†REFLECTION Monitoring and Ensuring Quality Care

REFLECTION Monitoring and Ensuring Quality C ar gateThe purpose of this paper is to consider on a recent personalised hold of unhurried criminal maintenance, which enabled me to achieve a module 9 competency, actively disciplineks to extend own whopledge.I willing be critically analyzing virtuoso breast playing practice accident using Boud, et al (1985) model of animadversion, (please insure add-on 1) which will enable me to monitor and ensure prime(prenominal) longanimous administer in future practice. The nursing incident happened when I was t iodine after a forbearing of requiring enteral electron tobacco pipe pre insureing (ETF). It is eventful to note that all confidential information relating to patients, wards, infirmarys and professional colleagues has not been include in this paper to ensure ethical practice and adherence to the NMC edict of professional conduct, section 5 which affirms that I must guard against breaches of confidentiality (NMC 200 8). criticism is a practice sessionful alsol for the continuation of professional development among admits (Somerville and Keeling 2004). The intelligence operation reflection originates from the verb reflectere which means to bend or turn backwards (Hancock 1998). It is a tool, which unlike text books and videos, does not have a limited shelf-life, it is represent effective, is portable and pile be used world wide.Patient inditeThe aspect of nursing care I have chosen to reflect on is the care of a patient who required enteral tube feeding (ETF) cod to dysphagia a condition in which the action of take overing is tricky to perform (Unison wellness Care 1998). This nursing noise was essential for a patient in my care, who I shall call trick. Please see appendix 2 for gutters past medical history.The Plan of Treatment for bumJohn was admitted to my area of practice six twenty-four hour periods ago side by side(p) his CVA. He is receiving ETF via an NG tube as an immed iate intervention and is being assessed to see if he is a suitable reardidate for a percutaneous endoscopic gastrostomy (PEG) tube which are used as a more enduring form of enteral tube feeding (Holmes 2004). The naso gastric tube is ab come to the fore 22 inches 55.9cm in length (Holmes 2004) and was inserted into his left nostril down through and through the pharynx, through the oesophagus and through the cardiac sphincter muscle and into the stomach (Marieb 2001). nutriment send word be administered through the tube directly into the stomach and the swallowing growth does not need to take place. The food is administered by a core that controls the amount of feed overhauln in mls per hour. This description could sound as though ETF is always proficient and effective and has no complications. Elia (2001) affirms that ETF is typically safe and easy to administer. However John did experience a matter of difficulties that could have been rectified sooner than they were. On re flection of Johns care it is come about to see (with the benefit of hindsight) that if Johns care was managed differently and if complications were noticed and acted on promptly, his hospital experience could have been very different.1.) Returning to the experience Problems John faced.John experienced two main complications as a solving of ETF. The graduation exercise was vomitus of the feed into his throat and mouth and the second was dissolution. The rate of the feed had been increased over a period of days to its optimal rate, following the ETF guidelines provided by the NHS trust that I was work in. The excerption was commenced during the night bit he was sleeping to allow John greater freedom during the day as he could be disconnected from the pump. The regurgitation happened during the first night that the pump was running at the optimal flow rate. Davis and Shere (1994) report that regurgitation is a common complication of ETF. As a consequence, John had to swallow what had come up into his mouth. The rationale for John to undergo enteral tube feeding was to prevent tho weight loss and intent which sack be caused by dysphagia (DeLegge 1995, Gibbon 2002 and Davies 1999). Aspiration has various meanings, however in this context it refers to the movement of foreign material i.e. fluids or food, into the trachea and further down into the lungs (Unison Health Care 1998). This can occur when the swallowing mechanism is ineffective or impaired. Infection of the lobe of the lung, in which the foreign material has lodged, occurs. This is called aim pneumonia (Unison Health Care 1998). Patients suffering from dysphagia are at risk of developing de terminationination pneumonia (DeLegge 1995 and Gibbon 2002). ETF was commenced to