The Healthcare Quality Strategy for NHS Scotland (Scottish Government 2010) was a further development from ‘Better Health, Better Care’ (Scottish Government 2007). In this reflective account I wish to concentrate on the peoples priorities for the people of Scotland outlined within this document, the ultimate aim is to provide the highest quality of care. It has as their objectives that care given should be consistent, person centered, clinically effective and safe and equitable with patients receiving clear communication with regards to conditions and treatment (Scottish Government 2010). Hubley and Copeman, (2008) state communication skills are paramount in healthcare to ensure that tailored advice is delivered effectively.
This reflective account is based on an experience from my 3rd year management placement. Using Gibbs’s Reflective Model (1988) I aim to outline what occurred throughout the incident which involved providing clear communication and patient centered care and how this can be linked to the Quality Strategy in relation to the people’s priorities. This reflective model has been selected as it enables reflection on practice in a structured way allowing one to identify critical learning and development from their experience to enhance future practice (Bullman and Schutz, 2008). This scenario will consider how this incident will aid in my transition from student nurse to staff nurse.
To comply with patients’ rights to confidentiality and in accordance with the Nursing and Midwifery Council (NMC), (2010) I will use the pseudonym Mrs Wade.
This reflection involves a 78 year old lady Mrs Wade who was an inpatient on the ward for 10 days after being diagnosed as having a cerebral haemorrhage. This had left Mrs Wade with a left sided weakness and aphasic. It was during afternoon visiting and taking the routine observations I noted Mrs Wade to be scoring one on the National Early Warning Score chart (NEWS) due to reduced oxygen saturation levels of 95%. However, on comparing this with previous readings this was within the parameters of her levels taken over the previous days. . I had just moved on to the next patient when Mrs Wade’s son who was visiting asked me to come back as his mother was indicating that she had pain in her chest radiating to her left jaw. I immediately took another set of observations and Mrs Wade was now scoring 10 on the NEWS chart. I immediately went to seek guidance from my mentor who instructed me to show my findings to the doctor whilst she administered GTN spray. The doctor came and assessed Mrs Wade and instructed me to administer 5mg of morphine, 15 liters of oxygen and commence an initial 250ml bag of normal saline and if Mrs Wades BP had still not risen I was to continue with a second bag, whilst he arranged an ECG and chest X-ray.
At this time my mentor advised me that I was to take control of the situation and she would assist me if I required help.
My initial feeling was one of complete fear. However, I felt within seconds I regained my composure and I took control of the situation. I was relieved that training had indeed prepared me for a situation like this where I automatically began to use the ABCDE assessment (Jevon, 2010). I was also anxious but relieved in being able to communicate effectively with the doctor, my mentor, team members and Mrs Wades son. I felt I was able to handover clearly and concisely. I feel that I was able to do this as I had been dealing with Mrs Wade on each of my days on duty over the previous two weeks.
The negative aspect from this incident is how a patient in one’s care can deteriorate so rapidly. However, in the case of Mrs Wade I repeatedly asked myself if I had missed some signs and this incident could have been avoided.
The positive aspect of this incident was that Mrs Wade’s deterioration had been caught instantly. I had the opportunity to discuss this incident with my mentor. At this time she praised me on how I had taken control of the situation in a calm and professional manner. I was competent when communicating with team explaining the background to Mrs Wade’s condition thus aiding an effective result in Mrs Wade’s condition being stabilized. It was also reiterated that this was an unavoidable situation and there was nothing I could have done differently to alter the outcome.
The people’s priorities outlined by The Healthcare Quality Strategy for NHS Scotland (Scottish Government 2010) and in caring for Mrs Wade on reflection I wanted to be establishing if I covered all areas and were I could improve. The priorities are to be caring and compassionate, have clear communication skills and be able to explain conditions and treatment have effective collaboration between clinicians, patients and others; A clean and safe care environment; Continuity of care; and Clinical excellence.
Jones (2012) advocates that it is essential in nursing to have good communication skills. This is also advocated by Dougherty and Lister (2008) who states that communication is an integral part of maintaining a high quality of record keeping which is regarded as a vital standard of practice by the NMC (2008). Communication and written care records aid to establish a continuity of care.
As I found Mrs Wade to have deteriorated it is stated by Hill (2012) that the outcome for a deteriorating patient is dependent on the knowledge and skills of the person or persons who find and care for them and the recognition of the acutely ill. As I was the first responder and having called for help I used my mentor and other team members to assist myself in assessing and stabilizing Mrs Wades vital signs. At this time I also asked my colleague to ensure Mrs Wades son was taken to the day room and someone would come to speak with him as soon as possible. This is fundamental to patient centered-care to communicate openly and honestly with all concerned (Brooker and Nicol, 2008).
