Observational Clinical Experience and Simulation Practice - Coursework Example

Reflective essay on personal experience at the NHS Trust intensive heart unit Name Course University/College Lecturer Date Introduction High fidelity simulation is a major component in every aspect of the medical practice. The concept enables the medical team including nurses, doctors and medical students to have real time experience of a typical medical case in a manner and setting that depicts the actual human situation (Weller et al. 2012, p.594). The idea behind fidelity simulation revolves around the fact that medical cases often present in varied ways demanding varied degree of medical care. As such, it is important to take a simulated operational trial on ‘living’ and ‘breathing’ mannequins before taking the perceived operation on real human patients. The practice and debriefing helps learners to reflect on the experience and draw valuable insights that would improve their performance in a real life situation (Fanning & Ga0ba 2007, p117). Considering the significance of high fidelity simulation, this paper presents a chronological evaluation of the nursing frameworks and medical philosophies that culminated from my simulated clinical experiences as observed in the intensive coronary care unit. Particularly, this reflective evaluation focuses on the nursing skills and knowledge gained during the clinical experience at a metropolis NHS Trust facility. It also highlights the critical areas of debate in contemporary nursing practice. With that in mind, the paper will utilize the six components of the GIBBS model to present the personal reflection of the encounters and insights developed during the clinical experience to enhance my professional portfolio. In mention, GIBBS model is an ideal tool for presenting reflective insight as reiterated by Indra and Alinier (2006). The model is straight forwards and systematic as it allows the simulator to capture the vital details of the experience in a flowing and integrated manner. Besides, GIBBS model enables the practitioner to critically evaluate the entire episode of a clinical situation while drawing new insights that can reliably enhance professional performance with respect to current nursing frameworks as argued by Weller et al (2012). Practical Clinical Experience Having enjoyed the opportunity to undertake practical clinical experience, it is worth noting that the whole exposure was quite valuable in terms of knowledge development and performance enhancement. In my encounters as a nursing learner at the NHS Trust facility in the UK, it emerged that leaning can be structured and guided through simulation based settings that highly reflects typical realism as it would happen in a critical real life situation. As a result, the experience presented an array of new insights which in essence have prompted me to critical reflect upon the incidences and simulate them to my own professional portfolio. Thus, the following sections elucidate the evaluative narration of the insights drawn from the clinical experiences as applicable in the intensive heart care unit. The reality of activities in the intensive coronary care unit can be described as vibrant, concentrated, critical and highly sensitive to professional competency. Any slight mistake or simple oversights may cost life and render the case lost. For that reason, the nursing practice in every critical heart care unit requires undivided attention, commitment, clear communication as well as reliable mastery of the clinical components that goes with intensive care procedures (Thorpe 2004, p.328). It is on such grounds that I find it prudent and professionally modest to reflect upon every bit of the experience observed during the clinical practice. On arrival at the NHS Trust facility for practical experience, all the nursing and doctor students were briefed by the facility in-charge and each of us assigned to our areas of speciality interest. The allotment saw me and a couple of my colleagues taken to the intensive heart care unit. This was to be our second home for the entire period of the practical learning experience which involved a multidisciplinary learning and practice episodes. Typically, the medical practice thereof was geared towards saving patients’ life as well as enhancing professional performance of each individual in the healthcare team. The same concept underpins the whole essence of simulation-based education in nursing practice as reiterated by Indra and Alinier (2006, p.98). Whereas the learning session were varied and many cases involved actual human patients, it was always an opportunity to learn new skills and a set of practical nursing knowledge. For instance, the simulation session offered me the chance to learn from mistakes and adopt the right attitude for handling critical heart failure patients as would be expected of me in my future professional engagement. As such, the practice took a rather intensive commitment both from the instructors and the learning team. It placed me at the centre of everything, meeting with reality and correcting my competency flaws as our healthcare team took charge