The experience of reflection as a implement for understanding in workplace education, can allow the student to problem solve in practice. By exploring the persons own unique circumstances and past experience they can, in order to learn, bear in mind past beliefs and recollections as a basis to accomplish a desired learning result. (Rolfe, 1998). Taylor (2000) suggests that, to reflect on action from an event, we must recollect our thoughts and memories. That is when we must use the faculty of contemplation, meditation and consideration, which permits us to realise the insight of our past experiences and thoughts, in order to adapt our behaviour, should we encounter similar related incidents in the future.
This reflective case study has been written using the Gibbs (1998) model of reflective writing. Confidentiality has been preserved throughout in accordance with the Health Professions Council (HPC) Code of Professional Conduct (HPC, 2002) and I have chosen the pseudonym of Joyce Charles for my patient.
Although this was the first week of my second placement in general practice this was the first time that we had met, therefore, I introduced myself and made clear at the practice and explaining that I was a Paramedic undergoing further training to become an Emergency Care Practitioner (ECP) (as described by Silverman et al 1999). Joyce gave me verbal consent (Department of Health 2001) to take part in her consultation and treatment.
The rationale for reflection in relation in to this topic is to understand the difference in today’s standards and how important the Health Care Professionals role will impact in providing care for patients suffering chronic disease.
Joyce had returned to the surgery following a glucose tolerance test, for diabetes, she was a 43 year old clinically obese female. The previous week she was seen by the Doctor as she had some sores that were not healing properly. Joyce was asked to return to see the diabetic nurse at the surgery clinic to obtain her results and ask any questions, that arose. I was invited to work along side Faith, who was one of the nurse practioners assigned to the Surgery and she would take the main lead in the consultation.
Although part-time, one of her many roles, was to facilitate the diabetic clinic, with lots of experience, she was willing to share a considerable amount of her medical wisdom. Kadushin (1992) suggests that primary components of clinical supervision should be about education, support and management. Being a practice nurse in the village surgery she had implemented many of the National Service Frameworks (NSF’s) and Integrated Care Pathways (ICP’s) enabling the practice to initiate Government targets in promoting healthcare to the community. My role in this consultation was to obtain a full history (appendix 1) (Hatton and Blackwood) and to lead the health promotion conversation and to give general health information and diet and lifestyle.
Joyce was going to be given the news that she had Type 2 diabetes and after a few minutes she asked a number of questions and as she did so, her voice started to waiver and she clearly was quite shocked at this news. She had tears welling up in her eyes, then burst into tears. This outburst of emotion overwhelmed and surprised me, however the nurse was also a trained counsellor and was very supportive and sympathetic in her manner. I was now quite worried that I would become too focused in this one area of her emotion.
Benner (1984) indicates that one of the exceptional attributes of expert nurses is that they spend a great deal of their nursing time thinking about the future course of a patient, anticipating what obstacles might occur and what they would do about them. I always seem to lose my confidence and train of thought as a result of being watched, probably fear of being criticised in a non conducive manner. Dreyfus and Dreyfus (1977) note that as long as the beginner is following the rules, his/him performance will be halting, rigid and mediocre.
Whist I was attending one of my first lectures, I was advised to use the acronym LEAPS which is a way of effectively conducting a consultation by listening, empathizing, asking questions, paraphrasing and summarising. Techniques like this enables practitioners who are at the beginning of their new roles, a foundation on which to build the consultation, leading to confidence, which I hoped would be communicated to Joyce.
I did feel a degree of consternation when I started talking about diet, as Joyce had a body mass index of 39, which is just one below the morbid obese level (Simon et al 2002) and she appeared embarrassed and visibly upset. I managed to answer her questions concerning her condition, and how it would affect her daily life, such as could she still drive, would she have to have injections every day, and she has a holiday abroad, could she still go. Once she had the information, Joyce, seemed to relax and manage to retain some of this information, this assisted to make me more relaxed too, as I felt that at least this part of the consultation was being received well.
Even though Joyce was upset, I was very pleased to have the occasion to play an important function in the explanation to Joyce that she had a Long Term Condition (LTC) and that I was asked to provide the most significant features of managing the condition, diet and lifestyle information. The discussion was well planned and undertaken in way that was both sensitive and constructive and make sure that Joyce was given appropriate health and lifestyle information and had the chance to share in the decision-making processes regarding the long-term management of her condition.
Sonkensen et al (1986) stated that unfortunately, most diabetic education is centred around the time of diagnosis. This is the time when the patient is least receptive and is unable to comprehend what is being said. Therefore, I asked Joyce to make a further appointment with the dietician, who would address any deeper problems. I had already gathered a small amount printed leaflets and provided some website addresses with appropriate information. This was to ensure that when Joyce left the surgery she would be able to find information on her condition, when she felt that she would need it. The level of planning that had taken place before the consultation began was very good and met the patients needs of, honesty, attention, time allowed for questions and the use of clear language as described Mueller (2002) in his recent paper on this subject. These factors are essential in ensuring that the patient accepts their chronic condition early, this ensures that long-term management can begin, and the patient can begin the long process of learning to live with their condition.
Two main areas emerged during the history taking, the psychological factors of obesity and the affects of obesity on diabetes, and the recognition that there was a history of depression. Depression is not generally listed as a complication of diabetes. However, it can be one of the most common and dangerous complications. The rate of depression in diabetics is much higher than in the general population. Diabetics with major depression have a very high rate of recurrent depressive episodes within the following five years. (Lustman et al 1977) A depressed person may not have the energy or motivation to maintain good diabetic management. Depression is frequently associated with unhealthy appetite changes.
