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In this assignment I will be exploring the legal, professional and ethical issues involved in bed bathing a patient/client in a hospital setting. I will be reflecting on a personal experience, experience during a seven week placement on a diabetic ward. I have decided to use a reflective cycle which is an adaptation from Gibbs’ (1988) model.This reflection has provided a systematic approach to my learning and to my nursing practice. Within this essay I intend to discuss approaches to assessing, planning, implementing and evaluating care.
Heron (1977) refers to the process of reflecting as a ‘conscious use of the self’. Once one becomes consciously aware of their actions, it is easer to recognise the reason for doing them in the first instance. The first stage of this process is to acknowledge our actions by reflecting we reveal to our selves how we act, such actions are spontaneous and without forethought attention.
To maintain my clients autonomy I am unable to disclose any client information, accordingly I have given my client the name Mrs Jones this is to protect and respect my client’s confidentiality as stated by the NMC Code of Professional Conduct.
Gibbs’ model of reflection (1988)DescriptionDuring any client’s admission stage an assessment on the client’s skin care regime is made, this takes into account the clients personal preferences, the level of function the client may have to provide self-care and the amount of assistance required to promote optimal hygiene procedures in the form of bed baths, in respect of encouraging independence. The reason why we bed bath clients is to promote personal hygiene and to give them a sense of well-being it also maintain intact skin i.e. prevention of pressure sours. Bed bathing allows the caregivers to monitor changes in the client’s skin condition. (Staff Nurse, during placement)It was approximately 07:45 Friday morning of mid June, three weeks into my placement. After handover I was given the task of bed bathing a female client. Mrs Jones, what I learned about Mrs Jones in handover was very brief. She was admitted to hospital as she was suffering shortness of breath, she had been suffering from Parkinson’s disease for ten years, she also had a catheter instituted, she had very little control of the lower half of her body, her right shoulder was dislocated and she was MRSA+. Mrs Jones took part in a trial drug many years ago this was to help her control her Parkinson’s disease coming off the drug became impossible and as a result Mr Jones is reliant on this drug, this drug was referred to as apple morphine on the ward.
The basic bed bathing equipment I required was one bath towel, one hand towel, several disposable swipes, clean bed linen, (2 x sheets) laundry bags, (in this case red bags as the client is MRSA+) a slide sheet, small yellow bag for clinical waste, pad and incontinence sheet, bowl of warm water and a set of pyjamas and or gown all provided by the hospital.
The client had acquired her own personal toiletries before admission this consisted of a bar of soap, shower gel, talcum powder, perfume, two flannels, (one for the upper part of the torso and the other for the lower half) moisturiser, a comb, dentures pot, tooth brush and tooth past. In addition to this the client required saline solution, disposable wipes, new dressing cut to size and tape and a yellow clinical waste bag for the disposal of old dressings.
Myself and Claire the Auxiliary Nurse who I was paired with to work alongside put on our protective disposable gloves and red aprons on after collection the supplies from the linen room. I greeted Mrs Jones and introduced myself and Claire. “Morning Mrs Jones, how are you this morning?” She replied “Oh, hello, I could be better” I continued “my name is Sharon (as this was easier for people to pronounce, after consulting Sister) I’m a student nurse and I’m going to be looking after you today”, “and I’m Claire, and I’m also going to be looking after you today too”. I continued “can we help you to get ready for breakfast?” Yes please,” Replied Mrs Jones. Before we began we asked if Mrs Jones if she had any objections to either me or Claire giving her a bed bath, as she looked apprehensive, she replied that this would be fine. We also asked if she had any pain and how her night was, she stated that she was in pain quite a bit but that it was normal for her at this time in the morning. She also stated that her night was awful, as patients in the next bay kept her awake most of the night. Myself and Claire consulted the staff nurse about Mrs Jones’ pain, the staff nurse spoke to Mrs Jones about her medication and said that it was not due until 8:30 and so we were asked to continue as long as the Mrs Jones was happy for us to do so. Mrs Jones replied if that was the case there was nothing she could do other than for me and Claire to continue.
We explained the procedure to Mrs Jones and gain her consent she allowed us to obtain any necessary toiletries from her draws whilst I did this Claire prepared a bowl of warm water. I removed Mrs Jones’s personal belongings from the table and placed them in the draws for safe keeping. I wipe over the table with an alcohol wipe to sanitize the surface and place on there the necessary items we would need to give Mrs Jones a bed bath. We draw the curtains closed to maintain Mrs Jones’s privacy and dignity at all times. Before we began I asked Mrs Jones if she would like to use a bed pan before we continued any further. She informed us that it was probably too late and she felt she had already made a mess. We reassured her that everything was alright and we would help to get her cleaned up as quickly as possible. Mrs Jones apologised a number of time and started to get upset. We again tried to reassure her again and clam her down, we in forced the reason that we were there and that was to help her in any way to see that she is alright. She agreed with us and asked us to continue.
