Exemplars Critical nursing incidents where you made the difference - Contemporary Nurse: Healthcare Across the Lifespan

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Exemplars

Critical nursing incidents where you made the difference

Helen Calabretto
School of Nursing, University of South Australia, SA

PP: 083 - 086

Article Text

Cultural differences

I was recently on clinical placement at a large public hospital. I was placed on a ward of children whose ages ranged from 2 months to 14 years. The majority of clients were not confined to bed all day long so there was much activity on the ward. Parents were allowed to stay with their children all day and folding beds were put up for them next to their children's beds if they wished to stay over night. In this setting, family involvement and family health education was a reasonable slice of the nursing care. It was quite usual to see nursing staff at bedsides talking to clients, families or care-givers.

Around some beds there seemed to me to be quiet space. Here, not so much activity was going on. The children were not more ill or debilitated. I thought at first that they were quiet clients with quiet families. The people in this group were an Aboriginal girl and her mother, three Vietnamese parents and their children and one 13- year-old Vietnamese girl.

Did these people prefer their own company? At visiting time these clients, with the exception of the Aboriginal family, had large groups of relatives and friends surrounding their beds. Was there a language barrier? One Vietnamese mother spoke very little English, as did one Vietnamese father. The other Vietnamese mother spoke fluent articulate English, as did the Vietnamese teenager and the Aboriginal mother and daughter. Did the perceived language barrier cause difficulties? Did the staff feel uncomfortable spending time in an area where another language was spoken? Did unknown cultural norms and boundaries make staff feel uncomfortable? The staff, without exception, were white 'Europeans'.

One of the Vietnamese children was very ill, remaining in bed while her mother, or other family member, hardly left her side. Opposite her was a white Caucasian boy who was also very ill. Many nurses came and went around his bedside and talked with his family about his progress. The child was never in my care and yet I knew of his condition and progress from a running staff commentary. I didn't ever find out the reason for admission, or progress, of the little girl opposite.

She didn't seem to warrant the same attention. The Aboriginal mother and child sat by themselves and watched television except when observations were performed. This was also the case for the Vietnamese father and son. These were my perceptions. It could be argued that as a neophyte nurse I am dripping with idealism and oozing altruism. However, I am a mature- age student and am aware, from being in the work-force, that practicalities like staffing, time-constraints and work-loads can easily squeeze one's best intentions and ideals into a small corner. Did unknown, unfamiliar norms and boundaries make the staff feel uncomfortable about spending time with these clients? Or did unknown, unfamiliar norms and boundaries make the clients and families feel uncomfortable? The nurses on this ward were genuine, caring, careful people who were concerned for the welfare of their clients. I believe they were unaware of the discrepancy in their behaviour toward clients of differing ethnic backgrounds.

It seemed it may have been easier for them to make a bed, wipe a dirty nose or take a faeces sample, than it was to sit awhile with a client and/or family from a culture unfamiliar to their own. It could be said that these clients, who themselves are in a foreign culture, whose English language skills are minimal, and whose perception of hospital may be vastly different from that of the dominant culture, require an even larger slice of nursing time than those who are in more familiar setting and who are thus able to find out information themselves by asking and reading literature, reading signs and networking with other families of sick children.

I am writing from the position of the dominant culture. It is not possible to be au fait with all the cultural differences that one might meet in a healthcare setting. Australians now live in a community comprised of many different national groups.

These groups have different ways of relating and a nurse does not always know when to smile, or to whom or in what manner to address the family group. Nor is it obvious when, where, or with whom friendly body contact is appropriate. Nurses, however, belong to a professional body of care-givers and this means setting aside our own biases, prejudices and discomfort and treating our clients with impartial care. We may fear doing the wrong thing but in this multicultural society.

Karma Anthony

Whose choice?

Use of these medications brings not only the benefits of controlling disturbing experiences for the psychotic person, but also unwanted side effects. These side effects can range from transient feelings of restless jitters and a dry mouth, to an irreversible movement disorder called tardive dyskinesia. The term 'tardive' indicates a late appearance. Thus the associated symptoms of lip-smacking, grinding of teeth, rolling and protrusion of the tongue and diaphragmatic movements may appear months or years after commencement of antipsychotic medicines. Keltner, Scweck and Bostrom (1991), report that 15- 25% of persons receiving these drugs long-term will manifest tardive dyskinesia.

