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6NU547 Care Of The Surgical Patient

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6NU547 Care Of The Surgical Patient

1 Download18 Pages / 4,283 Words

Course Code: 6NU547
University: University Of Derby

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Country: United Kingdom


Learning Outcomes
On successful completion of this module, students will be able to:

critically appraise their own role in relation to the care of the surgical patient
critically examine contemporary issues and challenges in surgical care
synthesise theory and practice in relation to learning from incidents and implementing solutions to minimise the likelihood of them reoccurring

Assessment Criteria

When marking assignments the examiners will be looking for the following criteria:
Clear legible presentation.
There should be good use of spelling, grammar and language throughout.
Appropriate focus meeting learning outcomes/assignment criteria
Logical progression and structure of arguments.
Normally assignments will require an introduction, a well-developed discussion and a conclusion summarising the work.
The introduction will include an exploration of the focus of the assignment and discuss the way the assignment has been approached.
There should be a coherent flow of information/discussion with clear links back to the question set.5


This assignment will focus on the process used for effective communication to promote recovery in surgical patient. As a surgical nurse in acute care clinics, I have encountered many types of surgical patients with different types of health complexities. Along with the type of surgery, the challenges in pre-surgery and post-surgery phase also increase because of the presence of many other co-morbidities or other health condition in patient. Co-morbidities have a significant impact on surgical outcomes of patients. Surgical outcomes are also influenced by many other factors such as types of operation, quality of care, patient characteristics and presence of other concurrent disease (Inokuchi et al. 2014). Identification of risk factors for complications in the pre and post-operative complication is an important approach to reduce complications in patients (Hollis et al. 2016). We follow series of pre-operative assessment and post-operative assessment activities to find out any risk associated with patients past medical history and current health status. However, based on my experience of caring for surgical patient in a busy hospital setting where wide range or surgeries are performed, I can say that effective communication with surgical patient and the multi-professional team is an important pathway for a safer surgical journey.
As a surgical nurse, I have worked in busy hospital settings where both general and specialized surgeries are performed.  I have met and interacted with surgical patients on a daily basis to conduct routine assessment before and after surgery. Apart from the clinical aspects of care, I was not aware that communication can promote safety practice and positive health outcome for patients in such a significant way until I experienced an event of communication breakdown with surgical patients. I started paying attention to the communication aspects of care after I experienced many challenges in providing care because of communication related errors. There were many situations where complications for patients could have been avoided had I taken the approach to effectively communicate with patients regarding necessary preparations before surgeries and the things they should avoid before surgery as per their clinical condition. After critically reflecting on discussion post related to effective communication during the peri-operative phase, I learnt about the communication methods while providing care to the surgical patient. Reflection on the learning material and activities completed throughout the unit will help in providing a critically reflective portfolio of evidence regarding synthesis of theory-practice interface in relation to effective communication for the care of the surgical patient.
The main purpose of the reflective portfolio is to reflect on the importance of effective communication to prevent complications and promote safety in surgical patient, to evaluate contemporary issues and challenges related to engaging in effective communication with the surgical staff and patient. The assignment has been approached by first discussing on the role of effective communication in surgical care along with support from research evidences. The next step would focus on critical appraisal of own role in relation to the care of the surgical patient and critical reflection of personal discussion postings related to the effective communication and use of WHO surgical safety checklist in practice. It also demonstrated how the theory-practice gap is minimized by learning from incidents and implementing lessons from the discussion posting to minimise the likelihood of adverse events in the future.
