Nurses are encouraged to evaluate and improve their practice by reflection. In order to help guide my reflection process I am using Gibbs (1988) as the model. This is a six step model which will allow me to reflect on the critical incident and look at ways in which I can strengthen and improve my own practice and that of my colleagues for the future. Within the analysis of the incident the patient will be known as Mr. B. This is in order that his real name is protected and confidentiality maintained, in line with the NMC (2004) which states:

“You must guard against breaches of confidentiality by protecting information from improper disclosure at all times”.

The purpose of this essay is to critically examine an incident from recent practice whilst using a model of reflection. This will enable me to analyse and make sense of the incident and draw conclusions concerning personal learning outcomes.

The term ‘critical’ introduces a further dimension to analysis, in that judgements are made about the strengths and weaknesses of the different parts, as well as of the whole, Burns (2000). Reflection follows on from this by encouraging the analysis of clinical practice, this in turn, helps the healthcare professional to develop his/her knowledge and to acquire a deeper level of understanding about the complexities of nursing practice. Boud et al (1985) suggests that this type of learning contributes to the development of clinical competence.

The critical incident is taken from my recent clinical practice within the Endoscopy Unit. I will be reflecting upon and critically analysing gaining informed consent prior to the patient’s emergency Endoscopy and when to act within patient’s best interests.

My rational for the chosen clinical incident is because of the impact it had on me. I realised I was not fully informed on the process of obtaining informed consent and was an area to be explored. Informed consent is always needed within every daily activity and individuals should hold the right to decide what happens to one-self. Many people do have the capacity to consent, but others are incapable. The British Society of Gastroenterology (BSG) Guidelines, (2008) would agree as they also believe patients have a fundamental human right to determine what happens to their own bodies. Respect for this right to personal autonomy is a cornerstone of good medical practice.

Mr. B was a seventy four year old gentleman who was seven days following a right hip replacement and had a two day history of fresh rectal bleeding. His past medical history included angina and hypertension. He had no allergies and medication included aspirin, lisinopril, simvastatin, paracetamol and diclofenac. Among the list of medication, two drugs are non-steroidal anti-inflammatory (NSAID’s). The elderly are more susceptible to side effects of these drugs which can cause gastro-intestinal side effects such as nausea, dyspepsia and gastro-intestinal bleeding and ulceration, British National Formulary (BNF) (2005).

Mr. B’s recent HB was 8.4 and previously been transfused with 2 units of blood on the orthopaedic ward. He had been referred to Endoscopy by our Gastrointestinal Consultant of the Day (GOD) with a referral form. His referral form is an assessment of severity of need for Endoscopy and gives a Rockall Score to determine how urgent the procedures are needed, Rockall et al (1996). MR. B’s Rockall score was five so needed an urgent Endoscopy.

Mr. B was on his own bed which was elevated at the head, he had a non-rebreathe mask in-situ delivering 10L oxygen therapy, 2 large bore cannula in-situ but did not have any fluids or blood in progress. My first impression was he looked pale, felt cold and did not look well perfused. I introduced myself and my role to Mr.B who communicated well but I could see he was tired and weak. I explained that he was in Endoscopy and asked him if he understood why he was here and what procedures he would be having.
On recording baseline observations Mr.B was hypotensive 98/50, tachycardia of 110bpm, respiratory rate 18 and saturations of 100% on 10L oxygen therapy. This gave him an Amber score of 3. Our pre-procedure checklist was completed accurately, legible and complete. The checklist ensures you are checking you have the right patient, highlights medical history, allergies and any other risk factors. When the Endoscopist arrived I explained the observations and suggested some IV fluid resuscitation which was declined and I was told “it is not necessary at present”. The Endoscopist introduced them self to the patient in the recovery area. Only verbal consent was obtained as Mr.B was very tired and could not sign his own consent form. He was then rushed into the procedure room. The procedures weren’t explained nor were risks and benefits. When I confronted the Endoscopist about this I was told the patient had received this information on the ward.
Both procedures were undertaken by the Endoscopist which proved very difficult as Mr.B had continuous blood loss from his rectum so procedure was abandoned as a bleeding point could not be located. Mr.B became very worried and anxious about this. His vital signs were monitored frequently and I comforted my patient appropriately and gave reassurance. Mr. B became more hypotensive at 60/42 and tachycardia of 124bpm during the Flexible Sigmoidoscopy. The Endoscopist was informed and I took it upon myself to alert my other colleagues to collect more blood from blood bank. This arrived very quickly and was checked by another registered nurse and commenced appropriately according to our trust guidelines. Once my patient was stabilised and well enough he was transferred back to the orthopaedic ward.

