Nursing skills at a vascular surgery unit

University Degree Subjects allied to Medicine

Principles of care delivery NM1505 Steve Farley 09/03. 0312768

This account aims to reflect on the skills of a nurse, observed at a vascular surgery unit. It will focus on the principles of the delivery of care and will give an understanding of the tools used to clearly establish the needs of a patient.

Attention will be given to the style of introduction and the effective use of non- verbal communication skills. Observations will be discussed from the event and justification of its learning will be supported by extensive, and documented research.

It will conclude with a reflective account and critical assessment of the shortcomings of the interview, and provide supporting recommendations in an attempt for excellence.

In order to respect the patient’s confidentiality and comply with the Nursing and Midwifery council, code of conduct, the precise location and name of the patient has been changed (Nursing and Midwifery Council 2002).

Therefore the patient will be called, Mrs Singh.

For reflection a model discussed by (Gibbs1988), cited in (Burns and Bulman 2000), will be followed, as it gives an opportunity to produce a structured account of the discussion, and clearly shows that true reflection in practise has occurred during its research.

The needs of the patient are the primary objective, when considering a plan of care for the continuation of good health and well-being. Nurses must be made aware that inadequate formal procedures to assess patients' underlying medical problems have been blamed as a contributing factor in around 70% of preoperative deaths, as reported by (Hoile 2002).

The findings of the National Confidential Enquiry into Preoperative Deaths (NCEPOD), was based on reports of deaths within 3 days of a surgical intervention, and follows the patient's journey through an illness and the delivery of hospital care.

Consideration for the psychological, sociological or spiritual needs of the patient, become equally important. And a holistic approach to care, not only provides a clear and specific set of guidelines and objectives, but also tailors the care for the individual. It is been proven to enhance recovery and provide the service user with a seamless approach to care and recovery. (Kozier Erb,Blais,Wilkinson 1998)

Commencing the process, needs the patient to be open in their response at the initial interview stage. And requires a process of two-way communication between the patient and the care provider. This can only start to take place once a genuine rapport is established between them both. This rapport cannot be demanded and requires skills, from the nurse to make the patient feel at ease by using an appropriate manor of verbal, and non-verbal, communication.

Mrs Singh is an Asian lady, of 53 years. She has been referred to the surgical team from her GP suffering from an askemic right toe. It was the observation of the consultant that the toe was in fact, gangrenous, and further investigations, would be required to establish the extent of the condition. The results of these tests may result, in a need to remove the toe. After her discussion with the consultant for consent she accepted his diagnosis, and seemed to be clear of the consequence and severity of her condition. This reflection takes its observation followed by the nurse.

Although the doctor had obtained consent, studies have shown that a patient may be concerned or uncertain about their treatment and turn to a nurse for clarification and advise (Dickinson, Hargie, and Morrow 1997).

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It had become apparent to the staff nurse, that Mrs Singh was starting to become distressed, and was complaining rather a lot about what seemed to be minor issues. She was not happy with being in a public ward. She also complained that her foot required dressing once again. When it was apparent, that the infected area was dressed well, and did not require any further attention at that stage. English was not Mrs Singh first language. She was a little difficult to understand especially when she was upset. Some staff made an assumption, that she was confused, due to her medical condition, and that was the reason for her behaviour. She may have been considered a problem patient, as described by (Stockwell 1972).

Before meeting Mrs Singh, the staff nurse made sure that she had the correct documentation needed for the discussion. She chose her timing to ensure that Mrs Singh had no visitors, and the ward was quite so there would be minimal disruption. She ensured that she had adequate time to spend with her patient. She also ensured that Mrs Singh was dressed and sitting on the chair next to her bed. This created an environment that was as comfortable as possible.

To minimise any risk of cross contamination from others common practise is to wash hands as discussed by (Larson 1995), before meeting another patient.

She then asked Mrs Singh if she would kindly permit a student nurse to be present during the discussion, in compliance with the Nursing and Midwifery code of conduct (2002). She further advised her patient, that all information obtained would remain confidential and a record of the discussion would be made. This complied with the (Data protection act 1988). Mrs Singh obliged the request and the staff nurse introduced herself and the student.

The staff nurse placed a chair a right angles to her patient, within a comfortable distance between them, not too close to be overpowering and not to distant to enable a discussion at a quite mannerism. Proximity was discussed by (Hall 1969) and cited in (Kozier Erb, Blais, and Wilkinson1998)

She then asked Mrs Singh what she would like to be known as, (Holland and Hogg 2001) reported that nurses must not assume that it is everyone wises to be known by their first or last name. This clarification promotes friendliness as well as professionalism.

It was noted that the nurse remained at the same level as her patient at all times. She leant slightly forward in her chair, maintained an open posture and remained relaxed through the whole period of discussion. These characteristics have been well explained by (Farley 1992) and have been proven to facilitate communication and focus on the patients concerns.

The staff nurse clarified the need for the discussion, as to make a base line assessment of where we were at this stage of her procedure, and also to address some of the concerns she was facing. Once Mrs Singh accepted clarifications for the need for discussion the assessment began.

