– REFLECTION Monitoring and Ensuring Quality Care

Introduction

The purpose of this paper is to reflect on a recent personal experience of patient care, which enabled me to achieve a module 9 competency, Actively seeks to extend own knowledge.

I will be critically analyzing one nursing practice incident using Boud, et al (1985) model of reflection, (please see appendix 1) which will enable me to monitor and ensure quality patient care in future practice. The nursing incident happened when I was looking after a patient requiring enteral tube feeding (ETF). It is important to note that all confidential information relating to patients, wards, hospitals and professional colleagues has not been included in this paper to ensure ethical practice and adherence to the NMC code of professional conduct, section 5 which affirms that I ‘must guard against breaches of confidentiality’ (NMC 2008).

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Reflection is a useful tool for the continuation of professional development among nurses (Somerville and Keeling 2004). The word ‘reflection’ originates from the verb reflectere which means to bend or turn backwards (Hancock 1998). It is a tool, which unlike text books and videos, does not have a limited shelf-life, it is cost effective, is portable and can be used world wide.

Patient Profile

The aspect of nursing care I have chosen to reflect on is the care of a patient who required enteral tube feeding (ETF) due to dysphagia – a condition in which the action of swallowing is difficult to perform (Unison Health Care 1998). This nursing intervention was essential for a patient in my care, who I shall call John. Please see appendix 2 for John’s past medical history.

The Plan of Treatment for John

John was admitted to my area of practice six days ago following his CVA. He is receiving ETF via an NG tube as an immediate intervention and is being assessed to see if he is a suitable candidate for a percutaneous endoscopic gastrostomy (PEG) tube which are used as a more permanent form of enteral tube feeding (Holmes 2004). The nasogastric tube is about ’22 inches [55.9cm] in length’ (Holmes 2004) and was inserted into his left nostril down through the pharynx, through the oesophagus and through the cardiac sphincter muscle and into the stomach (Marieb 2001). Food can be administered through the tube directly into the stomach and the swallowing process does not need to take place. The food is administered by a pump that controls the amount of feed given in mls per hour. This description could sound as though ETF is always safe and effective and has no complications. Elia (2001) affirms that ETF is typically safe and easy to administer. However John did experience a number of difficulties that could have been rectified sooner than they were. On reflection of Johns care it is clear to see (with the benefit of hindsight) that if Johns care was managed differently and if complications were noticed and acted on promptly, his hospital experience could have been very different.

1.) Returning to the experience – Problems John faced.

John experienced two main complications as a result of ETF. The first was regurgitation of the feed into his throat and mouth and the second was diarrhoea. The rate of the feed had been increased over a period of days to its optimal rate, following the ETF guidelines provided by the NHS trust that I was working in. The infusion was commenced during the night while he was sleeping to allow John greater freedom during the day as he could be disconnected from the pump. The regurgitation happened during the first night that the pump was running at the optimal flow rate. Davis and Shere (1994) report that regurgitation is a common complication of ETF. As a consequence, John had to swallow what had come up into his mouth. The rationale for John to undergo enteral tube feeding was to prevent further weight loss and aspiration which can be caused by dysphagia (DeLegge 1995, Gibbon 2002 and Davies 1999). Aspiration has various meanings, however in this context it refers to the movement of foreign material i.e. fluids or food, into the trachea and further down into the lungs (Unison Health Care 1998). This can occur when the swallowing mechanism is ineffective or impaired. Infection of the lobe of the lung, in which the foreign material has lodged, occurs. This is called aspiration pneumonia (Unison Health Care 1998). Patients suffering from dysphagia are at risk of developing aspiration pneumonia (DeLegge 1995 and Gibbon 2002). ETF was commenced to overcome this risk but now the very intervention that was intended to eliminate the risk has caused an even greater risk of aspiration pneumonia.

