Delivery of Care - Personal Statement Example

Part I Introduction In this assignment comparison of a range of contemporary health care issues involved in two different care settings. While a range of factors play in care processes in these areas, the main purpose is to reflect on these differences and analyse the reasons for such differences which impact care of the client. In order to do so, the current drivers of change in that area of care will be examined in close quarters through the critical reflection of my visit to that area of practice, mainly to identify at least one example of better delivery of care that may be transferred to my original area of practice where a change in delivery of care will take place. In this note, the differences and their significance will be the focus of the research. As a nurse, my area of work is a 9-bedded Intensive Therapy Unit in a district hospital, where 6 beds are allocated to intensive care unit patients, 3 for patients with need for high dependency care. Apart from that, we have two side rooms, one each allocated for acute patients needing isolation and for paediatric patients. This is about my visit to an alternate care setting in the same hospital, which occurred few days back, when I visited the Oncology unit of our hospital where patients with cancer receiving both chemotherapy and radiotherapy are admitted. Before coming into the Oncology Ward, I thought that our unit, ITU is the busiest unit in the hospital, but when I saw the Oncology Ward, I felt that they are also very busy in their sense of the term. This unit houses 25 beds arranged in one row with open nursing stations. There are closed cabins also, but they are used for clinical oncology nurse specialists. There were dining room, kitchen, a recreation room, and a small library. The nursing stations were open, no separate drug administration room, and a room dedicated for counseling. The staff told me that the patients in these beds are suffering from different cancers, some of them are receiving continuous chemotherapy, and some are recovering from intensive treatment. Since this is a district hospital, these beds were shared with Haematological Oncology. Three other important observations in this unit were a dedicated pharmacy area where chemotherapy regimens are formulated, preparation area where chemotherapy drugs were prepared (Bond and Raehl, 2007), and a dedicated information technology room which utilises a computer program to calculate dose and formulate drugs so error is eliminated. They have a two-bedded laminar flow unit and a one-bedded isolation unit for patients needing infection precautions and isolation respectively. Acute emergencies are handled in collaboration with ITU, and this unit is an example of multispecialty collaboration since most of the decisions are made in collaboration with other super specialists in relevant organ systems. This was in stark contrast with the environment in our unit, where the beds were arranged in one large open area, but all beds were equipped with a plethora of gadgets and equipments, most notably the monitors, ventilators, and intubation equipments. I felt that both these environments have been designed actually to suit their purposes which appeared very relevant to the conditions that they treat. However, after seeing this unit, I felt that the bustle was a little more in our unit which may appear to be intimidating to some patients or family members. In contrast, the environment of the oncology unit was more homely, relaxed, informal, and extremely supportive, where truly holistic care was possible. Moreover, this unit is suitable to provide acute, chronic, and palliative care, which in our case is not possible, which has been designed to provide hyperacute care. Consequently, the therapy areas that they cover are patients with different cancers. Cancer patients receive chemotherapy, radiotherapy, or both. In some cases added surgical therapy is needed, but that does not preclude continued medical therapy. The system they follow is that the patient remains under the care of the oncology physicians, who creates a team with physicians or surgeons of relevant specialties to design the therapeutic protocol. Of course, many patients receive chemotherapy as outpatients in the day units. Many others are given as a short-stay method. However, this unit also plays important roles in community cancer care. This centre is networked with local tertiary cancer centre creating service provision for more complex treatments and clinical research. This centre is linked with DGH cancer units throughout the city, which follow commonly agreed protocols for management. This means this centre is linked with the outreach clinics, all of which share the common clinical pathways for management of different cancers (Department of Health, 2000). There are specialist oncology nurses and clinical nurse specialists in each clinical area. Cancer treatment is closely associated with clinical trials, which are assisted by research nurses. For patients who will need palliative services, there are provisions for Macmillan nurses, liaison with local hospices, community nurses, and general practitioners. This department runs parallel clinics with radiotherapy departments and surgical oncologists. However, now many cancer patients are being treated in the community, and care pattern is holistic. It appeared these high-intensity activities in a district hospital oncology units are at par with the current polices of cancer care in the United Kingdom. The current care policy aims at prevention, speedy diagnosis and treatment, reduction of inequalities in access to care among population. The current status of cancer therapy outcome is very promising in that many cancers are treatable of appropriate therapy is begun in the right time. This indicates the need for such units at the district level since many patients who live beyond cancer would need therapy and supportive healthcare structures, which this unit is a part of. This unit collaborates with higher centres and other specialities