Reflection on Experiences of Challenging Patient: Developing Proactive Planning Skills

Introduction:

Jasper (2013) argues that an essential tool used by students and health care professionals is to reflect upon clinical practice as it is beneficial learning and improving upon a specific practical experience.  I will be reflecting upon my experience of an assessment whilst on clinical placement of a challenging patient using the “Gibbs Model of Reflection”. Gibbs (1988) is a framework to examine experiences in a cyclic nature that results in you learning and planning from prior experiences. I will be using Gibbs Model as keeping with my clinical experience, it provided myself an agenda of how to learn and utilise the skills acquired from clinical practice. One of the standards of proficiency for radiographers is being able to assure superior quality of their practice through the ability of reflection and review of practice is a gold standard (HCPC, 2018).

Description:

A request for acutely unwell patient was received by the accident and emergency department. The patient’s request included a chest and abdomen x-ray querying sepsis and dilated bowel. The patient had a history of clostridium difficile (CDI) and recent tests had tested positive. The patient was an infection risk and strict protocols had to be followed. Staff working with the patient had to wear appropriate personal protection equipment (PPE) – gloves and apron. Before the patient was brought into the room it was essential to prepare the room; ensuring the detector was in the upright bucky and the table with the correct orientation, the grids in place and all the necessary computer systems were ready. I was assigned the role of working with the patient and their belongings. Whilst another radiographer was assigned the role of working with the imaging equipment only. Patient identification was made verbally by the patient alongside confirmation the patient felt confident to stand for the chest x-ray. Before aiding the patient to standing, I was prompted to remove items of clothing and belongings that could be a possible artefact. I positioned the patient whilst communicating with the assisting radiographer of how I wanted the tube positioned, correct collimation and centring for the chest x-ray.

After the chest x-ray, the abdomen x-ray was conducted. I assisted the patient onto the bed whilst the ‘clean’ radiographer positioned and aligned the tube. I was able to move the bed using the foot pedals whilst communicating to the radiographer where I wanted to collimate. As this patient was an infection risk, I was advised to not place my markers on the images – this was added in post-processing to reduce the risk of cross-contamination to other patients.

Afterwards, I supported the patient back into the wheelchair and alerted the porters the patient was ready to be taken back to the assessment unit – clearly communicating precautions had to be taken including PPE. Once the patient had left, the room and any area of contact was thoroughly cleaned using disinfectant before using the room for a new patient.

Feelings:

Prior to the examination I felt mindful of the situation. I wanted to remain calm and composed; for the benefit of the patient as I wanted to ensure the patient was not in any unnecessary distress. However, during the examination the strict infection control precautions made me feel apprehensive. I wanted to ensure everything was put in place to follow the protocols of the clinical site. Correspondingly, as I haven’t had a lot of experience of ‘infectious’ patients outside of an intensive care unit or ward it made me feel nervous to ensure there wasn’t any cross-contamination and remembering my assigned role that otherwise wasn’t usually a conscious effort. Ultimately, as the examination progressed my apprehensive eased as I found my ‘professional’ role to combat the anxiety. Communication was essential between myself and the radiographer; together we forward planned, assigned roles and worked together on a more focussed plan for the beneficence of the patient.

Evaluation:

In hindsight, the experience was positive which has led to a greater understanding of infection control protocols, rational thinking and forward planning. This will improve my role as a student radiographer which I will take forward into my future career. Planning the examination with the radiographer ensured roles were assigned, communicating the requirements needed from each other and arranging the room for efficiency and safety. As a radiographer, it is our duty to conduct an examination to the highest of standards to achieve an optimal diagnostic image despite obstacles arising. Furthermore, it’s our duty to ensure patient safety in all aspects of infection prevention and control (HCPC, 2018).

Regardless of devising a plan with the radiographer prior to the examination, a few issues arose that could have been prevented. I need more awareness of situations that may occur out with my plan; initially removing artefacts that may obscure the image and patient wellbeing. Whilst making a conscious effort to remember the extent of the precautions for infection control are dependent on individual patient circumstances. Especially the selection of PPE; assessing the risk of transmission of microorganisms to and from the patient and the contamination risk of the healthcare worker (NICE, 2017).

Analysis:

On reflection, the main contributor to the positive experience was effective communication. Connelly and Turner (2017), states to achieve greater patient compliance and satisfaction good communication skills is the key to success. They further explain communication skills are an essential tool for healthcare workers for interacting with patients to ensure effective care is provided. Likewise, communication between healthcare workers ensures patient care is completed effectively, efficiently and safely; especially if extra precautions are required. Adler and Carlton (2015) supports whilst communicating with patients is a necessity: collaborative work between radiographers is an important factor to consider the possible human diversity issues that could arise – in this case the infectious patient. Radiographers must be able to appropriately adapt their technique to suit the individual procedure to ensure it is completed safely and successfully (Alder & Carlton, 2015).