Having completed the episode of care and reflecting upon the events which occurred everything could have been less rushed and more time spent with the patient prior to his entry to the procedure room. I thought had there been more effective communication between staff and the patient he would have been better informed of the procedure, risks and benefits. Looking back I should have been more forceful and asked the Endoscopist to explain the procedures, risks and benefits again prior to entering the procedure room.

The whole episode to me felt rushed and as if the Endoscopist wanted to get the patient in and out so he could move on to the next or leave the department to go to clinic. Being rushed can cause unnecessary mistakes to occur and harm to patients. The Hippocratic principle “Do no harm” has long been fundamental anchor of medical ethics and this is ingrained in the principle of beneficence, an ethical obligation to improve patients well being without causing harm, Stancin and Ladas (2001).

I felt as if I was not being listened to with regards to fluid resuscitating my patient prior to his Endoscopic procedure as I asked the Endoscopist and was told “it is not necessary at present”. Corey and Lawrence (2009) would argue this as they believe it is paramount that fluid resuscitation should be the focus of initial management and this should take place over Endoscopy. I believe it is important to stabilise a patient prior to any clinical activity in case of this causing more unnecessarily problems for the patient.

On evaluating this incident we must all stop and look at what the definition of consent really means to one self’s. Royal Cornwall hospital (2005) gives a definition of consent: “Consent is a patient’s agreement for a Health professional/worker to provide care. For consent to be valid the patient must be competent to take the particular decision, retain, or decide upon the information. Have received sufficient information to make it and not be acting under duress and given sufficient time to decide”.

There are many ways to indicate consent non-verbally by presenting an arm for blood pressure to be recorded, orally, or in writing. A consent form is only a record, not proof that genuine consent has been given. It is good practice to seek written consent if treatment is complex, or involves significant risks or side-effects. If the person has the capacity to consent to treatment for which written consent is usual but cannot write or is physically unable to sign a form, a record that the person has given oral and or non-verbal consent should be made in their notes or on the consent from, Department of Health (DOH) (2001) (1A).

Within my incident as stated previously Mr.B was too tired and weal to sign his consent but gave verbal consent. The Criticism I would like to make is the Endoscopist did not document in the patients notes and they should have signed that ‘verbal consent obtained’.

I do believe that the correct methods in obtaining informed patient consent were hap hazard and some didn’t really follow BSG (1999) guidelines who laid down certain principles to be followed while taking informed consent for any Endoscopic procedure. The best place for the patient to consider their consent is in a non – threatening environment. The best practice in Endoscopy setting is for the discussion of consent to take place prior to the patient entering the Endoscopy room. In this incident this occurred correctly as the Endoscopist obtained consent in the recovery area prior to the Mr. B entering the procedure room. Consent was obtained by the Endoscopist and it is usually best practice that the person doing the procedure should be the person obtaining consent. On discussion with some of my university colleagues who are registered nurses, in their Endoscopy setting it is common practice for them to obtain consent from the patient. I feel this puts them at a greater liability as they are not carrying out the procedure and if anything was to go wrong it would be their registration at risk.

Endoscopic procedures are safe and practiced extensively world wide. These techniques offer a powerful range of diagnostic and therapeutic interventions. There are of course some risks to these procedures as stated below which are written on our trust consent forms. There is no set standard of consent form as each trust has there own but the set out is taken from the BSG guidelines and adapted to each trust. The Endoscopist should have fully informed the patient of the procedures, risks and benefits before entering the procedure room as the patient was not in a stable condition.

Gastroscopy procedures carry a very small risk (1 in 10,000 cases) of haemorrhage (bleeding) or perforation (tear) of the gut following which surgery may be necessary. Other rare complications include aspirate pneumonia (inflammation of the lungs caused by inhaling or choking on vomit) and an adverse reaction to the intravenous sedative and analgesic drugs.

Flexible Sigmoidoscopy procedures carry a very small risk (1 in 5,000 cases) of haemorrhage (bleeding) or perforation (tear) to the bowel. These are more likely to occur after the removal of a polyp. Perforations usually need to be repaired with an operation, and might require a temporary stoma (which involves the bowel being brought out through the skin of the tummy so that stool passes into a bag), SDHCT, (2001).

Acute lower gastro-intestinal (GI) bleeding includes a wide clinical spectrum, ranging from minute bleeding to massive haemorrhage with heamodynamic instability and this matches Mr.B’s condition. The British Medical Journal (BMJ) (2009) have some statistics regarding lower GI bleeding in that it is approximately one fifth as common as upper GI bleeding and accounts for approximately twenty to thirty hospitalisations per 100,000 adults per day.
A study found from the Nationonal Confidential Enquiry into Patient Outcome and Death, (NCEPOD) (2004) website gives some interesting points. 252 NHS and 11non-NHS took part in 136,000 therapeutic endoscopies in England and Wales. Within this study relating to obtaining informed consent statistics show 32% of patients could not say if consent had been obtained for the procedure carried out. 21% said it hadn’t. Also 16% of patients had either dementia or acute confusion and of these 66% had signed their consent forms. It also points out that some of the consultants who were doing the procedure had undertook less than 20 procedures a year so shows how de-skilled they possibly were and how there practice was not up to date relating to the consent process, and assessing patients mental capacity to consent.