Reflective narrative
Role and advantage of effective communication in the care of the surgical patient:
Majority of errors in the peri-operative setting occurs due to communication failures (Seifert, Graling and Sanchez 2017). The likelihood of communication breakdown is high because of the fast paced nature of the peri-operative environment. Nurses who enter newly into surgical practice lack the skills to handle the fast paced nature of the surgical environment and they fail to share and communicate vital patient information to other medical staffs. Lack of skills in effective communication leads to patient safety issues and affects morale, self-esteem and engagement of health care workers. Hence, it can be said that poor communication has impact both on patient and staffs. Cvetic (2011) explains that improving communication between peri-operative team and patients can improve the likelihood of providing competent, efficient and safe surgical care to patient. It also minimizes burden during surgical practice by decreasing uncertainty regarding surgical procedures, promoting harmony during team work and facilitating cost savings.  Due to these benefits, staffs entering into surgical setting are expected to have effective interpersonal communication skills.
While preparing for my surgical nursing course, my educator also gave brief idea regarding communication process during peri-operative care. My professional nursing course built theoretical knowledge on the topic. However, I experienced theory-practice gap when I started practicing in real setting. Communicating with patients as well as other care providers became a challenging task for me as I failed to keep up with the demands of other tasks. Communication aspect was ignored by me at this time. However, after facing the aftermath of communication breakdown, I realized that education related to safe communication measure was essential for me. After receiving proper mentoring in communication aspect of surgical care, I realized that implementation of safe communication protocols and checklist provide great support to nurses in reporting about patient’s condition and minimizing errors. Further insight into specific scenarios, the challenges that I faced as a surgical nurse in clinical setting and the lessons that I learnt from them has been provided below.
Issues and challenges in the care of the surgical patient and identification of solutions to the issue
I started practicing in the area of surgical care after obtaining formal degree in the field. I work in a critical setting where all types of surgical procedures are performed. My specialty is in peri-operative nursing. A peri-operative registered nurse has wider scope of nursing responsibilities compared to other registered nurse. Peri-operative registered nurses have to accurately implement their duties in all three phase of surgery- before, during and after surgery. They need to provide care to patients by proper assessment, planning and implementation of nursing care in all the three phase of surgery. Other specific responsibilities include patient assessment, maintenance of sterile and safe surgical environment, patient education, monitoring of patient safety and coordinating with patient throughout the surgical care journey (AORN 2016). However, various environmental, team and individual barriers created challenges for me in fulfilling all the responsibilities.
In the area of communication during surgical practice, Cvetic (2011) explained that having good communication is crucial to aid practitioner in asking the right question from patient. Interpersonal communication skills help health care staffs to build rapport with patient and promote therapeutic relationship with patient. However, the communication should not be a one-way process. Instead it should be a two way communication process where a practitioner should ensure that the person receiving the information have correctly understood the message. Taking this responsibility is vital to prevent communication breakdown. Kurtz, Draper and Silverman (2016) states that active listening is also important to keep patients engaged in the decision making process. However, theoretical knowledge is not always explicit and new and unique challenges confront health care staffs when they start to internalize the process in their clinical practice (Austin 2016).
Based on my experience as a surgical nurse in clinical setting, I realized that following the above mentioned steps was not an easy task in practice setting. For example, during my initial days of practice, I had to take care of an old lady who was to undergo a hip replacement surgery. During the assessment, I got to know that the patient was allergic to a medicine. I asked the patient to notify this to the incoming support staff. I also had the responsibility to note it down in the handover chart before my shift time. However I missed updating the information on the chart as I got distracted by an emergency call from another ward. On the next day, I had to bear the consequences as the patient’s surgery was delayed because of the communication breakdown. She developed acute allergy and was in great discomfort. Reflecting on this activity, I learnt that I could not accurately fulfil my responsibility as a surgical nurse because of the presence of various distractions in clinical practice. Persoon et al. (2011) supports the fact that distractions in the clinical environment are detrimental to clinical performance and quality of care. Distractions may come in the form of telephone calls, irrelevant conversation between clinical task and overcrowding. Although, the effect of distracting stimuli are difficult to measure, however dealing with them is one of the contemporary issues for surgical nursing staffs.
