Introduction
This essay aims to critically analyse and reflect on a 10-minute consultation independently led by me under the supervision of my mentor who is an Advanced Nurse Practitioner.
In the essay I will aim to analyse and reflect on the skills I have used, the rationale behind all decision making skills and reflect on my practice using John’s model of reflective account, I will critically evaluate the use of my communication skills during the consultation, the types and rationale for each communication and consultation skills used, reflect on the ability of history taking, my findings, physical assessment techniques which will include inspection, palpation percussion and auscultation holistically examining different anatomy of the body interpreting findings with good knowledge of the normal and abnormal findings making referrals where applicable and also recommendations for medication under the supervision of my mentor who is an Advanced Nurse Practitioner, the essay will also aim to identify and evaluate the mental health assessment during consultation, I will use John’s model of reflective model for the purpose of this essay as a preferred choice.
The purpose of a consultation is to listen to a patient talk about their difficulties and any abnormality they experienced over a period of time and carry out assessment, examination and make diagnosis which will aid in either making a referral, prescribing medication or empowering them with health promotion advice or solution.
Graham Perry stated in his article that the success of a nurse consultation depends on clinician’s clinical knowledge, communication skills and interview skills and in addition to that nature of relationship between the clinician and the patient with increased emphasis laid on communication skills alongside history taking this is important as the patient needs to feel at ease during the consultation in order to be able to express their feelings and explain their condition very well.
Consultation modules
Consultation models are established lists of questions or areas to be explored, and provide a framework for a consultation. They can be useful, especially to those of us who like to think and learn in a structured or more organised way, especially when developing a skill such as consulting with patients, I had practiced and studied a range of consultation skills and prepared myself with a range of models which I had at the back of my mind that I will implement depending on the patient and consultation time allowed by my Mentor for me to use and assess each patient assigned to me for the day under her supervision.
Consultations are vital part of assessment and diagnosis during the patient’s journey, it is imperative for the practitioner to carry this out in a holistic and systematic manner in order to promote wellbeing, creating a safe and evidence based management plan tailored to each patient (Nutall and Rutt-Howard 2015). Neighbour (2005) identifies the effectiveness of consultations, irrespective of which professional registration is held, as a key element each individual should aspire to improve and maintain to a high professional standard. Thomson et al. (2005) concluded that effective consultations give positive outcomes. To the benefit of Advanced Nurse Practitioners (ANP), research has shown that consultations completed by such professionals give excellent satisfaction percentages, more time spent consulting/information given, especially regarding self-care and management (Horrocks et al. 2002; Kinnersley et al. 2000 and Shum et al. 2000). In the case of primary care and Out of Hours (OOH) appointment times are strict and therefore spending more time consulting has an effect on waiting times.
Generally, consultation models are divided into two types: normative and descriptive (Nutall and Ruth-Howard 2015). Meaning what does happen and what should happen during a consultation. Byrne and Long (1976) model is an example of a descriptive model. Split into six phases in a logical manner, the aim is to complete each phase. However, if one part of the phase is not completed or fails then the consultation is unlikely to be complete and could lead to the wrong diagnosis or treatment (Courtenay and Griffiths 2010). Mead, Bower and Hann (2002) feel that patient centred care has been taken into consideration and done well by this model. The creators themselves did point out that a practitioner (in this study, medical) was shown to interrupt a patient within 18 seconds of the beginning of the consultation. Therefore, this model does not appear as patient-centred as the aim and more doctor-centred. For use in OOH this would not be appropriate, having a very short period with the patient and most likely to have been the first time to consult with the patient, there needs to be a well-established relationship during this short time and allowing the patient to speak and trust the practitioner’s diagnosis and plan. Cooper, Forrest and Cramp (2006) show that a patient decides in the first 90 seconds if he/she likes or trust you, therefore it is vital to establish a connection within this time period.This certainly is patient-centred rather than doctor-centred. The idea being the practitioner is able to acknowledge the concerns the patient has, allowing for the practitioner and patient to create a solution which both parties accept (Courtenay and Griffiths 2010). However, not all patients wish to be involved in the decision making. Therefore, the practitioner requires to discover the patient’s perspective and level of involvement they would like in the decision-making process (Illingworth 2010). Pendleton et al. (1984) model would be appropriate for use in OOH as it is a useful way of building a relationship with the patient, involving them in care and decisions during the short time the practitioner will meet them.
