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This essay aims to reflect on an incident that took place during my six weeks practice placement on an elderly day care hospital. I chose this incident because it had a big impact on me due to the fact that I was not aware of the serious nature of feeding patients diagnosed with dysphagia as would be demonstrated in the critical incident. The model I have chosen to use is Gibbs (1988) reflective model because it gives a framework which I am able to follow in order to develop my understanding of the situation. Reflection is a process that involves gaining practical knowledge, the ability to get used to new situations, developing self-esteem and satisfaction as well as valuing professional practice (Taylor 2006). For the purpose of confidentiality and to protect the patient’s anonymity I have called her Tee, these measures are in accordance with the Nursing and Midwifery Council (2008) guidelines regarding consent and confidentiality.

I was assigned to help feed Tee during lunch time, Tee had suffered a stroke, resulting in very limited speech, suffered from dysphagia. Dysphagia is a medical term for difficulty with swallowing and is common in patients with neurological disease, dementia and parkinson’s disease (Chang and Roberts 2011). Tee has a pureed diet and thickened fluids. I collected her meal and dessert from the trolley, sat next to Tee then started to feed her. After the first helping I proceeded and gave her a second helping while she still had food in her mouth. As I hurriedly continued with the feed, Tee started to cough, her eyes started to blink rapidly, I thought I should give her some juice and realised I had left it on the trolley, I rushed to get the juice and gave Tee but the food and the juice was coming out from her mouth. Tee continued to cough but I was not sure if it was a cough or she was choking. I hastily cleared the plates but left the drink on the table, wiped Tee and cleaned around the place since it was messy. One of the nurses came by to see what was happening and noticed that I had not added the thickener in her juice.

I was irritated by Tee’s slow response of eating and thought she did not want me to feed her and when she started choking I thought it was a way of getting attention from the nurses. I wanted Tee to finish quickly so that the plates she used could be collected at the same time with the rest of the other patients’ plates. I felt the pressure to impress and thought if Tee ate all her food in a few minutes my colleagues will think highly of me as I would be seen as an efficient student. I thought Tee should have indicated to me that she did not want to eat and felt frustrated that she could not talk properly and felt guilty and hopeless because I could not understand her. At that time it felt alright to blame Tee for what happened as she did not eat and drink the way I expected her to.

At the time, my focus was to complete my task within a short time, that is at the same time when other patients finish their meals. I did not consider that Tee had difficulty swallowing therefore she will take quite some time to finish her meal. I knew Tee could not speak, I did not accommodate her communication difficulties, I hardly spoke as I felt that it was pointless as she was not going to answer me. Arnold and Boggs (2011) state that patients with speech impairment or loss have a more difficult task sending the messages they want and are sometimes unsuccessful in making themselves understood.

