Healthcare practitioners plan patient's care to ensure their best interests and a smoother patient pathway. However, the nurse may consider different clinical decisions when the patient undergoing surgery has learning needs. Reflecting on such decisions enables the nurse to critically examine current practice and expectations which can lead to improved patient care, changes in practice and enhance their personal development.
This article will critically analyse the implications of one episode of patient care, using Gibbs’ ‘reflective cycle’ [Reference Gibbs1988]. This reflective cycle will provide a framework to reflect on my practice, deepen my learning and improve patient outcomes. This reflection involves removing a peripheral cannula in an unconscious patient.
For the purpose of maintaining confidentiality, the patient discussed in this incident I will refer to as Mr B [NMC, 2008].
Description
Mr B, who has severe learning needs, had a change of dressing under a general anaesthetic. His carers were with him in recovery. The carers requested that the nurse removed the patient's peripheral cannula before he fully regained consciousness. The carers stated that the presence of the cannula would become more difficult to safely remove due to the patient becoming more distressed, non-compliant and likely to withdraw consent to treatment. A peripheral cannula usually remains in situ until the patient returns to the ward. Removing this cannula could potentially leave the patient at risk if they needed emergency intravenous access.
I needed to make a clinical decision as to whether or not to remove the cannula before the patient regained consciousness. The anaesthetist stated on handover that the cannula could be removed and the organisational policy stated that unnecessary cannula needed to be removed [Name withheld, 2009].
I waited until Mr B was haemodynamically stable and removed the cannula as he emerged from the anaesthetic. The patient woke up, without the need for an intravenous access and was transferred back to the ward, with minimal distress.
Feelings
I wanted to act in the best interest of the patient and at the same time avoid negligent practice. I was concerned about my professional code of conduct and disappointed that the organisational policy lacked clarity. I felt in a dilemma of how best to minimise patient distress and provide a calm environment, with minimal intervention, while promoting the patient's safety after a general anaesthetic. I had considered the potential risks to the patient, my duty of care and organisational policy before making my decision. As a competent practitioner I felt justified removing the cannula because I was acting in the patient's best interest, I knew that the patient had undergone a short procedure and I waited until he regained consciousness and was haemodynamically stable.
Evaluation
Removing the cannula before Mr B was fully awake caused less distress and did not cause harm. Mr B did not have a further need for a cannula and returned safely to the ward. It was important that the carers had raised concern about the cannula, based on the patient's previous experience and that the anaesthetist had given clear instructions.
The patient's risk could be increased because he did not have peripheral access for intravenous drugs and raises ethical issues of non-malefience and beneficence. However, leaving the cannula may cause the patient distress or non-compliance to treatment. If the patient removed the cannula himself, there would have been a risk of bleeding. It may have become more difficult to provide a safe environment and protect the patient from further harm [NMC, 2010]. Besides, the possible use of restraint would have raised further ethical dilemmas.
Analysis
The main points I have raised in this reflection are the ethical principles of non-malefience and beneficence, consent and the patient's best interest I aim to relate this to the nurse's duty of care as an autonomous practitioner, evidence-based practice and clinical governance to enable me to reflect on my decision making [Reid, Reference Reid2005].
I felt there were many conflicting factors influencing my decision to remove the cannula. I was trying to establish which action would be in the patient's best interest. However, the patient's best interest does not just mean their medical needs but also their emotional, social and psychological requirements [Leyshon and Clark, Reference Leyshon and Clark2005]. This argues in favour of the decision to remove the cannula and not cause further distress, therefore acknowledging the patient's emotional needs in an unfamiliar environment. The perioperative environment is distressing and disorientating especially for patients with learning difficulties and healthcare professionals should reduce anxiety and return patients to a recognisable environment as soon as possible [Humphreys, Reference Humphreys2005]. This is why; once Mr B was awake I transferred him back to the familiar surroundings of the ward. Although the patient's best interest should be central to any decision nurses’ professional judgement, nurses are governed by legal, professional and ethical principles [Humphreys, Reference Humphreys2005; Reid, Reference Reid2005; Koubel, Reference Koubel2006; Dimond, Reference Dimond2008; NMC, 2008].
Acting in a patient's best interest may cause conflict between professional conduct, organisational policy and the nurse making challenging decisions [Turner et al, Reference Turner, Wicker and Hind2000; Koubel, Reference Koubel2006]. The organisational policy should incorporate professional code of conduct [NMC, 2008] and best practice to enable nurses to work within organisational policy and remain within legal and professional boundaries of practice because all such elements have an impact on safeguarding the patient [Reid, Reference Reid2005].
When I reviewed the organisational policy there was no specific guidance concerning the need to maintain a cannula in recovery, but it makes clinical sense to keep an intravenous access for post-anaesthetized unconscious patients. The policy lacked clarity and raises questions of whether my action demonstrates best practice. On reflection, this could be rectified by updating local policy to incorporate clearer guidance to support nurses in their decision making and maintain their legal contract with employers [Hind, Reference Hind2005]. The policy would need to be clearly written to adequately encompasses all needs of patients with learning difficulties because each patient will have different levels of need. I have since discovered that there is a special needs focus group in my Trust who would guide changes in policy.
I felt that the risk of harm caused by self-removal and increased patient distress as the anaesthetic wore off, however, outweighed the benefit for leaving the cannula. I was acting as an autonomous practitioner to reduce the potential of malefience to the patient and acting in his best interest. My decision making was partly influenced by my clinical judgement and previous experience of similar situations [in line with Turner et al, Reference Turner, Wicker and Hind2000].