We raised the bed to the appropriate height to avoid putting undue strain on our backs, whilst I did this Claire emptied Mr Jones Catheter and placed the bag on the bed. We decided to place a sliding sheet under the client to assist us in rolling the client. I took the liberty of explaining the procedure to Mr Jones as we carried out the task. I asked if it was possible for her to roll on her right side as I was aware the Mrs Jones right shoulder was dislocated, she insisted that this was fine as it had been seen by the doctors and nothing could be done about it and insisted that she had rolled on it sever times before. We assisted Mrs Jones in removing her night gown, we freed her left arm first then her over her head and then gently freeing her right arm avoiding injuring her arm any further, to maintain Mrs Jones dignity we placed a large bath towel over her covering her private areas. I helped Mrs Jones to bend her left leg and asked her to hold on to the cot side with her left hand. I placed my right hand on the left side of Mrs Jones’s waist and my arm across her left leg to provide added support. I placed my left hand on her left upper back. Claire had prepared the slide sheet, clean linen sheet and an incontinence sheet to go under her. On the instruction ready steady (then the manoeuvre intended, in this case it was) roll, we all assisted in rolling. Claire placed one of her hands on Mrs Jones’s back to provide added support and prevent her from rolling back. Claire folded the old linen in to its self, to as far as it would go until it reached Mrs Jones. Claire placed the clean slide sheet, linen sheet and incontinence sheet already folded in preparation under the old linen sheet. On Claire say so we rolled Mrs Jones on to her back, Claire “we’re rolling you over a slight bump now, ready steady roll”. To roll Mrs Jones on to her other side me and Claire switched roles and this time Mrs Jones was holding on to right side of the cot side but with her left hand. I removed the old linen and placed it inside the red linen bags. I took the liberty of cleaning Mrs Jones with her permission. I used a damp disposable wipe which Clair handed over to me and wiped away from the genital area, I placed the soiled wipe on the soiled incontinence sheet I continued doing this until the are was clean, once this was clean I washed the area with soap and water. I folded the soiled incontinence sheet into its self and disposed of it in the yellow clinical waste bag. I took this opportunity to wash Mr Jones’s back, neck and the backs of her legs with soap and water, I then wash off the soap and dried. I straightened out the clean slide sheet, linen sheet and the incontinence sheet and then Mrs Jones lied on her back.
After a few minute, I placed the hand towel over the client’s chest and with her permission began to wash her face at the clients request I used water only on the face. I used separate wipes for each eye to prevent any cross contamination and a separate wipe for the rest of the face and then dried. Whilst I was doing this Claire began to wash Mrs Jones’s hands with soup and water after gaining permission to do so, Claire continued down the arms and rinsed off, whilst I dried the hands and arms Claire continued to wash the client’s chest. Claire removed the dressing from around the tube of the catheter and disposed of it and her gloves in the clinical waste bag, she then went to wash her hands. When Claire retuned she had a fresh pair of gloves on she began to cleanse the skin from the tube outwards and then dried the area, she decided not to reapply another dressing as she felt it was not required but did tape down the tube to Mrs Jones’s stomach to prevent it from dislodging. Claire carried on washing and rinsing Mrs Jones (Underarms, stomach, waste, genital area, (working outward to prevent infection) legs and feet) and I dried following Claire as she washed. The water that we used was kept clean at all times, as the used deposable wipes were not re-entered into the bowl. Whilst carrying out the bed bath myself and Claire assessed the Mrs Jones’s skin condition for any sours or broken skin. We applied talc to those areas Mrs Jones requested and then helped her to dress. We put the right arm in the nightgown first as this was her bad arm then subsequently her neck and left arm, there was no need to lower the nightgown much as this was a hospital nightgown with an open lower half, we then placed a linen sheet and blanket over her to keep her warm at Mrs Jones’s request. We raised the head of the bed to a seated position so that Mrs Jones was sitting upright. As I attended to Mrs Jones’s oral hygiene Claire combed Mr Jones hear to her particular style. I then started to tidy and clean the area and Claire began to document and update the care plan. Once I had cleaned and sanitised the table I replace Mrs Jones’s belonging on the table and placed the table close to her so everything she may need was of reach.
FeelingsIn reflection to the incident at the time I felt as though everything went fine, but as I have had the opportunity to reflect on my experience in much more depth and detail I in writing this essay I felt as though I took the lead but only because I was given the opportunity to do so. Claire was fairly new to working as an Auxiliary Nurse and was somewhat inexperienced as this was the only ward she had worked on she had more knowledge of the ward setting and the type of conditions people are admitted with on the ward. I was quite confident in assisting in a bed bath of a client as I have worked in providing personal care to all type of client for a good few years now and believe that my experience as a Health Care Assistance helped me immensely. My uncertainty was of the client’s abilities and reactions to what we were actually doing it, that’s when I decided to talk to the client and guild her through what we were doing. The thoughts in my head at the time were that the client may not have experience the type of bed bath that we were performing and may have not been something she was used to. I felt calm but a little apprehensive due to this but could find the words at the time to ask her if this was the way her carers would normally perform a bed bath. It is important to remain professional at all times and make sure the client didn’t feel too uncomfortable. I remember feeling somewhat responsible for the client as I was looking after her. I believe I acted in the best interest of my client and have acted in such a manner set out by the NMC Code of Professional Conduct.