As healthcare workers it is our professional duty to follow established guidelines regarding infection control. Ehrlich and Coakes (2017), states the duty of healthcare professionals is to follow policies that will promote patient and staff safety. The Royal College of Nursing (2016) expand upon this by stating the sequence of protocols are followed to help break the chain of infection: this sequentially reduces infection arising or cross-contamination. Thus, specific recommended control methods strive to reduce the transmission of the CDI (Ehrlich & Coakes, 2017). Washing of hands using running water, liquid soap and paper towels is recommended for staff after contact with the patient, the patient environment and after removal of PPE. Furthermore, there are specific recommendations to reduce the transmission of CDI with the use of PPE. Disposable gloves and aprons should be worn by all staff whom have contact with the patient, contaminated environment and within direct vicinity (NHS, 2017). Whilst ensuring appropriate hand hygiene and PPE is conducted, NHS (2017) have collated good evidence that environmental decontamination plays a vital role in reducing the transmission of CDI spores. This process involves using a disinfectant with 1000 parts per million to clean the contaminated environment including imaging equipment.

Coinciding with effective communication, strategic planning ensures prior objectives are completed in the most effective and efficient way for the benefit of the patient. Schober (2017), defined strategy planning as the intended course of action; a guideline to tackle the situation. The planning of the assigned dedicated roles and responsibilities in advance to develop consciously and purposively. From the patient’s perspective it installs confidence and pacifies any unnecessary anxieties as it appears everyone has knowledge of what needs to be achieved (Schober, 2017).  Strategic planning similarly allows for healthcare resources to complement an individual patient’s needs (Hall et al, 2011). In this examination, the information we were given of the infection risk allowed for the radiographer and myself to select the appropriate PPE and organise the room effectively. The key aspects to the examination pathway are to ensure the room is safe and tidy, equipment prepared for correct study and exposure and the x-ray tube prepared for correct procedure (Whitley et al, 2017).  Hall et al, (2011), affirms effective planning facilitated with the efficiency of the examination, improves health outcomes and helps manage the flow of patients.

Whilst strategic planning ensued a competent and successful examination, an aspect which I will improve upon in my future practice is to always expect the unexpected. Although a plan was devised, I need to be open to unexpected issues arising particularly in an emergency department. Whitley et al, (2017), states contraindications and any confounding factors should be considered with every examination for the safety of the patient and staff. Whilst every examination is influenced by the patient’s individual circumstance, good practice is to always be prepared for the unexpected to arise for the benefit of improved patient safety and reducing risks or harm (WHO, 2017). Whether it be deterioration in patient health, non-compliance or specific to this exam; removal of artefacts from the patient, to prevent the image being obscured whilst complying with infection control. As the prior discussions were focused on infection control procedures, planning and assigning roles; the removal of artefacts was overlooked. Artefacts on images can obscure interpretation or confound the interpreter of the image: this in turn could affect the quality of care the patient receives (Walz-Flannigan et al, 2018). Thus, on reflection despite the advantages of strategic planning confounding factors should always be included even if they don’t arise for the benefit of the patient and staff. 

Conclusion:

From this experience, I am more mindful of the importance of effective communication and strategic planning in practice if similar situations were to arise in the future. The insight I have gained from this experience means I am more aware of infection control standards implemented for the safety of staff and patients. Also, the benefit of strategic planning demonstrates competency and alleviates any anxieties. A concluding insight I gained was to factor in confounding factors into premediated plans to certify improved examination outcomes.

Action plan:

The goal I want to accomplish is the skills of being more proactive with forward planning of unexpected issues with encompassing effective communication. This goal will improve upon patient safety and satisfaction throughout, improve image quality and successful team working skills. The importance of this goal allows myself to improve upon my clinical skills of a student radiographer; additionally, follow me throughout my career as a qualified radiographer. This will involve myself working together with radiographers to conduct a successful examination to ensure the patient receives the correct care. Patient examinations will be enhanced by effective communication and strategic planning continuously throughout new experiences. However, if an examination is not as successful reflecting upon the experience allows for an understanding to be interpreted which will be implemented into future patient examinations.

To accomplish this goal, it is important to have continuous reflection throughout the duration of my clinical experience as a student radiographer and qualified practitioner. This allows for continuous learning opportunities to improve upon future practice of what was successful or what could be improved upon. Reflective skills have been implemented from the beginning of my student experience. As I progress my reflective skills will continue to improve and enhance as I gain more experience and confidence in a clinical environment. The motivation for this goal is to ensure the patient receives the correct quality of care whilst maintaining optimum safety for staff. The HCPC state the importance of reflective practice to improve upon future experiences; this goal is relevant to be established now since it is an objective that will improve as experience and confidence is gained. As this is a continuous goal I would aim to improve throughout experience. I want proactive strategic planning skills to be improved and enhanced as my confidence improves throughout my career. Finally, allowing for continuous reflective practice to implement new learning for the benefit of the patient and staff.

References:

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