Critical Incident Reflection

Reflective practices can be depicted as the way toward comprehending occasions, circumstances and activities that occur in the working environment (Oelofsen, 2012). Oelofsen 2012, contends that reflective practice (in medical clinics, psychological well-being and network wards), is indispensable in regard that attendants need to bring positive change particularly to individuals who are vulnerable in nature getting their services despite the fact that there is a emotional cost involved for thinking about the helpless gatherings (Oelofsen, 2012). The accompanying reflective practice will utilize the Graham Gibbs cycle (1988), to feature systems that upgrade correspondence and expel hindrances to compelling correspondence while limiting danger to these vulnerable individuals. The impression of a basic episode will highlight the approaches to boost communication where hearing, vision or speech is undermined. I have picked the name Mary Smith, a pseudonym in line with the General Data Protection Regulation (GDPR), 2018. The GDPR states that where proper pseudonym and encryption should be utilized to keep the anonymity and privacy of a patient (ICO, 2018). Graham Gibbs cycle (1988) has six phases which start with;.

  • Description-a clarification of what occurred
  • Feelings- what the author was thinking and feeling
  • Evaluation-a record of what was fortunate or unfortunate about the experience
  • Analysis-what sense can be made of the circumstance
  • Action plan- what should be possible if the circumstance emerged once more (Gibbs, 1988).
  • Conclusion-what else the author could have done Mary Smith, 80-year-old female was brought into the high observation ward where I had my placement, a stage down from the High Dependency Unit (HDU) around 3pm. She appeared to improve as her overall signs and examinations were pointing towards progress. At the point her observations were in the normal extents such as blood pressure recorded as 126/72
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mm Hg, oxygen saturation rate 96 % on room air (RA), temperature 36.8 ° C, respiratory rate 17 breaths per minute, heart beat 68 bpm, condition was found to be alert and imparting verbally. Mary had gone to a clinic from nursing home at first with a background of dementia, panic and disorder at night time. When she arrived my senior nurse carried a nutritional assessment of the patient and informed me that I would need to assist the patient during her feeding time. The following was in accordance with the Patient Mealtime Initiative (PMI) as implemented within our ward (NHS, 2007). During the time of dinner, I asserted the patient that I would help her to eat but she initially stared at the wall and then responded to me. I asked her to continue with her food but she kept on looking at the utensils. I understood that she was unable to follow my instructions therefore I took up the spoon with food into her mouth and touched her chin to remind her about the chewing of food. On reflection, I knew that communicating with aged patients of dementia is a challenging task as these patient suffers from cognitive impairment and it becomes difficult for them to express their feelings and emotions (NICE, 2006). The whole process took nearly an hour to feed my patient and my senior nurse reminded me while passing to often exert soft pressure on her chin so that she continues the process of chewing. At 9 pm, she was administered with her night drugs by the staff nurses. It is also evident that a significant number of aged patients of dementia are underweight because of the impaired cognitive abilities due to which they are unable to follow the instructions during feeding and also faces problem while swallowing of food resulting in difficulty during ingestion (World Health Organization, 2014). Therefore, according to the guidelines of NICE, 2006 on the nutrition of older patients where it stressed on the necessity to assist these people while feeding. Moreover, the advanced patients of dementia need to be provided with comfort feeding and proper hydration as the main motive of nutrition. Another important aspect that the environment of the hospital was new to my patient which might have triggered anxiety and fear within her (Lin et al., 2010). It was evident that older patients with dementia show adverse behaviour out of anxiety and fear response and it exacerbates with the negative behaviour of nurses (Jensen et al., 2010). Therefore, while reflecting on the above aspect I took a more patient and comprehending approach involving both verbal and non verbal modes of communication with my patient. Initially I was unprepared as a student nurse to deal with an old dementia patient and I shared my anxiety with my colleagues and senior staff and they asserted that these apprehensions are normal (Best and Evans, 2013).