of every incidence that was admitted at the intensive heart care unit. Each day at the intensive coronary care unit was a learning occasion. In addition, the simulation sessions offered unparalleled platform of learning and competency improvement based on guided practice and well articulated instructional debriefings. While I learnt from a couple of mistakes, the most important thing is that the entire period greatly shaped my understanding and professional performance abilities in the line of critical heart care practice. In any case, studies show that simulation based education in nursing practice is essential in helping learners acquire basic skills and practical expertise in contemporary critical incidence care (Isenberg 2006, p.204). Reflections with Gibbs Model on Clinical Practice Reflecting on what happened at the NHS Trust intensive heart care unit, it should be noted that majority of heart failure incidences referred to the ICCU required first rated teamwork founded on the veracity of best nursing practice. Every minute counted and each decision defined the thin line between life and death as echoed by Taylor (2004). As such, the entire team endeavoured to give the very best of efforts to save the life of every patient admitted at the ICCU. The unfortunate thing is that the unit lost four lives out of the thirteen patients entrusted to the care of ICCU healthcare team. Despite the utmost level of commitment and determination, some of the lives just slipped from between our fingers in a matter of seconds. I saw them die and there was very little the team could do to save those lives. In trying to construct the order of events prior to the occurrence of the third mortality incident, the team had just concluded a simulation exercise involving an elderly patient diagnosed with breathlessness and arrhythmia following a clinical history of severe heart attack. During the simulation procedure, the instructor hardly intervened except at one point when he temporarily stooped the exercise and questioned the students’ level of clinical reasoning. Perhaps the instructor meant no offense, but it seemed that a couple of the learners felt disillusioned and a bit disorganized in handling the procedural steps of assembling the oxygen tubing. It took a little longer than usual to complete the task, and occasionally the involved learners seemed to lack specific direction on who should do what in order to speed up the process as required in the ICU (Rovner et al. 2006). The second area of professional concern that emanated from the practical simulations pertained to the timing and procedural aspect of administering frusemide. Somehow, the student was tensed and over anxious as to what would happen in the vent that the arrhythmias failed to stabilize. She administered the frusemide and then concentrated on the monitoring machine, thus forgetting to keep physical observation of the ‘patient’. The issue was clearly addressed by the senior doctors during the debriefing session in line with the conventional techniques of simulation and guided learning (Burnard 2002, p.69). The session was followed by a real case incidence involving a middle aged adult whose clinical history revealed that she had earlier been discharged from the intensive coronary care unit to the specialized HDU. In addition, the records showed that the patient had recovered and thereafter discharged but then readmitted due to another bout of heart failure just 72 hours after leaving the hospital. While undergoing first line treatment at the ICCU, the patient passed on in the hands of a multidisciplinary team of both senior medical personnel and practicing learners. The incidence occurred at a time when the hospital management was constantly emphasizing the essence of professionalism and diligence of the highest order. In line with the generally code of professional conduct in medicine and nursing practice, it is imperative to always to construct a case based on the admission records and symptomatic observation so as to give the best line of intervention that suits the situation (Wingate & Wiegand 2008). Moreover, it helps a lot to seek second opinion from experienced members of the specialty in order to make an accurate judgment prior to commencing treatment in complicated cases. The application of these vital principles coupled with the use of strong medicine and life support machines have seen many patients recover from the intensive heart care unit (Omland 2008, p.20). With these in mind, one would wonder why a patient with such familiar clinical history would die in the hands of proficient ICCU team. The fourth patient died upon arrival at the intensive heart care unit when resuscitation efforts failed to yield positive results. He was pronounced dead despite the fact that his clinical history indicated that the patient had never suffered heart failure before except that he was slightly overweight. Notwithstanding the fact that majority of the cases were successfully treated, properly managed and ultimately discharged from the intensive coronary care unit, four died in the hand of well trained specialized within a span of two weeks. Such