Another comprehensive and widely used model is Calgary-Cambridge Guide which is based on previous older models which Kurtz and Silverman (1996) have used as a body to create a model which values patient’s ideas and compliments traditional holistic approach used by nurses (Munson and Wilcox 2007). Calgary-Cambridge describes the behaviour and skills required to complete each step. This model uses six steps for structure, which unlike most, includes closing the consultation. Similarly, to Pendleton et al. (1984), patient-centred care and joint decision making is incorporated into consultation. Kurtz, Silverman and Draper (2005) highlights communication to show skill and certainty, as without these it is likely to put doubt into the patient’s confidence in the practitioner.
For Advanced nurse to improve in their practice, its very important that Nurse are able to continuously reflect on their practice to identify areas to improve their practice, identify learning needs and improve patient outcome. I identified Reflection-in-action as an important aspect of my nursing career as this will enable me to make quick decision reflect on it and correct my actions if they are not appropriate especially with patient care where they have put their trust and believe you are the expert and I have employed this thought as I saw patients throughout the day. Scientific research by Oelofsen, Somerville and Keeling shows that reflective practices at work advance the development of skills such as awareness and the ability to influence others. Working reflectively ensures that people gain insight into practical events and how someone’s own approach and history has contributed to the way situations arose and how these were handled.
29years old woman came to have her ears irrigated by the Advanced practice nurse who is my mentor, Consent was gained for my presence and practice. Her name has been changed to protect her identify and confidently. She had previously seen the doctor a week before who diagnosed her with having impacted cerumen (earwax) in both ears as she had difficulty hearing properly. He advised her to put some ear drops in both ears and book an appointment with the practice nurse to have her ears irrigated. The patient will be referred to as Kate in order to guard against breaches of confidentiality (NMC, 2008). I had to carry out the consultation and manage this minor condition independently within a legal and professional framework as I was being assessed by my mentor who is the Advanced Practice Nurse for the surgery. The patient’s medical records were checked in order to determine if this was a reoccurring problem before I called her in.
Her past medical history and medication was also taken note of in order to determine if she had any other risk factors such as past or present perforation of the ear drum, vertigo, acute otitis externa, presence of a grommet or history of ear surgery as these are all contra-indication to ear irrigation (Aung and Mulley, 2002) which can have a direct impact on resolving this problem. The patient did not have any of these issues, but it was noted that she is a known asthmatic on salbutamol 100mcg as required and Qvar 100mcg, 2 puffs twice a day.
My ANP asked me to assess the patient and carryout the procedure as I had previous experience in ear irrigation as a community staff nurse. Courtesies such as going to the waiting room to call the patient by name and exchanging pleasantries before the actual consultation starts helped to reinforce the atmosphere and build rapport.
I introduced myself as a student practice nurse, who was being assessed by my mentor at the beginning of the consultation to gain the patient’s consent (NMC, 2008). Both the NMC’s code (2008) and the Department of Health’s (2001) Good Practice in consent Implementation Guide clearly states that patients can only provide consent if they have enough information and understanding on which to base a decision.
I considered the disease-illness model, also known as ‘Patient Centred Clinical interview’ (Stewart and Roter, 1989) as these methods places the doctor’s agenda (disease approach) in parallel with the patient’s agenda (illness approach). However, Beaumont (2012) have criticised this method as he suggested that this approach may presents tension between the patients and the doctor’s agenda, which may defeat the aim to consolidate the two agendas in an amicable way. Instead, I adopted the Calgary-Cambridge consultation model (Silverman et al, 1996), which is an evidence-based approach used extensively in medical schools in the UK (Kurtz et al, 2003) and my rational for choosing this model is that it goes beyond description as it provides basis for establishing and resolving problem in order to improve clinical outcome and patient’s satisfaction. The consultation process explores a holistic approach which includes: Initiating the session; Gathering information; Building the relationship; Physical examination; Explanation and planning; Summarizing and closing the session.