curb this risk but now the very intervention that was intended to eliminate the risk has caused an even greater risk of aspiration pneumonia.According to Marieb (2001) on that point are two stages of deglutition (swallow ing). The buccal phase, which is a voluntary action, occurs in the mouth and is the first phase of deglutition. The tongue increasingly elevates anteriorly to posteriorly, propelling the bolus through the oral cavity. When the bolus has moved to the base of the tongue, the spongelike palate is raised, preventing food from being regurgitated via the nasal passage(Davies 1999). The second is the nonvoluntary pharyngeal-oesophageal phase which Davies (1999) describes as a complex sequence of muscular movements. later on a CVA the ability to initiate the secondary phase of deglutition can be disrupted resulting in ineffective or effected failure of this phase of deglutition. This abruptly explanation of pathophysiology demonstrates how important it is to know nursing rationales for nursing interventions. Patients suffering from dysphagia can somemultiplication overcome the problem by eating a pureed diet and drinking thickened fluids, but this depends on the severity of the dysphagi a (Stringer 1999). John needs ETF because his dysphagia is too advanced to be overcome by a change in diet.Arrowsmith (1993) recommends that patients who are receiving ETF via a NG tube that are lying in bed, should have their head and shoulders towering 30-40 degrees during feeding and up to one hour afterwards to minimise gastric pooling and reflux of the feed. This example demonstrates how a simple action can read a substantial wedge on the fictional character of care that they experience. It has the doubled purpose ofImpact of the quality of care that they experience. It has twofold purpose ofpromoting the lastingness of the intervention and minimises harm to the patient by reducing the risk of aspiration pneumonia. Assessing for signs of aspiration in a patient suffering from dysphagia should always be taken seriously by nursing supply. Stringer (1999) reports that if dysphagia is serious enough it can prevent the victim from swallowing their own saliva. The average pers on swallows approximately 590 clock each day 146 when eating, 394 when awake and not eating and 50 snips during sleep (Davies 1999). With the average person swallowing literally hundreds of times each day, patients are at risk of aspirating (on their own saliva) regardless of ETF. Barer (1989) found that over one third of conscious acute crack patients admitted to hospital had unsafe swallowing. Davies (1999) citing Ellul and Barer (1994) affirms that dysphagia in the first three days after stroke is associated with a fin to tenfold increased risk of chest infection during the first week. This is due to varying degrees of aspiration. Aspiration is a potentially fatal complication of ETF.John also experienced three episodes of dissolution since starting ETF. John was only when provided with a commode which was only dealing with the symptoms rather than treating the cause. No butt against was made with the senior house officer or dietician. Furthermore at that place did not appear to be much concern among the nursing squad and there was no talk ofion or sharing of knowledge mingled with colleagues accept what came from myself. I told my mentor what I had been reading during my reflection time and pointed out some reasons that have been identified as causing diarrhoea for patients receiving ETF. The attitude of my mentor was apathetic, and commented, Hes bound to pick up a bug, give it time, it will pass. This shocked me as Somerville and Keeling (2004) reports that the nursing profession depends on a culture of mutual support, and this was not what I received from my mentor.I valued to discuss the temperature of the feed, his current medication and the cleanliness in which the feed was prepared and administered. If the feed is too cold when it is administered it can cause diarrhoea (Arrowsmith 2003). Howell (2002) reports that diarrhoea can be the result of ETF but it can also be due to the side effects of medications. Antibiotics can cause the co mmon side strickle of diarrhoea (BMA 2001) but John was not receiving any. Diarrhoea in ETF can also be caused through the introduction of bacteria through unworthy hygiene standards in the planning and administration of the feed however the preparation and administration does not need to be performed aspptically.This is only indicated if the patient is immunocompromised (Arrowsmith 1993). My professional knowledge reminded me that I could not dismiss the diarrhoea as a coincidence. If there were nursing interventions that could be used and I didnt use them, I