I went to check her vital signs at 1 pm as she was on four hourly checks and I noticed the clinical manifestations of hypotension with BP at 57/30 mmHg, temperature 37.1 degrees Celsius, heart beat 90 bpm and respiration rate of 32 bpm. In this regard, the expertise of time management was viewed as urgent for this patient as she might collapse due to minor carelessness. Moreover, she was showing the symptoms of cardiorespiratory depression with the saturation value of oxygen at 80-82% at room conditions and was found to be very sleepy. Though she was receptive to torment yet not imparting verbally, had her eyes shut, and was making unusual moaning sounds. I checked her airway and found patent. During that time of crisis I immediately informed my senior medical staff and bleeped the specialist. I felt extremely terrified of the fact that Mary had been improving till that point and her condition suddenly deteriorated. I was considering who I should contact promptly to get help as I perceived that the episode would be past my restrictions as an understudy nurse and then I called a senior nurse, a specialist and outreach group of critical care. I was aware of the fact that she was under the care of outreach group of critical care, High reliance unit and Intensive care unit prior to this and therefore, they should be reported right away. Subsequent to cautioning the senior nurse I returned to rehashing perceptions at regular intervals as I felt that was my method for contributing in the circumstance. I was feeling that Mary was presumably in torment as she was groaning and moaning, which are the non verbal indicators of pain according to the guidelines of Pain Assessment in advanced dementia scale (Zwakhalen, 2007) . Now choices were made according to the Mental Capacity Act 2005 which states that choices can be made for the benefit of a patient if that contributes to best quality care practice. In spite of the fact that Mary was showing proper mental capacity when she showed up in the ward, the circumstances changed suddenly and she was unable to conveying her needs verbally to the staff. The Mental Capacity Act 2005 likewise expresses that anybody engaged with the patients care i.e carers and family should be informed to consider their perspectives before a choice is made. But then, her family was not quickly approached to inform about her worsening condition as there were lot of differentiation between the multi-disciplinary group and her family with respect the approach of treatment. The senior specialist who was in charge of her case chose to put a Do Not Attempt Pulmonary Resuscitation (DNAR) set up after evaluating the situation. The acceptable practice is to support a shared decision approach by including the patient and their carers, according to the Resuscitation committee .

(2016).The NHS England (2015) proposes that there should be an improvement in the correspondence section between patient advocates and professionals. At that point when I experienced this situation for the first time, I discovered that there are different issues to consider as opposed to simply the input of family. I also acquired knowledge concerning the significance of quality of life after Cardiopulmonary revival (CPR), to be a critical factor instead of paying little heed to the information provided by carers. As an understudy nurse I understood that in critical conditions, I had to face many restrictions and in any way this should not stop me from taking the necessary actions by maintaining those restrictions according to the guidelines of (NMC) 2018. I had the option to take an electrocardiogram of the patient's heart, constantly checking of her baseline observations, to set up a catheter unit prepared for a senior staff, to keep equipments ready for collection of blood gas and blood. I discovered that in such a critical situation and in the presence of critical care team, I was unable to understand what help I could offer them from my side. After self reflection of the entire experiences I have set myself some specific, measurable, attainable, relevant and timely (SMART) objectives to progress my improvement, as delineated by NHS England (2016) as given below -

  • To participate in three conversations with focus on correspondence between patients with dementia and experts (in a medical clinic setting), with senior associates on my next situation. This had to be finished before my placement in another department. The Alzheimer's general public (2019), guides the experts to take caution about their area, tone, selection of words, speed and non-verbal communication when attempting to speak with dementia patients. Simple adjustments have to be made with these patients such as use of short sentences, warm vocabulary and tone along with a smiling face which are central to quality care service by nurses. Self-assessment has been supported as one of the powerful aptitudes that evacuates obstructions and recognizes mediations connected to positive outcomes. If the circumstances were to emerge once more, I feel that I would be very much prepared with respect to effective communication and management of a patient in comparative circumstances (Davis, 2018). In conclusion I would specifically reflect upon my communication skills with elder patients with dementia. It is evident that a beginner nurse has no experience to handle such critical situations. For the first time I showed lack of confidence in carrying out the task but that improved after several meetings with the lady. As a student nurse my professional tenure will guide me to learn the specific verbal and non verbal cues of the patient and this model guided me to understand my feelings and also in evaluation of the situation without bias.

