Introduction
The role of the Anaesthetic Nurse Specialist (ANS) demands an autonomous, accountable practitioner to lead and champion change within a dynamic and fickle healthcare system [Frankel, Reference Frankel2008]. All patients in need of anaesthesia are entitled to the same high quality peri-operative care and therefore those assisting the anaesthetist must be in possession of the appropriate level of skills and competency to be an effective practitioner as recommended by the Association of Anaesthetists for Great Britain and Ireland [AAGBI, 2010].
The position of clinical nurse specialist is a relatively contemporary phenomenon within the healthcare fraternity, evolving in response to social, technological and political transformation in service provision by the NHS as discussed by Cutts [Reference Cutts1999] and Bryant-Lukosius et al [Reference Bryant-Lukosius, DiCenso, Browne and Pinelli2004]. This development has been accelerated by a combination of factors, primarily the reduction in junior doctors’ hours, waiting times for treatment and organisational performance targets [Griffin and Melby, Reference Griffin and Melby2006]. Over the last decade this opportunity for practitioners to embrace the development of specialist knowledge and skills has extended across a wide range of practices creating a wealth of innovative nursing knowledge that debates existing practice while endorsing extension of nursing and healthcare services.
As a consequence of this unprecedented rise in specialist practitioners there is much confusion over a definitive title that encompasses the role that they participate within. In its infancy Castledine [Reference Castledine1995] defined the specialist practitioner as a nurse who was a recognised, accountable expert leading and seeking advice from within a specific field of clinical nursing practice. The Nursing and Midwifery Council (NMC) [2004] highlighted that those with an academic, recordable qualification of specialist practitioner be required to demonstrate superior levels of judgement, prudence and decision making in clinical care thereby enhancing standards of care. In addition to this resolute consideration, Cernius and Wilson [Reference Cernius and Wilson2009] tackles the need to extend advanced practice in nursing as highlighted in the government report ‘Modernising Nursing Careers: Setting the Direction’ to enhance patient safety and essence of care while enabling nursing services to expand their service provision [Department of Health, 2006].
The arena of peri-operative nursing is constantly changing and demanding specialist knowledge, skills and expertise to embrace these changes. Enhancing service provision for patients and clients as an accountable, competent, specialist nurse practitioner is fundamental within modern professional practice [NMC, 2008]. Chaloner [Reference Chaloner2007] emphasises that patient advocacy and ethical nursing practice are integral components of professional practice, and this is endorsed by O'Connor and Kelly [Reference O'Connor and Kelly2005] who state that patient vulnerability, lack of autonomy and disempowerment are the main reasons why this ideal should be embraced.
Background
With this in mind an incident that challenged these core issues and highlighted the need for autonomy by the ANS in fulfilling the role of patient advocate in the provision of quality patient care will be addressed in this article. Reflective practice is the ability to critically analyse actions and use intuition, experience and knowledge to improve professional practice [Schon, Reference Schon1988; Osterman, Reference Osterman1990]. It has been described as an integral element of education and learning for professional nursing which contributes to the exploration of many issues in practice, for example, ethics and confidentiality, communicating with patients and relatives and advocacy. Additionally it encourages practitioners to continually develop their knowledge and skills throughout their professional career [Keen, Reference Keen2000; Bulman and Schutz, Reference Bulman and Schutz2004]. The patient name is a pseudonym to maintain confidentiality and protect personal identity [NMC, 2008].
Pre-Operative Assessment
Kayta was a 39-year-old Polish lady with very limited comprehension of English who was an elective admission for total abdominal hysterectomy due to multiple fibroids in her uterus. As the ANS on the morning of her surgery, while assembling all the information relating to the potential patients booked on the theatre list and prioritising our objectives to enable us to operate effectively and efficiently Kayta's readiness for anaesthesia and surgery was established. This was achieved using information communicated from the multi-disciplinary pre-assessment team, the ward staff, in addition to the computerised theatre management system that is designed to highlight special considerations or potential hazards that could compromise patient care and safety. Despite highlighting to the locum consultant anaesthetist that Katya had language barriers limiting her ability to communicate, he took the decision to use intrathecal diamorphine as post-operative analgesia. This is an unconventional choice of analgesia for the type of surgery planned and one that flagged reservations about its suitability for Kayta.
Owing to her age and relative good health, pre-operative and admission assessments for Kayta were conducted by postal written questionnaire formats which failed address that her spoken language skills were extremely deficient. Furthermore, on admission to the ward that morning she was unaccompanied and no interpreter had been arranged to ensure patient understanding and informed decision making to guarantee high-quality evidence-based care. Simmonds [Reference Simmonds2008] highlights that advocacy within nursing practice is an ideal, guided by national and professional recommendations and standards, that compels practitioners to respect patients decision making and support their choices.
