The Association of Operating Department practitioners (AODP, 2003) Code of Conduct states each registered ODP shall:
Carry out all roles and responsibilities in such a way as to promote and protect the rights and health of patients (No 2).
Practitioners appear to have taken this to mean acting as the patient's advocate. The Oxford Student’s Dictionary (2001) defines an advocate as "a person who supports or speaks in favour of somebody." The concept of theatre practitioners acting as the patients advocate continues to be the subject of debate but it is personally felt that the practitioner involved in the incident demonstrated a good example of how practitioners can with knowledge of the patients wishes, act as the patients advocate.
Practitioners are often led to believe that they should act as the patients advocate (Baldwin, 2003). During the first year of the ODP course, students within the authors class generally accepted this concept and would often be heard to say, "we are the patient's advocate". What is now personally recognised is that to act as patients advocate an individual has to understand what the patient's feelings are, to hear what the patient is really saying and to have the necessary knowledge and understanding to represent the individual. The practitioner also has to be accountable for their actions and has to be able to defend their decisions (Hewitt, 2002).
The patient had been unable to express her feelings and concerns to the anaesthetist so the practitioner had spoken for her. The practitioner emphasised the patients wishes challenging the decision whilst remaining respectful of the anaesthetist, his reasoning and knowledge of anaesthetic techniques. Good communication skills and the ability to defend the patient without causing unnecessary conflict were demonstrated by the practitioner involved in the incident and are felt vital when acting as an advocate for any individual (Hewitt, 2002).
Discussing the situation with the practitioner after the incident she admitted that although she agreed with the anaesthetist, she was also aware that as the person the patient had confided in, she had a duty to act upon the wishes of the patient. The practitioner's initial action had been to try and help the patient understand why the anaesthetist considered the risks of a spinal anaesthetic to be less than that of a general anaesthetic. It was only when the patient continued to reinforce what she was saying and refused to discuss the issue in any detail the practitioner guided the anaesthetist to the patients wishes.
By remaining calm, reassuring the patient by holding her hand and respecting the anaesthetists knowledge and expertise the practitioner was able to ensure the patient's decision regarding her care was acted upon, without causing unnecessary conflict or making the patient or anaesthetist feel uncomfortable.
The Patients Charter (1995) informs patients that they have the right to have their proposed treatment, the risks involved and any alternatives clearly explained before they decide whether to agree to it.
Not having heard the initial discussion between the patient and anaesthetist it is not known whether this route was taken. The patient was obviously anxious, in pain and distressed so it is possible she did not take in all the information given to her during the initial discussion. Hind and Wicker (2000, p124) state, "disclosure of information is not enough if the patient fails to understand."
Whether the patient would have made the same decision if she had not been involved in the emergency situation and was calm and pain free is not known. Hind and Wicker (2000, p124) state,
“Patients who require surgery are vulnerable to the suggestion of well-meaning healthcare professionals who may be clear about what needs to be done”.
The patient seemed to be vulnerable but felt that the practitioner was someone who could help her. Exactly why this was is also not known but a personal thought when reflecting on the incident was that after introducing herself by name the practitioner immediately sought the patient’s permission to having a student with her. By doing this she had involved the patient in a decision concerning her care and had demonstrated to the patient that she had the right to make a choice (Department of Health, 2000).
Doctors, nurses and ODP's are all accountable for their practice (AODP, 2003). Each of the two individuals involved in the incident acted in a way, which they felt were in the patient's best interest. The anaesthetist had made his decision by deciding that the risks involved to the patient and baby from a spinal anaesthetic were less than for a general anaesthetic (Appendix 6). The practitioner having been informed by the patient that she did not want a spinal anaesthetic informed the anaesthetist that it would be against the patients will. As Hughes (2002 a, P. 99) states,
“Practitioners are not exempt from accountability because they are acting on the instructions of anaesthetists or surgeons and should be encouraged to challenge decisions and requests if these instructions seem improper”.