Before Joyce’s situation can be considered it is clear that the underlying depression as well as the diabetes needs are met in the her treatment plan. Failure to do so would prevent us from achieving our first goal of weight reduction. Obesity may be called the ‘modern living’ disease and is an associated condition to many long term health conditions such as coronary heart disease, kidney failure, cancer and diabetes. Over the last 25 years, the level of obesity in the UK has grown by over 400 % (House of Commons Health Committee 2004). A huge amount of research is underway across the world to try to understand the causes of this obesity explosion. Most people who are obese are not aware of why they overeat, how much they eat, or how frequently they eat (Bellack, 2000). Joyce had been overweight since her teenage years and as a result, had been teased and bullied, this may have been a prelude to her initial depression too.
Nutrition education is an integral part of all behavioural approaches to weight control. Bellack (2000) also indicated that patients must have the relevant information to use in understanding and structuring their dietary practices and in assessing the potential effects of behaviour change. I had advised Joyce of the adverse effects of quick weight loss and fad diets, so it was important for her to seek further advice from the dietician. The Nurse Practitioner was an advocate of the Health Action Model (HAM) which was devised by Tones () and it emphasises the importance of self-esteem on behaviour.
This model identifies a variety of physiological, social and environmental influences which research and practice have shown to be imperative. Using this model has help Faith to achieve desirable behaviour changes in all areas of LTC patients under her care, and Joyce would benefit from this experience, eventually when Joyce had settled into the realisation of her newly diagnosed condition. It is clear that to prevent an ever-increasing burden on an already stretched healthcare budget that primary care will play a vital role in the promotion of a healthy lifestyle. Diabetes is already costing the UK in excess of 9% of the entire healthcare budget and this is predicted to rise over the next 25 years to a level around 25% (House of Commons Health Committee 2004).
The NHS is committed to developing a range or strategies to reduce the risks of type 2 diabetes developing in the population. This is enshrined in standard 1 of the National Service Framework: Diabetes (2001). This Standard looks at the key interventions increasing and promoting physical activity and by increasing the amount of training and education available to health professionals on the interventions that are effective in preventing and managing obesity.
When analysing the entire case it is clear that Joyce was Identified as an at risk patient at an early stage and that the required diagnostic tests where carried out without any delay. Once a diagnosis was made, a planned and structured approach was used to convey this to Joyce in an honest, sensitive and understandable way. Information was made available to Joyce as well as providing addresses for her to source her own information. In consultation with Joyce, a follow up regime was designed that suitable for her needs as well as adaptable for the future. On reflection, I feel that this case was dealt with in a highly successful manor. As with all chronic conditions it is imperative that Joyce understands her unique care pathway, that will, with her compliance support and aid her to lack of complications in her future years.
I can summarise my reflections on Joyce’s case as follows. Before breaking news about a chronic disease or life threatening illness careful thought should be given to planning. This should follow close as possible the SPIKES (Baile 2000) model of breaking bad news, which advocates that setting up the correct environment, being prepared to deal with the patients emotions and having a strategy and plan prepared to manage the patients condition are fundamentally essential.
To prevent the healthcare costs of the nation spiralling out of control over the next few years, in conjunction with chronic disease health surveillance and health promotion under the guidance of the NSF’s and Nice guidelines will demonstrate a marked improvement in further As demonstrated in Joyce’s case it is important that the clinical team employ a holistic approach when dealing with patients, this becomes even more crucial when dealing with the complexities of a chronic illness. My final conclusion is that early detection and diagnosis of a chronic condition will need to become higher on the health care agenda. This will require more collaboration between health professionals and the greater sharing of patient information.
As I have previously mentioned the SPIKES model provides an excellent strategy for breaking bad news and is one that I shall be adopting into my clinical practice. This system asks you to plan the Setting. Think about the patients Perception. Invite the patient to give their permission to break the news. Provide adequate information and Knowledge, be prepared for the patient Emotions and ensure that there is a Strategy to provide on going support. I feel that this will be an excellent tool for my future as an Emergency Care Practitioner. It is essential that in my role as a modern health professional that I have a responsibility to ensure that I continually upgrade my knowledge of where to obtain good quality health information.
Patients have a right to information that is easy to understand and is available to them when they need rather than when the clinician decides that they should receive it. When in consultation with a patient it listening is an essential skill, I will continue to improve my listening skills which are of particular benefit when dealing with issues such as health promotion this is described as the listening process by Ewles and Simnett (2003).
Finally, it is of absolute importance that all health care professionals and I continue to use evidence-based practice. The area of chronic disease management is one that will continue to grow over the next few years, during this time there will be many changes and adaptations to current guidance on diseases such as diabetes. I will need to ensure that I have access and adequate time to seek out these changes and update my clinical practice accordingly.
Should I ever encounter a comparable experience in the future, I will try to revaluate this occurrence, Palmer et al. (1994) considered reflection to be the retrospective contemplation of practice, suggesting that a careful review had to take place of what had happened previously. L’Aiguille (1994), on the Other hand, implies that reflection also prevents the Practioner from becoming complacent with everyday aspects of work and to reflect and learn from a new experience everyday. The occurrence of education must be developed to facilitate the clinician to provide a sound basis enabling advancement that leads to advanced skills.
Baile W.F. et al. (2000) SPIKES-A six-step protocol for delivering bad news:application to the patient with cancer. Oncologist. 5. (4):1597-1599
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