Patients who have reached end stage renal failure need to have some form of dialysis commonly there is a choice of haemodialysis or peritoneal dialysis. A few patients may choose conservative treatments. Conservative treatment helps to maximise the patient comfort by using diet and medication but patient's health will continue to fail and die eventually. In my study I am going to discuss how I dealt with a new patient in the past by using Gibbs Model of Reflection (1988). Gibbs's reflective cycle is a theoretical model which is used for reflective writing.
One evening I was introduced to a new haemodialysis patient ,referred to as Mr A due to protect confidentiality in line with code of conduct.Nursing Midwifery Council (2008) He had come to his first dialysis in our unit with his wife. He has had two more dialysis sessions the previous week in hospital. As I greeted Mr A and Mrs A in the waiting area, Mrs A responded politely to me but Mr A was quiet and awkward. Mr A's reluctance to maintain eye contact with me, convinced me that he was anxious. I sence anger too .I found breakthrough with a general conversation where I went on further mentioning that he was the third new patient at this point, Mr A tried to release his anger on his wife by talking in their native language even though both were fluent in English. Suggested by research patients with high anxiety levels and low perceived control of situations more likely to have more complications with in situation. (Polimeni and Moore ,2002). I immediately changed the subject by offering a tour around the unit to orientate the buildings , fire exits, weighing areas, toilets, treatment areas and gave him an information hand book. Furthermore, I introduced Mr A to staff members and other patients who were undergoing their treatment at that time. Research states that individually patient take different amount of time according to patient perception and individual factors. I decided to spend more time with the A family and I observed his gradual adaptation to the new environment. I saw Mr A greet a patient with a smile on his face. When we reach bay two of the unit, one of patients greeted him in his own language and Mr A was delighted and greeted the patient back straightaway by shaking hands. Mr A could notice the diversity of engagement of patients where some were watching football matches on television, busy with their laptops and listening to music. Patients' beliefs and past experience can affect the relationship between personal control and the hospital environment (Williams and Iruita 2005). After introduction Mr A gave me permission to start treatment without any hesitation.
As Sheard and Garrud (2006) stated in their study; providing information and artwork improve patients' perceived control and satisfaction. During my shift, I managed to educate him in the simplest way about the functions of a healthy kidney and the undesirable outcomes when it is malfunctioning according to guide lines. .(NMC 2008). I explained to him that we have doctors, engineers, and full time students in high school and universities who attend dialysis concurrently. Most of them have family and good quality of life. I let him understand that dialysis and renal care is team work and working as a team to overcome side effects. A part from medical, nursing, technical staff and dietician, patients family members and patients themselves have their own responsibility in controlling fluid volumes, diet and exercises to work together to minimise complications. Initially, patients will react in different ways to dialysis. Some people feel unwell at the beginning or unwell after the treatment or both. Once the body gets used to the treatment, the patient should feel much better . I referred Mr. A to a renal dietician too. During our conversation my unit manager managed to visit and welcome new patients and to find out any issues. Mr. A family was happy and left the unit promising that he will come to the next dialysis session.
- My Feelings
According to my past experience as a nurse, I have learnt to plan nursing care and approach each patient with individual basis even though it is the same procedure. When dealing with Mr A, I felt that I had to be patient, and I felt that it was a challenging situation. I felt that I had to show respect even though I could feel that he was irritated at my help and showed a clear dislike and ignorance towards me. As we began to talk I felt, surprised, quite offended and isolated as Mr A began to speak in a native tongue I could not understand, clearly against and angry towards me and his wife and the help we were trying to give. In addition, as I had to spend a fair deal of time, focused on Mr A, I felt quite guilty as my fellow colleagues had to cover for my work for other patients in my team. Gradually, as Mr A began to accept and interact positively in the new environment, I felt extremely delighted, at ease, and proud of my difficult accomplishment. I also felt great relief a as I was confident that Mr A was comfortable, and I was happy to be able to move onto my other scheduled work.
- The patient's feelings
Mr A showed great anxiety at the beginning of our meeting and was reluctant to accept that he had kidney failure and required Haemodialysis. As we began to talk Mr A felt conflicted and annoyed at my help, and soon became aggressive as a result of that. As he felt frustrated, he began to take out and display his negative emotions on and to his wife, through his tense body language and sharp, raised, fast tongue in which he spoke his native language fiercely. However, mid-way through our meeting Mr A began to feel defeated, and began to accept and listen to me, though I suspected that he still felt negative towards the dialysis. We reached a point where it was clear that Mr A felt silently angry and greatly annoyed, and I had to present Mr A with the straight forward choice of Dialysis which will keep him as healthy as he can be and ensure him a longer life, than the one he would have if he refused to co-operate and accept Dialysis. After this Mr A showed me fairly more respect as he felt that I too was as serious as he and realised finally that at the end of the day I am only trying to help. Mr A felt more responsible now, as he finally accepted the reality that his life is in his hands, and he became more responsive towards me and our purpose of meeting. As I gave Mr A a tour around the ward I could see a major change in him.