Consequently from reviewing all of the pre-operative evidence it was evident that Katya was in an extremely vulnerable position and unable to make autonomous decisions about her care as her ability to comprehend aspects of her peri-operative journey were particularly limited. Early studies conducted by Bischoff et al [Reference Bischoff, Perneger, Bovier, Loutan and Stalder2003] and later in conjunction with Bischoff and Hudelson [Reference Bischoff and Hudelson2009] indicate that language barriers between patients and healthcare providers is a major obstacle to the provision of high-quality care in culturally diverse populations despite a plethora of literature reinforcing that effective nursing care is strengthened and enriched by high-quality communication as discussed by Sheldon et al [Reference Sheldon, Barrett and Ellington2006].
New waves of immigration within the United Kingdom due to expansion of the European Union challenges healthcare providers to ensure that the health and social care needs of linguistically diverse migrants are met [MacFarlane et al, Reference MacFarlane, Singleton and Green2009]. Regardless of key policy documents readily available at local levels on the provision of interpreting and translation services, access to this area of expertise was not utilised for Katya. Studies carried out by MacFarlane et al [Reference MacFarlane, Singleton and Green2009] attribute the implementation of policies for language support as problematic, with access to trained, professional interpreters being erratic, resulting in heavy reliance on bilingual colleagues or family and friends to provide linguistic support.
At this point Kayta had received information regarding her surgery from her consultant gynaecologist who fortunately was Polish; therefore informed consent was achieved in relation to the risks and outcomes of the actual operation itself as there was no language barrier. The ANS's primary concern was in relation to pain management for Kayta post-operatively and strongly felt that the locum consultant was not considering the difficulties that this could present for Kayta herself and the ward staff trying to ensure her comfort and initiate her recovery process. Ensuring patient's analgesia during and after surgery is both an important clinical priority as well as an ethical component in contemporary healthcare practice [AAGBI, 2006].
Pain Assessment
The ‘gold standard’ in pain assessment is the ability of patients to self report the existence and severity of pain [Pasero, Reference Pasero2009]. Seminal work by McCaffery [Reference McCaffery1983] awarded the landmark definition of pain; ‘Pain is what the experiencing person says it is, existing whenever he says it does’ [McCaffery, Reference McCaffery1983, p. 23]. This philosophy is reflected in accepted pain management strategies today, reinforcing a method for patients to communicate with healthcare providers in relation to effective evaluation of pain management policies and must be adapted to the communication abilities of the individual [Voepal-Lewis, Reference Voepal-Lewis2004].
Failure to manage post-operative pain can have profound detrimental physical and psychological effects on patients that can result in unnecessary levels of distress and suffering. Mackintosh [Reference Mackintosh2007] demonstrates how this can manifest itself in anxiety, sleep disturbance and mobilisation difficulties in combination with elevated heart rate and blood pressure, nausea and vomiting, chest infections and an increased susceptibility to deep venous thrombosis and pulmonary embolus.
As eluded to earlier, all patients in need of anaesthesia are entitled to the same high-quality peri-operative care and this is highlighted in the guidelines by the AAGBI [2006] Good Practice – A Guide for Departments of Anaesthesia, Critical Care and Pain Management. It clearly states that those providing anaesthesia and pain management must ensure patient understanding for non-English speaking patients by providing interpreting services to facilitate communication and prevent post-operative complications as aforementioned. The ANS's primary concern for Kayta post-operatively was that the analgesia chosen by the locum consultant was inappropriate for her type of surgery and there was significant potential for inadequate pain management.
Pain Management
Intrathecal opioids administered directly into the cerebrospinal fluid (CSF) diffuse rapidly into the spinal cord and are highly effective for intra and post-operative pain relief [Bennett and Brown, Reference Bennett and Brown2003]. However after 24 hours alternative forms of analgesia would be required to maintain Kayta's comfort and her ability to communicate with the ward staff to provide an accurate pain assessment would be compromised as a result of the language barrier.
As an ANS the most recurrent effective form of post-operative pain relief prepared for this type of gynaecological procedure would be patient-controlled analgesia (PCA), containing a set, and prescribed measure of morphine that can be administered by the patient. This allows patients to accurately determine their level of discomfort and self medicate appropriately promoting the concept of autonomy and independence by actively involving them in the decision-making process of their care [AAGBI, 2006; NMC, 2008]. Patient education is essential before the implementation and use of a PCA system, but one strongly believed this to be a more appropriate form of pain relief for Kayta, therefore as patient advocate the decision to intervene to bring about its inclusion in her post-operative pain management was made.
Advocacy
Patient advocacy and ethical nursing practice are integral components of professional practice [Chaloner, Reference Chaloner2007]. As patient advocate the ANS had to ensure that Kayta came to no harm and that her autonomy would be respected, therefore embracing the ethical principles of beneficence, non-maleficence and justice [NMC, 2008]. Choosing to intervene on behalf of Kayta presented a conflict of interest between the ANS and the anaesthetist highlighting the possibility of failure.