What was learnt and how this will be used in future practice
Throughout the Diploma in Operating Department Practice the emphasis has always been that the patient is the focus for perioperative care. Reflecting on the critical incident highlighted how important and sometimes difficult this can be. Despite the organisation of equipment, the following of procedures and the rush that came with the emergency situation the practitioner ensured the patient remained the focus of the care she provided. Within minutes of meeting the patient the practitioner had developed rapport enabling the patient to confide in her. She acted in a way that allowed the patient to feel like she was involved in the decision making of her care and helped to guide the anaesthetist to understand what the patient's wishes were.
Theatre practitioners have often complained that individualised care planning could be greatly improved if they were able to undertake preoperative visiting (Carter & Evans, 1996). This incident demonstrated that it is the ability to really listen to what the patient is saying, clarifying that they have understood what was said and acting on the information gained that really helps provide effective care. Although there is often only a short time between the practitioner meeting the patient and the patient becoming unconscious through being anaesthetised it is time which is vitally important in clarifying whether the patient fully understands the procedure they have consented to (Department of Health, 2001). The incident highlighted that patients may consent to procedure without fully understanding them or because they feel they are not being given a choice. By simply asking the patient if they understand what it is they have consented to and whether they are happy with the plan of care gives the patient the opportunity to raise any concerns and the practitioner the knowledge that the patient is fully informed.
Working in the theatre environment means working as part of a multiprofessional team. Campbell (1999) suggested the essence of theatre nursing is teamwork and Harris (1996) suggests that teams can achieve together what individuals could never achieve alone. By working together and showing respect for each other, the anaesthetist and practitioner ensured the patient received their chosen care. It is individuals who make up a team and each individual will have their own ideas, values and beliefs. By being able to respect and listen to what each individual in the team is saying conflict can be avoided and each individual's contribution is valued.
Although it is personally felt as a student ODP sufficient knowledge and experience is necessary to make such an effective decision. The experience gained from the incident will be taken into account and reflected on in future practice. Benner (1984, cited by Hughes, 2002 b, P. 214) states,
“A nurse is only able to make conscious and responsible decisions if these are based on experience”
even though the practitioners involved in this incident are not nurses, the author feels that this is relevant to all health care professionals. When learning the theory surrounding issues of accountability and advocacy it can sometimes be difficult to relate them to practice. Observing the practitioner in the incident helped reinforce how important it is for practitioners to act in the interest of patients and the necessity of being able to justify any action or omission in the course of professional practice. Without the confidence to delay what was an emergency procedure, even though it was only for a few minutes, the practitioner might possibly have had to justify not only to the patient but also to herself and her profession why she had failed to act on the information the patient had given her (AODP, 2003).
Conclusion
Although this assignment has focused on a critical incident it is not the incident itself but the process of reflecting on it that has facilitated further learning, challenged practice and enhanced the delivery of future care.
Working within the perioperative care environment and working with the individuals who make up the multiprofessional team can be demanding. When this is added to the constant changes surrounding healthcare, increasing advances in technology and the complexity of procedures it can be easy to forget that the patient has the right to be involved in planning their individualised care.
Although the theory surrounding the issues discussed in this assignment have been taught both at university and in the clinical placement the process of reflective practice has helped link theory to practice and change personal thinking and actions for the future.
By continuing to reflect on experiences and continuing to look for improved ways of delivering care it is hoped that the issues of communication, teamwork, accountability and advocacy will never be forgotten when planning and delivering the high standard of planned, individualised care that every patient deserves.
References
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Carter, L., Evans, T. (1996). Preoperative visiting: a role for theatre nurses. British Journal of Nursing. 5(4) 204-207
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Collins, C., Gurung, A. (1998). Anaesthesia for Caesarean Section. Update in Anaesthesia 9 7-17
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Appendix 1
Advantages of Spinal Anaesthesia
Cost. The costs are minimal.
Patient satisfaction. The majority of patients are happy with a spinal anaesthesia.
Respiratory disease. Spinal anaesthesia produces few adverse effects on the respiratory system.
Patent airway. Airway is not compromised; there is reduced risk of obstruction or aspiration
.
Diabetic patients. Little risk. Diabetic patients can usually return to their normal food and insulin regime soon after surgery
.