A brief period of general talk commenced, this was used to break the ice and create some warmth to the interview. This introductory phase is also referred to as the orientation or pre helping phase. The three stages of this introduction are, opening the relationship, clarifying the problem and structuring and formulating the contract. (Brammer 1988).

Open questions were presented to clarify Mrs Singh’s feelings and concerns. Areas that raised some concerns were justified and finalised before moving onto other issues. As the interview progressed, Mrs Singh at one stage become a little upset, the staff nurse was quick to offer her hand to the patient. This observation has also been noted from the work of (Morse, Bottoroff, Anderson,,O’Brien, and Solberg,.1992), they commented that therapeutic empathy is a learned, conscious way of responding in which the nurse uses various communications techniques to convey understanding of their client’s reality. The writings of (Bottoroff et all 1992) were also supported when it was observed how, the staff nurse, clearly changed her vocal tone to a pitch lower and showed empathy and accepted that it was natural to feel upset and that she would be here to help her through her concerns.

On conclusion of her questions the nurse asked Mrs Singh if she was happy with the discussion and asked her if she would like to ask any further questions about her treatment. As there where no questions forthcoming the nurse very briefly clarified the key points of the discussion once again. It was then evident that she returned to the same general conversation that she started the interview with, this saw to bring the discussion to a completed close. She once again thanked Mrs Singh for the discussion, and reminded her of her name.

After leaving the patient she once again washed her hands. (Larson 1995)

The interview went very well and it was comforting to see how effective the nurse had been. All information required was obtained, and the patient was left far better informed of her procedure. The staff nurse was able to make observations as to the psychological state of her patient as well as her biological condition, she clarified areas of concerns without dismissing the patient’s obvious distress. At all times a professional approach was maintained and a genuine two-way communication was established.

The concerns for a dressing were justified, and it was found that she wanted the dressing secured with tape to prevent her from seeing her gangrenous toe, which was giving some psychological distress for her.

Other concerns where based on her religious beliefs and a spiritual package of care was adopted.

The conclusion of the interview demonstrated that a structured model of nursing had taken place following the principles of, Assessment, Planning ,Implementation and Evaluation as discussed by (Arets and Morle 1995)

This nursing process is a set standard of guidelines that nurses work to in order to provide the best possible care for the patient (McFarline and Castledine, 1982). They further stated that this problem solving approach to patient care ensures that all patients’ care is personalised to their specific needs

There were some parts of the intervention that may have been altered to make the somewhat flawless, discussion more pleasant for the patient. Although every effort was made to protect Mrs Singh’s confidentially, other patients were close by and it was apparent that some patients were interested in what was happening with another patient close by. Unfortunately it was not possible to conduct the discussion in absolute privacy due to the operational demands on the ward at that stage.

Mrs Singh’s first language was not English, and although she had a good command of the language an interpreter may have seen to be appropriate. People who are suffering from illness or distress may be more comfortable expressing themselves in their mother tongue. (Robinson 1998).

There were some questions that appeared to have been duplicated during her stay and better administration could of benefited all parties ensuring that already known details such as current medication taken, date of birth etc were previously reported. The National Service Frameworks, recommends a single assessment process and its studies are recorded by the (Department of Health 2002)

It is always important that accurate and precise information is gained from the patient; the skills used to obtain them require practise, observation and continual learning.

Each patient is an individual and an individualistic approach to each situation is required. One size does not fit all and the nurse should be conscious of factors that influence their patient’s condition and responses other than the pure biological state.

The modern nurse needs to be a reflective practitioner and consistently strive for perfection. True patient care comes not only from the deontological approaches or the dedicated caring attitude that a nurse would expect to follow but also from a structured and professional approach for the provision of care for their patients.

I have learnt by instruction, practical placement and the reflective approach to my development, that the patient is always a unique quality. As a nurse the duty to ensure biological well being is not enough, care starts from the very first introduction to the patient, first impressions are always difficult to change, so care must be taken to create a genuine warmth from the nurse to patient relationship. The use of non-verbal communication is vital and the nurse must look for non-verbal clues from his patient as well as the response s that he gets from them.

Diagnosis and prognosis of care can be dramatically affected from the findings of the nurse. I have learnt the benefits of holistic approaches from previous models, but this module has clarified the importance for attention to detail from the patient’s observations. Ethnic and cultural implications should be given consideration at all times.

I have further learnt not to expect the obvious and to suppose that patients are usually upset due to general conditions. Being placed in an unfamiliar environment, such as a ward creates its own dilemmas. Issues that may seem trivial may appear to have little consequence to the treatment of the patient, in the absence for our deeper interpretation of their concerns.

Effective listening and attentive listening skills are vital at all times, as is the ability to be genuine with your patient. To take an objective view to the situation and try and put myself in their shoes will benefit my development.

I have benefited from experiencing clarity and simplicity in the approach of my mentor, and aim to develop my skills, through further theoretical and practical settings to complement my experiences.

I have been fortunate to have been given the opportunity to see many patients and nurses discussions and the provision and delivery of care has been of the highest standard at all times. Although the character of the individual conducting the interview should never aim to be removed, the consistent approach to patient centred holistic care is observed to be common throughout my placement.

Word Count 2190.

Steve Farley.

April 2004.

0903/0312768

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