would be failing to provide quality care for my patient. Nurses are responsible not only for their actions but also for their omissions (NMC 2008). I treasured to refer to each others professional knowledge through discussion, and to the ETF guidelines to see if there was a simple cause to the problem that could be rectified in the first place consultation with the doctor or dietician became necessary. I was able to asce rtain out most factors that can cause diarrhoea. This led me to believe that the infusion rate could be too fast. These are the factors that I precious to discuss with my mentor so I could contact the dietician to seek cooperate from the multidisciplinary aggroup. Gibbon (2002) asserts that stroke care requires the services of a multi-professional team, working towards an concord therapeutic plan hence my reason to collaborate with the dietician.2.) Attending to line upings What did I feel was Positive?During reflection time I was very enkindle and pleased to find this explore to suggest that there could be something that I could do to put an end to the discomfort, distress and potentially disastrous complications of a patient in my care. Many times as a bookman I have felt that I personally, am not reservation a great difference to my patients health and wellbeing as I am not working independently, but under my mentor who in general decides on a course of action for our pa tients. This time I have found the answer from my own research. All that frame is for me to study this research to my mentors attention and then put the intervention into practice. The patient will benefit, and I will have a great sense of operation as I will have, in a small way, alter the quality of someones life, accomplishing one of the reasons why I decided to take a career in nursing.Attending to feelings What did I feel was Negative?In response to the apathy that I encountered, I felt disappointed and ineffective and undervalued. My original mentor was off on temporary short term sickness due to a small operation and therefore I was allocated another Junior Ward Sister to take her place for the short period of time in her absence. I felt disappointed because my component part to the care of my patient was not welcomed and that this mentor was not as patient or worryed in my eruditeness and on-going development. I also notion it was unfair because I had evidence to b ase my suggestions on. It was not a swooning idea I had conceived but it was grounded in research. I felt ineffectual because as a junior and inexperienced member of the team I felt I had little influence over the overwhelming hierarchy. Morris (2004) states that student nurses possess little power because they are viewed as inexperienced. I wanted to make my mentor realise that the patient could be suffering (from diarrhoea and regurgitation) because of our negligence and not from inevitable causes.Why was Cognitive Learning universe Achieved?In this situation I was information a number of things, in the main relating to communication, team work, assertiveness, accountability and office. I learned that my priority is with the care of my patient and not with my popularity among colleagues, just as the NMC (2008) signifies when it states when facing professional dilemmas, your first musing in all activities must be in the interests and safety of patients. When I met with my or iginal mentor on her return back to work we discussed this incident of practice and she praised my efforts in extending my knowledge to improve patients care. I therefore achieved the competency, actively seeks to extend own knowledge.Do Any Barriers to Learning Exist?The barriers that existed to my learn were the apathy of the nurses and the limits of my own assertiveness. It was very hard on this ward to feel proud of the care that was being given. The ward was poorly staffed, the ward charabanc was unanimously unpopular, the ward relied heavily on agency staff that was not familiar with the ward and my temporary mentor wanted to leave nursing because of all of the above (and more). As a new and enthusiastic team member I found my self fighting against the low morale and low motivation of the current staff. Job atonement can impact on the care that nurses provide. Brown (1995) believes that when nurses enjoy exhaustively job satisfaction they provide a higher standard of car e to their patients. Rohrlach (1998) and Govier (1999) cited by Kitson (2003) observe that nurses who were happy with the care they were giving were more likely to stay at heart the clinical area which would in turn provide some perceptual constancy and security within the workplace. According to this research, the inability to give quality care (due to the