such as gynecology, pediatrics, gastroenterology and many other, construct a board, and offers treatment in a perfectly collaborative framework, which is a glaring example of interprofessional care (Crichton, 2007). While reflecting on this framework and philosophy of this unit, I understood that my unit differs basically at the level of framework with this unit. Communication, counseling, explanation, and empathy are very important components of care in this unit. Whereas in contrast in my unit, the staff is hard pressed for time, and priorities are very critical and quite frequently immediately life threatening. There is hardly any time for communication. Moreover, in an intensive care unit, most of the patients are incapacitates to such a degree that communication is next to impossible with this patient. Although communication with the family is very essential, in most cases urgency of the issues precludes any possibility to interact with the family. Thus the nursing approach becomes very different and contrasting. While most of the patients in the oncology unit get quiet time from the nurses, except for certain cases such as postoperative patients intensive care unit nurses have barely minimal opportunity to interact with the patients, and they remain bust most of the time with different parameters that with other concerns of the patients. Interprofessional care is involved in the intensive care unit too, but the nature of that is very different from that of oncology unit. However, it must be stated that despite such differences, the environment and policies of each of these units are perfectly suitable for their goals of care and types of patients (Silvestro and Silvestro, 2008). Part II Introduction In this part of the assignment I will reflect on an adverse event that occurred in the ITU during my duty hours, in my placement. I have chosen Gibb’s model of reflection to reflect on this incident which will follow the following cycle, incident, feeling, evaluation, analysis, conclusion, and action plan, which will guide future practice. Obviously, this will provide an opportunity for learning from my experience and critical reflections on this incident. Following the presentation of the reflective account, this incidence will be debated in order to have more in-depth examination of the issues involved in such incidents and their practice implications. Scenario As a nurse, my area of work is a 9-bedded Intensive Therapy Unit in a district hospital, where 6 beds are allocated to intensive care unit patients, 3 for patients with need for high dependency care. Apart from that, we have two side rooms, one each allocated for acute patients needing isolation and for paediatric patients. Incident This event was related to a patient who was admitted to the ITU with history of brain tumor. This patient was admitted with vomiting followed by unconsciousness which eventually progressed to coma. The patient was admitted to the ITU where care was assigned to me. On initial evaluation, I found that the patient was bradycardic, his blood pressure was low in the range of 90/60 mmHg, and he appeared grossly dehydrated, perhaps due to repeated vomiting before losing consciousness. There was some nuchal rigidity, and after establishing the intravenous line and connecting all the monitors, I informed the junior resident to come, examine the patient, and provide initial instructions until the attending intensivist comes. The junior resident advised mannitol for infusion for a diagnosis of intracranial hypertension. I drew his attention to dehydration and hypotension and asked whether mannitol was indicated. The junior doctor was visibly upset and told me to do what is ordered. I informed my senior and refused to start mannitol. Reflection I felt very bad since I knew I was right, and what the doctor ordered was wrong, clearly construing a medication error. This problem must have been running for quite some time with the patient which could have limited his intakes, and added to that, the vomiting has caused considerable dehydration. As a result, the blood pressure was very low, although bradycardia might be due to intracranial hypertension which is cause of this coma. My assessment and knowledge indicated that although for the patient’s brain condition, mannitol is indicated, due to low blood pressure, mannitol is contraindicated. Mannitol is an osmotic diuretic and would lead to further dehydration in an already dehydrated patient, which might precipitate renal failure. Evaluation Obviously, this is an adverse event and can be potentially fatal and would be entirely iatrogenic. The saddest part of the whole matter was that the junior resident was taking hasty and potentially risky decision without considering all relevant facts and even without consulting a senior. Moreover, when pointed out, he was not giving a good example of collaborative practice in the ITU environment and coercing me to follow his wrong decision (Al-Ansari and Hijazi, 2006). Conclusion This was a drug related error in the intensive therapy unit committed by the physician; however, this was prevented since I was aware of the fact, and my assessment suggested that giving mannitol may be very harmful for the patient. As a result, I refused to carry out the order, and in this situation by refusing to cooperate with the junior resident, I actually demonstrated collaborative interprofessional care that is very necessary in an ITU. Action Plan Next time, I see similar situation, I would phone up the attending intensivist, inform the findings of the vital signs, and inform my senior about the scenario, so the junior resident is forced to take appropriate action. Since we work together, I hesitated to fill Adverse Event Reporting Form, which in next occasion I will fill without hesitation. Debate Since the administration of mannitol did not occur and was prevented, the potential fatality of this event is theoretical. It may be argued that it was a near miss, the adverse drug event did not occur at all. In my view, any adverse event related to medication