While reflecting on the above incident, I could interpret that actual practice is challenged both by environmental and individual barriers. For example, environment specific barriers like distractions and emergency calls pose risk to patient safety. However, I realised that personal accountability also plays a role in correcting errors or preventing errors. Hence, the error during the assessment of the old lady with surgery could have been avoided, had I taken the step to engage in one-to-one communication by asking whether the patient had understood my message or not. O’hagan et al (2014) affirms that checking correct understanding of patient during information delivery is critical for safe and high quality care. This action leads to the completion of an effective communication activity during care of the surgical patient. Hence, the degree to which a surgical nurse or surgical staff is accountable during the communication process also has an impact on risk event. Peri-operative nurse are accountable not only till the time they deliver care, but also for ensuring continuity of patient care (Renholm et al. 2017). For this reason, implementation of certain communication resource like checklist and communication is considered useful as these tools provide easy way to shared patient’s information in the right manner to maintain continuity of care.
Certain communication resource in the pre-operative setting standardizes the communication process and plays a beneficial role in patient safety. For example, patient handover charts, patient safety checklist and crew resource management are tools to address unintentional events. They cannot address all types of barriers in communication process, however they aid surgical staffs in maintaining continuity of care and ensuring that the care delivered is free from any errors (Cvetic 2011). New research and new evidence constantly adds up new resources for surgical staffs so that they can enhance the quality of care delivered to patients with complex surgery. After reading the discussion posting, I came to know about the use of the WHO Surgical Safety Checklist in minimizing risk and improving communication across the peri-operative staff. The utility of the tool is that it ensures consistency across the team caring for a surgical patient by providing 19-point checklist. It provides list of activities to be done before induction of anaesthesia, before skin incision and before patient leaves the operating room (World Health Organization 2016). The briefings for the WHO checklist mentioned that-
‘The WHO safe surgery checklist contains the important steps to ensuring that each and every operation is performed correctly, reducing morbidity and mortality risks’-(World Health Organization 2016)
After reading the WHO briefing, I realized that simply following the checklist may not improve patient’s outcome after surgery. While reflecting on of the utility of the WHO briefing checklist on the discussion posting, I could interpret that the tool can be successful in offering multiple safety checks only when it is executed as it is intended. Adherence to the checklist is dependent on the safety culture and awareness of the staffs regarding the utility of the tool. Strong leadership also plays a role in encouraging the whole medical team to use the checklist (Zingiryan et al. 2017). Resistance and poor acceptance of service is common within health care environment. The evidence regarding the utilization of WHO checklist in surgical setting of eight countries revealed challenges in implementing the tool because of difference in guidelines for routine intra-operative management in many countries (Treadwell, Lucas and Tsou 2014).  However, after overcoming the implementation related challenges, it was found that introduction of checklist significantly decrease patient mortality rate and inpatient complications within 3-6 months. In my own practice setting, many surgeons resisted to using the checklist. However, once the checklist was implemented after proper training, it was found that the WHO safety checklist became an activity that could be initiated by any discipline without any difficulty. I also acknowledge the usefulness of the tool as it gives both nurse and other senior staffs the opportunity to accurately report about patient’s status in the right manner.
On critical evaluation of the reasons for which the WHO checklist worked in my practice setting, I could identify that local adaptation factors like safety culture and preoperative briefing worked to our advantage. Synergy between safety culture and positive patient safety outcome has been found based on research evidence synthesis. Fan et al. (2016) conducted a survey on patient safety cultural factors such as communication openness, feedback and communication about errors, handoffs and transition, staffing level and team work across surgical units. Presence of effective safety culture was associated with better safety culture. Employee satisfaction, responsive management and liberty to speak about patient safety issues favoured getting such outcomes. The findings is consistent with the arguments by Hemingway, O’malley and Silvestri (2015) as the study reported that changing the process for safety reporting, adding resources and communication related to adverse events prevents surgical errors and ensures that appropriate safety measures are in place to promote recovery of patient.  
