Cure sometimes, treat often, comfort always.

Profile

My name is Nick Howson and I am currently working toward getting a Bachelor of Nursing from Western Sydney University with an aim to graduate in 2018 with a combined degree Bachelor of Applied Leadership and Critical Thinking (BALCT).

Previously I worked as a Networks and System Engineer with the NSW Department of Education & Communities providing computer support to both teachers and students, providing personal development to staff as well as administrating and running the schools IT infrastructure on a day to day basis. After working with the NSW DEC I began work as a contract IT Consultant and worked with a number of small business and provided home based IT services to people in Western Sydney. I was contracted to Blue Mountains Grammar School for a year where I was asked to conduct what would end up being a year long, multiple campus, site wide hardware survey which culminated in a written report to highlight potential problem areas within the schools IT infrastructure.

I am also volunteer with the NSW RFS and enjoy giving back to my community. After being with the RFS and talking to some members I decided that I wanted to work more within an emergency service context and I began to consider nursing as a worthwhile role and decided to go to university as a mature age student to attain my Bachelor of Nursing and become a Registered Nurse. My community experiences with the RFS have contributed to a sense of respect and kindness that I feel is also reflected in the Code of Ethics for Nurses (Nursing and Midwifery Board of Australia, 2006).

Reflection

We were called to a nursing home where a man was found unresponsive. On arrival there was a nursing assistant giving a man CPR on the floor. The paramedics cut his shirt off and setup the portable electro cardio graph and applied the defibrillator patches to his chest. A breathing tube was inserted and I setup the bag valve mask, oxygen flow and began to provide oxygen to the man. The nursing assistant was asked to check if the man had any resuscitation directives in place. She returned and told us that the man was not for resuscitation. The paperwork was double checked and medical intervention was ceased and the ECG was monitored as heart activity ceased. Medical equipment and rubbish was removed, his eyes closed and covered he was with a sheet. During the incident I felt disconnected and was more focused on getting things correct. Afterwards during the cleanup I found myself wanting to talk to him as I removed equipment from his body. Overall I rate the experience as sad but worthwhile. Going into nursing I knew I would experience death on a regular basis and it is important to understand and cope with it. I do not believe I could have done any anything medically different in this situation. I would have however liked to have done more for the man in death. I would have liked to stay and wash and redress him. Unfortunately I was not there in a nursing capacity and had to leave with the paramedics. The only change I would make is that I would ask for a little more time to provide the body with the proper dignity and integrity that section 9.3 national competency standards require of us (Nursing and Midwifery Board of Australia, 2006).

PPE 3 2016

My reflection has been written using the tools for self-reflection provided by Gibbs in the work “Learning by doing: a guide to teaching and learning methods” (Gibbs, 1988).

During my placement in the Cardiac Care Unit of Nepean Hospital I was paired up with an RN working in the single occupancy rooms with the more dependant and at risk patients. A patient had been waiting in his single room for transfer out of the single rooms into the multibed rooms as he was deemed no longer a higher dependency patient. The patient requested supervision while walking to the toilet. After the patient had gone to the toilet the RN and myself assisted with standing them behind their walker. The patient informed us that they would like to walk behind the walker and the RN and I encouraged them to do so. The patient got halfway back to the bed and asked if they could sit on the walker. The RN and I seated the patient on the walker. Upon sitting down the patient became unresponsive and started to slip out of the walker. The RN attempted to rouse the patient while I pressed the emergency button. The patient had stopped breathing and had a weak and erratic pulse. The RN started to get equipment together to get oxygen and I commenced CPR on the patient while the other nursing staff arrived with the emergency trolley. After 25 minutes of attempted resuscitation the lead ICU doctor asked if anyone had any objections to ceasing resuscitation efforts, no one objected and then the doctor called a stop on the call.

My feelings after the incident were conflicted, I felt partially at fault for the death of the patient after encouraging them to walk, worried that my skills perhaps had contributed to the unsuccessful resuscitation attempt and that perhaps we hadn’t tried for long enough. I also felt a bit useless not knowing about all the equipment we used during the resuscitation. After everything had settled down I went and got a drink from the staff kitchen and found that my hands were shaking. One of the ICU doctors had also come into the kitchen and struck up a conversation with me about the MET call. He reassured me that my skills had been sufficient and that I was not at fault for encouraging the patient to walk.

