Рефлексия върху стаж в гинекологична хирургия и критичен анализ на спешни ситуации.

Evidence of learning and achievement in practice

Anelia Rumenova Chevrakova-Mihaylova

January 2016 Adult Nursing

100103422

Skills Development

Developing skills and knowledge in nursing practice is one of the most important aspect of being a nurse. In my reflection I will be using a Gibbs Model of reflection (Gibbs G., 1988).

Following NMC Code of Conduct 2015, and according to respect people’s right to confidentiality, patients discussed in this reflection are not with their real names.

Description: It was my first placement in acute settings. Everything was new to me and I had no idea what to expect and what is expected from me. My first week was mainly getting familiar with the ward and what learning opportunities my placement can offer. It was fast and busy environment with many professionals, quick turn over of patients and totally opposite to my first placement. A lot of the daily routine was new to me and I couldn’t understand most of the abbreviations, conditions and why specific procedure was done. Many patients was coming prior their surgery or after surgery. Physical observations were taken often, and prior to surgery there was many questions asked and pre-operative check done. It took me a while to understand the perioperative care, as it is the broad nursing care delivered to patients before, during and after surgery (Dougherty, Lister, and West-Oram, 2015).

Feelings: I felt unprepared, nervous and not knowing enough about acute settings and specially lack of knowledge in regards to gynaecological surgery. There were female patients only, but all ages and different conditions. Gynaecological surgery is very much general surgery and use the same principles but deals with disorders of the female reproductive system, and not to the one related to hormonal dysfunction (Simpson, 1998).  I was nervous when having to approach patient when suffering with bad pain or having to go throughout medical or surgical management of miscarriage. I wasn’t sure if I am effective and helpful when admitting patients, and preparing them for surgery. I had no knowledge as well in regards to post- operative care and if I can spot any abnormal signs.

Evaluation: The positive experience was that I read a lot in regards to gynaecological surgery and pre- and post- operative care. Other positive experience was that when having my preliminary interview my mentor organised for me spoke placement with other professionals which gave me broader understanding and better learning opportunities related to gynaecology. Negative experience was that I was unprepared and couldn’t involve in patients care from the beginning of my placement and it took me longer to build confidence, and communicate effectively with patients. I have done some reading in regards to perioperative care, so I can answer some common asked questions and being able to calm a patient. Very often they asked why they need to wear antiembolic stockings, not eat and drink, or being weight. After few weeks I was able to explain that it is all necessary prior surgery, stockings reduce the risk of deep vein thrombosis postoperative, fasting reduce the risk of vomiting when introducing of anaesthetic, and weight is needed so the anaesthetist can calculate the dose of the drug to be used (Dougherty, Lister, and West-Oram, 2015). I have seen some bad practice, when patient have been asked for their weight instead of taking it there and then.

Analysis: Out of my experience I have learned more than expected. Now I am much more aware of perioperative care. Spending time with different professionals, in theatre, in recovery and outpatient clinic helped me understand patient’s journey and holistic. I have now perceptive of why it is so important to have so many different professionals in surgical wards, what their role is and in which stage of patient care they participate. The nurses in surgical wards are not only looking after the patient physical health but patient’s emotional and psychological support. Gynaecological surgery is very intimate and is threatening body image, therefore nurses play very important role and their communication skills and knowledge can change completely patient experience (Simpson, 1998).

Conclusion: I don’t know if I could dealt with this situation in a different way. It is difficult to have such a broad knowledge at this stage of the course. Probably it is my mistake that I have read only the welcome pack but not actually looking up in more details what to expect and how to be effective. I would know that next time in acute settings I will be better prepared and will make sure that I am familiar with patient conditions.

Action Plan: I still have to learn a lot about gynaecological surgery and nursing patients. I have now seen many aspects of it and that is much broader than I thought. It was interesting and challenging experience and therefore I know how to prepare myself for next acute setting. I will be more active and will take each opportunity to learn and ask questions, will involve and observe, when possible, and will look up at information in more details.

Professional awareness

 On my second placement I looked back and found out that skills, knowledge and qualities are required, but never enough for nurses. Treating people as individuals and uphold their dignity is the first to see when reading NMC Code (NMC Code, 2015).

On my placement I have seen vaginal examination done many times, as it is the way of finding relevant information for managing many gynaecological conditions (Simpson, 1998). My mentor is trained to do them and I had the opportunity to observe her, assist with the light and ask questions after. What I found out is that my mentor was not only physically doing the examination but emotionally supporting the patient undergoing the examination. Patient privacy and dignity in this case was expected to be relenting to certain level, because of the nature of the examination itself. Therefore the nurse doing the examination need to have the communication skills, having knowledge about female anatomy, equipment, and procedure. 

I am far behind from that level of knowledge and confidence but I know my strong and week sides. I keep assessing myself in different situations and keep finding qualities I need to improve. In regards to the skills I am finding that it takes time to learn certain skill, improve it and then become practitioner with wide range of skills maintained. As a student nurse I am expected to show basic skills and learn new ones when opportunity is given. On my placement I was very lucky to have mentor who showed and teach me new skills, provided me with constructive feedback and always respected my decision to refuse doing something, when I felt it’s above my limits of competence.

