It is important that we use reflection in order to further develop our skills in practice. No matter which reflective cycle chosen it is important that you identify what has been learned from the experience, how it has helped, if it is negative, how to overcome the problem in the future, and how it relates to theory and knowledge you have been taught. Reflective practice has been identified as one of the key ways in which we learn from our experiences in practice (Jasper 2003). As a concept for learning, reflective practice was introduced in the 1980’s (Jasper 2003). Boyd & Fales (1983 cited in McGuinness 2009) suggests that “learning from experience can be very personal and, because of this, the process of reflection must allow the individual to address all aspects of each situation encountered”. There are many types of reflective cycle and they are only there to offer a guide and format to reflection. Schon (1983) suggests that “we can engage in one of two ways; either by reflecting on action, after the experience, or by reflecting in action, during the experience”.
I researched many different cycles before selecting the one I thought was right for me. I will explain 3 I could have chosen and then explain the cycle I used and why. Firstly is Gibbs model of reflection (1988) (appendix 1). The pros to using this method are that it is very simple and directional. It splits your work into 6 sections and gives you a very structured essay. However I find it does not give you much help as to what you need to include within your essay. It is very basic and does not expand upon each section. The second cycle is John’s model of reflection (1994) (appendix 2). This model also provides structure and more detailed information of what to include by prompting with suggestional questions.
This being said, I found the questions to be a bit lengthy and over complicated reflective practice. The final model was Atkin’s and Murphy’s model of reflection (1994) (appendix 3) I thought that this model was very directional and to the point offering a 5-sectioned essay plan, however it was still too basic for my learning style and therefore I found it best not to use it. For the purpose and intent of this essay I shall be using Driscoll reflective framework (1994). The reason for this is that I found it the most suited for me to follow. His reflective cycle uses just three simple questions as the main body of the framework, which are then expended upon in greater detail. Driscoll’s framework has since been updated in 2000 (appendix 4).
This reflective essay is based on a negative experience I had as a student operating department practitioner while on placement in anaesthetics. My reason for choosing this experience is that I found it to be a very valuable way to learn what needs to be done in order to ensure the smooth running of an operating department. This particular experience had some good issues to explore. Throughout the duration of this essay I will be using fictitious names for all patients and staff in order to protect anonymity and confidentiality. This is in order to comply with the codes and conducts set out by the health professions council (HPC). Due to word limitation the main focus of this essay will be surrounding the first patient and the complications that arose prior to anaesthesia, such as communication, consent, allergies, and the importance of all of these things. What? – a description of the event
One morning I came into work and found out I was going to be involved in a urology list that involved 4 patients; 1 female and 3 males, all needing different urological procedures. You would have thought that after the lengthy pathway that a patient goes through before finally having their surgery, everything would run smoothly when getting to theatre. This was not the case on this particular morning. Not one patient was appropriately fit for surgery on that day. We were setting up our anaesthetic room for the morning list. Before sending for the patient you should always see both the anaesthetist and the surgeon, the reason for this is so that the patient is not sitting in the anaesthetic room for longer that they need to be as they may be extremely nervous. Typically theatre lists start at around 9am however on this particular day we had seen neither the anaesthetist nor surgeon so were unable to send for the first patient.
At 9.05am the junior anaesthetist, Dr K, came in explaining she had seen the patients however we still had to wait as Dr F, the consultant anaesthetist, had to go and see the second patient on the list as there were concerns with proceeding with his surgery. After explaining this she then went on to brief us about the rest of the patients. The first patient was Mrs. G. Dr K informed us that this patient told her that she has a latex allergy and comes out in welts when it touches her. It was questionable as to whether or not we should proceed with her surgery. The surgeon then phoned our theatre shouting at the staff, asking who it was that told everyone his patient was allergic to latex. This is because Mrs. G had now told the surgeon, Mr. B, that she did not have a latex allergy. Whilst on the phone Mr. B stated that he wanted the patient to be collected immediately for a prompt start as soon as he got down to theatre.
Finally Mrs. G arrived in the anaesthetic room, however when I was running through the checklist with her, asking her several important questions, such as when was the last time you ate and drank, and obviously, do you have an allergies? To which she responded, yes, I am allergic to latex. We could have still cancelled the procedure however now she was in the anaesthetic room the anaesthetist and surgeon were both happy to proceed. This unfortunately was not the end of the complications with this patient’s procedure. When shown the consent form to confirm the surgery she was having done and that she had signed it herself previously that day, she was also consented for a cystoscopy, Mrs. G was unaware that she was also having this and when asked if she was aware of the procedure she told us that she did not know what a cystoscopy was, even though she had consented to the procedure. After finally checking in the patient and making sure she was comfortable and aware, we continued with the anaesthetic induction.
So what? – an analysis of the event
Whilst Dr K was explaining the complications with each patient I thought of how key communication is within a theatre team. Without that communication all of the patients could potentially have had further problems when finally arriving for their procedure, be it during induction, during surgery or in recovery. Communication is not just important between the staff, but as shown it is extremely important between healthcare workers and patients. For example, it should not have taken as long as it did for someone to find out that Mrs. G had a latex allergy. This should have been picked up during her pre assessment or even when she was admitted to the ward. When patients have an allergy they should always have an extra wristband stating their allergy. (Trust Policy 2010). Many patients suffer from fear and anxiety surrounding anaesthetic procedures, it is therefore important that a clear and effective communication takes place between the anaesthetist and patient prior to coming to theatre. If this is done correctly it increases patient compliance and satisfaction (Kindler et al 2005).