Unless it is noted very early and the drug ceased, the symptoms once established often stay with the person throughout his/her waking life, subsiding only with sleep. Compliance by clients in taking major tranquillizers is negatively affected by several factors, none the least of which is the range of side effects which may be experienced.

The following exemplar illustrates the state described above. We met when I was a charge nurse in a small psychiatric unit specifically devoted to the treatment of early psychosis. The client was an intelligent young woman with an established career. Two episodes of paranoid psychosis had crashed into her, wrecking her worklife, turning her around like a cord twisting on itself.

Equally, the experience laid her family waste to the effects of self-recrimination. At the time of our meeting she was vociferously making known her dislike of the unwanted effects she experienced from the prescribed medication. Given her stand and the mistrust implicit in her psychiatric diagnosis, it was with relief all round that a particular antipsychotic drug proved to impact on her thinking and perceptions without causing distressing side effects.

As she recovered she developed an explanatory model of her painful experiences which aligned with the medical view. She accepted her diagnosis and believed in the necessity of on-going drug treatment. She responsibly attended all community clinic appointments, but over the years has always resisted suggestions by her psychiatrist to reduce and gradually withdraw medication. He had informed her of the risks of tardive dyskinesia. Despite this she staunchly maintained her view, the fear of a return to being out of control was too large to face. For six years she has remained well with no further psychiatric hospitalizations. She has grieved the death of her father, found alternate part-time work, lives with her mother and has been innovative in developing coping strategies for dealing with her life stressors.

Recently she contacted me because her family had noticed she was displaying the lip-smacking movements. Once this is pointed out to her, she can stop for a short period. However, she is unaware of the action without others making the observation. Her conversation began in a frightened tone with great concern that her doctor would automatically cease her medication on discovering the movement problem. She wanted to know, 'Do I have a choice?' She sought further assurance that seeking an alternative medical assessment was acceptable.

In confronting her fears she wanted enough information to make an informed choice about her behaviour and its relationship to her medication. She also wanted time to consider the possible outcomes of any course of action she might embark upon. Following our conversation she sought a second medical opinion. She accessed literature on tardive dyskinesia. She has made a decision to gradually decrease the dosage of her medication as she prepares to stop taking it. In light of her worst fears she has enlisted hospital support should she require readmission and she has sought family feedback on her behaviour. To decrease the level of stress in her day-to-day life she has also organized the postponement of a training program she was to undertake at work.

I believe our conversation facilitated her in this problem solving in several ways. Firstly, it allowed her to paint her own picture of the situation. I asked questions which helped her clarify her feelings and allowed time for her to verbally explore her fears. I then provided information and considered a range of options with her. By doing so I validated her right to choose a course of action, as well as being the person in control of this decision. She didn't feel pressed to make an on-the-spot choice, but rather I encouraged her to take some time to reflect on the range of possibilities we had covered.

Underlying these distinct components were less tangible elements which made this a successful encounter. It was facilitated because we already knew each other. We respected each other. I believed in her capability and right to choose what was best for her. I liked her as a person and cared about her well-being. It may seem strange that a person might choose to continue taking a medication knowing the inherent risks of tardive dyskinesia.

Some might suppose that those prescribing and administering the medication should automatically stop doing so once this side effect had emerged. But, it can also be argued that we cannot offer a patchy life-raft to keep someone afloat only to sink it as soon as it proves itself faulty. Nurses and psychiatrists as mental health professionals cannot force a person to swim, perhaps back into a shark infested reality. The choice is not ours to make.

Rhonda Goodwin

There is more to CPR than ABC

Nurses in general ward areas face the possibility of having to perform Cardio-Pulmonary Resuscitation (CPR) on a daily basis. In terms of educational practice all nurses receive instruction on basic life support at least once a year and are assessed to determine competence. The relevant equipment is kept up-to-date and tested regularly to provide reliable and functional service. Periodically there is a review of resuscitation policies and protocols. These elements are central to the provision of an effective emergency service, however there is reason to believe that in many instances they are perceived as being representative of the total nursing responsibility rather than the minimum requirements.