I have never worked in acute settings and my ability to adapt and learn quickly helped me to work on my weak sides. I have learned from my first placement and I was observing, asking questions and reading relevant information at the time of the event. This helped me build confidence and have interest in learning new skills.

However as I still feel I am at the beginning of the course, I will have the opportunity to show what I have learned so far and add more skills and knowledge, have different experience, work and learn from nurses and other professionals, build confidence and receive constructive feedback, so I can feed forward.

Opportunistic learning:

 Looking up to find a definition of Multidisciplinary team (MDT) Oxford Dictionary of Nursing (2014) says: “a group of health-care professionals with different areas of expertise who unite to plan and carry out treatments of complex medical conditions” and “integrated care pathway is a multidisciplinary plan for delivering health and social care to patients with a specific condition or set of symptoms. Such plans are often used for management of common conditions and are intended to improve patient care by reducing unnecessary deviation from best practice.”

I had a lot of opportunities to work with other professionals. As I mentioned before the ward I was on is a busy ward with many different health-care disciplines involved. I had four spoke placements, three of them organised from my mentor. I have attached my forms and can be seen at the end of my written work.

I spent a day with gynaecology specialist nurse which was very intensive and interesting. Participating on MDT meeting and asking my spoke mentor questions gave me better understanding of diagnoses and plans of treatment for patients. Observing the consultant in the outpatient clinic was really good experience, as he was very helpful and explained to me each diagnose, what is the next step and why. There was quite high amount of patients given diagnose of cancer and I found it to be very difficult to communicate with them in this situation. However I was wrong, as my spoke mentor showed me this part of their role. They have very good relationship with patients and broad knowledge of the condition and how to help them. Specialist nurses can be contacted any time and make an appointment at outpatient clinic. I found that their role is very important for patients as they need someone to be closely related, be able to answer all questions and support them. I found a study which shows that patients benefit from specialist nurses and build trust in health care professionals (Thygesen et al., 2012).

I spent a day with sonographer specialist nurse, learning about her role and observing early pregnancy scans. It was another very good experience, which helped me understand her role at the clinic. It was very emotional, can be very sensitive and distressing as well. I have observed diagnosis of miscarriage, ectopic pregnancy, normal pregnancy and I have seen a lady miscarriage while having her scan. This was very sad and stressful experience for the patient, but very difficult for the nurse as well, as she had to explain what have just happened, be empathetic, communicate effectively with the distressed patient and then pass the information to the ward, so they can admit her.

I have spent a day with uro-gynae specialist nurse and observe morning clinic. I wasn’t aware before that of her role and it was very interesting to find out what her daily routine is and work character. It was more complex that I was expecting. I have observed and had the chance to ask questions my spoke mentor, she was very passionate and explained to me thoroughly some procedures, symptoms and treatments. I have seen: treatment of Interstitial Cystitis, where small size 8 catheter was inserted, bladder emptied and medication inserted directly to the bladder via the catheter. I found it very interesting as I have never heard of this condition before. My spoke mentor explained it to me in details. Interstitial cystitis is a condition which results in bad pain and discomfort in the bladder. It is caused by recurrent UTI, bacterial infection or damage to the protective lining of the bladder (Rosamillia, 2005). I have seen pessary insertion and intermittent self-catheterisation teaching practice and I found all of them very interesting and well explained from my spoke mentor. After clinic was finished we had a chance to discuss what I have seen and ask questions related to her role and all she showed me in the morning.

As part of my surgical placement I had a spoke placement in theatre. It was related to my current placement and I was in gynaecological theatre. I found it very interesting and it helped me gain further knowledge and better understanding of surgical patients, their condition, the undergoing procedure, female anatomy, nurse role in the theatre, and why patients present different after surgery. I observed Laparoscopic BSO, diagnostic laparoscopic endometriosis, excision of vulval lesion, block dissection of inguinal lymph nodes, LAP BSO and colposcopy. After my experience at the theatre I felt more confident when patient ask me question related to their condition and presentation of symptoms after surgery.

As a conclusion I can say that I do have better understanding of other nurse’s roles and the importance of good communication between health-care professionals. As a student nurse I found that interprofessional learning give better chance to learn from other professionals and share knowledge, as well as, respecting other’s role, building better networking and reducing ignorance (Arnold and Boggs, 2015).

