Gynecology Emergency Care - Case Study Example

A REFLECTION OF AN EPISODE OF CARE IN GYNAECOLOGY EMERGENCY CARE Introduction This is a reflective account of the events surrounding my work at my current placement. As I see from the entries in my diary, this is just a matter of a week back in my current placement in the gynaecology unit, where activities in the unit are hectic, laborious, and extremely engaging. I decided I will relook into this event in a closer and structured manner to examine my experiences surrounding this event in the care of the patient who was admitted to the unit with a gynaecologic emergency. I felt John's model of structured reflection will be useful, and I will follow that in this reflective process (Johns, 1995: 226). Reflective Model Reflection in nursing is within the context of practice (Burns and Bulman, 2000). Burton (2000) states reflective practice is designed to raise more questions as threads that may extend into future but on lived experiences (Burton, 2000). Cotton (2001) called it a process of dynamic evolution to examine appropriateness of action (Cotton, 2001). Johns (2007: 8) states reflection to be an intellectual effort on the part of the professionals that incorporates thinking, feeling, and action that essentially arise from practice (Johns, 2007: 8). Therefore exploration of self through reflection on experiences would develop self-awareness and ability to evaluate actions. McKenna (1999) stated that philosophical assumptions serve as contexts in reflection (McKenna, 1999). Teekman (2000) wrote reflection to be a system intended for actions based on philosophy in nursing (Teekman, 2000). Valuable learning can take place within clinical nursing practice, often using reflection as the key strategy. Reflection offers an opportunity for practitioners to enlighten the essential nature of the care (Fejes, 2008). This reflective account is about an incident on my placement in the gynaecology unit in an NHS Hospital. For reasons of confidentiality and other ethical issues, the identity of the patient will remain undisclosed, but for the purpose of ease in description, I will use "Molly" as her name (NMC, 2004). I will examine critically while delivering care to this patient, whether I had understood the importance of practice of nursing in the context of her assessment, care planning, and care delivery. This reflective practice would also help me to identify my strength areas and weaknesses in competence, so I can understand better the importance of maintaining and developing professional competence. Description Molly is a 23-year-old married lady admitted to the Gynaecology ward from the Emergency Unit with the diagnosis of severe left sided lower abdominal pain, nausea, and weakness and fainting suspected to be left sided tubal ectopic pregnancy. Molly had a past history of pelvic inflammatory disease following an induced abortion 6 months ago. She had missed a period which is 2 weeks overdue, and two days back, she had just a slight spotting. Her problems of abdominal discomfort started yesterday which she terms as vague soreness on the left lower abdomen. Today this vague discomfort was replaced by sharp, colicky pain in the left lower abdomen accompanied by vaginal spotting. In the Emergency Room, a vital sign record revealed tachycardia and a low blood pressure. She had demonstrated some air hunger, and the emergency department physician detected cyanosis and started her on mask ventilation on 100% oxygen (Edwards, 1997). An intravenous fluid infusion was started, and a FBC drawn revealed severe anaemia in the range of 7 g percent (Adam and Osbourne, 2005). When the patient stabilized in the emergency room, an ultrasonography revealed an ectopic pregnancy in the left utero-ovarian tube with imminent rupture. She was immediately admitted to the inpatient Gynecology ward where emergency management was started and a considerable extent of care was delivered by me under guidance of my mentor. While the patient was decided to be prepared for an emergency surgery, I had to monitor her vital signs, support her haemodynamically, monitor her fluid, make a requisition for blood transfusion, communicate with the family members and her (Asensio et al., 1996). Obviously, the care process followed a care planning that was dependent on assessment. The reflexive narrative is presented as an exemplar of researching self as a process of self-inquiry and transformation (Souter, 2003). Therefore, this reflective account will provide insight into various dimensions of my practice including systemic observations of what I learned as a nurse clinician from my practice (Mantzoukas, 2008). Looking In Reflection is a process in practice, meaningful reflection indeed influences and informs practitioners to critically analyse practice situations so the practitioners can respond to and approach situations in a professional manner where standards of practice are maintained. This also provides the practitioner a framework where actions can be planned (Nicholl and Higgins, 2004). Reflection