There were positive and negative aspects in this situation. It was a positive point that Mr. A had followed a pre renal clinic for eight months before he come to my unit. Even though he was reluctant to accept his kidney failure he has permitted to perform arterio venous access into his left arm which we use at present. Hospital staff had carried on the patient's blood tests regularly and has kept the patient and family up to date with results. Therefore, Mr A could remember some of the pre-renal clinic nurses who assisted him beforehand that are now in his future care plan. Initially the patient did not realize that there are considerable amount of people in the same situation, until he visited the dialysis unit .Mr. A had good family support and his wife always tried to make him think positively. Giving Mr. A opportunity to visit the dialysis unit ,letting him interact with patients and spending extra time with him worked effectively in satisfactorily dealing with the situation and overcoming patients reluctance towards dialysis.
Mr. A's main problem was anxiety, difficulty in adjusting to the new treatment and to accept kidney failure. We could have paid more consideration for some medication, dietary and psychological referral he needed. Mr A has not seen a dialysis unit nor get opportunity to talk with a dialysis patient before his treatment. If so he would have reacted differently on his first day in the unit. The patients first three dialysis sessions were short one to two hours He did not know he was going to have four hour standard session eventually. If he knew that he would have prepared himself mentally and physically for that.('''''.)
This patient had very limited knowledge about kidney and related diseases, dialysis etc. When a patient visits pre-renal clinics we need to assess their knowledge and need to provide necessary information. As he was a 46 year old with good communication skills, we could have encouraged him to access library and web links to update knowledge about his health condition. The practical repercussion in dealing with this situation was its high time consumption. Generally, dialysis units are very busy because of time bounded patient slot times, transport issues etc. If I had to face similar situation with multiple patients at the same time I could have failed to look after them properly. As I spent more time with Mr. A I had to ask my care assistant and colleague to monitor my other patients for long time. I felt myself bad about that but there was no other option for me.
I intend to use the method of a SWOT analysis to consider the strengths, weaknesses, opportunities, and threats in my situation.
' The friendly, welcoming dialysis unit, both staff and patients appealed to the patient as he felt accepted and comfortable.
' The positive atmosphere reduces the patient's anxiety and negative, hopeless impression of the ward.
' The patient lost the feeling of isolation, and loneliness as he saw other patients with a condition similar to his own and was influenced by their positivity and pleasant approach.
' The patient was educated by myself on the procedure of dialysis and understood his condition better due to the health education.
' The patient had good family support
' The patient expanded his social life as he was able to develop good relationships with other patients
' The patient was very anxious, nervous and scared.
' The patient had negative impression of the hospital environment due to a bad previous experience.
' The patient did not have as much knowledge or information regarding his health condition.
' The patient had not been in contact with any other dialysis patients and had not visited any dialysis units before so it was unfamiliar to settle in.
' The patient was not looking forward or willing to undergo treatment.
' I had to dedicate a fair deal of my time to the patient excessively.
' The patient was able to receive more information on his condition.
' The patient was able to develop more social relationships with fellow patients.
' The patient was able to be introduced welcomingly and was given a lot of attention by the unit.
' The patient was given one-to-one attention by me and had any questions he had answered.
' Too much time was focused on the single patient and others had to fill in for my place.
' If the patient had not liked or been able to adjust to the new environment, the patient could have become more aggressive and violent.
To summarize the analysis, most patients are anxious when they come to the hospital environment. However, depending on the patient, time, comfort, reaction, interaction and how a patient may adapt, the situation varies.
Overall, from this experience I have learnt that in the nursing profession we cannot afford to rush even the simplest situations. This is because we all have to make sacrifices to do our job and we have to teach and discuss the matter with the patient at a pace which they can understand and keep up. I have also learnt that patients feel more comfortable when they are amongst people of the same culture and language. If there is a similar situation I will encourage all patients to come and visit their new dialysis unit and the people there, before commencing treatment ,in order to reduce their anxiety and nervousness.
If this situation was repeated there are a few things which I would I would do differently and a few extra things which I would do. I have already arranged for patients to visit the dialysis unit so that they can adjust, be introduced and settle into the unit before treatment.
What I would change in the future'
' I would arrange for a support group to take place out of the unit, so that patients both new and current can visit to discuss their problems
' Health education would be made better by ensuring that each patient has a pastoral session where they can speak to the nurse one-to-one, learn more about their condition themselves and have any questions which they might have answered.
MOORE (2002).Quality of life. Patient Satisfaction.
NURSING MIDWIFERY COUNCIL (2008)
SHEARD AND GARRUD (2006) Evaluation of patient generic information: Effects on health outcome, knowledge and satisfaction. Available from: http://www.pec-journal.com/article/S0738-3991(05)00055-8/abstract
WILLIAMS AM & IRUITA VF (2005) Emotional Comfort: the patient's perceptive of a
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