This is a reflective essay based on a situation I encountered during my first week of placement on a surgical ward at a local hospital. In order to maintain confidentialityand make appropriate use of patient information as stated in the Nursing and Midwifery Council (NMC 2015) code of conduct, I will use pseudonyms to protect thepatient’s and staff identities. I am going to analyse, evaluate and make conclusions about the incident using John’s model (2000) which suggests that the “Model for Structured Reflection” is a technique useful in learning and developing how to reflect. This model challenges our tendency to negatively judge our actions and feelings by using the “Looking in” and “Looking out” way of reflection.
In order to gain insight into my development, I will focus on central issues such as communication, person- centred care and consent.Whilst working on an assessment unit during placement, I was approached by Dr Hill, a senior consultant who asked me to assist a team of junior doctors with clerking patients who had been referred to the unit. The first patient I was assigned to was Lionel, a 77 year old male who had been referred by his General Practitioner after presenting with acute urinary retention. Dr Hill explained that because I was a student, he would seek consent from the patient first before I could see him. Consentwas gained and I was introduced to the patient. When I walked into the consultation room, I noticed that Lionel was lying on the bed with his hand rubbing his lowerabdomen. Next to him was a lady who held on to his other hand tightly seemingly frightened with her eyes wondering around the room. I introduced myself as a student physician associate and asked for his consent to insert a cannula and take some blood samples from him and he agreed.
I don’t think he understood everything I said because he looked confused but I quickly dismissed my suspicions and began to take a history. Roy had presented with acute urinary retention which had been going on for the past three days . From what I gathered, this had happen before and on one particular occasion he ended up staying in hospital for three weeks as he had developed sepsis from complications of a urinary tract infection. I completed taking a medical history and examining his abdomen and just as I was about to insert a cannula he pulled his arm away.
He seemed unsure about having a cannula because he thought this meant he would be kept in hospital for longer. I explained that Dr Hill had asked me to insert a cannula on him as part of his investigation and treatment plan. He then asked me to clarify whether or not I was a student and questioned my ability to do the procedure.
I explained that I was a trainee Physician Associate who had received adequate training and had inserted a lot of cannulas since commencing placement five months before. I also explained that this did not guarantee that I would successfully complete the task but would inform a doctor in the event of failure who would attempt doing it. He nodded his head and stretched out his arm towards me which I interpreted as non- verbal consent. I became nervous at the thought of failing and began to feel my hands visibly shaking.
Unable to open the cannula pack, I knocked down a water jug from the table, spilling water all over the floor. As if that was not enough discouragement, he shook his head and said he hoped I was not going to attempt inserting a catheter with my shaky hands. I informed him that the decision to catheterise was with a senior doctor who would also insert it if necessary.
I then offered to call one of thedoctors to come and observe in case something went wrong but he declined and asked me continue cannulating. At that moment, Dr Hill walked into the bay to find out how I was getting on. I explained that there had been a few mishaps and asked him to take over but he insisted I complete the task as long as Lionel was happy for me to.
As I had never encountered anything like this before, I was getting more and more frustrated with myself for failing to regain composure and look past my clumsiness.All I was trying to do was gain venous access in order to obtain blood samples and to allow administration of fluids and medication if needed. Even though I had cannulated many times previously, I felt nervous as to what to do and whether I was doing it correctly and each time the patient twitched, I felt worse. I slowly convinced myself that I was hopeless and incapable. At first, I thought Lionel had something against me being a student. It was difficult for me to understand why he seemed anxious but I later found out he was his wife’s main carer, who suffered with dementia and when I went to cannulate him, he associated having a cannula with a longer stay in hospital, leaving his wife with no one to look after. I did not seek support early enough because I wanted to prove that I was capable of handlingchallenging situations on my own, not realising I was only making the situation worse for both myself and the patient.
My actions caused Lionel to panic and have distrust in my ability to do any procedure on him, plunging me into further discouragement. However, Dr Hill’s presence in the room eased the tension which in turn gave meconfidence to complete the task. I later felt good because instead of giving up and walking away, I was determined to learn how to work and cope under stressful conditions, which I did.Several factors affected my response, including my position as a student, the inability to communicate effectively and lack of understanding the ethics of consent.Isaacson et al. (2014) recommended that teaching institutions should maintain patient safety and satisfaction as a paramount issue while trying to develop models of care that integrate teaching.
