Reflective Skill

In this assignment, I reflected on one nursing skill in clinical practice upon a specific client group. The skill was selected to underpin the appropriate therapeutic interventions within the patients. The tracheostomy suction would be reflected within this assignment by using a reflective model based on the previous practice on the tracheostomy patients. The skill was focused on the management of airway due to the blocked of the patients’ respiratory. As Siviter (2004, p.165) explains the important of reflection is about gaining selfconfidence, identify when to improve, learning from own mistakes and behaviour, looking at other people perspectives, being self-aware and improving the future by learning from the past. I select to reflect and discuss this skill for my reflection based on the past incidents because I want to improve my suctioning skill for tracheostomy patients in managing airway for future practice. In order to achieve the goal, the adequate knowledge underpins regarding the skill was essential to be explored to offer the safe practice. Therefore within this assignment, the knowledge that contributes to the way in performing the skill also been identified. In this reflection, I would use Gibbs (1988) Reflective Cycle. This model was a recognised framework for reflection. The essential of using model in the reflection was supported by Brooker and Nicol (2003, p16) because it provided the conceptual frameworks in structuring the nursing practice. As Gibbs (1988) model consists of six stages to complete one cycle which is able to improve my nursing practice continuously and learning from the experience for better practice in the future. The cycle starts with a description of the situation, analysis of the feelings, evaluation of the experience, analysis to make sense of the experience, a conclusion of what else could I have done and final stage is an action plan to prepare if the situation arose again (NHS, 2006). Baird and Winter (2005, p156) state that a reflect is to generate the practice knowledge, assist an ability to adapt new situations, develop self-esteem and satisfaction as well as to value, develop and professionalizing practice.

Generally, tracheostomy is a preferable intervention to the patients which involved in long term mechanical ventilation especially in the critical care settings. McPhee et al (2008, p200) indicates the tracheostomy is done due to the respiratory failure and the obstruction above the larynx. Therefore in order to enhance the patients’ airway, the patients underwent the intubation procedure under the surgical intervention. According to Barnett (2005, p4) tracheostomy is a surgical opening in the anterior wall of trachea. The tracheostomy provided more comfort to the patients by clearing secretions which could reduce the resistance of respiration (Marino and Sutin, 2006, p495). Once the surgical intervention done, the suctioning via the tracheostomy tube would be performed to assist in clearing the blockage of the respiration airway. Furthermore, the tracheostomy tube suction is a vital skill in a way to promote better and effective respiration for the patients. Barnett (2008, p26) supports that the suction technique allow the secretions out from the patients’ chest via the tracheostomy and consequently provide the patent airway. During clinical practice, I observed, assisted and performed the tracheostomy suctioning. The skill was quite challenging and it required the good understanding and competency. According to the local guideline, the suction should be performed when necessary (Kaur, 2008, p1). This indicated that the frequency of suction performed would depend on the patients’ condition. The most important part to ensure that whether the patients required the suction was to assess the patients’ condition either the oxygen saturation, percentage of oxygen supply, chest movement or the level of cyanosis. Higgins (2005, p36) outlines few assessment which is a comprehensive patient assessment included the respiratory characteristics, chest movement, palpation and auscultation is more important thing to look for rather than the regimented frequencies. Fortunately I got chance to perform the skill on patients during my practical in the ward as the patients were struggle for adequate breathing. I noticed the saturation of oxygen decreased and skin changes from pink to blue even though the supplemental oxygen was still administered. There were also changes in

breathing sound among the patients. I realized that the conditions of the patients might be due to compensate of air to breathe in. Therefore I notified my clinical instructor to perform the suction. I gained consent from patients, provided safety, maintained their privacy, prepared equipments and performed the procedure. I did suction via tracheostomy tube under the supervision of the clinical instructor. Even I learnt the skill at the clinical lab in college, the clinical instructor still guided me from the beginning until the procedure completed as I was not competent enough to conduct the procedure on my own. I encountered the objective in performed this skill as the patients’ respiration gradually improved after the procedure. I felt anxious during performing the procedure compared with my feelings during practicing the skill in clinical lab at college. Performing encompassed more strength and confidence. However, I was able to precede the skill until it completed. During the procedure, I worried of my actions even though my clinical instructor was next to me to support and guide my performances. My feelings were mixed up especially regarding the pressure that I had to put on in order to suction the patients. 80 to 120 mmHg was the pressure recommended by Smith et al (2004, p912) because higher pressure provide a risk of mucosal damage. Apart from that, I was taught by the clinical instructor to count until 10 seconds to insert the catheter, do rotation and remove the suction catheter. Tollefson (2005, p1073) mention the advantage of doing the rotation of catheter enhances the removal of mucous. During the insertion of the catheter, no pressure applied yet until one third of the catheter was inserted. Perruzzi and Candido (2007, p493) explain no application of vacuum for the catheter should be placed until the catheter beyond the tip of the tube. In the meantime I was scared that my suctioning could do excessively make the patients worst. However Smith et al (2004, p913) restrict the duration of suction should not be more than 10 seconds to minimize loss of oxygen that could lead to hypoxia. Event though I did the suction in 10 seconds but fortunately the patients did not turn to hypoxia. These feelings lead me to the responsibility in duty of care to the patients. According to

