Reflecting on practice

As nurses we are encouraged to reflect on our practice. I did this personally, using a framework for reflection and as a team we used this model for group supervision. This is an example of one of my reflective pieces.

Mr B was referred to me by the practice nurse who was currently caring for him. Mr B had extensive ulceration to both his legs that also affected the dorsal aspect of his feet and his toes. His pain at the time was described as excruciating and relentless and as 5 on a score of 0 – 5. His legs were saturated with wound exudate and were malodorous. Mr B was visiting the practice nurses twice a week for dressing changes, but this regime was not adequate for him as the dressings were often saturated after 24 hours. He was therefore living with wet, malodorous dressings and bandages for days at a time. Mr B was known to the vascular team at the local hospital where he had had several surgical procedures on his arteries, however, he told me that they had ‘wiped their hands of him’ as he had refused to have his legs amputated which he said was their solution to his problem. Mr B was low in mood and spoke emotionally about the impact of his situation on his life. The practice nurse prior to me meeting Mr B had said that he was ‘difficult’, that he often refused to have the dressings they recommended, and he would often remove the bandages that they applied. They told me that the GPs were questioning the time spent on his wound care and the costs associated with this. I was told that the District nurses had been involved at times, however, because he was classed as ‘mobile’ they were no longer able to see him at home. Mr B was still currently driving although he was taking high levels of morphine for the pain. It appeared that no-one had advised him against this.

Prior to meeting Mr B I was feeling very frustrated, saddened and slightly angry about the perceived attitudes and behavior of some of the Health care professionals involved in the patients care and recall thinking that this unfortunately was not an isolated case, that it was a regular observation I came across in my role. I approached the consultation in an open minded, impartial way with my focus being on trying to help a patient who clearly was in some distress. His practice nurse was present in the room, I introduced myself to Mr B and shook his hand and asked whether I could sit next to him for a chat. He agreed to this, so I placed a chair close to where he was sitting. I enquired whether he knew about my role, he asked whether I could explain more about this which I did and offered Mr B a patient information leaflet about the tissue viability service.

The initial part of my consultation focused on Mr Bs understanding of his condition, the history that preceded my visit and how in his words his condition was affecting him. It became apparent that he felt that everyone had given up on him and he was being passed from one nurse to another with no one taking responsibility for his care. He told me he felt scared at times as some nurses didn’t know what they were doing and mentioned that his GP had told him that they were spending too much money on his dressings. Mr B told me that his pain was so severe at times that he resorted to ring the Samaritans in the middle of the night as he had no-one else to talk to but felt that his pain was not being taken seriously by his GP. I felt incredibly sad when I was listening to this and thought that no-one should suffer this way. I felt angry and disappointed that other services in the NHS were making Mr B feel this way and felt they were letting him down. I recall thinking about how they would feel having to live with his condition.

I asked Mr B what the worst thing was about his condition and what his main treatment objective would be. He told me that the pain was the worst thing and that he could cope with the wounds if this could be taken away.

I then asked Mr B if I could look at his leg ulcers, removing the bandages and dressings as carefully as possible to avoid inflicting additional pain. Although I have seen many patients with leg ulcers over the years, I found the extensiveness of his ulceration depressing and my heart sank as I immediately knew that healing would be a difficult outcome. His wounds were infected and the surrounding skin on his legs macerated by the unmanaged exudate. The malodour was significant and made me think about the impact of living with this on Mr Bs quality of life. His legs were very oedematous and tight and I immediately thought that much of his pain was related to this congestion in his limbs.

After fully assessing the wounds I asked Mr B permission to summarise on my findings and to discuss a plan with him that would hopefully improve his situation. He agreed to this.

I discussed the factors that I felt were contributing to his pain which I thought were associated with his wound infection, the maceration to his skin and the congestion in the limbs. However, I was not fully certain about his arterial status and felt frustrated that this information was not fully available to me due to the disjointed way services share patient data.

I suggested that his wounds required more frequent dressings changes and offered a solution to this that involved some shared care between the practice nurses and the District nurses. I enquired about the possibility of getting a lift to the surgery instead of driving and Mr B said a niece could bring him in.

I discussed a plan for his wound infection and for managing the high exudate levels and concluded that ideally, a firmer bandage was required if the congestion in the limb was to be reduced. Mr B was clearly anxious about this as he felt that the bandages contributed to his pain. I was not surprised by this reaction as this is a common response by patients with leg ulcers, but I knew that pushing this point and ‘telling’ Mr B what needed to happen would be counterproductive. I knew that this directive, sometimes bossy approach should never be used by clinicians as this frequently results in non- concordance with care and a breakdown in the therapeutic relationship nurses should develop with their patients.

I suggested a bandage which wouldn’t feel so tight and asked whether he was prepared to try it. I suggested that a follow up after 24 hours be in place to monitor the impact of the new bandage and that this would be discontinued if too uncomfortable. Mr B agreed to this.