According to Marieb (2001) there are two stages of deglutition (swallowing). The buccal phase, which is a voluntary action, occurs in the mouth and is the first phase of deglutition. The tongue progressively elevates anteriorly to posteriorly, propelling the bolus through the oral cavity. When the bolus has moved to the base of the tongue, the soft palate is raised, preventing food from being regurgitated via the nasal passage

(Davies 1999). The second is the involuntary pharyngeal-oesophageal phase which Davies (1999) describes as a complex sequence of muscular movements. After a CVA the ability to initiate the secondary phase of deglutition can be disrupted resulting in ineffective or complete failure of this phase of deglutition. This short explanation of pathophysiology demonstrates how important it is to know nursing rationales for nursing interventions. Patients suffering from dysphagia can sometimes overcome the problem by eating a pureed diet and drinking thickened fluids, but this depends on the severity of the dysphagia (Stringer 1999). John needs ETF because his dysphagia is too advanced to be overcome by a change in diet.

Arrowsmith (1993) recommends that patients who are receiving ETF via a NG tube that are lying in bed, should have their head and shoulders elevated 30-40 degrees during feeding and up to one hour afterwards to minimise gastric pooling and reflux of the feed. This example demonstrates how a simple action can make a substantial impact on the quality of care that they experience. It has the twofold purpose of

Impact of the quality of care that they experience. It has twofold purpose of

promoting the effectiveness of the intervention and minimises harm to the patient by reducing the risk of aspiration pneumonia. Assessing for signs of aspiration in a patient suffering from dysphagia should always be taken seriously by nursing staff. Stringer (1999) reports that if dysphagia is serious enough it can prevent the victim from swallowing their own saliva. The average person swallows approximately 590 times each day – 146 when eating, 394 when awake and not eating and 50 times during sleep (Davies 1999). With the average person swallowing literally hundreds of times each day, patients are at risk of aspirating (on their own saliva) regardless of ETF. Barer (1989) found that over one third of conscious acute stroke patients admitted to hospital had unsafe swallowing. Davies (1999) citing Ellul and Barer (1994) affirms that dysphagia in the first three days after stroke is associated with a five to tenfold increased risk of chest infection during the first week. This is due to varying degrees of aspiration. Aspiration is a potentially fatal complication of ETF.

John also experienced three episodes of diarrhoea since starting ETF. John was only provided with a commode which was only dealing with the symptoms rather than treating the cause. No contact was made with the senior house officer or dietician. Furthermore there did not appear to be much concern among the nursing team and there was no discussion or sharing of knowledge between colleagues accept what came from myself. I told my mentor what I had been reading during my reflection time and pointed out some reasons that have been identified as causing diarrhoea for patients receiving ETF. The attitude of my mentor was apathetic, and commented, ‘He’s bound to pick up a bug, give it time, it will pass’. This shocked me as Somerville and Keeling (2004) reports that the nursing profession depends on a culture of mutual support, and this was not what I received from my mentor.

I wanted to discuss the temperature of the feed, his current medication and the cleanliness in which the feed was prepared and administered. If the feed is too cold when it is administered it can cause diarrhoea (Arrowsmith 2003). Howell (2002) reports that diarrhoea can be the result of ETF but it can also be due to the side effects of medications. Antibiotics can cause the common side affect of diarrhoea (BMA 2001) but John was not receiving any. Diarrhoea in ETF can also be caused through the introduction of bacteria through poor hygiene standards in the preparation and administration of the feed; however the preparation and administration does not need to be performed aspptically.

This is only indicated if the patient is immunocompromised (Arrowsmith 1993). My professional knowledge reminded me that I could not dismiss the diarrhoea as a coincidence. If there were nursing interventions that could be used and I didn’t use them, I would be failing to provide quality care for my patient. Nurses are responsible not only for their actions but also for their omissions (NMC 2008). I wanted to refer to each others professional knowledge through discussion, and to the ETF guidelines to see if there was a simple cause to the problem that could be rectified before consultation with the doctor or dietician became necessary. I was able to rule out most factors that can cause diarrhoea. This led me to believe that the infusion rate could be too fast. These are the factors that I wanted to discuss with my mentor so I could contact the dietician to seek help from the multidisciplinary team. Gibbon (2002) asserts that stroke care requires the services of a ‘multi-professional team, working towards an agreed therapeutic plan’ hence my reason to collaborate with the dietician.