He also found that the majority of patients who wereasked to give their opinion about having students in their care were satisfied and their care was unaffected by student involvement. In an earlier study, Gress et al. (2002) found that while the majority of patients were willing to see medical students, some expressed anxiety and annoyance of the medical education process and were not willing to see students at their next appointments. This study reveals the importance of encouraging patients to give honest opinions about how they feel having students involved in their care and explaining their opinion would not affect the quality of care they receive. When I spoke to Lionel the day after this incidence, I found out he did not mind seeing students but had had a traumatic experience years before when a student doctor attempted to insert a catheter, hence he had been apprehensive about me attempting to do any procedures on him. I feel that had I been able to explore his concerns, he would have opened up to me about his past traumatic experience which I would have discussed with a senior doctor, preventingfurther anxiety to both myself and the patient.
Another factor that affected my response was my lack of knowledge and understanding around the issue of consent. The General Medical Council (GMC 2008) states that informed consent to investigations and treatment is required and considered the basis of a patient- doctor relationship. Selinger (2009) outlines the four main principles of medical ethics as justice, non- malificence, autonomy and beneficence. According to the General Medical Council (GMC 2008), patients have the right to choose whether or not to undergo investigations and treatments and this decision must be respected by all health professionals.
However, in order for consent to be valid, patients need to be given sufficient information before making an informed consent and an individual should have capacity. Evaluating this incident, Lionel was not given sufficient information about his management plan which only led to confusion and anxiety on his part. Doctors are also recommended to find out about patients’ individual needs and priorities when providing information about treatment options, which again was not done. While Lionel had given consent to be seen by a student, he seemed unsure about why he was being cannulated. The GMC (2008) again states that when trainees and students carry out procedures (assuming they are appropriately trained) to further the patients care, it is not a legal requirement to tell the person that the clinician is a student although it would be good practice to do so. While Dr Hill had gained Roy’s consent to see a student, he did not clarify that the patient was entitled to change his mind and withdraw consent at any time including during the performance of a procedure.
Stewart et al. (2000), suggests that good communication should include exploring the patient’s ideas, concerns and expectations also encouraging questions and clarification regarding their health and treatment. I did not encourage Roy to ask me questions nor did I clarify his understanding of what I wanted to achieve during our consultation. Salzman (1995) found that patients participate fully and are likely to besatisfied when there is successful communication between the healthcare giver andthe patient. I do not feel I handled this situation well nor considered the patient’s feelings and anxiety. There were cues which I should have picked up and addressed during my consultation with Lionel, yet I chose to dismiss them even though I had noticed confusion and anxiety through observing his body language. According to Benbenishty, Hannink (2015), non -verbal communication involves body language, touch, listening, mimic gestures, body posture, facial expression and feelings. All these help to build trust and healthcare professionals are encouraged to deliberately commit to listen as this has been proven to encourage patients’ compliance and improving outcome.
I also do not feel that Dr Hill included Roy in the decision making about his treatment as it was clear that Roy associated having a cannula with hospital admission. Although the cannula had been inserted in anticipation that Roy would need fluid infusion, considerations could have been taken into account to wait until it was certain he needed one. Peripheral cannulation is invasive and increases risks of phlebitis and systemic complications which can result in lengthy hospital stay and associated healthcare costs (Waitt et al 2004). Blood samples could have been obtained using venepuncture which is less invasive (Rivera et al.
2007). In a study, Valverde et al.(2014) found that although a person centred physician consultation approach was lengthy, relationships between patients and their doctors was improved and consequently better health. Building a relationship with Lionel would have likely caused him to open up and talk about any concerns he had, in this case caring for his wife.
Engaging and negotiating with patients has been shown to be effective in encouraging cooperation and participation in their health management to achieve specific goals.There are several elements to person centred care that benefit both the patient and health professional. Person centred care is central to the mission of healthcare and takes into account individual needs and preferences, placing the patient at centre of decision making tailored to their needs.
This then allows them to better manage and make informed decisions about their health (Unknown 2011).Looking back, I realise that my lack of knowledge in areas of communication with patients, consent and patient perception on having students involved in their care, caused me to act in an incongruent way and I could have handled things differently. However, this incident taught me the importance of acquiring in depth knowledge in these specific areas. Also, I should have consulted with my senior and asked for support at the earliest opportunity to prevent escalation of anxiety. In future, I would like to improve on my communication skills to enable me to communicate effectively with patients who may not be able to verbally express themselves. I have already begun literature searching as well as taking histories from patients with different communication capabilities.
I have also learnt that listening and good eye contact are equally important when communicating as these can help identify key words and cues which can sum up how the patient is feeling, whether they are worried, fearful or in pain (Royal College of Nursing 2015). I willalso utilise all the support around me without hesitation, this includes nursing and medical staff, as well as the ward clarks who have on numerous occasions helped me find misplaced patient notes and borrowing me a pen when I turned up on my first day without one. I will seek to take advantage of this support to advance my learning experience.
Literature search in preparation for this reflective essay has also increased my knowledge and understanding about the importance of a person centred care approach when consulting with patients, as it places patients at the center of all decision making.