REFLECTIVE ESSAY ON THE LEARNING CONTRACT CONSIDERING THE SURGICAL AND ANAESTHETICS ROLES OF ODP FOR AN ABDOMINAL HYSTERECTOMY. By AKINYEMI AKINTARO 0711964 Dip of HE (ODP) Enhanced Theatre Practice OPE09-1 REFLECTION ON THE LEARNING CONTRACT. This is a reflective essay based on my experience of participating in delivery of anaesthetic and surgical care to a patient undergoing abdominal hysterectomy under general and regional anaesthesia.
I will be describing the process involved, my participation and contributions, what I learnt during the experience and how this gained knowledge will improve my professional competency. Reflection is a way in which health professionals can bring theory into practice because reflection has a potential to uncover knowledge and promote action. Reflection also promotes better clinical judgement. Dyke (1999) emphasised that reflection is a vital part of the practitioner’s daily work.
Johns(2000) also described reflection as a window through which the practitioner can view and focus self within the context of his/her own lived experience in a way that enable him/her to confront, understand and work towards resolving the contradictions within him/her between what is desirable and actual practice. The use of a recognised frame work allows for a more structured interpretation when reflecting upon practice (Dyke, 1999). For the purpose of this essay I am going to use Gibbs’ (1998) mode of reflecting.
This is a reflective cycle which provides a straight forward and structured framework and encourages a clear description of the situation, analysis to make sense of the experience, conclusion where other options are considered and reflection upon experience to examine what the professional would do should the situation arise again. It must be noted however that any reflective practice is reliant on memory and interpretation of events – selective memory is a particular problem especially following a negative event (Newell, 1992).
I will for the purpose of reflecting on this experience pay particular attention to the administration of epidural, the surgical scrubbing technique, accountability, and my roles as ODP in the above mentioned processes After deciding on hysterectomy as the topic for my learning contract, I had a discussion with my lead mentor, anaesthetic and surgical mentor on how best to give me the opportunity to be involved in two specific hysterectomy cases so that I can have both the anaesthetic and surgical assessment.
Then I set about getting materials; literatures from journals, internet, textbook, and discussion with my mentors, other senior colleagues and consultants. In the period of sourcing for this specific knowledge base I have learnt a lot about hysterectomy; types, choices, emotional implications, and alternatives and I can say this will really help me in my future role as a professional. Analysis and Evaluation. Anaesthetic. For the purpose of fulfilling this learning contract I assisted the anaesthetist in preparing the patient who is to undergo abdominal hysterectomy under general anaesthesia.
And I was supervised by my anaesthetic mentor during this process. I earlier prepared the room, check the anaesthetic machine, set up the intravenous fluids ,brought out anaesthetic drugs , prepare for difficult intubation and set up for epidural. I checked the patient in by confirming her name, date of birth, last time she had anything to drink or eat. I was actually left alone to totally work with the anaesthetist without any contribution from my mentor. The anaesthetist also showed me how to set up the PCA pump infusion for post operative pain relief which the patient will take to the recovery.
The anaesthetist talked me through the epidural insertion which was later connected to the Epidural pump. The experience was very good for my confidence and I also learnt the importance of preparing and be organised for the anaesthetic process; anything can happen in a split of a second. Epidural On completing this learning contract I now know that the advantage of epidural over spinal anaesthesia is the ability to maintain continuous anaesthesia after placement of an epidural catheter, thus making it suitable for procedures of long duration.
This feature also enables the use of this technique into the postoperative period for analgesia, using lower concentrations of local anaesthetic drugs or in combination with different agents. Also I have a better understanding of the anatomy of the Epidural space, loss of resistance Arachnoid space, and Cerebrospinal fluid. I have also learnt about the potential complications of epidural e . g Hypotension, Inadvertent high epidural block, inadvertent high epidural block, Local anaesthetic toxicity, Total spinal, Accidental dural puncture (Visser, 2001).
Learning about the potential complications of epidural reinforced my knowledge in being able to choose the right anaesthetic monitoring equipment. Knowing that Spinal and epidural anaesthesia can cause unpredictable and profound arterial hypotension necessitate the use of adequate monitoring like the; Pulse oximetry, ECG and Blood pressure cuff. This knowledge will help me to be able to select appropriate monitoring devices during epidural catheter insertion. Also it goes without saying that an epidural must be performed in a work area that is equipped for airway management and resuscitation.
I now know that the hypotension is caused by vasodilatation because the sympathetic nerves that control tone are blocked. Peripheral pooling of blood occurs, resulting in a reduced venous return to the heart and a decrease in cardiac output. This is the reason for having a Hartmann’s fluid at hand and the important of hartmann’s fluid was emphasised by Casey (2000), along with the establishment of an intravenous access, because the effect of the epidural may cause vasodilatation and a drop in blood pressure due to autonomic and sensory fibres being blocked before motor fibres.