Team briefings are also regarded as an important aspect of safety culture and incorporation of this with the WHO checklist can enhance outcome of surgical patient. I would say that our surgical team were able to successfully implement the WHO safety checklist because we had the team briefing already in place before the introduction of the checklist. Evidence supports the positive effects of peri-operative briefing and debriefing on patient safety outcomes in surgical setting. On the contrary, Duclos et al. (2016) argues that even when safety checklists are implemented in hospital setting, it cannot completely remove errors and patient complications. With my own personal experience, I can also relate with the point because I had the handover checklist, however my failure to appropriately document patient’s information contributed to communication and patient safety issues. Hence, correct utilization of resource is also a challenge while providing care for the surgical patient. I realized the importance of team briefings after going through the evidence by Leong et al. (2017). The evidence revealed the potential of team breifing in readily sharing information and lowering barriers to speaking up with individual health care staffs. Briefings and debriefing before and after daily surgical routines has been found to positively influence team climates and increase the efficiency of the surgical programme Therefore, team briefings can be a solution for surgical team to address the challenge of poor utilization of safety resource.
During the discussion posting, one of the responses was that ‘WHO Safety checklist  ….gives that moment for the team to come together and stay focus on that particular patient’. On reflecting on this posting, I had the question whether WHO safety  checklist can improve team communication process and prevent errors in surgical settings that occurs because of poor team communication. Although communication is a crucial part of the surgical care pathway, however failure in communication and information transfer has been widely witnessed. I was myself involved in one such incident because of incomplete handover process. Mahaffey (2010) gave idea regarding other instance of communication failure during the care of the surgical patient. The semi-structured interview with multi-disciplinary surgical team such as surgeons, nurses and anaesthetist revealed communication failure in each phase of surgery. During the preoperative assessment phase, communication failure occurred because of poor communication between surgical and anaesthetic teams. In both the pre and post operative phase, communication failures occurred because of poor handover and incomplete or missing information. In response to these challenges in the surgical care setting, I found that briefing and the WHO checklist together can address this challenge. Mahaffey (2010) explained that WHO checklist can support multi-professional surgical team in improving patient safety outcomes within operating theatres where as the briefing and debriefing process has the potential to improve care planning and communication before and after the operations. Therefore, combination of both strategies can be crucial to prevent communication breakdown between inter-professional surgical staffs.
Effective communication is also important in a culturally diverse environment as intercultural doctor-patient contacts is also a potential source of misunderstanding and poor quality communication (Paternotte et al. 2015). Effective communication between patient-staffs is regarded as a necessary part of the surgical care process. Research literature also provides evidence regarding challenges in peri-operative communication process due to intercultural gap between staff-patient. During my practice as a peri-operative nurse, I experienced challenges in communication with a patient from other cultural background as I could not interpret the patient’s communication related to pain. The patient did not favoured taking analgesics for pain because of side effects and she wanted to take herbal drugs to cure herself. Instead of rationally explaining the patient the necessity of taking analgesics, I allowed her to use her herbal drugs. This resulted in longer hours of suffering for patient due to pain. Barrington et al. (2016) also identified the above mentioned types of problem while providing care to surgical patients.
A qualitative study by Clayton, Isaacs and Ellender (2016) explored lived experiences of challenges faced by peri-operative nurses in a multicultural surgical setting. The interview response revealed how multiculturalism affected patient-staff communication process. During pre-operative care, anaesthetics section is an opportunity to enter into good communication process with patients. However, many patients fail to convey their needs to the nurse and they may not express what they want contributing to quality and patient satisfaction issues. Patient who do not know English language fail to get desired care. The discrimination faced is understood from the following quote in the study: ‘…….because they couldn’t speak English properly, turned up, she wasn’t happy’ (Clayton, Isaacs and Ellender 2016). This quote reflects that pre-operative nurse need additional skills set to effectively communicate with patients from diverse cultural background. I think to address this problem, the role and responsibility of a nurse manager is critical. The above evidence also gives implications for change in peri-operative nursing education in countries where multiculturalism is a norm. As a peri-operative nurse, looking for factors that can for effective communication with patient is important. As stated by O’hagan et al. (2014), certain techniques in interactions such as open or close ended questions, paraphrasing, clarifying information and giving patient the opportunity to talk lead to effective communication process. Manners like tone of voice, smiling gestures and sense of friendliness towards patients can facilitate rapport building and information gathering phase.