negative outcomes could raise the questions of defaulted competency, possibility of professional malpractice or clinical complacency (Cowen & Moorhead 2011; Ekebergh 2007, p.338). In addition, learners could be discouraged and fatigued when their best efforts seems inadequate to save life even with the support of senior colleagues. To that end, there is need to explore the feelings and thoughts that culminated from such clinical experiences in the ICCU. In terms of feelings and thoughts, the whole experience generated a mixture of emotional and psychological disillusion due to the four deaths that occurred in my presence. These incidences were a big blow to my confidence and enthusiasm in the nursing profession relating to adult coronary care in the intensive care unit. Studies suggest that practice makes perfect especially when integrated in a wide scope of theoretical body of knowledge (Ely & Scott 2007). Nevertheless, the entire ordeal of three deaths in one week and another one just a week later was quite disturbing especially that almost all the patients presented with relatively familiar cardinal signs as depicted in the simulations. From a different point of view, it appears to me that either our team of student learners were over confident or we happened to be somewhat naive as to work with fair expectations of good or bad outcome. Whatever the case, I feel disenchanted for the lost of four lives on one hand and on the other hand, I feel encouraged to having taken an active role in saving the life of at least nine patients. To some extent, I feel that we needed to have gone an extra mile out of the ordinary practice to even pray for our patients. However, the lost is now irreversible in what has left me feeling that more sessions of simulation practice would be ideal to help restore my confidence and readiness to handle future cases of intensive heart care patients. It is however reassuring to bear in mind that death is a way of life and there is no guarantee that all patients would successfully recover as a result of medical intervention (Hargreaves 2004). Apart from experience description and account of feelings derived from the clinical exposure, Gibbs model of reflective learning also encompasses narrative evaluation of the good as well as the bad clinical frameworks observed Guido (2006). In that light, it is good to note that various sessions of the simulated education greatly enhance my learning endeavours at the NHS Trust. In particular, the high fidelity simulation settings provided that opportunity to implement theory in a typical medical situation while giving the learner ample chance to correct mistakes beforehand. The other important good aspect of the learning experience relates to the fact that learners closely interacted and worked with experienced members of the healthcare profession. Such approach to multidisciplinary learning improves understanding and synchronization of a wide range of professional knowhow for the betterment of healthcare service provision as postulated by Allan (2011, p.277). When put together and objectively harnessed, the concept of simulation-based education and guided practice can highly transform the path of knowledge transition from senior members of the profession to upcoming young minds in medicine and nursing fields. Apart from the fact that our trainers and senior instructors always encourage teamwork and perfection, there was lack of well articulated communication protocol. Every learner was assigned a specific duty in the team, but much of the challenges arose from weak flow of communication and messaging criteria medical operations. The hitch was observed during the simulation but real life incidences received a rather commanding lead from the senior doctors and nurses. Taking such encounters into professional perspective, it is emphasized that all instructors and learners should always embrace the importance of precise and effective communication in medical and nursing practice (Dar & Cowie 2008, p.5). The concept should begin in class throughout to high fidelity simulation settings and in reality situation practice. Having reflected upon the issues that surrounded the clinical experience, it is prudent to critically analyse the experience to derived sense and learning insights from the observations as recommended by Greyson (2012, p.426). For that reason, it is worth noting that simulation practice was very informative and transforming. The session clearly depicted realism and how various cases could present in critical heart failure scenario for which intensive care is required. Secondly, the idea of simulation debriefings is vital in practical nursing education. Many a times, learners or even senior practitioner may make mistakes due to oversight of misjudged calculations in decision making without noting such mistakes. For instance, some of us portrayed a bit of disorganization in terms of coordinating with other members of the team to assemble emergence apparatus including the very basics like oxygen tubing. If not corrected in time, some of the clinical blunders can be fatal and detrimental to the life of surviving patients. Besides, errors