I offered reassurance to Mr B that I would remain involved in his care and would be responsible for coordinating and communicating the treatment plan to the services involved in his case, and that I would review him on a regular basis. At this point, Mr B became very emotional and started crying and told me that he had not received such kindness or compassion from anyone in his care until now. This statement was extremely powerful and triggered a range of emotions in me from empathy with Mr Bs situation, sadness and disappointment that he felt that no-one involved in his care had expressed kindness or compassion but also concern that his condition was so complex that I may not be able to help him. I really wanted to make things better for this man but I needed to be realistic about what could be achieved in terms of healing.

What did I learn from this experience?

This experience has highlighted to me the importance of a holistic approach to patient assessment and not just seeing a patient as the condition they are presenting with (e.g. The leg ulcer man!).  I also learnt how destructive a Health care professionals’ attitude and behavior can be on patient care. Labelling patients as difficult or non – concordant without trying to ‘bottom out’ why they aren’t engaging with care will not only lead to failed outcomes but to a culture of care that is accused of lacking kindness and compassion. We cannot expect every patient we work with to be receptive to the care plans we suggest but we have a responsibility to build a relationship with that will nurture trust and honesty. With this in place we will develop a better understanding of the motivation surrounding any changes they may need to make if they are to improve their outcomes.

I learnt the importance of good communication when interacting with our patients. I should not assume that patients want to hear the information I am giving so this should be established at the outset. Using a motivational interviewing (MI) approach to my assessment ensures I ask permission to talk about a subject or to hear about the treatment options I may be considering. If a patient doesn’t want to hear it, they are not ready to make a change and therefore treatment outcomes are unlikely to be positive. Active listening is an essential component of MI – have I really heard what is being said? There was a lot of information gained from this consultation that the practice nurse hadn’t heard. Maybe she hadn’t asked the right questions or maybe she hadn’t listened carefully enough.

This experience has also highlighted the importance of clinical leadership and nursing knowledge within a specialist field. The tacit knowledge I have gained over many years of community nursing helps prepare me for difficult scenarios. My nursing knowledge underpinned by research and experience is fundamental to what I do but its also about trying to live the experience, putting yourself in that patient’s world, having a good understanding of what its like for them to live with conditions such as leg ulceration. Empathy, kindness and compassion is essential for our role and this experience demonstrated this had been lacking from some service areas.

Finally, this experience highlighted the need for services to collaborate more and to have a better understanding of each other’s roles and the challenges/ pressures they are facing. There needs to be flexibility within the referral criteria based on what is best for the patient, not what is best for the service. There also needs to be someone leading on a patients care plan who would be the link with other Health Care Professionals (HCPs) such as the GP and would be the patients advocate when there are challenges in the care.

Would I have changed anything I did on reflection?

I don’t think I would have changed anything I did during this initial consultation as my approach (and the skills used within this approach) appeared to have a positive outcome in terms of the patient’s experience and the agreed plan of care that was put in place. We always offer patients the opportunity to provide feedback on their consultation/ care through the I Want Great Care (IWGC) process.

I would never get complacent with my interaction with patients though. Everyone is an individual and may respond differently to the approach I use, and I am always mindful of this.

Following my consultation with Mr B I suggested to the practice nurse that I returned to facilitate a de- brief of the visit so that some learning could come from the experience. This was welcomed and seen as a positive.

Did I make a difference?

I had to think long and hard about this question and about what I made a difference to. Writing this section is particularly sad for me as shortly after writing this reflective piece Mr B passed away after being found on the floor by a friend. He died alone and unfortunately still in pain. When I heard about it my initial response was that I had let him down.

Regrettably, I did not make a difference to wound healing. His condition and underlying risk factors were so complex that healing was unlikely. Despite exploring all options for managing his pain, this remained a problem and was complicated by Mr Bs reliance and overuse of opioids towards the end of his life. I frequently became frustrated at the inability to help manage his pain and increasingly isolated as other HCPs appeared to disassociate themselves from Mr Bs case. It highlighted the challenges nurse led tissue viability services have when trying to get engagement from our medical colleagues.

I did however coordinate a shared care programme that avoided the need for Mr B to attend the surgery and instead involved care from the district nurses and the tissue viability team. This continuity resulted in the reduction of wound exudate and malodour which went some way to improving Mr Bs quality of life.

But what I did feel I made a positive difference to was Mr Bs mental and spiritual health. I afforded him the time to talk and to be listened to and I showed him respect, kindness and empathy. We explored his fears, his beliefs, his passions. We talked about his past, his time as a bass guitar player in a rock band, his love of art and during these moments, his pain seems to reduce. This has to be a positive difference I think?

How I applied this reflection to practice

I used this case as a clinical supervision scenario for the tissue viability team and analysed the approaches used to facilitate a positive consultation with a patient. This approach is now used by all the team and we now teach it throughout all of our training.

The isolation we can feel as a specialist service when managing complex patients like Mr B is common and this case has highlighted the need to have a network of similar specialists to collaborate with when faced with complex cases. I have now started the process for the development of a regional tissue viability forum who will be a great resource for advice and support.

In terms of the attitude or behaviour of other HCPs who label or stereotype patients, examples of these incidents are anonymised and included in training sessions to staff together with changes they can make that would enable them to understand their patient’s ‘behaviour’ too. To date, these sessions are always very positive with nurses keen to use motivational interviewing techniques when assessing patients or planning care.