The critical reflection of my own role in the care of the surgical patient summarized various situations where complying with peri-operative nursing responsibilities became a challenge for me. I entered into practice accompanied with much theoretical knowledge regarding the skills set needed to correctly assess patient in the surgical setting and the responsibilities related to communication with patient and the multi-professional team. However, exposure to real setting confronted me with many types of challenges in surgical practice. Internalizing theory into practice became difficult when I realized that practice in real setting is associated with many barriers such as distraction, work overload, language and culture gap and communication gap. Inability to overcome some of these barriers created practice issues for me.
Peri-operative care setting is a fast paced environment and the reflective portfolio described distraction as the first challenges for me which lead to communication breakdown between staffs and affected patient outcomes. Distraction is one of the examples of environmental barriers while entering into effective communication process during patient assessment before or after surgery. The portfolio identified that by displaying accountability in care, peri-operative nurse have the potential to overcome environmental barriers too. For example, in the scenario of incomplete handover process for the old lady, taking the step to ensure that patient has correctly interpreted the message could have prevented communication and medical errors during care of the surgical patient.
Earlier I had the assumption that several resources in surgical setting such as handover report, patient chart and other tools are for the ease of surgical staffs so that they can easily pass on information to each members. However, I realised that these resource can become redundant if accurate safety culture and team work does not exist. In response to the discussion posting on the utility of the WHO safety checklist for surgical practice, the paper summarized that the WHO checklist can provide all staffs irrespective of experience the opportunity to accurately report abort patient’s status in crucial stages of the surgical journey. Despite this advantage, review of research evidence revealed that success of WHO safety checklist was dependent on the presence of safety culture and effective team work in clinical setting. Team briefing and debriefing before and after surgery together with the WHO safety checklist can promote efficiency in surgical care. The paper also summarized challenges for peri-operative nurse because of the multicultural environment in surgical setting. In response to the issue of communication gap because of cultural and language difference between patient-nurse, training of newly placed surgical in the area of cultural competence and communication techniques has been identified to enhance the quality of care. Changes in nursing education program is also necessary for countries where multiculturalism has become a norm so that newly placed surgical nurse do not experience theory-practice gap during care of the surgical patient.
Reference list
AORN 2016. Standards of perioperative nursing. Retrieved from: https://www.aorn.org/-/media/aorn/guidelines/aorn…/ii-01_standards_2015.pdf
Austin, J., 2016. A failed perioperative nursing journal club: Reflections on mistakes made, and lessons learned. ACORN: The Journal of Perioperative Nursing in Australia, 29(2), p.18.
Barrington, J.W., Lovald, S.T., Ong, K.L., Watson, H.N. and Emerson Jr, R.H., 2016. How do demographic, surgical, patient, and cultural factors affect pain control after unicompartmental knee arthroplasty? A multivariable regression analysis. The Journal of arthroplasty, 31(9), pp.97-101.
Clayton, J., Isaacs, A.N. and Ellender, I., 2016. Perioperative nurses’ experiences of communication in a multicultural operating theatre: A qualitative study. International journal of nursing studies, 54, pp.7-15.
Cvetic, E., 2011. Communication in the perioperative setting. AORN journal, 94(3), pp.261-270.