Critical Incident Analysis:

Description: Angel was admitted to hospital due to cerebral abscess, which is infection of the brain (Stefaniak, 2015). She was diagnosed with HIV/AIDS as well. HIV stands for human immunodeficiency virus, which is a virus responsible for AIDS (acquired immune deficiency syndrome). HIV destroys a large group of lymphocytes, this results in suppressing of the immune response of the body. It’s mainly transmitted sexually but can be transmitted via infected blood as well (Martin, McFerran, and Oxford University Press., 2014). As HIV can present and produce different neurological symptoms, it can be very easily mistaken with something else, and diagnosis can be a real challenge. There are cases where cerebral abscess to undiagnosed HIV/AIDS has presented with signs which are common signs of a stroke (Stefaniak, 2015). At the beginning of the shift when we do physical observation she was found unconscious in her room. Emergency bell rang and everybody ran to the side room. I went as well and saw a lot of people around her. They was talking about suspecting toxoplasmosis. Toxoplasmosis is an infection which is caused by the intracellular protozoan parasite and is often distributed by infected cats or by raw meat. It is not dangerous for people as the immune system can deal with it, but it can be dangerous for people with HIV/AIDS, as they have compromised immune system (Hyo-Jeong Lee et al., 2013).

Feelings: I felt unprepared for this situation, as I knew a little bit about the patient, but at the same time I felt that I need to observe what other professionals are doing, so I can ask more questions my mentor after they dealt with the situation. I wasn’t sure as well if I understand everything they was talking and doing while assessing the patient. My perception of HIV/AIDS was wrong because of my lack of knowledge and that’s why I have done some further reading. I found out that very often assessment of patients with HIV/AIDS delay because of the stigmatisation and prejudice from health-care providers (Huang, 2013).

Evaluation: It was a very good experience as I realised how quickly a patient can deteriorate, how difficult is to deal in some situations and conditions. However all I knew about HIV/AIDS is that is untreatable condition and have fatal end, but what I learned is that it becomes manageable disease because of the advanced medicine, and is now suggested to be approached differently and if palliative care is combined with the treatment, patients will have better quality of life (Huang, 2013). My limited understanding made me feel nervous and unable to learn from the experience. I had many questions but I wasn’t sure if they are relevant to the situation.

Analysis: The most important thing for me in this situation was observing and then asking questions. I found that all health-care professionals involved in this incident was communicating all the time and was calm and concentrated all the time. It was assessed systematically and each professional was doing different part in the assessment and then communicated back with others. I have seen that when blood was taken from patient, there was different label on it. I found that all specimens need to have biohazard label, so other departments are aware that they might be potentially dangerous (Dougherty, Lister, and West-Oram, 2015).

Conclusion: I have seen how professional are dealing with the situation and managed to stabilise deteriorating patent, used systematic approach and transfer patient to ITU for further investigations. This have given an example of physical needs assessed and responded to, that they practice effectively, and all worked within the limits of their competence (NMC Code, 2015).

Action Plan: Next time when emergency arise to observe and ask questions, to listen what other professionals are talking, make notes, so I can have clear questions related to the case. Not to be afraid to ask why it’s been dealt that way. Reflect on the experience and try to find more information.

References:

Arnold, E.C. and Boggs, K.U. (2015) Interpersonal relationships: Professional communication skills for nurses. Philadelphia, PA, United States: Elsevier - Health Sciences Division.

Dougherty, L., Lister, S. and West-Oram, A. (2015) Royal Marsden manual of clinical nursing procedures. Hoboken, NJ, United States: John Wiley & Sons.

Huang, Y.-T. (2013) ‘Challenges and responses in providing palliative care for people living with HIV/AIDS’, International Journal of Palliative Nursing, 19(5), pp. 218–225. doi: 10.12968/ijpn.2013.19.5.218.

Kim, J.H., Psevdos, G., Gonzalez, E., Singh, S., Kilayko, M.C. and Sharp, V. (2012) ‘All-cause mortality in hospitalized HIV-infected patients at an acute tertiary care hospital with a comprehensive outpatient HIV care program in New York city in the era of highly active antiretroviral therapy (HAART)’, Infection, 41(2), pp. 545–551. doi: 10.1007/s15010-012-0386-7.

Martin, E.A., McFerran, T.A. and Oxford University Press. (2014) A dictionary of nursing. 6th edn. .

Nursing and Midwifery Council (2015) We are the nursing and midwifery regulator for England, wales, Scotland and Northern Ireland. Available at: http://www.nmc.org.uk (Accessed: 20 October 2016).

Rosamilia, A. (2005) ‘Painful bladder syndrome/interstitial cystitis’, Best Practice & Research Clinical Obstetrics & Gynaecology, 19(6), pp. 843–859. doi: 10.1016/j.bpobgyn.2005.08.004.

Simpson, P.M. (1997) Introduction to surgical nursing. S.l.: Singular Pub. Group.

Stefaniak, J. (2015) ‘HIV/AIDS presenting with stroke-like features caused by cerebral Nocardia abscesses: A case report’, BMC Neurology, 15(1). doi: 10.1186/s12883-015-0437-7.

Thygesen, M.K., Pedersen, B.D., Kragstrup, J., Wagner, L. and Mogensen, O. (2012) ‘Gynecological cancer patients’ differentiated use of help from a nurse navigator: A qualitative study’, BMC Health Services Research, 12(1). doi: 10.1186/1472-6963-12-168.