The most effective form of communication is face to face however, there are many different ways this can be achieved, for example, written forms such as graphs and notes. There are also non verbal forms using body language and touch. It is vital that all patients understand what their procedure is, how it will be done, recovery rate and anaesthetic procedures, regardless of their mental competency. It is vital that you know how to communicate in different forms because every patient deals with stress and nervousness in their own way, some will come in and cant stop talking, some won’t say anything, others will be shaking and others may be experiencing some form of chest pains, low blood pressure and a very fast heart rate. Anxiety levels of patients are much higher when admitted to hospitals, this is believed to be due to the thought of the procedure/surgery and the fear of the pain they may feel post operatively (Clancey et al 2002).
Communication between staff members, as well as patients, is continuous, from the moment they enter the hospital, to pre admission, the ward, theatres, recovery etc. All staff are there to aid the patient to a quick and effective recovery. When Mrs. G came down to theatre and was asked about her consent form, I found it appalling that she had not been given this effective communication as every patient is entitled to and deserves the best form of care possible. When consenting a patient, the Dr should inform the patient of the full procedure and explain any doubts, questions or worries that the patient may be feeling as well as explaining the full procedure to them. (Brigden 1998) In Mrs. G’s case this was not done therefore left her confused and slightly nervous. We explained the procedure to her and told her there was nothing to worry about and it was just a routine procedure that is done with the other. This leads me on to the issues surrounding informed consent. It is the legal and ethical right of a patient to direct what happens to their body.
In order for their consent to be valid it must be voluntary and they must be considered mentally competent to make the decision. (Brigden 1998). In order for consent to be considered legal and valid it is essential that the patient be deemed competent to make the decision and their consent must be voluntary (Hind and Wicker 2000). When obtaining consent from patients it is essential that you find out whether they have any individual needs and priorities, such as religions beliefs, occupation or other factors that may affect their treatment. For example, Jehovah witnesses will not accept any form of blood transfusion as it is not recognised in that religion. If however the patient is deemed to be incapable of making an informed decision under the mental capacity act e.g. they are unconscious, then it is not, as it is typically assumed, relatives or a care giver that has the right to give consent for them, but is generally two doctors that have the right to make the decision. (Radford et al 2004).
This being said in an emergency situation where consent can not be obtained, providing that the treatment necessary is directly linked with what needs to be done to ensure patients safety and health, then you can provide medical treatment to whoever may need it. If, for example, the patient has previously refused treatment and you are aware of this fact, but the case is now deemed emergent, you cannot proceed and must respect the patient’s previous wishes. Once the patient is stable and mentally aware, you must inform them of what has been done and make sure they understand fully. (Kinder et al 2005). Sadly Mrs. G was already nervous about her procedure before she found out she had been misinformed. Also discovering her latex allergy could cause complications to herself and her surgery increased anxiety when she arrived in the anaesthetic room.
This sent her heart rate racing. It went from a normal steady 86 beats per minute (BPM) to an irregular 176 bpm. Luckily Dr F is an extremely calm and sensible consultant anaesthetist and knew exactly how to handle that situation in order to keep her calm and lower her heart rate. All of these things should have been explained to her prior to her surgery, or better still prior to her attendance of the hospital. After I reassured her of what she was having done and had held her hand for a while, she finally understood and calmed down, therefore allowing us to proceed. This made me think of how people cope with stress and anxiety, and it showed me that everyone deals with things differently, just by explaining what was happening and having bodily contact with Mrs. G helped her greatly. She was very thankful and happy with the level of care she received in the anaesthetic room. After the list had finished I started to wonder why the world health organisation checklist (W.H.O) was not completed.
The W.H.O checklist should be completed at 3 stages during each operation; prior to anaesthetic induction – known as sign in, immediately after induction or just before the incision of skin – time out, and finally once the operation is complete before going to recovery – sign out. (World Alliance for Patient Safety 2008). One of the questions asked is ‘does the patient have any allergies?’. If the team had completed the checklists prior to the start of the list then the complications should have been located and would have meant that they would be dealt with accordingly. For example, the issues surrounding Mrs. G’s latex allergy would have been able to be avoided if we had known before she was due to come down.
It is vital that patients with latex hypersensitivity must go first, in a theatre that has had all latex products removed. It is trust policy that the theatre must be latex free for at least 1-2 hours. As none of this was done it was very questionable as to whether this patient could have her surgery or not. We informed the theatre floor person, who agreed that she thought the risk was too great as patients allergic to latex can go into anaphylaxis. These can all be incredibly dangerous when under anaesthesia. She told us that if the surgeon and anaesthetist decided to proceed then we should complete an incident report form, just in case any reaction was to occur throughout the procedure.
Now what? – proposed actions following the event
After looking into the aspects of this experience I have found it very useful in furthering my skills and knowledge into becoming an operating department practitioner. The issues surrounding informed consent, patient anxiety, communication between staff members as well as the patients and the surgical safety checklist are all linked together in one way or another. Had all of these been carried out correctly the list would more than likely ran smoothly. However there is no sure fire way to guarantee something else would not have occurred hindering us further. I can use the information I have researched in practice as I now have a better understanding of how the peri-operative department should work. Each member of the team should ensure that these issues are dealt with at the time they arise.
They should not be passed around from person to person. It is the staff’s responsibility to make sure the standards and expectations are maintained. Each patient has the right to their own dignity and modesty and should all be treated with respect. Treat patients how you would wish to be treated if you were having surgery. Each hospital has a set of trust policies that should be adhered to, it is expected that any new members of staff read them so that they are aware of the procedures and standards that should be met. Information about the NHS and its practices can be found in vast quantities in libraries or on the internet. This is also there to provide support and assistance to further your knowledge and ensure correct procedures are carried out. The points previously discussed are just some of the reason it is vital that reflection is so important to health care professionals, it is essential for maintaining a high standard of care.