After the MET call and talk with staff I felt a lot better about the situation. I also asked the team leader that night if they would mind going through the whole emergency trolley with me so we could restock it and I could learn more about the equipment. Looking back on the situation I now believe that my presence as a student being there to perform CPR almost immediately from the commencement of the MET call provided the best possible chance of survival for the patient as well as freeing up an RN to do tasks that I was not able to do such as getting medications, IV access, scribing and attending to other patients on the ward.

The following day I did some research and found recent that research shows that a small amount of people receiving CPR in hospital survive to discharge and even less are discharged home and capable of being independent (Gershengorn, Li, Kramer, & Wunsch, 2012). I also looked at survival rates versus time statistics for CPR and noted that after 25 minutes the survival rate drops off quite significantly (Goldberger et al., 2012). I also had a look into the effects on patient death with nursing staff and found that my reaction is common even amongst highly experienced nurses (Wilson & Kirshbaum, 2011).

I do not believe that I could have done anything differently during the incident given my current skill set and exposure to emergency nursing situations. However faced with a similar situation now I believe I would be able to help more than I was able to in this incident. I need to learn more about the contents of the emergency trolley and more about the process and requirements of a MET call within the NSW Health system with regards to scribing, timing of medication administration and processes such as airway management.

To further my clinical skills I need to learn more about the contents of the emergency trolley and learn about the correct airway management. I also need to ensure that I am well versed in the NSW Health policy on deteriorating patients to ensure that the appropriate response is used when working with a deteriorating patient (NSW Health, 2013).

PPE 4 2016

Week 2

Situation: I was in the simulation room doing a mock resuscitation. Roles where assigned and I was the scribe.

Action: I was trying to watch all the monitors and what everyone else in the resuscitation team was doing. It was confusing because it was the first time for all of us and people were also not sure of what information they needed to give. I did not end up with enough information recorded for it to be a meaningful record. In a real event this would be detrimental to patient outcomes and research has shown that effective communication in a trauma resuscitation leads to better patient outcomes (Clements, Curtis, Horvat, & Shaban, 2015).

Outcome: As the scribe it is important that you get all the information you need to fill out the resuscitation record. Next time I should actively ask for the information I do not have as well as encourage others to verbalise what they are doing so the scribe does not need to ask.

Week 4

Situation: I was priming and preparing a burette to administer dose of ceftriaxone to a patient suffering from COPD after sputum cultures indicated an infection.

Action: I was holding the burette in one hand with the giving set in the other and I dropped the end of the giving set and it touched the ground. In my attempts to stop the end of the giving set touching the ground I also dropped the burette. I picked all of my equipment up and let someone else do their simulation while I sorted out a proper work environment for myself. After sorting out my work environment I attempted the procedure again and was successful in maintaining a sterile environment for the patient.

Outcome: The patient received the required medication in a sterile manner to minimise the risk of a hospital acquired infection complicating their stay in hospital. An organised work environment is essential to maintaining a safe and therapeutic environment for patients (Huisman, Morales, van Hoof, & Kort, 2012).

Week 10

Situation: Today I was preparing an electrolyte solution of potassium to administer to patient with hypokalaemia and administer and ECG.

Action: I conducted a ABCDEFG assessment on the patient and noted the need for the infusion due to potassium level being below the normal range. I gathered my equipment, conducted my first patient ID check, validated my order, did the 3 drug checks, did my final patient ID check and hung the bag. I calculated the drip rate and commenced the infusion. Upon commencement of infusion I completed my documentation and handed over to another student. The receiving student noted that I missed some information in my handover. Lack of proper handover regardless of handover method can contribute to treatment errors in the subsequent shifts (Drach-Zahavy & Hadid, 2015).

Outcome: For future practice I will make sure that my handovers are detailed, relevant and easily understood by the receiving party by practicing the ISBAR method of handover to ensure that I practice in a safe and competent manner and stay within the Code of Professional Conduct for Nurses in Australia (NMBA, 2008).

