Reflective practice has become a key aspect of nursing, and of other contemporary professional practices around the world (Ford, 2012). Reflective practice helps one to learn “through and from an experience,” to enhance self and practice (Finlay, 2008; Jasper, 2013). This reflection, therefore, focuses on my experience as a first-year nursing student, with a service user, in an endoscopy unit. I will use the Gibbs cycle, a guide to self-evaluation and to improving care in a work setting (Ford, 2012), as the key reflective model covering the six steps: description, feelings, evaluation, analysis, conclusion, and action plan (Gibbs, 1988). The Gibbs reflective cycle (Priestly, 2015) offers very precise steps that guide the learner’s thinking in critical situations in and outside of the work environment, to decide what changes he or she needs to make in the future (Zeichner and Liston, 1996; Priestly, 2015).
An experience I will reflect on involves a female service user aged 89. Due to confidentiality, I have given her a pseudo name, Mrs Doe. On reading her medical history on file, we found out that Mrs Doe was admitted to the endoscopy unit because she was having difficulties keeping food down, after meals and was generally feeling unwell. We also discovered that Mrs, Doe had previously had malignant tumours in her stomach, in 2011 and had received Chemotherapy treatment.
Thus, this time, Mrs Doe was scheduled to undergo a duo procedure – colonoscopy and gastroscopy. Gastroscopy examines the oesophagus, stomach, duodenum, the first portion of the small intestine, using a thin, flexible tube, called the upper endoscope with a camera at the tip. A Colonoscopy examines the large intestine, and the more distant parts of the stomach using a fibre optic camera attached to a malleable tube inserted through the anus.”
The surgery was prepared, with all necessary equipment in place, for the procedure to be done that afternoon, And in line with hospital policy; a team briefing was done prior to the patient being brought into surgery. A WHO endoscopy safety checklist with questions about the patient’s name, known allergies etc. was completed, and signed by a circulating nurse. It was important to have these checks done to avoid making the mistake of having a wrong patient for the wrong procedure or the other way round. “Nurses have a duty of care to keep clear and accurate records” (Kozier et al., 2012, p.217).
I also noticed, the clinician, emphasised, before carrying out the medical procedure that if the patient was on any blood thinners such as Warfarin, then the procedure would have to be cancelled, because of the potential of severe bleeding during the procedure. After the team briefing, the staff nurse brought Mrs Doe into the examination room, introduced her to the rest of the team, after which she asked if the service user would be comfortable with me, a student, being present while she was undergoing the procedure. Mrs Doe consented. Obviously, she had had this procedure done in the past but still, I noticed from her non-verbal communication that she was very anxious.
As a student, I was the least experienced on the team. I was in the early part of my placement in this unit. However, I had learned from both my mentors and other healthcare professionals, to use distraction techniques, to calm a service user down. But I was gripped with anxiety, especially after reading on file, that seven years prior to this, Mrs Doe had had this same procedure done and was diagnosed with bowel cancer. I felt inadequate to try to alleviate the patient’s unspoken fear. On reflection, I should have tried to, especially when some on the team kept speaking about Mrs Doe, in the third person, apparently because of her age. I remained calm and professional throughout the process but I could have done more to help Mrs Doe to cope emotionally and mentally even at the end when the results from the colonoscopy and gastroscopy showed that she again had cancer.
Looking back, the above experience brought to the fore both positive and negative aspects that have enhanced how I respond to service users, and to my practice, currently and in the future. As a student nurse, I must always prioritise the interests of the service user. Regardless of the pressure of the work situation, the service user must always be at the centre of my practice.
Being part of a multidisciplinary team means that I was equally responsible for how the service user was being looked after, throughout the procedure. “Looking after older people is never easy” (Rozzette, 2018). At 89, Mrs Doe was frail, and with her hearing not perfect, the health care team attending to her had to repeat some of the information they were giving to her, several times, and it was obviously stressful to both the patient and the physicians.
Besides, the service user needs to be treated with respect and to be helped to make independent decisions by the healthcare providers, while undergoing treatment (CQC, 2014). My task on this occasion was to provide support to the senior health care providers on the team; to see to it that Mrs Doe was made to feel relaxed and to generally ensure that all her fears where alleviated, for the entire duration of the medical investigation. However, I think that I was not equal to the task on the day. I let anxiety have the best of me instead. However, I think that the team briefing should have included information on how to communicate effectively with an aged service user. This would have greatly augmented my practice as a student nurse, in that situation, and going forward.