The following account illustrates that whether or not the resuscitation team's efforts are successful, there may be a number of issues raised which require management staff to look beyond the routine activities of Contemporary Nurse restocking equipment, notifying the relatives and documenting the incident. Whilst working as a nurse manager in a large rehabilitation hospital, Henry received a message that a patient required resuscitation.

Two minutes later he found staff in the preliminary stages of conducting basic life support on an elderly man. The man had collapsed at the back of the ward and was lying on the floor. A short time after Henry had completed his clinical assessment and employed a resuscitation mask, the medical staff arrived. The patient was intubated and artificially ventilated with a four litre rubber rebreather bag. After only a few cycles the doctor discovered that the bag had developed a puncture and would no longer inflate.

The staff standing by quickly produced a second bag but within a short time it also developed a leak. This time the leak was sealed with water-proof tape. A second doctor took longer than expected to attach the ECG leads and obtain a reading. Soon after the doctor had administered endotracheal adrenalin, Henry delivered a series of defibrillating shocks but there was no improvement in the man's status. After twenty-two minutes the doctor asked the staff whether there were any objections to curtailing the activities and the procedure was stopped. This particular event raised several issues which Henry considered required following up. In response to the experience of a critical incident, Henry arranged a debriefing session.

The benefits of critical incident stress debriefing are well documented however it is by no means a routine occurrence within Australian hospitals. During the session, the nurses who discovered the patient expressed some anxiety regarding their response to the situation. They had hesitated before instigating CPR in view of the patient's poor prognosis. Moreover, from their long association with the patient they believed that he would not want to be resuscitated. This accounted for the fact that CPR was only in the preliminary phase at the time of Henry's arrival.

Following a brief discussion about legal and ethical responsibilities, the staff were surprised to learn that as the patient was suffering from a terminal illness he could have legally refused resuscitative measures by exercising his rights under the Natural Death Act. This information provided an impetus for opening a dialogue with medical staff concerning management options for the many patients in similar situations.

In relation to an equipment failure; unless part of a civil law case, the item is replaced and the manufacturer is notified about the fault. However in this case a more substantial approach was taken. Without serial numbers or expiry dates it was impossible to judge the shelf-life of the bags. The hospital had an emergency situation less than five times a year, however the bags were fully inflated during weekly equipment tests. Henry contacted the manufacturer and several intensive care units in large metropolitan hospitals who used the bags on a regular basis.

As a result of his investigation he wrote a report to the hospital procedures committee recommending the use of silicone rebreather bags as first line resuscitation equipment. A recent study showed that they had fewer problems and were far more 'user friendly'. The fault was reported to the Therapeutic Devices Problem Reporting Scheme. Finally, members of each ward were informed of the problem and shown a video produced by the Therapeutic Devices Branch outlining reporting procedures and encouraging staff to report any equipment problems to this central body.

Henry contacted the two doctors involved in order to gain their perspective on the resuscitation procedure. One of the doctors related how inadequate he felt during the event as he had experienced difficulty in removing the adhesive tape from the ECG sensors. This simple factor had caused a delay in the defibrillation procedure. As a result of this discussion the doctor was given the opportunity to rehearse with the emergency equipment and discuss any other foreseeable problems.

As evidenced from this account, numerous incidental issues were generated from the emergency CPR activities. There were issues which were a source of stress for those involved. The decision to resuscitate challenged the emotional and moral fabric of the nurse at the scene, whilst the logistical problems, the skills and confidence of the team members were put to the test.

The types of problems illustrated are not uncommon in hospital situations where emergency CPR is performed. Yet there are few coherent management strategies for the post-emergency period. Consequently, the resolution of these problems is left to the individual affected. This episode will always linger in my memory as a reminder of how much can be done with few resources and a creative approach. Henry's decision to follow up on these incidentals reflected his priority toward long-term quality management and a commitment to the staff who face these problems on a regular basis.

Tom Laws

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