is clearly related to critical thinking, but I did not explore this directly at that time. I did, however, feel and came to understand how reflection might be an inherent element in the engaged and interested learning of the phenomena in practice when a deep approach to learning is the goal. I suspect that I did not consider the relationship with critical thinking in greater detail because, at the time, I had not considered the dimensions of depth of reflective learning. The exploration of reflective learning also stimulated me to pull together my ideas of what we do when we engage in the immensely complex process of learning something. To begin with, however, it was difficult to discern where to begin. Looking Out It was important to note that I did an assessment of Molly on my own. Since the pelvic ultrasonography demonstrated leakage of blood, the patient would not meet criteria for conservative therapy. Molly desired future fertility, but her shock indicated that there was active bleeding intraperitoneally. It was a left tubal pregnancy with imminent rupture of the tubal mass of larger than 6 cm. From my reading I knew that she had features of acute abdomen, hypotension, and a very low haematocrit. Moreover, ultrasonography detected pelvic collection of fluid which most probably is blood. She was very restless and sometimes disoriented. On the face of this emergency, I was instructed to monitor her vital signs and send blood for creatinine and AST to ascertain the status of her renal and liver functions. I also sent a full blood count since bleeding may lead to low platelet count leading to further bleeding, which would further worsen her condition. The surgical treatment was therefore chosen and the operating theater was notified. The surgeons made the decision to attempt a laparoscopic salpingostomy, if not as a life saving measure, left salpingectomy with removal of tubal pregnancy. I had a careful nursing assessment of her vital signs which established shock with gradually deteriorating blood pressure and accelerating heart rate. A blood was sent for grouping and Rh typing which Molly proved to be Rh positive. I checked for her vaginal bleeding which was nothing more than a spot. Molly was in considerable pain, and I had to give her morphine 10 mg. This would sedate her and cause relief of her pain. Her pregnancy test was positive, and she had considerable abdominal tenderness in the left iliac fossa. To do a care planning, as I see in my journals, my nursing diagnoses were, risk of deficient fluid volume related to blood loss from rupture of the left tube, acute pain related to rupture of ectopic pregnancy and intraperitoneal bleeding, and anticipatory grieving related to loss of pregnancy and potential future infertility (Ghaye and Lillyman, 2006, 21-25). Significant Issues I was concerned about her and was anxious. When I reflect on her care now, I now come to recollect my feelings about her and about myself. At some point, I was thinking, whether I was fit to deliver her care or not, since Molly's case was my first exposure to such cases. At the same time, I felt concerned about her, since it raises a question, whether she understands her condition appropriately and correctly (Platzer et al., 2000). Obviously, she has advanced disease which would need extirpative surgery, chance of loss of fertility, considerable suffering and pain, imminent surgery and chances of complications. I felt really awkward since I did not know what to do. I was feeling extremely sorry for her and sorry for me too. In some points, I was not able to make a decision as to what to do. I am sure it will be demonstrated in this reflective account how I was enabled to examine decision making in patient situations. Also I believe from my previous experiences of reflection that this would be able to uncover the knowledge and the artistry that are embedded in practice (Howell and Pelton, 2001). The quality of care giving is advanced through reflection. While delivering Molly's care, I knew that it would offer me challenges regardless of my expertise and setting of care. The first problem was that there is a body of knowledge in emergency Gynaecology nursing that had been built through experience and research, and I in my current position was just more than a naive in it. Her clinical problems would be unique, and this could lead to challenging opportunities for clinical problem solving. Family is an important part of the care process, and it would be my role to help the patient and the family along her care continuum. Whatever may be the fact, I could understand when I was assigned to her care that there would invariably be a range of patient care concerns that needed to be taken care of through skilled interventions. I was feeling afraid and was extremely doubtful about my abilities to care and to communicate with her. My lack of experience was my weakness, but my strengths were zeal to do something for her and my academic learning (Jasper 2003: 11). Although the complexity of her disease is frightening given my academic