Conclusion:

The discussion mentions Daisy is experiencing multiple sclerosis that has made her experience tremor, lack balance, dizziness and other related symptoms regarding the disease. The administration of medication and complementary therapies as well as accessing support from the Multiple Sclerosis Society in the UK would help her care needs to be supported effectively.

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References:

Alzheimer’s society. (2019). Communicating and language. [Online]. Available at: https://www.alzheimers.org.uk/about-dementia/symptoms-and-diagnosis/symptoms/communicating-and-language [Accessed 10/08/2019]. Best, C. & Evans, L. (2013) ‘Identification and management of patients’ nutritional needs’, Nursing Older People, 25(3), pp. 303-6. British Thoracic Society. (2017). Thorax: An international journal of respiratory medicine. BTS Guideline for oxygen use in adults in healthcare and emergency settings. June 2017. Volume 72 supplement 1. (Online). Available at: Davis, C. (2018). Self-reflection, vision and inquiry. Nursing made incredibly easy: September/October 2018 -Volume 16-Issue 5- Page 4. DOI: 10.1097/01.NME.0000542482.76561.69. From "Learning by Doing" by Graham Gibbs. Published by Oxford Polytechnic, 1988. Gibbs G (1988) Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford. Information Commissioner’s Office. (2018). Guide to the General Data Protection Regulation (GDPR). (Online). Available at: https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/ [Accessed on 31/07/2019]. Jensen, G., Mirtallo, J., Compher, C., Dhaliwal, R., Forbes, A., Grijalba, R., Hardy, G., Kondrup, J., Labadarios, D., Nyulasi, I., Castillo Pineda, J. & Waitzberg, D. (2010) ‘Adult starvation and disease-related malnutrition: a proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee’, Journal of Parenteral and Enteral Nutrition, 34(2), pp. 156-159. Lin, L., Watson, R. & Wu, S. (2010) ‘What is associated with low food intake in older people with dementia?’, Journal of Clinical Nursing, 19(1-2), pp. 53-59. Mental Capacity Act 2005 (2008). Deprivation of liberty safeguards. Issued by the Lord Chancellor on 26 August 2008 in accordance with sections 42 and 43 of the act. Published by TSO. Pages 67-75. National Institute for Health and Clinical Excellence (NICE) (2006) Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. London: NICE. NHS (2007) Protected mealtimes review: Findings and recommendations report, London: NHS. NHS England. (2015). Communication. Available at: https://www.england.nhs.uk/signuptosafety/wp-content/uploads/sites/16/2015/09/su2s-comms-safety.pdf [Accessed on 31/07/2019]. NHS England. (2016). Managers guide to setting SMART goals. [Online]. Available at: https://www.porthosp.nhs.uk/Learning/apdr/SMART%20Objectives%20-%20Guidance%20v3.pdf [Accessed on 10/08/2019]. Nurses and midwifery council (NMC). 2018. The Code. Professional standards of practice and behaviour for nurses, midwifes and nursing associates. (Online). Available at: https://www.nmc.org.uk/standards/code/ [Accessed on 10/08/2019]. Oelofsen N (2012) Developing Reflective Practice: A Guide for Health and Social Care Students and Practitioners. Banbury: Lantern Publishing. Resuscitation council, British medical association and Royal college of nursing (2016). Decisions relating to cardiopulmonary resuscitation. 3rd edition (1st revision). World Health Organization (2014) Nutrition for older persons [Online]. Available from: http://www.who.int/nutrition/topics/ageing/en/index1.html (Accessed: 1 February, 2020). Zwakhalen, S. M., Hamers, J. P., Peijnenburg, R. H., & Berger, M. P. (2007). Nursing staff knowledge and beliefs about pain in elderly nursing home residents with dementia. Pain Research and Management, 12(3), 177-184. .


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