I am better aware now why it is important that that the patient should be informed of the possible risks and complications associated with epidurals. While the anaesthetist would have done this it is an essential role of the ODP to reassure the patient and encourage the patient to ask any question that might be important to them. It is also possible to talk the patient through the procedure of the epidural, like the position; what the patient will feel or won’t feel; the cold spray to the back etc
Roles of ODP in during Epidural When preparing for the epidural administration , I made sure the followings were ready and on hand; A basic universal pack which includes catheter, filter, Tuoy needle and loss of resistance syringe ; 1% or 2 % lignocaine, fentanyl, 10 – 20 mls normal saline, tegaderm and epidural dressing , sleek, transpore e. t . c I also made available Skin preparation solution of Chlorhexidine gluconate and I litre of Hartmann’s solution.
The ODP also makes sure that before an epidural is performed, the anaesthetic room should be checked to make sure that there is proper equipment for airway management, resuscitation and routine vital signs monitoring must be available. The most important role of the ODP in assisting the anaesthetist to carry out an epidural procedure is to make sure everything that will be needed is on hand and ready to go. It is also important to make sure all the drugs and consumables to be used are in date and the ODP should be ready to assist the anaesthetist by opening things that are needed and also drugs on request.
Another important role of the ODP which I recognised is in the positioning of the patient for epidural catheter insertion. The position could either be Sitting or Lateral Decubitus positions. When discussing with the anaesthetist, he said the position should be lateral decubitus to allow for ease of insertion. And as mentioned earlier reassuring the patient is another important skill that an ODP needs to develop. Surgery. I scrubbed for the case, set up the instrument, check the patient with the name band and consent form. I prepped and draped the patient with the surgeon’s assistant and positioned my trolley for the start of the case.
Completing this learning contract afforded me the opportunity to build up on the knowledge I had gained previously on scrubbing, gloving and gowning In each operating area there is a separate ‘scrub-up’ zone outside the operating room. The scrubbing process involves series of steps like brushing of nails, cleaning and drying of hand and arms. However, the aims are to remove dirt, skin oil, and transient micro-organisms from the nails, hands, and forearms; to reduce the resident microbial count to as near zero as possible and to leave an antimicrobial residue on the skin to prevent re-growth of microbes for several hours (Nicolette, 2007).
During the completion of this learning contract; and through my discussion with senior colleague , reading journal and textbooks ;I learnt more about the importance of aseptic surgical scrubbing is essential and needs to be done religiously, with the practitioner being accountable to make sure that; they use proper scrubbing technique; only sterile items are used within the sterile field; check for the package integrity before use; make sure that items of doubtful sterility are considered unsterile and whenever a sterile barrier is permeated, it must be considered contaminated.
The scrubbed practitioner must never forget that sterile gowns are considered sterile in front from shoulder to level of sterile field and at the sleeves from 2 inches above the elbow to the cuff. The cuff should be considered unsterile because it tends to collect moisture and is not an effective bacterial barrier. Other areas of the gown that must be considered unsterile are the neckline, shoulders, areas under the arms, and the back. These areas may become contaminated by perspiration or by collar and shoulder surfaces rubbing together during head and neck movement.
Accountability as related to swabs and sharps counting. According to Hughes (2002) the concept of professional accountability remains an ever-present issue in the operating theatre; with nurses and ODPs often acting under the instructions of anaesthetists and surgeons, assuming that they are void of responsibility. Accountability is different from responsibility. Accountability means that the practitioner is able to give an explanation of, and justification for his or her actions. Whereas, responsibility relates to carrying out instruction accurately and within an agreed time – frame.
HPC (2004)standard of proficiency for ODPs , outlining the autonomy and accountability for ODPs, states that an ODP must be able to practice within the legal and ethical boundaries of their profession…… and be able to exercise a professional duty of care. Hence, an ODP involved in the scrub or circulating role must be accountable for swabs and sharps counting and cannot pass the responsibility to another person. Scrubbing for an abdominal hysterectomy case made me to appreciate better the importance of swab counting, anticipating the surgeon and decision making.
Because of the different layers in structural anatomy of the abdominal wall it is important to follow the case closely as it progresses so as not to loose any swabs or sharps. According to Dunscombe (2007) Instrument count is as important as sharps count and should be carried out concurrently by the circulating and the scrub person before the procedure, with each person simultaneously viewing the instrument and audibly counting it. Items added during the procedure must also be counted and recorded. Swabs, sharps and instrument must be counted as each layer or major cavity is being closed and towards the end of the case.