I felt that it would have been better for the staff nurse on duty to explain to the client in much more depth, why it was not possible to administer the drugs at the time of the clients request rather than just to say it’s not the right time and the drug round starts at 8:30.
Although my client had told me the truth about her dislocated shoulder had been seen by the doctors and that it was safe to manoeuvre on as long as it was comfortable it was my responsibility to seek professional advice because of my uncertainty at the time. If for any reason had this not have been the truth there may have been serious repercussions. I don’t think I would have known what to do if her condition had worsened due to the manoeuvre. “The steps forward build on the steps backwards or sideways. They are also the steps necessary for self-reflecting” from this statement emphasised by Tschudin (1999) I able to understand that “confidence in the self” is quite an important quality to be have in order to acknowledge setbacks and mistakes, your should be able to learn from them and even see them as part of the overall picture.
EvaluationI have grater knowledge of such issues that can arise if set guideline, policies and procedures are not followed. There are very few bad points that had taken place during this reflective experience. I believe it is important to involve the client in decision making which I failed to illustrate wherever possible this was when we redressed the client after bed bathing without involving the client and allowing the client to choose. We all have a professional responsibility to provide care to all patients/clients to the highest possible standards of care that will not be compromised by infections standard set out by the NMC Code of Professional Conduct.
I acknowledged limitations set out by the NMC Code of Professional Conduct, in that my knowledge and experience of the drugs on the ward was very limited and therefore I acquired help from a qualified member of staff.
“You must behave in a way that upholds the reputation of the professions” outlined by the NMC Code of Professional Conduct this was maintain throughout the whole experience as I never spoke over the client nor did I ignore the client I showed the client up most respect. I was able to build a level of trust with theMy experience of working as a Health Care Assistance for and agency has enabled me to perform better in such conditions. By planning and discussing with the care team during handover and then with the patient about what our intentions are, what we are going to do and why, I was able to identify and minimise risks to the client.
Seeing the way in which others behave or make mistakes allowed me to reflect on the point of view of others and to learn form them help me build on my knowledge.
AnalysisI chose this experience as it is a procedure that I am quite confident with performing.
Thiroux (1995) created his own set of principles of ethics, which can be applied to any situation. 1) The value of life, 2) Goodness or rightness, 3) Justice or fairness, 4) truth telling or honesty and 5) individual freedom. Ethical acts are executed in every day life even if we acknowledge it or not, the way we greet colleagues and clients even in the way in which we say ‘good morning. Tschudin (1999) p175.
As a training professional we are accountable for our actions and therefore must be able to backup any decision making with evidence I could see from my client’s facial expressions that she was uncomfortable and was experiencing some sort of upset, during which in actual fact she was in a fair amount of pain.
ConclusionI felt that the approach I took was in the right way and with the right intentions set out by the NMC Code of Professional Conduct. My reflective experience was very basic I felt and did not allow for much discussion, although a lot of the experience was preparation, planning and assessing which prevented the experience to go bad in anyway. I feel that as I am a first year nursing student I am very limited in what I can do and because of this little opportunity is given to me to experience other than what I have preformed as a Health Care Assistant. I felt that myself and the Auxiliary Nurse worked well together and were able to share the responsibility equally.
Overall I found reflection on my experience interesting as it allowed me to look at legal, ethical and professional issues surrounding nursing practice.
Action PlanIf a situation like this was to arise again I think I would like to try to take out more time to talk to the client about how they are feeling, at time I felt like I was prying too much as I felt like I was doing most of the talking. I also feel that it is important for me to work along side more experienced members of staff or qualified member of staff to be able to learn more whilst on my placements. Although I experienced in providing personal care to client I am not too familiar with ward setting. I do not think I have learnt an awful lot on the practical side of my experience but by reflecting on my experience in this assignment has allowed me to understand professional, legal and ethical issues of providing care and the dilemmas surrounding health care professionals.
In the future I would not always go on the clients say so and seek professional advice and not just take the patient word.
BibliographyBartter. K, (2001) Ethical Issues in Advanced Nursing Practice. London: Reed Elsevier Plc GroupBurnard. P, Chapman. C, (2004) Professional and Ethical Issues in Nursing. 3rd Edition. London: Elsevier LimitedGlasper. A, Grandis. S, Jackson. P, and Long. G, (2003) Foundation Studies for Nurses: using Enquiry Based Learning. New York: Palgrave MacmillamThe NMC Code of Professional Conduct Standards for Conduct, Performance and Ethics. Standards 07-04. London: Nursing Midwifery CouncilTschudin. V, (1999) Nurses Matter: Reclaiming Our Professional Identity. London:Macmillan