I discussed this issue with colleagues; some agreed that in this particular situation they would remove the cannula, while others disagreed; they would delay removal of the cannula unless causing the patient distress. Nurses make decisions as to what they deem is right and often with discussion from colleagues [Turner et al, Reference Turner, Wicker and Hind2000]. However, would this action be ethically justified if the patient needed peripheral access?
Further reading suggests that nurses need advanced clinical skills and professional judgement to understand what is in the patients’ best interest [Koubel, Reference Koubel2006]. This is relevant when nurses in recovery are caring for patients who remain dependent; even after emergence from anaesthesia [Turner et al, Reference Turner, Wicker and Hind2000].
Following government legalisation such as the Mental Capacity Act [2005], nurses in recovery have an important role to act as independent autonomous practitioners and optimise safe patient care [Pittaway, Reference Pittaway2004; Fullbrook, Reference Fullbrook2007]; nevertheless, decision making needs to be evidence based and nurses still remain accountable for their actions under professional law [Turner et al, Reference Turner, Wicker and Hind2000; Hind, Reference Hind2005; Reid, Reference Reid2005; Koubel, Reference Koubel2006; NMC, 2007]. Therefore, nurses need to understand the ethical principles to avoid causing harm, malefience and to avoid negligence as part of their duty of care to the patient's best interest [Sutton, Reference Sutton2003; Dimond, Reference Dimond2008; Fullbrook, Reference Fullbrook2007; NMC, 2008]. Omission of care can be negligent [Howard and Shelly, Reference Howard and Shelly2004]. On reflection, it would be difficult to view omitting to remove the cannula as malefience, as this action would not have been outside of hospital policy. However, the action of removing the cannula could relate to the principles of beneficence because I had tried to act in a way to promote good [Humphreys, Reference Humphreys2005; Reid, Reference Reid2005; NMC, 2008]. Or would the reverse be true if the cannula had been needed?
Another factor that influenced my decision was consent and the ethical principle of respecting the patient [Fullbrook, Reference Fullbrook2008]. Gaining consent is difficult if the patient becomes non-compliant and refuses treatment even if this is due to confusion during a vulnerable period for patients. NMC [2008] stresses the importance of consent for treatment but this is difficult with an unconscious patient, especially when they have learning difficulties [Leyshon and Clark, Reference Leyshon and Clark2005].
Humphreys [Reference Humphreys2005], recognises that anaesthetic drugs impair an adults’ ability to give consent but the law allows nurses to carry out interventions that are considered reasonably necessary and in the best interest of the patient. This acknowledges that sometimes nurses make decisions without being able to gain consent from the patient.
In emergency situations, health professionals are protected with the ‘treatment of necessity’ when treating unconscious patients. In recovery, the unconscious patients are not in an emergency situation but nurses still need to demonstrate that the decisions they take are reasonably necessary and in the patients’ best interest [Reid, Reference Reid2003]. Leyshon and Clark [Reference Leyshon and Clark2005] support this and stress that nurses need to remain accountable for their actions and to maintain update to ensure that they are familiar with recent changes such as the Mental Capacity Act [2005].
Another relevant point raised by Reid [Reference Reid2003] is that nurses must not make assumptions within the perioperative setting due to the patient's apparent mental capacity. It can be difficult to distinguish between respecting a patient's best interest and avoiding negligence [Humphreys, Reference Humphreys2005; Dimond, Reference Dimond2008].
Conclusion
I have learnt a lot from critically analysing this experience and using Gibbs’ [Reference Gibbs1988] reflective cycle has enabled me to question current practice within my workplace [Lange, Reference Lange2009]. I realise that nurses caring for patients with learning difficulties use elements such as experience and clinical judgement. Nevertheless to improve patient care, nurses need to ensure that they are familiar with current literature, policy, legal and ethical principles and that their decision making is evidence based.
On reflection, I feel I am able to justify my clinical decision for this patient. I realise it is not appropriate to remove the cannula in recovery for every patient with a learning disability. If a similar situation occurred, my decision making would follow the same process and still be dependent on many factors including organisational policy and the patient's best interest.
This reflective practice has enabled me to relook at ethical principles and other elements that would affect my clinical judgment decision and interventions. Care needs to be planned preoperatively to minimise distress to patients with learning difficulties in order to enable smoother patient pathway. It is not unusual for similar patients to be discharged from recovery instead of transferring back to the ward. On reflection with colleagues, it is clear that this incidence was not an isolated incident but a dilemma that can often occur.
Action plan
To prevent this from happening again and as part of my action plan for practice development, I will highlight this incident at our next staff meeting and recommend that an audit is carried out to establish how frequently similar situations are occurring. Once I have the audit results, I plan to consult with the special needs focus group and develop a policy specifically for patients with learning needs in the perioperative area. A review and update of the hospital policy would ensure that best practice is still underpinning current policies.
This policy will clarify practice that is currently carried out in recovery. This will be particularly essential for junior staff caring for this specific group of patients and enable them to make appropriate decisions for best practice and maintain organisational policy. I will liaise with the Day Surgery Unit and theatres to facilitate standardised care and documentation [Turner et al, Reference Turner, Wicker and Hind2000; Reid, Reference Reid2005] and maintain good communication between multidisciplinary team to smooth the patient's surgical pathway. This can include making sure carers are near recovery for when the patient wakes up. Furthermore, I will plan teaching sessions on legal and ethical principles as a refresher to staff within my unit. Staff can also attend learning disability masterclasses offered within our trust.