This outcome can be commonplace for the ANS caught between a feminist ethics nursing perspective and the paternalistic approach of the medical profession. As nurses we seek to implement the theory of the caring relationship with patients and their right to autonomy within the decision-making process that can conflict with the male dominated authoritarian approach that still endures in medical practice today. Oakley [Reference Oakley2006] and Simmonds [Reference Simmonds2008] both recognise this variance and together draw attention to factors that can inhibit and facilitate patient advocacy within the peri-operative environment.
Within the literature the principle barriers to patient advocacy by the nursing profession are powerlessness, lack of support from management, time and communication constraints, spearheaded by conflict and confrontation with the medical fraternity. O'Connor and Kelly [Reference O'Connor and Kelly2005] underline how these negative aspects to patient advocacy can lead to anger and frustration among nurses despite the positivity of acting as a professional, autonomous practitioner and the satisfaction of meeting the needs of the patient. However, they did highlight that conflict appeared less stressful for more experienced nurses whose clinical knowledge and expertise may have been influential in their ability to challenge traditional healthcare power and hierarchical organisations. O'Connor and Kelly [Reference O'Connor and Kelly2005] expand this concept by addressing that clinical knowledge in conjunction with organisational knowledge enabled nurses to advocate more effectively bringing empowerment to facilitate the practice of patient advocacy.
While one felt confident in the role of ANS and patient advocate for Katya on reflection it was with some trepidation that one approached the locum consultant anaesthetist to discuss an alternative form of post-operative analgesia. Their perceived elevated status within healthcare teams can be challenging to question and as ANS and patient advocate one was conscious that in this instance the anaesthetist was a locum who was unfamiliar with both the environment and the peri-operative staff present within the theatre as well as the local policies and procedures that guide practice. That aside, however, the priority had to be professional responsibility and accountability to Kayta and commitment to promoting ethical nursing practice and facilitating patient advocacy.
As an ANS interpersonal and communication skills were tried and tested as one had to be open and honest but knowledgeable without being seen to be critical or judgemental. In a composed firm fashion one explained to the anaesthetist concerns regarding the post-operative analgesia and the potential for a negative impact on Kayta's post-operative recovery. Agreeing and recognising how effective intrathecal opiates are for initial post-operative pain relief with the anaesthetist. However, in this instance, due to the difficulty with language barriers between the healthcare providers stated that a PCA would be more appropriate and promote independence earlier for Kayta. Thankfully the anaesthetist welcomed the input and was open to exploring an alternative on examination of the concerns raised.
Intra-Operative
With the help of Kayta's consultant surgeon who is Polish we were able to converse with Kayta on arrival to the anaesthetic room and discuss her proposed pain management post operatively. We were able to explain and demonstrate how to use the PCA using a training device for patient education, ensuring she was confident how to use it, reinforcing that supplementary oral analgesic medication would also be prescribed and administered to promote her comfort and recovery. Daily ward rounds by Kayta's Polish consultant gynaecologist surgeon would ensure that avenues of communication remained open in the interim, in the absence of any family and friends, while awaiting interpreting services should any problems arise in the post-operative period. By adopting an ethos of nurturing effective team working, we were permitting excellence to flourish through a shared commitment to achieve goals within health and social care [McSherry, Reference McSherry2008].
Post Operative
Kayta had her planned surgery and returned to the ward in a comfortable state and competent in the use of her PCA. Effective communication was established and maintained using the professional input from Kayta's consultant and interpreting services in partnership with that from family and friends. There were no negative outcomes with her surgery or post-operative recovery and she found that any post-operative pain was managed successfully with oral analgesics. This scenario while problematic has served to draw attention to the need for improved service provision and policy development to overcome language barriers within healthcare practice.
Conclusion
To conclude, the role of the specialist practitioner has evolved in response to societal, political and economic issues and has provided nurses with the prospect of moving beyond the role of general nurse and be innovative in practice development [Bryant-Lukosius et al, Reference Bryant-Lukosius, DiCenso, Browne and Pinelli2004]. As an ANS the ability to lead and manage within the peri-operative environment will need to be nurtured and facilitated to achieve professional autonomy and promote patient advocacy [NMC, 2008]. With that in mind one will call upon intuition, experience, knowledge and skills to influence and determine patient care, which ultimately should promote those interests expressed by the patient. The threat of conflict and confrontation can leave practitioners at risk of being professionally ostracised causing personal anguish therefore there needs to be supported within healthcare organisations to promote multi-disciplinary negotiation.
With high-quality patient care a priority on the government health agenda [Department of Health (DOH), 2008], the nursing profession must look at ways to endorse development in practice to sustain the development of specialist nurse practitioner roles. Only then can we be confident that our professional practice is underpinned by the concepts within clinical governance frameworks and appropriate risk management.