problems mentioned) was resulting in low morale.The dilemma I faced was as follows. I had already approached my mentor once regarding Johns problems and detected that there was little interest in what I had to offer and in the nurses willingness to correct any problems. If I addressed the issue again, I risked worsening the relationship between my mentor and myself. Morris (2004) identifies that student nurses often feel nervous about speaking out because they feel the need to conform or do not longing to be viewed in a negative way. scholar nurses risk touch the status quo by speaking out. If I left the issue my patient ma y be suffering discomfort unnecessarily, but as a student I will never be held accountable in a way that registered nurses midwives or health visitors are (NMC 2008). Would this justify me sledding the issues and conforming to the apathy and bad practice of my mentor? Morris (2004) disagrees. She regularises that although students are not goodly accountable for their actions and omissions, they are morally responsible for ensuring that patients are receiving intimately standards of care. The student nurse must be responsible. Semple and Cable (2003) affirm that responsibility is concerned with answering for what you do. Registered nurses, midwifes and health visitors are accountable which, Semple and Cable (2003) defines as being answerable for the consequences of what you do.3.) Re-evaluating the Experience Drawing ConclusionsDrawing conclusions is the most lively part of the process of reflection. It will shape future practice and quality of care. Conclusions that are drawn from reflection must agree with the nurse and tocology Council compute of professional conduct. It is with the NMC that all matters of conduct, practice and attitude are placed to nurses. The NMC (2008) motto, protecting the public through professional standards can only be achieved if all those on the NMC register are willing to submit to the conditions and regulations that it upholds. thus Somerville and Keeling (2004) affirm that in order for nurses to meet the demands of the NMC, they must focus on their knowledge skills and behaviour which can be achieved through reflection.On reflection of the described incident, it was difficult to know what to do. My mentor was not up to date with the knowledge of this area of practice. I cannot, and do not expect her to know everything, however Glover (1999) points out the nurses should be reliant on others for information. The NMC (2008) states that nurses should work cooperatively within teams and respect the skills, expertise and c ontributions of colleagues, treating them fairly and without discrimination. Therefore I evaluate my temporary mentor to take more interest in what I had to offer. Indeed Morris (2004) argues that qualified nurses are obliged to listen to other staff regardless of their qualification status.Announcing that practice should be in accordance with the NMC is too simplistic an answer to such a diverse problem. It is correct to say this but how will this be achieved? The ward is in need of unattackable clinical leadership, first of all from the sister in charge. Nadeem (2002) states that the call for good leadership in the NHS has reintroduced the matron figure and also the new role of nurse consultants. Specialist nurses do have a role in ensuring safe practice and quality care but this should be in addition to effective local leadership i.e. leadership from the ward sister. Leadership is perceived as being good if there is good team working and if managers have good relationships with staff (Lipley 2003) which is one area that needs attachment in this scenario. Meeting the staffs needs improves satisfaction, productivity and efficiency (Nadeem 2002) which in this subject principally means the provision of resources, i.e. human resources. Nurses who are happy with the care they give are more likely to stay within their clinical area (Rohrlach 1998 and Govier 1999 cited by Kitson 2003). This would provide some stability and security in the workplace. Clinical political science has also come to play a bighearted role in ensuring quality care. The government has defined clinical governance as a framework through which NHS organisations are accountable for infinitely improving the quality of their services and safeguarding standards of care, by creating an environment in which faithfulness in clinical care will flourish (Department of Health 1998). It had been storied that unacceptable variations in clinical practice where becoming common in the NHS (Departmen t of Health 2010). While some patients were receiving excellent health care, e.g. in stroke care, other patients in the country were receiving sub-optimal