The consultation started off by me introducing myself, gaining consent as a student trainee Advanced Nurse Practitioner, asking open questions, such as “How can I help you today?” which gave the patient an opportunity to tell her story. Skills such as active listening, without interrupting the patient was employed initially in gathering the data before closed questions such as the onset of the problem and symptoms specific to this problem were later asked, luckily the patient is young and was able to explain her symptoms with the assigned 10 minutes allocated to us for consultation. According to Clark (1999) listening to a patient’s story is not just an opportunity for data collection, but an opportunity to establish a therapeutic relationship. However, Warren (2010a) have suggested that this technique may occasionally backfire as some patients may start to repeat themselves, therefore the nurse’s ability to take control of such cases is necessary for me on this session, it went well as I was nervous on how to stop her if she is really into telling so much story about her symptom.
Good communication skills are important as it allows the nurse to show interest by actively using both verbal and non-verbal skills such as eye contact, nodding of head and echoing during the consultation using the patient’s own words. Although, some gestures or body language such as posture, facial expression or touching a shoulder could send the wrong impression or discourage the flow of conversation (Warren, 2010b). The main points were summarised at the end of the initial history taking and I double checked with the patient that I had the same perception or understanding of her main concerns. Lloyd and Craig (2007) have suggested that professionals should avoid the use of technical terms or jargons whenever possible as taking a patient’s history is arguably the most crucial aspect of patient’s assessment (Crumbie, 2006).
The history taken established that Kate’s ears have been blocked for almost a month now, which initially caused her pain. She confirmed that the pain had subsided since she started using the ear drops recommended a week ago by the GP. She was also asked about the extent the presenting problem was affecting her lifestyle. Although, she said she was eating and drinking as normal, and has no red flags such as fever, ear discharge or severe pain. However, she did feel a bit anxious as this was the first time, she had experienced these symptoms. Lloyd and Craig (2007) emphasised the importance of enquiring about mental health issues as part of patient’s wellbeing during history taking, even though the nurse may feel anxious about it. She also confirmed that the ear wax caused her hearing impairment, which she found very frustrating, stressful, depressing and also caused her social isolation as she felt embarrassed asking people to repeat what they just said.
The patient did not have any pain or discomfort during examination of both ears and I used the otoscope to establish the presence of wax. I could not see her tympanic membrane as both ears were impacted with wax. I informed Kate that I was going to use wet irrigation procedure and then warned her before starting the procedure that she may feel uncomfortable when the warm water is entering her ear canal, but to raise her hand up to stop me if she experiences any pain or dizziness as irrigation should never cause pain (Harkin and The Primary Ear Care Centre, 2007). A systematic review by Clegg et al (2010) suggested that wet irrigation is better than dry irrigation. Although, the author confirmed that it was difficult to compare various studies due to the outcome measures used and heterogeneous interventions. However, there is limited good quality evidence of the benefit, cost and safety of the different method of ear irrigation (Clegg et al, 2010). I started the irrigation using the minimal pressure, gradually increasing it by checking that Kate was comfortable with the pressure. I was able to remove the wax from the left ear and then dry mopped the excess water from the meatus using paper towel as Guest et al (2004) suggested that residual water can promote ear infection. I then moved over to the right ear, following the same procedure as the left ear.
I immediately noticed tears flowing down Kate’s face as soon as I started irrigating the right ear and she then complained of a throbbing pain. I stopped the procedure immediately and offered her tissue to wipe her tears. I asked her if I could look into her ear and she consented (NMC, 2008). I had a look at the ear canal and could still see lots of wax in it, so I asked my ANP to have a look in Kate’s ear, which she did with her consent. She then confirmed that the wax in the right ear was not loose enough. It was then I realised that I did not ask Kate from the beginning which ear drops she was using. Nevertheless, evidence suggests that using any kind of ear drop is better than no treatment (Burton and Doree, 2009) and there is no evidence to indicate a preference of any cerumenolytic over another (Hand and Harvey, 2004). When I asked her, she confirmed that the pharmacist recommended the otex ear drops for her. I am aware that otex contains urea-hydrogen peroxide which may sometimes irritate some people’s ear. There is evidence that instilling tap water after failed irrigation for 15minutes can be used as a wax dispersant (Eekhof et al, 2001),which will be quick and convenient for the patient. Although, I did not give Kate this option as I felt it will be inappropriate as she was distressed and had complained of a throbbing pain.