Week 11

Situation: During my clinical placement I was at the Palliative Care Unit of Mt Druitt Hospital. During my time there I observed many interactions between staff and family members of patients in the process of actively dying. One specific interaction of mine with the family of one patient in particular has stuck with me. The patient had a history of drug abuse and had been diagnosed with cancer and was unable to live alone. We did a bed shuffle to segregate rooms along gender lines and we noted that the patient had become totally unresponsive to voice, touch or by pain just after the move. A nurse left to contact the family and I decided to wait with the patient until the family arrived.

Action: The patient’s family arrived with my supervising RN. They asked me about the patient and what had been happening. I informed them that I was a student and I would answer them as best I could. I informed them that the patient hadn’t been left alone and someone had been with them the whole time and that their pain was being managed. I asked the family if they needed anything and they asked for pillows for the patient and one of them laughed and asked if I could get them a beer. I laughed with them and let them know that the PCU did in fact allow alcohol for both patients and family members and they were welcome to bring some if it would help them. I returned with some extra pillows and some chairs for the family. The patient passed a few hours later.

Outcome: I feel that I interacted well with the family of a dying patient, the patient’s needs were taken care of and the patients status was communicated clearly to his immediate family members. Communication is important in a palliative care setting to give best outcomes to all involved as well as providing valuable student learning opportunities (Ballesteros, Centeno, & Arantzamendi, 2014).

Career

Professional Development

2015 - NSW Nurses and Midwives’ Association Student Member

2015 - Commencement of a Bachelor of Nursing

2015 - First Aid Certificate

2014 - Working With Children Check

2013 - NSW Rural Fire Service Village Firefighter

Contact

Send me an email or contact me via social media if you would like to get in touch.

nick.howson@gmail.com

References

Nursing and Midwifery Board of Australia. (2006). National competency standards for the registered nurse. Retrieved from http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

Nursing and Midwifery Board of Australia. (2008). Code of ethics for nurses in Australia. Retrieved from http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

School of Nursing and Midwifery. (2016). Clinical Placement Guide. Western Sydney University.

PPE 4

Ballesteros, M., Centeno, C., & Arantzamendi, M. (2014). A qualitative exploratory study of nursing students’ assessment of the contribution of palliative care learning. Nurse Education Today, 34(6), e1–e6. http://doi.org/10.1016/j.nedt.2013.12.010

Clements, A., Curtis, K., Horvat, L., & Shaban, R. Z. (2015). The effect of a nurse team leader on communication and leadership in major trauma resuscitations. International Emergency Nursing, 23(1), 3–7. http://doi.org/10.1016/j.ienj.2014.04.004

Drach-Zahavy, A., & Hadid, N. (2015). Nursing handovers as resilient points of care: linking handover strategies to treatment errors in the patient care in the following shift. Journal of Advanced Nursing, 71(5), 1135–1145. http://doi.org/10.1111/jan.12615

Huisman, E. R. C. M., Morales, E., van Hoof, J., & Kort, H. S. M. (2012). Healing environment: A review of the impact of physical environmental factors on users. Building and Environment, 58, 70–80. http://doi.org/10.1016/j.buildenv.2012.06.016

Nursing and Midwifery Board of Australia. (2008). Code of Professional Conduct for Nurses in Australia. Retrieved from http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

PPE 3

Gershengorn, H. B., Li, G., Kramer, A., & Wunsch, H. (2012). Survival and functional outcomes after cardiopulmonary resuscitation in the intensive care unit. Journal of Critical Care, 27(4), 421.e9-17. http://doi.org/10.1016/j.jcrc.2011.11.001

Gibbs, G. (1988). Learning by doing: a guide to teaching and learning methods. Oxford Polytechnic, UK: Further Education Unit.

Goldberger, Z. D., Chan, P. S., Berg, R. A., Kronick, S. L., Cooke, C. R., Lu, M., … Nallamothu, B. K. (2012). Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. The Lancet, 380(9852), 1473–81. http://doi.org/10.1016/S0140-6736(12)60862-9

NSW Health. (2013). Recognition and Management of Patients who are Clinically Deteriorating - NSW Health [Policy]. Retrieved May 18, 2016, from http://www0.health.nsw.gov.au/policies/pd/2013/PD2013_049.html

Wilson, J., & Kirshbaum, M. (2011). Effects of patient death on nursing staff: a literature review. British Journal of Nursing, 20(9), 559–563 5p. http://dx.doi.org/10.12968/bjon.2011.20.9.559