learning and skills, when I talked to my mentor about the potential problems that I might face in her care, my mentor assured me that, she will guide me closely throughout, and in the wake of her care, I would come to understand that it is her complexity of disease and other family situations, which would provide me both the opportunity and the challenge to make a tangible difference in patients' and families' lives. She reminded me that care apart, I must convey the message of hope to her through caring, provision of comfort, quality of life, and execution of effective treatment of symptoms (Kirklin, 2007). Informed consent is the usual way in which patient preferences are expressed. Informed consent is the practical application of respect for the patient's autonomy (Aveyard, 2005). The policy of patient-centered nursing care highlights the needs for shared decision making through active participation of the patient. As an ethical basis of patient-nurse, informed consent constitutes a central feature of an encounter characterized by mutual participation, good communication, mutual respect, and shared decision making (Breier-Mackie, 2001). I must state that although the family was informed adequately, given Molly's state of mind and pain and anxiety, there may be some lapse in securing her consent about extirpative surgery, and although she voiced desire to have future pregnancies, the very consent for surgery may lead to loss of her fertility. Communication is the most important aspect of healthcare practice including nursing (Williams and Gossett, 2001). This indicates communication will have to find out ways to tell truth. If the facts are uncertain they should be acknowledged and represented as they really are. The patient herself is very hopeful about her treatment outcomes. My question was did the patient really need to know the truth. Given her clinical condition, she is going to die eventually despite the best form of care, and the natural history of ectopic pregnancy suggests so (Schairer et al., 2004). I expressed my doubts to my mentor, and she told me about importance of nursing communication skills and the ways the truth should be told, where the extent of motivation can be very acceptable and it can also ensure hope. Current recommendations do not advise deception, and the ethical doctrines of autonomy and truthfulness suggests telling the truth at any given situation (Royak-Schaler et al., 2006). This would become more important when the patient will eventually understand the course of her treatment and future life. Despite that I was feeling shaky to tell her the truth, may be because I did not want to be a messenger with a bad mouth. The care would be in a shared decision making manner. In order for shared decision making to occur, patient was informed of her diagnosis, prognosis, and treatment options. I feel I worked by according respect for patient autonomy, and this played a central role in medical decision making, the paternalistic paradigm of the relationship needed to be exchanged for a shared decision making paradigm. When her initial shock subsided, she appeared to be quite willing to accept the risks of surgery; her hopes were prolongation of life and symptom relief despite very small probability of infertility (Chauhan and Long, 2000). Reflexivity The first challenge was to develop a care plan for this patient. Care plan of this patient would depend on the assessment of her clinical, psychological, social, and spiritual status. Since Molly was taken to Surgery, my job would be prepare her for surgery as per instructions and follow her through in the postoperative phase. In such cases my experience was poor, and my standards were below at par. I raised this concern to my mentor stating that I must be accountable for my work, and given my skills and training, I do not conform to the NMC standards (NMC, 2008: 26). My mentor ensured that she will supervise and guide me throughout so I need not worry. I established an intravenous line with a large-bore intravenous catheter and infused fluids and PRBC according to doctors; prescription and both preoperatively and postoperatively, I monitored her vital signs and urine outputs at regular intervals frequently. I sent the blood samples as I already mentioned and CBC, typing and cross matching reports were documented in the chart. I had to provide comfort to her for her pain with Morphine and before this, I used relaxation technique. I made sure that I would have to provide support to Molly, and I listened to her and her family's concerns. It has been suggested that using a framework would be better (Chabeli and Muller, 2004), so it makes the reflective process structured and guided. I personally feel those who are very experienced would not need a framework for reflection. For me as a nurse as a means of reflective practice, I have and would always prefer to have a framework, and I chose Johns' model. Johns' (1994) model of structured reflection allows the reflective practitioner to ask a series of questions to delve into the