Prescribing Process
I had to re-assess Kate again, but this time using symptom analysis mnemonic OPQRSTU approach (Newberry et al, 2005), but focussed more on the pain she was experiencing. I then came up with possible differential diagnosis of otitis externa or media; mastoiditis; malignant tumor; trauma of the ear canal or foreign bodies in the ear. However, it is most unlikely that she has mastoiditis as she did not experience any pain at the initial assessment when I applied pressure to the mastoid area. Trauma of the ear canal or foreign bodies in the ear is most unlikely as patient did not reveal that possibilities during history taking and she confirmed that she had never cleaned her ear canal with a cotton bud or hairgrips. It is also unlikely that she has malignant tumor as she is generally well and Rutter (2005) have suggested that this is usually associated with increasing age. However, it is most likely that she has acute otitis media instead of acute otitis externa because she did not have any pain at the initial assessment when the tragus or pinna was moved or when the otoscope was inserted into her ears.
Acute otitis media (AOM) is a middle ear infection which may be caused by bacteria or virus or sometimes both. The findings were then explained to Kate in a much simpler language as I gave more explanation especially with regards to the possible causes of AOM. She showed clarity and understanding of the explanation through her body language and facial expression as she was nodding and was able to repeat back some of the information given to her. I decided to prescribe as an independent prescriber under supervision some olive oil as her ear still needed to be irrigated, an analgesic to resolve pain and also give a delayed prescription for antibiotics in case the infection is caused by bacteria. For the purpose of this case study, the two main drugs that will be concentrated on are the analgesia and antibiotics.
A positive approach was conveyed with regards to treatment as I reassured Kate that AOM was generally self-limiting and that without antibiotics the symptoms can be expected to resolve within four days with other methods of management such as using paracetamol or ibuprofen to manage pain. There is evidence that both analgesics are efficacious in relieving pain in AOM as they both have good safety profile and few adverse effects when the recommended doses are used (SIGN, 2003). Paracetamol is indicated for mild to moderate pain and pyrexia while Ibuprofen is indicated for pain and inflammation. Nevertheless, I am aware of Kate’s current history of asthma and that ibuprofen should be used with caution because of its possible side effect of gastrointestinal bleed, but it is relatively safe if the lowest dose is taken for a short period to control symptom. However, I will be prescribing paracetamol in preference to ibuprofen because of Kate’s history of asthma. Paracetamol is considered to be a weak inhibitor of the synthesis of prostaglandins, but its analgesic effect is central due to the activation of descending serotonergic pathways (Graham and Scott, 2005).
I then offered Kate a choice of waiting for a few days to see if the problem resolves or a delayed antibiotics prescription. However, we agreed to adopt the delayed antibiotic prescribing strategy all this carried out under the supervision of my mentor who kept good eye contact with me and reassured me of good performance. However, NICE (2008) evidence suggests that antibiotics are unlikely to make much difference to symptoms [Sanders et al, 2004]. Delayed prescription reduces the intention to visit a doctor for future episodes; reduces the consumption of antibiotics which could lead to antibiotics resistance; and risk of possible side effects such as diarrhoea, vomiting or rash from its use (Spiro et al., 2006). All this information was made clear to Kate, before offering her the recommended first-line antibiotic treatment (Amoxicillin 1g every 8 hours for 5days) as she is not allergic to penicillin. Amoxicillin is active against certain gram-positive and gram-negative bacterial pathogens involved in otitis media by affecting the production of the peptidoglycan wall of the bacterium, thus rendering the bacteria cell wall useless (Barber and Robertson, 2009). Amoxicillin is a derivative of ampicillin, but its better absorbed when given by mouth as it produces higher plasma concentration and tissue concentration as it is not affected by the presence of food in the stomach. It is contra-indicated in people with penicillin hypersensitivity. I then told Kate to come back to see me if the paracetamol does not relieve the pain, symptoms not starting to settle within four days or worsening symptoms at any time. I am aware that routine follow-up is not required in the absence of persistent symptoms, but my rational for this advice is because we adapted a delayed antibiotics strategy (NICE, 2008) and Kate’s right ear still needs to be irrigated.
The key issues I needed to pay attention to are communication skills, interpersonal and prescribing skills. As a practice nurse, I am keen to help Kate resolve her hearing complaints and was quite worried when she complained of pain. Faulkner (2002) suggested that structure and focus must be given during an interview if patients’ problems are to be identified. I also realize that my body language after Kate complained of pain might have showed that I was worried and concerned as vast majority of interpersonal skills comprise of verbal and non-verbal component. Research have shown that the non-verbal elements can account for up to 80% of the meaning that is conveyed in face-to-face interaction and verbal and non-verbal behaviors are complexly intertwined in conveying meaning (Berry,2007).