I used ABCDE approach recommended by Jevons (2010) and The Resuscitation Council (2010). The ABCDE approach is a systematic tool were by you assess your patient and deal with the life threatening situations first. During this time I endeavored to reassure Mrs Wade at all times through effective communication skills (Scottish Government 2010, p6). Although Mrs Wade was aphasic her airways were patent and no obstruction was noted. Therefore it was acceptable to move on to B (breathing) within the ABCDE. Patients presenting with Myocardial Infarction (MI) or Pulmonary Embolism can show an increased respiratory rate. As Mrs Wade’s respiratory rate had increased and was desaturating she was commenced on high flow oxygen (O’Driscoll 2008).
Mrs Wades heart rate 109 beats per minute and on palpating the radial pulse it was fast but strong and regular. Mrs Wade’s blood pressure had decreased to 89/56 therefore commenced on a 250ml bag of saline. Urine output was already being monitored and IV access was in place.
The next stage is Disability. AVPU is a tool used to assess levels of consciousness within acutely ill patients (Jevon 2009b). This is a quick assessment tool within the NEWS and ABCDE approach; However, NICE 2007 recommend the use of the Glasgow Coma Scale to give a full assessment. At this stage my mentor checked blood glucose levels. Blood glucose levels can rise in acutely ill patients due to a result of sympathetic activation (Floras 2009). However at this stage they were within the normal range of 4-7mmol/L (Diabetes UK 2013).
During this situation to communicate my findings I used a systematic approach based on situation, background, assessment and recommendation (SBAR) tool to share the necessary information effectively and concisely (Pope et al 2009).
In the emergency situation with Mrs Wade this highlights the involvement of nurses in collaboration with other healthcare professionals and coordinate all resources to provided effective timely care. I feel that I took on the role as lead nurse in this situation I knew it was my responsibility as a student nurse in my final placement to show that I could take control of this situation, whilst in the knowledge knowing I still had my mentor if I felt I required assistance. I felt I had to show I could effectively delegate, show leadership qualities, prioritise the care of Mrs Wade whilst being able to communicate effectively in a challenging situation.
The outcome was positive in the aspect that a holistic approach to Mrs Wade’s condition was taken in accordance with The Scottish Government’s Initiative (2010) on patient centered care. I felt empowered by incorporating the use of the SBAR framework in effective collaboration with the multidisciplinary team aided clear communicating in accordance with The Scottish Government (2010). This resulted in a consistent continuity of care for Mrs Wade.
A result of this significant event was that it gave me the experience of dealing with an emergency situation. As stated by Scheffer and Rubenfeld (2000) “Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge
. I was also given the opportunity afterwards to reflect on my role and the role each member of the team took in this situation and where appropriate to remove oneself from a situation
I feel for future development I will take responsibility for my own learning in areas where I felt I lacked knowledge. In this situation I had assumed that Mrs Wade was having an MI were in fact it was a PE. I believe that in the future and with more experience I may be able to differentiate and although I would not expect to be an expert I would be better equipped to deal with similar situations in the future (RCN 2013). I was particularly anxious as I know I have no experience in Basic Life Support other than what I had learned at university and knowing this woman was for resuscitation I was anxious that this situation may occur.
On reflection of my own experience and in using this to aid in my transition from student nurse to staff nurse I feel I have enhanced my own knowledge on basic life support outlined by the British Resuscitation Council UK (2010) cited by (Dougherty and Lister, 2011) whilst reiterating the importance of good communication skills. It also highlighted the importance of having the confidence to acknowledge one’s own lack of knowledge and be able to admit to this and where to seek guidance to ensure that the correct protocol is followed to ensure patient safety at all times and to provide continuity of care. I feel that the care given to this patient is in line with the initiative of The Scottish Government’s Healthcare Quality Strategy for Scotland (2010).
In relation to how this incident reflects on my transition it shows that on graduating as a staff nurse I will immediately assume the role which includes leadership, delegation and supervision. Once NMC registered, a host of expectations are placed upon you. The RCN (2010) reported that newly qualified staff nurses feel unprepared and overwhelmed by their new responsibilities, making the period of transition very stressful rather than exciting and truly enjoyable. However, I hope to overcome these feelings by immersing myself in the knowledge that I will adhere to all policies and guideline by The Scottish Government (2010) to ensure the best possible care and service to all.
Hill Karen Critical to Care: Improving the Care to the Acutely Ill and Deteriorating Patient
Karen Hill, Acuity Practice Development Matron
Southampton University Hospital NHS Trust
May 2010 – January 2011
Jones, A 2012, ‘The foundation of good nursing practice: effective communication’,
Journal Of Renal Nursing
, 4, 1, pp. 37-41, CINAHL Plus with Full Text, EBSCO
, viewed 27 July 2014.
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