An upsurge in life expectancy in the U.K means that more people that are elderly are now three times more likely to be admitted in hospitals, than those below the age of 14, for example (Smith, 2010). Studies have shown that healthcare professionals tend to provide more information to young people than to the elderly. A recent study (Mitchell, 2016) found that huge patient turnovers in day surgery meant that interactions and/or communication with elderly patients were minimal. However, poor communication can adversely affect the quality of care for the aged. Therefore, this facet of practice requires extra care (Robinson II, White Jr & Houchins, 2006).
One of the key aspects of patient-centred care and “team-based-healthcare” (Babiker et al., 2014) is effective information sharing. The team needs to know a patient’s preferences, and for those whose illness has relapsed, like Mrs Doe, their fears, and other illnesses that come with age such as loss of hearing, dementia etc. All this needs doing before carrying out a clinical procedure (Regis College, 2018).
Informal interactions with physicians help patients to cope better with surgical procedures; they provide a platform for allaying fears. However, healthcare providers in day surgeries do not spend enough time with patients to be able to dispel any fears they may have (Mitchell, 2012).
Nevertheless, knowing how to manage the interactive responses of elderly patients as part of reflective practice in nursing, and both verbal and non-verbal communication skills, are important to promoting their health (Kozier et al., 2012, p. 45). Besides, nurses are the patients’ advocate; they speak up for those who cannot easily express themselves. The NHS believes in treating all patients with respect.
Where language, cultural or social barriers may arise, family members, community support groups, and interpreters may be invited to help ease communication thus helping both patient and healthcare professional to arrive at informed decisions. According to the NMC (2015) professional code of conduction, “nursing associates must avoid making assumptions and recognise patient diversity and autonomy.” Consequently, my experience with Mrs Doe who was visibly restless at the thought of the procedure she was scheduled to undergo and yet the professional healthcare team spoke about in the third person, fell far short of this code.
Mrs Doe’s case failed to take into consideration the fact that she was visibly worried and therefore needed especially those on the team who had previous experience dealing with elderly patients, to make full use of both verbal and non-verbal communication skills to alleviate her concerns. The patient was in a vulnerable position and needed all the compassion she could get at this time; she needed full eye contact, a listening ear and enough time between discussions, to digest what she had heard (Kozier et al., 2012, p. 45).
Furthermore, the nursing profession espouses the 6cs namely, care, compassion, competence, communication, courage and commitment. These principles and practices undergird healthcare delivery within the NHS. The reason for introducing these principles was to ensure that a patient was always the central focus of “policy and practice” (DOH, 2012; Dewar & Nolan, 2013).
When I was assigned to the endoscopy unit, my aim was to learn how healthcare staff on a unit with such a high turnover cope and engage with a variety of service users. I especially wanted to learn how to communicate professionally with service users who come for short outpatient appointments but struggle to express themselves or to make independent decisions, among them the elderly and those with learning disabilities. My experience with Mrs Doe in this unit showed me the consequences that a lack of confidence and nervousness, can have on clinical practice. I should have expressed my observations and opinions to the team and this would have helped to ease the patient’s uncertainties regarding the procedure. Faced with a similar situation in future practice, I will use the knowledge that I have acquired from this experience to be more confident and to promote patient-centred care, even when others on the team choose to act unprofessionally. However, the wealth of knowledge from a multi-skilled team of staff on a fast-paced day unit means that they can manage a variety of clinical situations (Voda, 2011).
Going forward, I plan to build on knowledge gained from this experience to take a more active role in any situation that may arise. I will put aside my fears and act in the best interest of the service user. This means using both verbal and non-verbal communication insights I have gained, to inform the service about what is to be expected from a procedure, and to partner with other members on the team to maintain the patient’s dignity, regardless of age, gender, creed or ethnicity.
I will also try to get all the information I can get from a service user’s medical history and team briefings to be able to provide a level of care that best reflects his or her needs. Being a person with the least experience on the team should not be a reason why I should think that the more experienced team members always conduct themselves professionally, in practice. I will continue to hone my reflective practice skills (Ford, 2012), and to promote the NHS values by:
• Putting patient needs above those of the institution.
• Ensuring compassion, among others, is at the core of nursing (The NHS Constitution for England, 2015), values further augmented by those of the Nursing league for nursing whose aim among others is to encourage, a caring ethos involving “a whole person, as a fundamental part of the nursing profession.”