experience, so the practitioner is able to find out a meaning of her actions and thoughts in this structure. As highlighted in Johns & Freshwater (2007) reflexivity involves a constant examination and re-examination of knowledge, learning, and practices which may get reformed as a result of impact with incoming information. Applied to nursing practice, reflection is now a necessary tool to examine traditional practice in order to justify them, and if the rationality and evidence for changes are detected, a change in practice is brought about (Freshwater 2002; Johns & Freshwater, 2007: 226). However, research has recognised that one of the major difficulties of critical reflection is implementation of a reflective model, not in outlining the approach. In any reflective process, there would always be multiple interacting and intricate issues that need to be handled including complex emotions, experiences, and feelings (Johns, 2002: 8). Bakke and King (2000) stated that nurses deliver care not only to the body (Bakke and King, 2000). Learning In the tune of Taylor (2006), the nature of nursing work needs the nurse to be responsive and reflective; this can be a process of learning, instead of simply carrying out the routine at work mechanically. Reflection from that sense is an opportunity for the nurses to be therapeutic in practice. Taylor (2006) also contend that self-awareness makes any person critical about self actions, which may be the beginning of a change and learning. For example, reflecting on a particular care, the nurse would face self satisfaction, incongruity, and facts about care delivered which makes her uncomfortable (Taylor, 2006: 6). Not only did I deliver care according to competency standards, I delivered the care ethically and I communicated well with the patient and the family. I collaborated well with the surgical team and other staff well during her care. Future Actions It is clear that these events offered opening to my perceptions and helped me to confront with my own limitations. This process made me more self-conscious. It has been displayed that the clinical decisions that we take and the care we provide tend to be prohibited by our conditioning and traditions. This actually might have happened due to the fear of consequences of acting out of the queue. However, the reflective thoughts that dawned upon me has pointed out clearly that I would have taken a different action if I would have taken help of evidence and would be able to work out of traditions. This is a contradiction with my "self" and showed that I was not as competent as I thought about myself (Bulman, 2004). From these reflections, it is clear Johns' view has been supported by the work of other theoreticians. Practice of nursing can also be viewed as a skill to develop self awareness. As Freshwater (2002) has contended, in creating possibilities of therapeutic nursing through reflection, the nurses have an opportunity to examine self as workers and learners and can have the scope to resolve their conflicts in decision making for care. Thus reflection can be a process through which self-awareness can be transformed into the patients' feelings of being cared for leading to build up of a therapeutic alliance (Freshwater, 2002). Raised consciousness is indeed a method of adult learning, where learners are empowered to have a self-directed knowledge. As evident in this discussion, reflection is a method of self education through analysis of actions where promises for change are hidden and imbibed. Johns is right in calling reflection as being mindful of self, either within or after experiences, as if a window through which the practitioner can view and focus self within the content of a particular experience, in order to confront, understand, and move forward resolving contradiction between one's vision and actual practice (Johns, 2007: 2). References Adam,S.K. and Osbourne,S., (2005). 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(2000) An evaluation of process and outcomes from learning through reflective practice groups on a post-registration nursing course, Journal of Advanced Nursing, 31(3): 689-95. Royak-Schaler, R., Gadalla, S., Lemkau, J., Ross, D., Alexander, C., and Scott, D., (2006). Family perspectives on communication with healthcare providers during end-of-life cancer care. Oncol Nurs Forum; 33(4): 753-60. Schairer, C., Mink, PJ., Carroll, L., and Devesa, SS., (2004). Probabilities of Death From Breast Cancer and Other Causes Among Female Breast Cancer Patients. J Natl Cancer Inst; 96: 1311 - 1321. Souter, J., (2003). Using a model for structured reflection on palliative care nursing: exploring the challenges raised. Int J Palliat Nurs; 9(1): 6-12. Taylor, B.J. (2006). Reflective practice: A guide for nurses and midwives. Berkshire, England Open University Press. 6-27. Teekman, B., (2000). Exploring reflective thinking in nursing practice. J Adv Nurs; 31(5): 1125-5. Williams, CA. and Gossett, MT., (2001). Nursing Communication: Advocacy for the Patient or Physician Clin Nurs Res; 10: 332 - 340. Read More