errors is a chance phenomenon, and by definition, any error in medication process construes an adverse event irrespective of the adverse effects (Moyen et al., 2008). This was a wrong decision about medication, and it was fortunate that it could be prevented before administration. I could detect it early on and thus it could be intercepted. As a nurse, I could have more chance of making the errors, since there is no provision for system check as to whether this decision was appropriate or not. Moreover, I was the single nurse involved in the care, and without any facility for cross-check human failure factor on my part could have been lethal for the patient. This is evidently an unsafe act and is an example of mistake. This was a knowledge based error on the part of the junior resident whose perception, interpretation, and decision making did not consider all the facts relevant to the patient. Incorrect analysis and inappropriate through processes are quite frequently associated with many adverse events in a critical care scenario, where many apparently trivial factors skip attention of the care professionals, since they confer more weightage to other pressing elements of care, which also are life threatening. Although it may seem that the junior resident did not behave responsibly, it has been argued that work pressure in a busy and critical environment may cause fatigue, stress, and other issues leading to diversion of attention leading to active failures (Landrigan et al., 2004). From this point of view this incidence this type of error has been classified in the literature as a mistake, which has been defined by a knowledge-based error due to incorrect thought process or analysis. If this error would have passed, this would construe a preventable adverse event, since a reasonable planning would commission of this mistake impossible. In an ITU environment, the prevalence of high-risk patients and frequency of complex interventions may set the stage straight for such errors. Although Mannitol has not been demonstrated to be implicated frequently in ITU related errors, many other medications, specially which need complex calculations for dosage schedule have high prevalence of such errors (Boyle et al., 2006). It has been demonstrated that, such errors should be prevented at any cost. The prescriptions of such medications occur in stressful, dynamic, and complex environment where there is a high chance for all the care professionals to be fatigued, clouding of decision making capability. This would have been such as case. Moreover, the patients in ITU are treated by multiple providers, and most of the patients are most frequently in crisis. The patients should get priority in all interprofessional collaborations since in comparison to other patients elsewhere, these patients have less defense against adverse events, and additional stress my a medication that is not indicated may lead to compromise the physiological condition to a state beyond salvage (Stelfox et al., 2006). Interprofessional collaboration may be effective in reducing drug related adverse events in the ITU scenario. Nurses are more practically oriented than physicians with the patients, and by the sheer time that they spend with the patients give them an edge over other stake holders. Moreover even if the nurse may not add to a physician’s advise, it can always be a learning experience for them, which might add to their understanding about the patient which might come to help in future care processes in this and other patients. Discussing this issue with the nurse, could have made the junior resident understand the clinical condition better leading to omission of this error (Kaushal et al., 2007). This debate indicates that the environment of ITU predisposes to adverse events, and nurses should always express their opinion regarding any doubt that they might have, which may initiate a collaborative process through which some errors may be prevented when care planning is done (Durbin, 2006). If they fail to initiate the process, they must refrain from committing the error and substantiate their decision with evidence keeping the interest of the patients at a priority. They should also not hesitate to report these adverse events (Osmon et al., 2004). References Al-Ansari, MA. and Hijazi, MH., (2006). Medical errors and adverse events: focus on the intensive care unit. Clinical Intensive Care, 17:9-17. Bond, CA. and Raehl, CL., (2007). Clinical pharmacy services, pharmacy staffing, and hospital mortality rates. Pharmacotherapy, 27:481-493. Boyle, D., O'Connell, D., Platt, FW., and Albert, RK., (2006). Disclosing errors and adverse events in the intensive care unit. Crit Care Med; 34(5): 1532-7. Department of Health, (2000). The NHS cancer plan: a plan for investment, a plan for reform. London: DH, 2000 Crichton, P., (2007). Cancer Ward. BMJ; 335: 673. Durbin, CG., Jr., (2006). Team model: advocating for the optimal method of care delivery in the intensive care unit. Crit Care Med, 34(3 Suppl):S12-17. Kaushal, R., Bates, DW., Franz, C., Soukup, JR., and Rothschild, JM., (2007). Costs of adverse events in intensive care units. Crit Care Med; 35(11): 2479-83. Landrigan, CP., Rothschild, JM., Cronin, JW., Kaushal, R., Burdick, E., Katz, JT., Lilly, CM., Stone, PH., Lockley, SW., Bates, DW., Czeisler, CA., (2004). Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med, 351:1838-1848. Moyen, E., Camiré, E., and Stelfox, HT., (2008). Clinical review: Medication errors in critical care. Critical Care, 12:208; 1-7 Osmon, S., Harris, C., and Dunagan, C., (2004). Reporting of medical errors: An intensive care unit experience. Crit Care Med; 32:727–73 Silvestro, R. and Silvestro, C., (2008). Towards a model of Strategic Roster Planning and Control: an empirical study of nurse rostering practices in the UK National Health Service. Health Serv Manage Res; 21: 93 - 105. Stelfox, HT., Palmisani, S., Scurlock, C., Orav, EJ., and Bates, DW., (2006). The ‘To Err is Human’ report and the patient safety literature. Qual Saf Health Care, 15:174-178. Read More