Reflective Journal on Clinical Issues

Introduction

Nursing is a multifaceted working field in which makes nurses face many challenging issues during their clinical experience. Reflective practice is one of the major tools within the quiver of an experienced nurse which can be used as a powerful weapon against these multiple clinical issues. Reflective practice helps a nurse to learn from experiences through careful evaluation and analysis of incidents so that she can deal with a new similar situation in a better way. This writing discusses 3 clinical issues using Gibb’s model of reflective writing and they are, inadequate staffing, misunderstanding of patient symptoms,s and problems associated with telephonic advice, supported by appropriate journal articles.

Inadequate Nurse-Patient Ratio

Staff shortage is one of the major problems faced by many hospitals in India, especially in public hospitals. Being a nurse experienced in India, I have experienced the problems related to this many times. The following is one of those issues. Around five years back, when I was a newly appointed nurse in one of the public hospitals, I was forced to give care for 40 patients alone due to a staff shortage. I was thinking that, if I cannot complete my routine work faster, I won’t be able to receive new admissions. Immediately after handing it over, I started checking vital signs beginning from bed no:1. I was in a hurry to complete my work as there was no one else to help me. When I approached the last patient in the ward, I have noticed that the patient looked irritable and confused. Also, he was sweating profusely. When I asked him about his feelings, he told me that he had some uncomfortable feelings for a few hours. Since it was not an easy task to remember the case history of all 40 patients it took 5 minutes for me to check his case file. He was a diabetic patient who had his first dose of insulin on that day. When I checked his blood sugar level it was too low. Immediate actions were taken for the reversal of hypoglycemia.

During this incident, I had multiple feelings in my mind. I felt guilty that I could not find time to talk with my patients so that I can understand their concerns. At the same time, I was satisfied that I could manage that patient without getting into further complications. Hypoglycemia was easy to manage compared to other issues that may have been experienced by elderly people. He might have fallen from the bed. The risk of fall-related injuries is higher in the elderly due to hypoglycemia.

On evaluating my actions during the incident, 2 questions were raised in my mind. If I missed his symptoms what could have happened? What might have caused me to do so? The answer is missed care due to failure in the nurse-patient ratio. Missed care is an indicator of an inadequate nurse-patient ratio. It was not a good idea to take too many patients at a time. The majority of the nursing errors are due to the increased workload of nurses beyond their capacity. Interruption during work can accelerate this. Medication errors and decreased patient satisfaction are some of the common effects of staff shortages. An inadequate nurse-patient ratio can risk a patient's life.

On analyzing the total events, I was a good observer that I could find out the signs of hypoglycemia. At the same time, it was my responsibility to keep an eye on that patient who had his first dose of insulin. I could have given priority to elderly patients. I have learned many things from this incident and they are, the importance of observing the after-effects of insulin and the need for priority setting.

In light of this incident, I have made a few action plans for the future as a reflective practice. Firstly, not to take too much responsibility at a time. But it is not possible to do so in all circumstances. So secondly, to always set priorities before starting patient care. Thirdly, to find out time to interact with patients and I used vital signs checking time for this. Finally, to offer my colleagues a helping hand during busy shifts. These steps were very useful for me when I faced similar situations.

Misunderstanding of a patient's symptom

Around 9 years back, during my internship program in India, I was posted in the observation room and I got 3 patients under my care. All the 3 patients came at almost the same time. One with the complaints of general weakness and throat pain, the second with shortness of breath, and the third with vomiting. When I checked the vital signs of the first patient it was all normal. There was an order for iv fluids with a multivitamin. He said that his throat pain is getting worse. Panadol was given for pain and iv fluids were started. Compared to other patients, I felt that the second patient was in need. There was a lot to do for that patient. After completing all his treatment orders, I have approached the third patient. By that time the first patient complained again of throat pain and he said that it is spreading to the neck. Thinking that Panadol was given to him for the pain I told him that it will settle down and I approached the third patient. After completing all work again, I approached the first patient. Since he was very irritable, I have made a call to the on-duty doctor. He ordered for ECG. Thinking that what is the role of ECG in this patient I have done his ECG. The report was quite shocking for me as it indicated signs of myocardial infarction. Immediately shifted that patient to ICU.

At that time, I was thinking about throat pain which turned into MI. Later I learned that pharyngeal pain is one of the rare symptoms of AWMI, which is difficult to diagnose. I felt sorry for not giving importance to his complaint. Also, I was satisfied that I could shift that patient to ICU promptly without losing the golden hours.