2.) Attending to feelings – What did I feel was Positive?

During reflection time I was very interested and pleased to find this research to suggest that there could be something that I could do to put an end to the discomfort, distress and potentially disastrous complications of a patient in my care. Many times as a student I have felt that I personally, am not making a great difference to my patients’ health and wellbeing as I am not working independently, but under my mentor who in general decides on a course of action for our patients. This time I have found the answer from my own research. All that remains is for me to bring this research to my mentor’s attention and then put the intervention into practice. The patient will benefit, and I will have a great sense of achievement as I will have, in a small way, improved the quality of someone’s life, accomplishing one of the reasons why I decided to take a career in nursing.

Attending to feelings – What did I feel was Negative?

In response to the apathy that I encountered, I felt disappointed and powerless and undervalued. My original mentor was off on temporary short term sickness due to a small operation and therefore I was allocated another Junior Ward Sister to take her place for the short period of time in her absence. I felt disappointed because my contribution to the care of my patient was not welcomed and that this mentor was not as patient or interested in my learning and on-going development. I also thought it was unfair because I had evidence to base my suggestions on. It was not a vague idea I had conceived but it was grounded in research. I felt powerless because as a junior and inexperienced member of the team I felt I had little influence over the overwhelming hierarchy. Morris (2004) states that student nurses possess little power because they are viewed as inexperienced. I wanted to make my mentor realise that the patient could be suffering (from diarrhoea and regurgitation) because of our negligence and not from inevitable causes.

Why was Cognitive Learning Being Achieved?

In this situation I was learning a number of things, mainly relating to communication, team work, assertiveness, accountability and responsibility. I learned that my priority is with the care of my patient and not with my popularity among colleagues, just as the NMC (2008) signifies when it states ‘when facing professional dilemmas, your first consideration in all activities must be in the interests and safety of patients’. When I met with my original mentor on her return back to work we discussed this incident of practice and she praised my efforts in extending my knowledge to improve patients care. I therefore achieved the competency, actively seeks to extend own knowledge.

Do Any Barriers to Learning Exist?

The barriers that existed to my learning were the apathy of the nurses and the limits of my own assertiveness. It was very hard on this ward to feel proud of the care that was being given. The ward was poorly staffed, the ward manager was unanimously unpopular, the ward relied heavily on agency staff that was not familiar with the ward and my temporary mentor wanted to leave nursing because of all of the above (and more). As a new and enthusiastic team member I found my self fighting against the low morale and low motivation of the current staff. Job satisfaction can impact on the care that nurses provide. Brown (1995) believes that when nurses enjoy good job satisfaction they provide a higher standard of care to their patients. Rohrlach (1998) and Govier (1999) cited by Kitson (2003) discovered that nurses who were happy with the care they were giving were more likely to stay within the clinical area which would in turn provide some stability and security within the workplace. According to this research, the inability to give quality care (due to the problems mentioned) was resulting in low morale.

The dilemma I faced was as follows. I had already approached my mentor once regarding John’s problems and detected that there was little interest in what I had to offer and in the nurse’s willingness to correct any problems. If I addressed the issue again, I risked worsening the relationship between my mentor and myself. Morris (2004) identifies that student nurses often feel nervous about speaking out because they feel the need to conform or do not wish to be viewed in a negative way. Student nurses risk upsetting the status quo by speaking out. If I left the issue my patient may be suffering discomfort unnecessarily, but as a student I will never be held accountable in a way that registered nurses midwives or health visitors are (NMC 2008). Would this justify me leaving the issues and conforming to the apathy and bad practice of my mentor? Morris (2004) disagrees. She says that although students are not legally accountable for their actions and omissions, they are morally responsible for ensuring that patients are receiving good standards of care. The student nurse must be responsible. Semple and Cable (2003) affirm that responsibility is concerned with answering for what you do. Registered nurses, midwifes and health visitors are accountable which, Semple and Cable (2003) defines as being answerable for the consequences of what you do.