Aspects of good consenting practice are also an important component in the Global Rating Scale (GRS) assessment of UK Endoscopy units. The GRS is a tool that enables units to assess how well they provide a patient-centred service. It is a web-based assessment tool that makes a series of statements requiring a yes or no answer. From the answers it automatically calculates the GRS scores, which provides a summary view of your service.

Within the department where I work as part of GRS standards data were collected between December 2007 and June 2008. This was from a patient satisfaction questionnaire which was given to each patient and then reviewed. This was to improve the service each individual receive in our department. The area I have focused on is obviously the scores for consent. One question asked was where did you sign your consent and under 50% said in the procedure room. The other question were you satisfied with the consent process for this procedure and scored 92% and above on all procedures. So the quality of patient experience scored a level B which is very good according to GRS (2008). As my clinical incident has stated not all of the consent process was achieved as it should have been.

The sense I make of this incident is consent was obtained verbally from my patient for both procedures to go ahead and the patients best interests were always paramount. Stancin and Ladas (2001) believes obtaining a proper informed consent from an adult patient can be difficult, so obtaining it from an older patient is often problematic, since old age is associated with an impaired grasp of informed consent and frequently with cognitive dysfunction, mostly dementia. My patient appeared to have the capacity to make informed choices and was given the appropriate information and time to make decisions.

I believe adults should always be presumed to be capable of taking healthcare decisions, unless the opposite is demonstrated. An older person or their frailty is not a reason for doubting a person’s capacity. When a person lacks mental capacity to give or withhold consent for themselves, no-one else can give consent on their behalf. The Mental Capacity Act (2005) came into force in October (2007), with the aim to empower and protect people who may lack capacity to make some decisions for them. They can clarify who can take decisions, in which situations and how this should be done. It is underpinned by 5 key principles: presumptions of capacity support for individuals to make their own decisions, unwise decision, best interests an act or decision made on behalf of a person who lacks capacity under the Act.

During this incident I feel everyone in the Endoscopy setting had Mr B’s best interests at heart. Best interests go wider than best medical interests, to include factors such as the wishes and beliefs of the patient when competent, their current wishes, their general well-being and their spiritual and religious welfare, DOH (2001) (1b). Caulfield et al (2005) agrees by believing if a person is unable to consent, treatment can be given without their consent providing the intervention is considered in the ‘best interests’ of the individual. The individuals own wishes and values should be taken into account if known.

Everything was explained to Mr.B by my self regarding what was happening, what we needed to do and why throughout the procedures. He was very compliant and appeared to understand what was happening, he stated to me during the procedures “please do what you need to do to make me feel better”. I ensured all documents were kept accurate, legible and complete and were placed in his nursing notes. The NMC (2004) states:

“Health – care records are a tool of communication within the team. You must ensure that the health care records for the patient are an accurate account of treatment, care planning and delivery”.

In conclusion, this assignment has examined and analysed my critical incident involving my patient’s best interests and the importance of obtaining valid consent prior to any Endoscopic procedure. I still believe the first line prior to Endoscopy involves fluid resuscitation and optimisation of heamodynamic status, this being backed by Corey and Lawrence (2009)

Using a validated reflective model has enabled me to look back at the situation and to examine ways of effecting practice change for the future. As a professional nurse, you are accountable for your practice and should always act within the best interest of your patient. The key principle in obtaining informed consent is to put the patient’s needs first. To participate effectively in informed consent processes, you should have the knowledge, expertise and capability to give sufficient information and be able to answer any questions raised by a patient.

The NMC (2002) states:
“Nurses are expected to keep up to date with their practice and the developments within their area of practice”.

Evidence based research is becoming an important part for this requirement. It is vital to remember that it takes time to practice and become skilled in the critical evaluation of clinical practice and research and one of the ways to achieve this is by continually reading and reflecting upon strengths and weaknesses of each article read and then putting any relevance into practice.

If this incident arose again I feel I am able to follow the process of obtaining informed consent and meet the needs of each individual patient. I am aware of the mental capacity act if ever I need to access this. I am able to reflect with my colleagues my experiences and assist in the way proper consent should be obtained. My action plan is always to keep up to date with evidence and implement this into my practice. I will always work as part of a team and continue to learn more about how best to communicate in order to contribute to good nursing care.