On evaluating my actions during the incident, it was my failure to misunderstand throat pain as a symptom of viral infection. I did not recognize the signs of MI even after he said that his pain radiated to the neck. If I did not inform his condition to the doctor on time, it could have turned into medical negligence. 'A nurse's accuracy in assessing, monitoring, and timely reporting to a physician can often mean the difference between life and death,'.

On analyzing this incident, I have learned that it is always important to pay attention to a patient complaint. Also, I learned that throat pain could be a symptom of MI. as a part of learning from this experience, I will ensure that all patient complaints are dealt with significance even if it is a minor one so that there will not be any chance of medical negligence.

A Problematic telephonic advice

Around 8 years back when I was posted in cardiac ICU, I was assigned to take care of a psychiatric patient with heart block. He was on temporary pacemaker support. It was a night shift. The patient was restless and trying to remove his pacemaker support. The patient relatives denied the use of restraints. As a part of that hospital system, I have informed the patient condition to the assigned DM cardiology student doctor and he had made telephonic advice of sedation. The next day morning when the main consultant arrived the patient was drowsy. When he asked about this to me, I said regarding that telephonic advice. But unfortunately, it was not documented in the doctor's advice sheet. It was documented in the nurse's record by me but without countersigned by other staff. I felt like fainting. The doctor was about to complain against me regarding this incident but by that time the one who had made the order was arrived and wrote the order. So there were no further issues.

It was my first experience being questioned by a consultant for my actions. I felt like he was questioning my self-esteem. On evaluating my actions, even though there was documentation of the advice, it was incomplete. What could have happened if the doctor refused that he did not give any such order? I might have got punishment for this. If there was proper documentation there will not be any issues.

When looking back into the issue for analysis, it is always advisable to follow institutional guidelines for telephonic advice. On a literature review, it is written that problems related to telephonic advice are mainly due to the nurse's unawareness of verbal order guidelines.

Through this incident, I have learned about the importance of proper documentation of telephonic orders and I have decided to follow institutional guidelines for such orders. Also, I have learned the importance of countersigning by RN and I will be very cautious in doing that in the future.

Conclusion

The incidents which I shared had played an important role to reform my attitude towards a similar situation. My experience helped me to deal with staff shortages, telephonic advice, and patient complaints. That is making sense of my experience and learning from that as a reflective practice. This practice should be started from the level of nursing students so that we can turn into expert nurses just like a well-polished diamond.

References

1. Anzai, T., Hroshige, Y., Ikeda, K., Iizuka, T., Nakamura, M.& Nakazato, Y, (2017). Unusual Pharyngeal pain Caused by Acute Coronary Syndrome: A Report of Three Cases. A Case Reports, International Journal of Medical case Reports, vol.7(1), p.904
2. Croke, E.M. (2003), Nurses, Negligence, and Malpractice. American Journal of Nursing, vol.103(9), p.54
3. Griffiths, P., Recio-Saucedo, A., Dall'Ora, C., Briggs, J., Maruotti, A., Meredith, P., Smith, G.B.& Ball, J, (2018). The Association Between Nurse Staffing and Ommission in Nursing Care: A Systemic Review. Journal of Advanced Nursing, vol.74(7), p.1474-1478
4. Iddrisu, S.M., Hutchinson, A.F., Sungkar, Y.&Considine, J, (2018). Nurse's Role in Recognising And Responding to Clinical Deterioration in Surgical Patients. Journal of Clinical Nursing, vol.27(9-10), p.3544-3553.
5. Kachroo, S., Kawabata, H., Colilla, S., Shi, L., Mukherjee, J., Iloeje, U.& Fonseca, V, (2015). Association Between Hypoglycemia and Fall-related Events in Type 2 Diabetes Mellitus: Analysis of U.S. Commercial Database. Journal of Managed Care and Specialty Pharmacy, vol.21(3), p. 243-253.
6. Moghaddasi, H., Farahbakhsh, M.& Zehtab, H, (2017). Verbal Orders in Medicine: Challenges; Problems and Solutions. JOJ Nursing and Health, vol.1(5), retrieved from https://juniperpublishers.com
7. Jenkins, D, (2018). Inadequate Staffing: Patient Safety in Todays Healthcare Marketplace-A Four-Part Series. Retrieved from https://allnurses.com