Duclos, A., Peix, J.L., Piriou, V., Occelli, P., Denis, A., Bourdy, S., Carty, M.J., Gawande, A.A., Debouck, F., Vacca, C. and Lifante, J.C., 2016. Cluster randomized trial to evaluate the impact of team training on surgical outcomes. British Journal of Surgery, 103(13), pp.1804-1814.
Fan, C.J., Pawlik, T.M., Daniels, T., Vernon, N., Banks, K., Westby, P., Wick, E.C., Sexton, J.B. and Makary, M.A., 2016. Association of safety culture with surgical site infection outcomes. Journal of the American College of Surgeons, 222(2), pp.122-128.
Hemingway, M.W., O’malley, C. and Silvestri, S., 2015. Safety culture and care: a program to prevent surgical errors. AORN journal, 101(4), pp.404-415.
Hollis, R.H., Graham, L.A., Lazenby, J.P., Brown, D.M., Taylor, B.B., Heslin, M.J., Rue, L.W. and Hawn, M.T., 2016. A role for the early warning score in early identification of critical postoperative complications. Annals of surgery, 263(5), pp.918-923.
Inokuchi, M., Kato, K., Sugita, H., Otsuki, S., and Kojima, K. 2014. Impact of comorbidities on postoperative complications in patients undergoing laparoscopy-assisted gastrectomy for gastric cancer. BMC Surgery, 14, 97. https://doi.org/10.1186/1471-2482-14-97
Kurtz, S., Draper, J. and Silverman, J., 2016. Skills for communicating with patients. CRC Press.
Leong, K. B. M. S. L., Hanskamp-Sebregts, M., van der Wal, R. A., and Wolff, A. P. 2017. Effects of perioperative briefing and debriefing on patient safety: a prospective intervention study. BMJ Open, 7(12), e018367. https://doi.org/10.1136/bmjopen-2017-018367
Mahaffey, P.J., 2010. Seductions of the WHO safe surgery checklist. BMJ: British Medical Journal (Online), 340.
O’hagan, S., Manias, E., Elder, C., Pill, J., Woodward?Kron, R., McNamara, T., Webb, G. and McColl, G., 2014. What counts as effective communication in nursing? Evidence from nurse educators’ and clinicians’ feedback on nurse interactions with simulated patients. Journal of advanced nursing, 70(6), pp.1344-1355.
Paternotte, E., van Dulmen, S., van der Lee, N., Scherpbier, A.J. and Scheele, F., 2015. Factors influencing intercultural doctor–patient communication: A realist review. Patient education and counseling, 98(4), pp.420-445.
Persoon, M. C., Broos, H. J. H. P., Witjes, J. A., Hendrikx, A. J. M., and Scherpbier, A. J. J. M. 2011. The effect of distractions in the operating room during endourological procedures. Surgical Endoscopy, 25(2), 437–443. https://doi.org/10.1007/s00464-010-1186-8
Renholm, M., Suominen, T., Puukka, P. and Leino-Kilpi, H., 2017. Nurses’ Perceptions of Patient Care Continuity in Day Surgery. Journal of PeriAnesthesia Nursing, 32(6), pp.609-618.
Seifert, P.C., Graling, P.R. and Sanchez, J.A., 2017. Preventing Perioperative ‘Never Events’. In Surgical Patient Care (pp. 413-448). Springer, Cham.
Treadwell, J. R., Lucas, S., and Tsou, A. Y. 2014. Surgical checklists: a systematic review of impacts and implementation. BMJ Quality & Safety, 23(4), 299–318. https://doi.org/10.1136/bmjqs-2012-001797
World Health Organization 2016. WHO Surgical Safety Checklist. Retrieved from: https://www.who.int/patientsafety/safesurgery/checklist/en/
Zingiryan, A., Paruch, J.L., Osler, T.M. and Hyman, N.H., 2017. Implementation of the surgical safety checklist at a tertiary academic center: Impact on safety culture and patient outcomes. The American Journal of Surgery, 214(2), pp.193-197.

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