3.) Re-evaluating the Experience – Drawing Conclusions

Drawing conclusions is the most vital part of the process of reflection. It will shape future practice and quality of care. Conclusions that are drawn from reflection must agree with the Nursing and Midwifery Council code of professional conduct. It is with the NMC that all matters of conduct, practice and attitude are dictated to nurses. The NMC (2008) motto, ‘protecting the public through professional standards’ can only be achieved if all those on the NMC register are willing to submit to the conditions and regulations that it upholds. Indeed Somerville and Keeling (2004) affirm that in order for nurses to meet the demands of the NMC, they must focus on their knowledge skills and behaviour which can be achieved through reflection.

On reflection of the described incident, it was difficult to know what to do. My mentor was not up to date with the knowledge of this area of practice. I cannot, and do not expect her to know everything, however Glover (1999) points out the nurses should be reliant on others for information. The NMC (2008) states that nurses should work cooperatively within teams and respect the skills, expertise and contributions of colleagues, treating them fairly and without discrimination. Therefore I expected my temporary mentor to take more interest in what I had to offer. Indeed Morris (2004) argues that qualified nurses are obliged to listen to other staff regardless of their qualification status.

Announcing that practice should be in accordance with the NMC is too simplistic an answer to such a diverse problem. It is correct to say this but how will this be achieved? The ward is in need of good clinical leadership, first of all from the sister in charge. Nadeem (2002) states that the call for good leadership in the NHS has reintroduced the matron figure and also the new role of nurse consultants. Specialist nurses do have a role in ensuring safe practice and quality care but this should be in addition to effective local leadership i.e. leadership from the ward sister. Leadership is perceived as being good if there is good team working and if managers have good relationships with staff (Lipley 2003) which is one area that needs consideration in this scenario. Meeting the staffs’ needs improves satisfaction, productivity and efficiency (Nadeem 2002) which in this instance principally means the provision of resources, i.e. human resources. Nurses who are happy with the care they give are more likely to stay within their clinical area (Rohrlach 1998 and Govier 1999 cited by Kitson 2003). This would provide some stability and security in the workplace. Clinical governance has also come to play a prominent role in ensuring quality care. The government has defined clinical governance as a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding standards of care, by creating an environment in which excellence in clinical care will flourish (Department of Health 1998). It had been noted that unacceptable variations in clinical practice where becoming common in the NHS (Department of Health 2010). While some patients were receiving excellent health care, e.g. in stroke care, other patients in the country were receiving sub-optimal stroke care due to differences in facilities, funding, education and staff. Each clinical area can improve the quality of care by (1) using modern matrons and nurse consultants as clinical leaders, (2) by having adequate staff to care effectively and to lift morale among existing staff and (3) by implementing clinical governance which will result in the flourishing of good practices across wards, departments and NHS trusts through the sharing of expertise, research and ideas. The wards problems could also be addressed through annual reviews or by encouraging staff to keep an up-to-date portfolio (Somerville and Keeling 2004). This will allow nurses to identify strengths and opportunities for development.

Critically analysing using reflection on this incident has been valuable in maintaining the quality of care as set out in the NMC code of professional conduct. Gallacher (2004) says that she questions different people’s practices in order to provide her patients with ‘first class quality care’. Clinical practice will not improve if it remains unquestioned. Hindsight gives the practitioner the opportunity to discriminate between good and bad practices. Safe, legal and quality care can only be given if it is in keeping with the NMC code of professional conduct.

Reference list

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Barer, D. (1989) The Natural History and Functional Consequences of Dysphagia after Hemispheric Stroke. In: Neurol Neurosurg Psychiatry. 52, 236-241

BMA (2008) New Guide to Medicines and Drugs.

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Appendix 1

Three stages to the process of reflection. Boud, Keough and Walker (1985).

a) Returning to experience

– Observations – what happened?

– What was my reaction?

– Clarify personal perceptions

b) Attending to feelings

– What did I feel at the time?

– What did I feel was positive?

– Why is cognitive learning being achieved?

– What did I feel was negative?

– Do any barriers to learning exist?

– Raise awareness and clarify feelings

c) Re-evaluating the experience

– Draw conclusions and insights together with existing knowledge

– Identify gaps in knowledge

– Integrate existing and new knowledge