Code of Conduct (Nursing & Midwifery Council, 2008, p1), a professional must accountable for the actions in practice. I would be responsible of my actions towards patients which eligible to receive the safe care. Therefore, even though I was a not a register nurse yet but I reminded myself to be a responsible towards the consequences of my actions in practicing the skill. I evaluated my experience in performing the skill during clinical practice as the significant and important part to develop the skill. Suctioning via tracheostomy tube is an advanced skill in nursing practice. The skill required me to understand the underpinning knowledge which relies on the procedure in delivering the care to the patients. The experience provided me with the new exposure to practice on real patients and I learnt to put the theory into practice. As I learnt in college, I practiced on the mannequin who did not display the signs and symptoms of the real conditions such as the skin changes, chest movement and level of oxygen saturation. These conditions were very essential to evaluate the patients in order to recognize the problem that encountered the patients. As soon as the problem had been identified, the action was taken to overcome the problem. Therefore according to Price (2008, p49) a combination of knowledge, experience, decisions and actions construct the beneficial effects for patients within the skills in practice. This was much related to my experience in clinical practice to perform suctioning. I identified what decreased the saturation of oxygen level, changes in skin colour and breathing sound. As a result I decided to notify my clinical instructor and perform the suctioning. These experience acquired knowledge to decide my actions towards patients.

I analysed that experience in clinical practice required more knowledge to evaluate the incidents with the patients. Moreover assess, plan, intervention and evaluate of the patients aided in delivering the care to the patients. The procedure encompassed the knowledge and attitude in performing the skill on the tracheostomy patients. The most important part I really had to have the

knowledge about the tracheostomy patients. The assessment on the patients breathing could indicate the respiratory problems occur. Audible bilaterally is the breath sounds signify that the air is flowing freely through the tracheostomy tube (Astle, 2003, p35). The indication of sound explain by McConnell (2002, p17) are the coarse breath sounds, noisy breathing, and prolonged expiratory sounds showed that the patients needed to be suctioned. Therefore if the patients could not breathe through the tracheostomy tube that indicated that there was blockage occurs in the tube. Since patients were not able to cough or secrete by themselves, I performed the suctioning procedure to assist in secreting the mucous. Barnett (2006, p6) identify the cough reflex had been impaired because of the tracheostomy tube which prevents to clear the secretions through coughing. Buglass (1999, p500) state that the patients could not have the sufficient intra-abdominal pressure to cough due to the tracheostomy. According to Barnett (2008, p25) mention that suctioning would be perform due to inability of the patients to secrete the mucous on their own in order to maintain the patent airway .The reason of performing the procedure was related to the patients’ conditions which occur due to the respiratory problems. The tracheostomy tube should provide the patent airway for tracheostomy patients in breathing process. However as the patients need more oxygen, the administration of supplemental oxygen was provided to improve the breathing process. Therefore the continuous monitoring of saturation oxygen of the patients via pulse oximetry was applied to show the reading of the oxygen level in the body. The purpose of the tool is to measure the arterial oxygen saturation of haemoglobin by continuously monitoring the patients’ oxygenation status (Editors of Nursing2008, 2008, p42). The decrease of the saturation oxygen indicated that patients were consumed the less oxygen even the administration of oxygen was provided. This situation specified that the airway was blocked. During performing the suctioning, the saturation oxygen was continuously monitored. Instead of that, the figure could determine and note the differences of the oxygen level of

the patients before and after the suctioning. The purpose is to indicate whether the patients responding to the therapy or deteriorate because the normal range is between 98%–100% (Higginsons and Jones, 2009, p458). The suction catheter was inserted intermittently to allow the patients consumed oxygen. However after the suctioning performed, the saturation oxygen increased. This situation showed that the tube was patent and patients did not require suction. Another consideration point was the positioning. I positioned the patients based on their conditions before performed suctioning. The correct position was very important to consider in suctioning. Edgtton-Winn and Wright (2005, p3) specify the different position for the different conditions of the patients such as the upright position suitable for the conscious patients compared to unconscious patients on the semi Fowler’s position assist in clearing the secretions. The positioning of patients to perform suctioning was varied because it depends on their conditions. Apart from that, I could clearly observe the colour of the nail beds patients changed. The normal colour of the nail beds’ patients were pink but gradually changed to slightly blue. I analyzed that the patients had the peripheral cyanosis. Hadaway (2009, p 50) determine the cause of cyanosis is due to impair venous return in the lower extremity. Apart from that according to Martin (2009, p1) cyanosis occurs when approximately 5g/dL of deoxygenated haemoglobin in the capillaries produce the dark blue colour which also indicate of hypoxemia. Moore (2003, p52) suggests that the size of the catheter should not be more than half of the diameter of the tracheotomy tube in order to prevent hypoxemia. Therefore, it shows that the correct size of catheter contributed to the effectiveness of tracheostomy suction depend on the patients’ size of tracheostomy tube. During the suctioning, the mucous were secreted out from the tube. I noticed the colour of secretion during suctioning. Colourless, green and yellow were the colour of secretion from the patients. According to Johnson et al (2008,