of omission or commission in medical practice are not justifiable and could jeopardize one’s career on grounds of negligence or professional malpractice (NMC 2008). In real life situation, there might be no chance of reversing the damage, thus the need to explore simulation and debriefing before embarking on actual human patients. The thirds analytical sense relates to interpersonal relations and proper orientation. When cases are highly simulated and the instructors seemed very hard on student practitioners, it is probable that a number of novices would tense in tying to achieve perfection. Whereas perfection is desired in any clinical setting, beginners may take to much time doing the basic procedures thereby consuming valuable time for other more demanding intervention (Wiegand & Kalowes 2007, p.419; Savoldelli et al 2005, p.947). In the case of breathlessness for example, one of the student took a longer time in setting up the oxygen tubing which in turn delayed another student from administering frusemide. It is therefore important to start with a rather friendly introduction (Angelidou 2010, p.33). This can then be followed by gradual scaling up in terms of seriousness, intensiveness, complexity and accuracy driven high fidelity simulation as learners progressively familiarize with practicality of different situations as they are on the ground. Otherwise, heightened learning environment and immediate exposure to critical incidences would be counterproductive as characterized by anxiety, tension and extreme caution for fear of probable mistakes amounting to malpractice or professional negligence. Besides, when a section of team members are less confident and uncertain of their input the team may experience significant lost of valuable time which could transcend to lose of life. Any weaknesses at any stage of intensive intervention could render the whole procedure futile because each second wasted is equivalent to an hour of life lost (Howatson 2010, 107). Losing three patients in the ICCU within a week could be indicative of either an internal problem or an external factor related to individual incidences. However, it is of paramount importance to take every practicable measure to perfect the internal parameters of functionality and clinical practice to guarantee the highest quality of intensive coronary care. For that reason, the fifth component of Gibbs model looks at what else could be done to improve the clinical experience (Suzie 2001, p.1206; Gibbs 1988). In this case, there are three measures that seems to me viable in helping reduce the rate of coronary mortality incidences at the ICCU. To begin with, the facility should deploy a system of balanced ratio of 1:4 for students to senior practitioners at any given episode of medical emergency at the intensive heart unit. This will improve the input of expertise intervention while giving the learner ample time to learn by observation and by doing without weakening the team. Furthermore, the idea of incorporating a few students among majority of senior professionals in the intensive care units improves the confidence of healthcare students as they work alongside their advanced mentors (Miranda & Best 2005, p.73). This can be differentiated from the case of general practitioner situation where one senior doctor can competently mentor a number of medical students and still deliver a proficient team of young doctors and nurses. Another thing that the management can do to enhance learning and intensive heart care is to increase the number of simulation-based educational sessions. This should be accompanied by well articulated debriefings with much emphasis on critical points of medical concern. It will be prudent to accentuate the value of clear communication and well-planned coordinated approach to intensive heart care intervention as reiterated by Tauber (2005). Besides, simulation instructors should ensure that debriefings are constructive and objective in natures as opposed to being punitive or made to appear as if the session was being utilized to settle personal vendetta. As such, the practice would inspire novices to learn from their mistakes and aspire to perfects their areas of perceived weaknesses. In terms of action plan, high fidelity simulations should be progressive and highly defined to depict a great deal of realism. Each session should be well planned and aligned with learning needs of each individual nursing of medical students. In that way, instructors and learners would have a common goal in pursing the desired learning outcomes (Ihlenfeld 2004, p.2; Minick et al. 1996, p.68). This will see to it that all learners and senior practitioners read from the same script when handing real life critical incidences. Secondly, the intensive heart unit should initiate a culture of reviewing the outcome of every incidence accomplished by members of the unit especially those that were pronounced fatal. Active participation in such post-event evaluation will enable the practitioners of the unit to re-examine the situation, generate new insights and draw relevance conclusions as to what might have gone wrong or what was competently