This experience taught me that I should not assume that I can assist anyone to eat because feeding a patient with dysphagia is not a simple procedure that can be assigned to a junior member of staff without experience (Weetch 2001). Had I known the consequences beforehand, that aspiration of food or drink is a particular risk which can cause a blockage in the bronchus and lead to aspiration pneumonia (Redfern and Ross 2006) I would have asked for supervision or been honest and say that I did not have the skills to do so.
This incidence made me feel very guilty afterwards as I ask myself what if things went wrong and for me to admit my inadequacies in understanding dysphagia in older people, but Rowe (1999) explains that a person must identify their weaknesses as an initiative for becoming self-aware, only with acceptance of one’s self, can a person begin to acknowledge another person’s uniqueness and build upon this to provide holistic care.
I did not respond efficiently to reduce Tee’s distress and this pressure led me to deal with the situation inadequately and for that I felt guilty (Nichols 1993).
I was influenced in this decision because I felt obliged to be seen as efficient knowing my actions would be judged by my colleagues. I could not identify the non-verbal cues provided by Tee and I showed no empathy. According to Gould (1990) the implications are that nurses who chose to use non-empathetic communication favour task-centred rather than patient-centred communication. This might be true as it seems my focus was based on completing the task in a short period of time rather than doing my job efficiently by showing respect, patience and communicating with Tee to check if she was ready for the next helping instead of rushing through. Davis (1999) explains that hovering with the next spoonful of food should be avoided , instead patience, attention and time are essential to avoid worsening any swallowing difficulties. This is why it appears that I was keen on the time scale rather than putting Tee’s safety first as outlined in the Nursing and Midwifery Council (2008) Code of conduct.
I feel that I should have been supervised when assisting Tee with the feed as Redfern and Ross (2006) point out that feeding dysphagia individuals is a highly skilled task which should not be delegated to junior nurses, who may have insufficient knowledge and experience to cope. This is true in this case because I did not have sufficient knowledge as I was unaware of the consequences except that Tee might choke, I did not know how to spot this potentially life-threatening condition. At the time I was assigned to help feed Tee was it because the nurse wanted me to learn more about feeding patients with dysphagia or was it one of the tasks that she got rid of because Weetch (2001) emphasises that often a student nurse or junior care assistant is asked to feed these patients. In support of this is the Department of Health (2001) who state that the task requires nursing knowledge and skill although it is often given low priority or not seen as a nursing intervention. I should have paid attention to the amount of food given to Tee as Brooker and Nicol (2003) point out that when feeding patients with swallowing problems appropriate sized mouthfuls should be given to avoid aspiration of food or drink into the lungs. This probably explains why Tee was choking as I filled her mouth with food.
When eating, I should have supported Tee so that her head and trunk were flexed forward slightly to avoid aspiration while swallowing so as to help protect the airway (Groher 1997)
I should have been brave to admit that I was not capable to help with the feed to avoid stress and discomfort for Tee as the Nursing and Midwifery Council (2008) points out that we must not add extra stress or discomfort to a patient by our actions. I could have shown more empathy in the form of my own body language to promote active listening I should not have worried about other people’s views on my decisions and beliefs and declined the clinical opportunity which I was unprepared for or lacked confidence in doing it as the Nursing and Midwifery Council (2008) explain that such a right should always be adhered to.

In future I will not rush or hover over a patient when feeding and will pay attention to the amount of food being eaten ensuring that small portions of food are given to avoid aspiration of food or drink into the lungs when feeding patients with swallowing problems (Davis 1999). I will give plenty of time for chewing and swallowing and make sure the mouth is empty before offering the next portion.

I will not put the second course on the table while the first is being eaten, instead I will make sure that fluid is at hand, making sure it is of the correct texture. This is pointed out by Weetch (2001) who recommends that to help patients clear their throats, food and fluid should be alternated.
I will talk to the patient and not ignore them and create an environment which is conducive to communication by considering alternative forms of interacting using gestures such as nods. I will retain my patience and understanding and talk calmly. Redfern and Ross (2006) states that this plays an important part in non-verbal communication, as it shows the nurse has time and respect for the patient and is not too busy to care.
I will describe the food to the patient as Brooker and Nicol (2003) suggest that letting the person see, smell and taste the food encourages saliva to flow and to improve their appetite before eating.

References: Arnold, E. C. and Boggs, K.U. (2011) Interprofessional relationships: professional skills for nurses. 6th edition. Missouri. Elsevier Saunders | | | | | | | | | | |

Brooker, C. and Nicol, M. (2003) Nursing adults: the practice of caring. Edinburgh : Mosby.

Chang, C. and Roberts, B.L. Strategies for feeding Patients with dementia. American Journal of Nursing: April 2011 - Volume 111 - Issue 4 - pp 36-44
Davies, S. (1999) Dysphagia in acute strokes. Nursing Standard; 13: 30, 49-55.
Department of Health (2001) National Service Framework for Older People. London Department of Health.
Gibbs, G. (1988) Learning by Doing: A guide to teaching and learning methods. Further Education Unit, Oxford, Oxford Brookes University
Gould, D.(1990) Nursing care of women. Prentice Hall. New York | | | | | | | | | | |
Groher, M.E. (1997) Dysphagia: Diagnosis and Management. 3rd edn. London. Butterworth Heinemann

Nichols, K.A, (1993) Psychological Care in Physical Illness. 2nd edition. London. Chapman & Hall
Nursing and Midwifery Council (2008) Code of Conduct. NMC. London.

Redfern, S. J. and Ross, F. M. (2006) Nursing older people. 4th edition. London Elsevier Churchill Livingstone
Rowe, J (1999) Self-awareness: improving nurse-client interactions. Nursing Standard, 14, 8, 37-40
Taylor, B. (2006) Reflective practice : a guide for nurses and midwives. 2nd edition. Maindehead. Open University Press
Weetch, R. (2001) Feeding problems in elderly patients. Nursing Times; 97: 16, 60.

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