stroke care due to differences in facilities, funding, education and staff. Each clinical area can improve the quality of care by (1) using modern matrons and nurse consultants as clinical leaders, (2) by having adequate staff to care effectively and to lift morale among active staff and (3) by implementing clinical governance which will result in the flourishing of good practices across wards, departments and NHS trusts through the sharing of expertise, research and ideas. The wards problems could also be addressed through annual reviews or by encouraging staff to keep an up-to-date portfolio (Somerville and Keeling 2004). This will allow nurses to secernate strengths and opportunities for development.Critically analysing using reflection on this incident has been valuable in maintaining the quality of care as set out in the NM C code of professional conduct. Gallacher (2004) says that she questions different peoples practices in order to provide her patients with first sieve quality care. Clinical practice will not improve if it remains unquestioned. Hindsight gives the practitioner the opportunity to discriminate between good and bad practices. Safe, legal and quality care can only be given if it is in keeping with the NMC code of professional conduct.Reference listArrowsmith, H. (1993) Nursing precaution of Patients Receiving a Nasogastric Feed. In British Journal of Nursing. 2 (21) 1053-1058Barer, D. (1989) The Natural invoice and Functional Consequences of Dysphagia after Hemispheric Stroke. In Neurol Neurosurg Psychiatry. 52, 236-241BMA (2008) New Guide to Medicines and Drugs.capital of the United Kingdom British Medical Association.Brown, R. (1995) Education for Specialist and Advanced Practice. In British Journal of Nursing. 4 (5) 266-268Department of Health (1998) First Class good Quality in t he New NHS. London The Stationery Office.Davies, S. (1999) Dysphagia in peachy Strokes. In Nursing Standard. 13 (30) 49-55Davis, J. Shere, K. (1994) Applied Nutrition and Diet Therapy for Nurses. second Ed. Philadelphia PA,WB Saunders.DeLegge, M. (1995) transcutaneous Endoscopic Gastrojejunostomy A Dual Centre Safety and expertness Trial. In Journal of Parenteral and Enteral Nutrition. 19 (3) 239-243Gallacher, G. (2004) Gaining a punter Understanding of Reflection to Improve Practice. In Nursing Times. 100 (23) 39Gibbon, B. (2002) Rehabilitation Following Stroke. In Nursing Standard. 16 (29) 47-52Glover, D. (1999) righteousness. In Nursing Times Clinical Monograph. 27, 1-11Elia, M. (2001) Trends in Artificial Nutrition Support in the UK during 1996-2000. Maidenhead BAPEN.Hancock, P. (1998) Reflective Practice using a Learning Journal. In Nursing Standard. 13 (17) 36-39Holmes, S. (2004) Enteral Feeding and Percutaneous Endoscopic Gastrostomy. In Nursing Standard. 18 (20) 41-43Howe ll, M. (2002) Do Nurses know enough about Percutaneous Endoscopic Gastrostomy? In Nursing times. 98 (17) 40-42Hutton C (2005) After a stroke 300 tips for making life easier, London.UKKitson, J. (2003) Education for High dependance Nursing. In Paediatric Nursing. 15 (1) 7-10Lipley, N. (2003) Research Shows Benefits of Nurse Leadership Training. In Nursing Management. 10 (2) 4-5Marieb, E.N. (2001) Human Anatomy and Physiology. 5th Ed. United States of the States Benjamin Cummings.Morris, R. (2004) Speak out or Shut up? Accountability and the Student Nurse. In Paediatric Nursing. 16 (6) 20-22Nadeem, M. (2002) Evolution of Leadership in Nursing. In Nursing Management. 9 (7) 20-5Nursing and Midwifery Code of victor Conduct. London NursingCouncil (2008) and Midwifery Council.Nursing and Midwifery An NMC Guide for Student of Nursing and Council (2008) Midwifery. London Nursing and Midwifery Council.Semple, M. Cable, S. (2008) The new Code of overlord Conduct. In Nursing Standard. 17 (23 ) 40-48Somerville, D. Keeling, J. (2004) A Practical Approach to arouse Reflective Practice within Nursing. In Nursing Times. 100 (12) 42-45Stephanie K, Daniels, Maggie downwind Huckabee (2008) Dysphagia following stroke (clinical dysphagia) London.Stringer, S. (1999) Managing Dysphagia in Palliative Care. In Professional Nurse. 14 (7) 489-492Appendix 1Three stages to the process of reflection. Boud, Keough and Walker (1985).a) Returning to experience Observations what happened? What was my reaction? Clarify personal perceptionsb) Attending to feelings What did I feel at the time? What did I feel was positive? Why is cognitive learning being achieved? What did I feel was negative? Do any barriers to learning exist? Raise awareness and clarify feelingsc) Re-evaluating the experience Draw conclusions and insights unitedly with existing knowledge Identify gaps in knowledge Integrate existing and new knowledge