exuded. On the contrary, the idea of regular incidence review could contribute to future alignment of the institutional code of practice for improving performance of the healthcare portfolio in intensive care unit as noted Gheorghiade and Filippatos (2005, p.15). Conclusion The clinical experience at the NHS Trust facility significantly shaped my professional understanding of the nursing practice in the intensive heart care unit. In particular, the exposure that took a multidisciplinary approach to learning was practical and professionally relevant. It incorporated competency development through high fidelity simulation and performance enhancement through reality participation. The experience provided an ideal platform for the application of various nursing frameworks and philosophies including pertinent matters relating to professional ethics, competency and the tenets of best practice in current nursing practice. References Allan, CK 2011, ‘Intensive care of the adult patient with congenital heart disease’, Progress in Cardiovascular Disease, vol.53, no.4, pp.274-80. Angelidou, D 2010, Caring for the Heart Failure Patient: Contemporary Nursing, Accessed March 16, 2013 Burnard, P 2002, Learning Human Skills: An Experiential and Reflective Guide for Nurses and Health Care Professionals, 4th Edn, Elsevier Health Sciences, New York, NY. Cowen, S & Moorhead, S 2011, Current Issues in Nursing Practice, Mosby Elsevier Publishing Group, St. Louis, MO. Dar, O & Cowie, M 2008, ‘Acute heart failure in the intensive care unit: epidemiology’, Critical Care Medicine, vol.36, no.1, pp.3-8 Ekebergh, M 2007, ‘Lifeworld-based reflection and learning: Contribution to the reflective practice in nursing and nursing education’, Reflective Practice, vol.8, no.3, pp.331-343. Ely, C & Scott, I 2007, Essential Study Skills for Nursing, Elsevier Health Sciences. Fanning, R & Gaba, DM 2007, ‘The role of debriefing in simulation-based learning’, Simulation in Healthcare, vol.2, no.2, pp.115-125 Gheorghiade, M & Filippatos, G 2005, ‘Reassessing treatment of acute heart failure syndromes: the ADHERE Registry’, European Heart Journal, vol.7, no.2, pp.13-19. Gibbs, G 1988, Learning by Doing: A guide to Teaching and Learning Methods, Further Education Unit, London. Greyson, CR 2012, ‘Right heart failure in the intensive care unit’, Current Opinion in Critical Care, vol.18, no.1, pp.424-31 Guido, W 2006, Legal and Ethical Issues in Nursing, Pearson/Prentice Hall, Upper Saddle River, NJ. Hargreaves, J 2004, ‘So how do you feel about that: Assessing reflective practice’, Nurse Education Today, vol.23, no.3, pp.196-201. Howatson, JL 2010, Reflective Practice in Nursing: Transforming Nursing Practice, Learning Matters, London. Ihlenfeld, JT 2004, ‘Applying personal reflective critical incident reviews in critical care’, Dimensions of Critical Care Nursing, vol.23, no.1, pp.1-3. Indra, J & Alinier, G 2006, ‘Reflective simulation: Enhancing the student' learning experiences through structure and guidance’, Simulation in Healthcare, vol.1, no.2, pp.98-109. Isenberg, B 2006, ‘The scope of simulation-based healthcare education’, Simulation in Healthcare, vol.1, no.2, pp.203-208 Minick, HP, O’Steen, DS & Kee, C 1996, ‘The retention of advanced cardiac life support knowledge among registered nurses’, Journal of Nursing Staff Division, vol.12, no.1, pp.66-72. Miranda, R & Best, D 2005, Transforming Practice through Clinical Education, Professional Supervision and Mentoring, Elsevier Health Sciences, Hoboken, NJ. NMC 2008, Guide on Professional Conduct: For Nursing and Midwifery Students, Accessed March 1, 2013: Omland, T 2008, ‘Advances in congestive heart failure management in the intensive care unit: B-type natriuretic peptides in evaluation of acute heart failure’, Critical Care Medicine, vol.36, no.1, pp.17-27. Rovner, A, Huynh, BC & Rich, W 2006, ‘Long-term survival in elderly patients hospitalized for heart failure: 14-year follow-up from a prospective randomized trial’, Archives of International Medicine, vol.166, no.17, pp.1892–1898. Savoldelli, GL, Naik, N & Hamstra, JS, et al 2005, ‘Barriers to the use of simulation-based education, Canadian Journal of Anesthesia, vol.52, no.1, pp. 944–950. Suzie, HK 2001, ‘Critical reflective inquiry for knowledge development in nursing practice’, Journal of Advanced Nursing, vol.29, no.5, pp.1205–1212. Tauber, I 2005, Patient Autonomy and the Ethics of Responsibility, MIT Press, Cambridge. Taylor, B 2004, Reflective practice: A guide for nurses and midwifes, Open University Press, Maidenhead. Thorpe, K 2004, ‘Reflective Practice: International and Multidisciplinary Perspectives’ Journals of Reflective Learning, vol.5, no.3, pp. 327-343. Weller, JM, Nestel, D, Marshall, SD, Brooks, M & Conn, J 2012, ‘Simulation in clinical teaching and learning’, Medical Journal of Australia, vol.196, no.9, pp.594-99 Wiegand, DL & Kalowes, PG 2007, ‘Withdrawal of cardiac medications and devices’, AACN Advanced Critical Care, vol.18, no.4, pp.415–425 Wingate, S & Wiegand, DL 2008, ‘End-of-life care in the critical care unit for patients with heart failure’, Critical Care Nurse, vol.28, no.2, pp.84-94 Read More