Muscle relaxation. Spinal anaesthesia provides excellent muscle relaxation.
Bleeding. Blood loss during operation is less than when the same operation is done under general anaesthesia.
Splanchnic blood flow. Because it increases blood flow to the gut, spinal anaesthesia may reduce the incidence of anastomotic dehiscence.
Visceral tone. The bowel is contracted during spinal anaesthesia and sphincters are relaxed although peristalsis continues. Normal gut function rapidly returns following surgery.
Coagulation. Post-operative deep vein thromboses and pulmonary emboli are less common following spinal anaesthesia.
(Casey, 2000)
Appendix 2
Disadvantages of Spinal Anaesthesia
Difficult. To find the dural space and occasionally, impossible to obtain CSF.
Hypotension. may occur with higher blocks.
Patient satisfaction. Some patients are not psychologically suited to be awake.
Time. Even if a long-acting local anaesthetic is used, a spinal anaethetic is not suitable for surgery lasting longer than approximately 2 hours.
Pressure Areas. Patients find lying on an operating table for long periods uncomfortable.
Infection. there is a risk of introducing infection into the sub-arachnoid space.
Headache. A postural headache may occur
(Casey, 2000)
Appendix 3
Monitoring
- Non-Invasive Blood Pressure
- Electric Cardio Gram (ECG)
- Pulse oximetry
The above is what is described as routine monitoring equipment as set down by the Royal College of Anaesthetists (The Royal College of Anaesthetists, 2000).
Appendix 4
Patient Positioning
Where the spinal cords ends at level L2 in adults Dural puncture above these levels is associated with a slight risk of damaging the spinal cord and is best avoided (Casey, 2000).
Hence why good patient positioning is important. As there are important structures that the needle will pierce before reaching the CSF (figure 1). A good landmark to remember is the line joining the top of the iliac crests which is at L4 to L5 (Casey, 2000) so positioning the patient so the anaesthetist can clearly see this landmark is important so that it opens up the vertebrae (figure 2).
Spinal anaesthesia is most easily performed when the patient is sitting (Ingils, Daniel, McGrady, 1995). (Figure 3)
Appendix 5
Main Reasons for having a spinal anaesthesia to general anaesthesia for a caesarean section are:
- Babies born having spinal or epidural anaesthesia may be more alert and less sedated as they have not received any general anaesthetic agents through the placental circulation.
- The patient’s airway is not compromised.
- Reduced risk of aspiration which could cause Mcndelson’s syndrome
- Opportunity to be awake during delivery.
- Opportunity of being able to breast feed their child as soon as they deliver.
(Casey, 2000)
Appendix 6
General Anaesthetic Risks
Pregnant women are at more risk of hypoxia and are more difficult to oxygenate than non-pregnant women because of the respiratory changes that occur, pregnant women use more oxygen because of their high metabolic rate. The situation can be made worse by other factors for example obesity and interstitial fluid retention all make it harder to visualise the larynx for successful intubation.
Even though fluid retention is a common feature in pregnancy, a more frequent problem is the risk of hypovolaemia which can be due to obstetric complications or very commonly prolonged labour leading to exhaustion. A pregnant women is at greater risk of pulmonary acid aspiration, as regurgitation of acidic stomach contents is more likely, 30mls of acid aspiration of stomach contents can lead to catastrophic aspiration pneumonitis (Mendelson’s syndrome). The general precautions for this are to give IV ranitidine as soon as they decide to operate and Sodium Citrate orally immediately pre op. the other precaution is to always use a rapid sequence induction with pre-oxygenation and drugs given in bolus injections.
The other problem with general anaesthetic is that there is moderate reduction in psyedocholinesterase in pregnant women compared to the non-pregnant women, this is notable post-partum. Although suxamethonium works the same it’s effects may be prolonged. Also some of the drugs used in a general anaesthetic may effect the fetus, anaesthetic drugs cross the placenta and can therefore a deep anaesthetic would sedate the baby and risk birth apnoea, so narcotics or sedatives should not be given to the mother before delivery.
(Collins & Gurung, 1998)