p452) those condition presented due to either viral or bacterial infection resulted from the inflammatory cells or sloughed mucosal epithelial cell. The findings were documented to the patients’ record and inform to the senior staff nurse. The physician notified from the findings from the senior staff nurse and further treatment was conducted. Though, I did discuss with my clinical instructor after performing the procedure regarding the doubt that encountered my thinking during suctioning. I did ask about the rest duration to the next suction but no accurate answer given for my question because of quite unsure about the accurate timing. However Tollefson (2004, p198) suggest that patients should rest 30 seconds before next suctioning. Yet, during the procedure I did not gap 30 seconds to perform the next suction but waited for 60 seconds. The evidence was contraindicated with my practice as I performed under the supervision and teaching of the clinical instructor. I could analyze that my practice could be improved if I referred to the evidence literature compared to the practice based from the unsure clinical instructor. I performed the further suction based on the same principle of actions but using new gloves and catheter. This is recommended by Dougherty and Lister (2004, p699) to repeat the same actions by using the new sterile gloves and catheter. I disposed the used sterile gloves and catheter into the clinical waste. Furthermore, Anderson (2006, p138) advises to use waterproof trash bag to discard the gloves and catheter. Dougherty and Lister (2004, p699) explain that the suction catheter should be used once in order to reduce the risk of infections during suctioning. Moreover, Timby (2008, p854) suggest that the further suction should be performed unless

the saturation oxygen remained 95% and above.

Nazarko (2008, p121) explains that suction could enhance the droplet transmission of infection. Therefore, the skill was performed in aseptic technique. Evidence (Thompson, 2000, p6) showed that it is important to apply aseptic technique when performing suctioning for tracheostomy patients in hospital. The

next consideration was the frequency of further suction could be performed. In my experience, I did the further suction twice. According to evidence presented it was recommended that the maximum of suctioning were twice (Thompson, 2000, p5). However Nicol and Bevin (2004, p288) argue that the tracheostomy suctioning should be repeated until the secretion and breathing sounds clear. This situation leads to the ability of decision-making to apply the best practice depend on the patients’ condition within the clinical practice. The effective suctioning provides the clear airway to the respiration take place. I felt glad because the skill I performed offered the patients more effective in breathing. The patients’ saturation oxygen increased and patients were evaluated after implementing the suction intervention. In performing the skill, the patients’ priorities were fulfilled such as privacy and safety. Price (2008, p52) state that the patients would feel valuable when the nurse concerned about their situation by showing the sensitivity, responsively and adaptable in nursing care. Based on my experiences about suctioning, I realized that the skill did not only require the competency but the underpinning knowledge within the actions during the procedure and the way I evaluated the situations. Price (2008, p50) mentions that the underpinning knowledge is likely based on the clinical experience research. In future if I were given a chance to practice the skill, I would practice better from my previous experience. Hence within my action plan, I would prefer to do further literature search on the knowledge and practice of tracheostomy tube suctioning. It could improve my understanding towards the care of patients and also enable me to put evidence-based into practice in order to provide the best care. I learnt to develop and enhance the skill under the supervision of the clinical instructor. However, due to my lack of experience the clinical instructor was fully guided me. In future, I must able to work with less supervision. According to Code of Conduct (Nursing & Midwifery Council, 2008, p7) in order to work without direct supervision, I must have the knowledge and skills to

promote the effective and safe practice. Therefore I have to upgrade myself with sufficient knowledge related to the evidence-base practice. Bowers and Jinks (2004, p159) stated that the practitioner feel confident in the development of practice from the constructive support and guidance in the consensuses literature. Even though the qualified clinical instructor experienced to handle in such incidents but I could not totally depend on the experiences in practice because the way of practice could be changed and improved within the time frame. Price (2008, p50) suggest that experience could be insight compared and shared. Therefore it could be better if the current evidence and practice applied in clinical practice. Jenkins (2005, p69) conclude that the work improve dynamically by the process of linking theory and practice and also sense of experience. In conclusion, it is beneficial to use a model to reflect and analyze the skill because it enables me to explore and evaluate my previous experiences in clinical practice. I managed to analyze within the stages of the model. Moreover, the development of the skill by analytical evaluate through the reflection process enhances my base knowledge regarding to the skill and professional improvement in future practice. The reflection provides me the opportunity to improve the area of weakness that has to be upgraded in performing the skill in future. I concern the existence of current evidence-base practice which provides the guidance to improve my professional practice development.