The instrument tray for abdominal hysterectomy is similar to most sets for general operations. There are scissors, artery and dissecting forceps, sponge holders, towel clips, needle holders, diathermy forceps etc. According to AfPP (2007) the scrubbed practitioner must recognise and identify the instruments and their purpose within the set. Gilmour(2008) maintained that the scrubbed practitioner is responsible for ensuring that all instruments are fit for purpose and able to perform the task required.
If sterility is compromised (instruments found to be contaminated with blood or body tissue) then the set and instrument must be removed from theatre and reported to the sterile service department. The scrubbed practitioner must ensure that all instruments are accounted for throughout a surgical procedure, and if an instrument was to break intraoperatively then all the pieces must be retrieved and discarded with the appropriate note made on the tray list if necessary. At the end of the procedure all instruments must be counted and checked by the scrubbed and circulating practitioner.
The scrubbed practitioner must ensure that all sharps and consumables are removed from instrument tray to prevent injury to either sterile services staff or those who transport the instruments between theatre and the sterile department. However, now I know that the most important instrument in the abdominal hysterectomy trays is clamps and retractors. Clamps are instrument specifically designed for holding tissue or other materials, and most have an easily recognisable design.
They have finger rings ,for ease of holding; shank, whose length is approximate to the wound depth; ratchets on the shanks near the rings, which allow for the distal tip to be locked on the tissue or object grasped(Dunscombe,2007). During the surgical operation, and when the incision was made through the abdominal wall to the peritoneum and the peritoneum was retracted with self-retaining retractor, I found it easy to follow the procedure and identify the tissue and organs around the uterus; identifying landmarks like he round and broad ligaments, bladder, cervix etc. This is possible because I had read up on the anatomy related to abdominal hysterectomy. According to HPC (2004) standard of proficiency, an ODP must be able to gather appropriate information…, be able to draw on appropriate knowledge and skills in order to make professional judgement…. and understand the need for carer-long self-directed learning. The feedback after the case was positive with some constructive advice on how to be a better scrub practitioner.
The completion of this learning contract afforded me the opportunity to build on my previous knowledge and for example develop my role from circulating to scrubbing. I have more confidence preparing, assisting and participating in general and gynaecological cases, both from anaesthetic and surgical point of view. It is essential that the ODP in the scrub role has a basic knowledge of the structural anatomy involved in the procedure to scrub for. This will help to anticipate the needs of the surgeon very well and on time
Conclusion During the process of fulfilling the learning contract I gained some important knowledge which I am certain will help to make me a better practitioner One of the most important thing I learnt is the importance of articulate preparation and anticipation in becoming a competent and reliable ODP, in both anaesthetic and scrub roles. Also having good basic functional structural anatomy knowledge of the procedure (both anaesthetic and scrub role) taken place helps to function very well as a practitioner.
Effective communication is also important, for example in the anaesthetic room I learnt the importance of informing the patient about effect of the procedure they are having. Like explaining the effect of epidural to reassure them. Before this learning exercise I usually think only the anaesthetist can give explanation to the patient about certain things. But from my discussion with the anaesthetist, I was made to understand that as long you are capable of taking responsibility for the information given then that should be okay.
According to Taylor and Campbell(1999) effective communication, both verbal and written, is fundamental to the organisational management of the operating department. I also appreciate better the importance of swabs, sharps and instruments counting and when to do the counting as each layer is being closed. As a practitioner, I have a responsibility to make sure that the instruments are adequate and functional before the procedure and to make sure that everything is accounted for at the end of the procedure. Generally, I would say that this learning contract afforded me the opportunity to progress from the circulating role to the scrub role.
Also I gained more confident assisting the anaesthetist in the anaesthetic room. On reflection I can say that I have gained more practical knowledge in anaesthetics and I can anticipate better than before, to assist the anaesthetist. I understand now what are needed to provide general and regional anaesthesia for typical gynaecological and general cases. I have learnt that the anaesthetic assistant’s key role were that they needed to continually anticipate and respond to the requirement of the anaesthetist, while at the same time remaining the patient’s advocate and ensuring that safe practice is maintained .
This view is supported by Harvey (2005) while emphasising the need for the whole anaesthetic team to work together, anticipating each other’s needs and requirement, this will help to dealt with, safely, any problem encountered during the administration of anaesthesia . Anytime I have the opportunity to assist in the abdominal hysterectomy operation either as a scrub practitioner or ODP assisting the anaesthetist I am certain I would be able to bring all these experience to good use. References Alexander. M, Fawcett. N, & Runciman. P,(1994), Nursing Practice – Hospital and Home – The Adult.
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