Nevertheless, I know I have a degree of autonomy with this expanded role as I may be the first point of contact for patients with minor condition, which then makes me more accountable for my practice. Autonomous prescribing is no longer a new experience for nurses as The Medicinal Products Act (1992) clearly sets out the conditions under which certain nurses are able to prescribe. Reveley (1999) have suggested that nobody has absolute autonomy as they are limited by their professional bodies, employers, health authorities and the law of the land. In the interest of public safety, practice nurses have a personal and professional accountability. Although, accountability may be associated with a blame culture, Savage and More (2004) have suggested that accountability promotes good practice and is not necessarily a negative concept. The NMC’s code (2008) clearly states that we are personally accountable for our actions and omissions in our practice and must always be able to justify our decisions as professionals. This simply means being able to answer for one’s action and omission by giving rational and explanation based on evidence practice at all times if necessary. However, I am aware that there is a major limitation to my autonomy, which will be based on my knowledge and skills, especially with regards to prescribing certain medications from the British National Formulary (BNF), which may be outside my scope of competency. Lunn (1994) have also stated that the nurse has to be equally sure of their ground in declining new roles on the grounds of limitations in competence.
The law and professional disciplinary bodies such as the NMC also views the nurse prescriber as a professional, whom certain standards are expected to be met on this particular specialty as it can be argued that nurse prescribing represents a major advance for nursing (McCartney et al.,1999).
I am also responsible for making management decisions from a range of various options which I will be accountable for when managing minor conditions. I also know I have a legal duty to act with care when dealing with patients as malpractice could lead to a civil action or even criminal prosecution in extreme cases (Reveley, 1999). the Misuse of Drugs Act 1971; and by NHS regulations, which a breach of these statutory professional law could lead to supervised practice, suspension or even dismissal from practice(Lymm et al., 2010).Nevertheless, the main purpose of the Medicines Act is to assure the safety, quality and efficacy of medicines marketed in the united Kingdom, while the Misuse of Drugs Act is an additional stricter supply controls for a number of medicines with a high potential for abuse. Prescriptions must always comply with the regulations made under the Medicines Act for it to be legally valid. I owe my patients a duty of care as a prescriber and should be able to provide evidence to support my prescribing decisions at all times
I am also aware that ear irrigation is a common cause of litigation cases amongst procedures carried out by nurses. According to Zoe (2012) the Medical Defence Union settled £154000 litigation cost for problems related to ear syringing between 1992 and 1997. Therefore, the nurse’s legal defence against civil action is to gain the patients’ consent at all time before any procedure is carried out as it is a legal obligation (NMC, 2008). For instance, Kate’s consent had to be gained before my ANP re-examined her as Dowling et al (1996) have suggested that consent to touching by one person does not act as consent to touching by any other professional.
Good communication between team members is crucial as record keeping is an important written communication tool for continuity of patient’s care in achieving this goal. According to Reveley (1999), good record keeping promotes good quality patient care, safeguards the nurse in case of legal or disciplinary actions and empowers the nurse to practice to the highest standard of care. Confidentiality cannot be over emphasised in record keeping as it is crucial to protect all information obtained from patients’ by ensuring that the record can only be accessed on a need to know basis.
Conclusion
In conclusion, I have learnt great lesson on different aspects of consultation which I will find very useful in my practice, carrying out the consultation and making a prescribing decision under supervision. Although my feeling of worry towards the end of the session was noticed in this case, I have learnt that in future my patients will expect me to act as a professional and be knowledgeable in my area of practice, Jasper (2003) suggested that a nurse showing panic may unsettle a patient and this shows lack of competency and confidence in practice and this may result in lack of patient’s confidence and trust in the nurse and also in healthcare system. However, increasing my knowledge on the theoretical concepts and principles underpinning consultation and prescribing will help me in future clinical practice and also make the patience to be at ease and have trust in our practice as healthcare professionals. This will assist me to understand some of the problems that I may be faced with when assessing individual needs therefore gathering adequate knowledge, skills and experience is the key to successful practice.
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