungs. I also decided to check for the patient’s radial pulse. The wheezing sounds and the coarse rhonchi could indicate pleural effusion. Pleural effusion is also common in patients with lung cancer (Ioannis Psallidas et al., 2016). However, James’ breathing improved after the nebulizer. I administered treatment to address James' treatment and repositioned him to help with breathing. I also reviewed his neurological system. He had not any witnessed seizures. However, it was difficult to conduct a GCS assessment because James could not communicate verbally. I examined James’ heart sounds using ECG. His pupils were reactive and equal. James also appeared to be in distress and pain. He had also complained about chest pains to his daughter. I also conducted a gastrointestinal assessment. James had been eating well. Overall, his fluid and diet intake was excellent. The inspection of his abdomen did not reveal any abnormality. His abdomen was soft and tender. James did not have any injuries or bleeding. A musculoskeletal examination was not irrelevant in this case.

Having gathered all the information about James and his medical history, and on reassessing him, my colleagues and I formed a hypothesis that James could have been suffering pleural effusion. This hypothesis was based on his symptoms and clinical signs that were consistent with pleural effusion. James showed pleural effusion signs that included chest pain, cough, wheezing, and difficulty breathing. Pleural effusion is also common in patients with lung cancer (Bhatnagar & Maskell, 2015). However, it was essential to consider James' differential diagnosis. We considered a differential diagnosis of myocardial infarction upon arriving at the hospital. Myocardial infarction has symptoms such as chest pains, cough, and fast heart rate. However, given that James had lung cancer, pleural effusion had the highest probability of being the correct diagnosis. After we had arrived at a diagnosis, we decided to relieve the symptoms to ensure that James did not have much difficulty breathing. However, hospital admission was the best option to treat pleural effusion, and this decision was made easy since the hospital under which James was agreed to receive him. Also, after a conversation with James' family, it was clear that James wishes were to be admitted to a hospital.

Conclusion

The final steps of the Gibbs reflection model involve a conclusion of the experience and an action plan to improve future practice. This experience affirmed to me how both verbal and nonverbal communication is vital for healthcare professional. Being able to interpret nonverbal cues of the patient was critical in many ways including giving consent. This event also highlighted the limited training that paramedics have regarding pleural effusion. Finally, it is essential to learn to accurately interpret nonverbal cues to handle patients who cannot communicate verbally better in the future.

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