Perioperative death is thankfully not a regular occurrence in UK operating theatres. However, when it does occur the perioperative practitioner is often denied the opportunity to grieve. The use of a clinical supervision session enabled a critical reflective approach to be followed after the death of a patient in the operating theatre.IntroductionReflection is a critical component of the continuous professional development (CPD) cycle and enables practitioners to objectively review their practice thereby enhancing their performance (Taylor 2000). Reflection-on-action is a method of reflection that can be used following an event, to problem solve and examine solutions to situations. Reflection-on-action gives practitioners the opportunity to challenge current practice and encourages transformative action that can ultimately lead to improvements in the quality of care delivery.
Glaze (1998) refers to the difficulties that practitioners face in developing critically reflective skills due to the this is the way we have always done it approach and suggests that nurses should engage with colleagues to develop critically reflective skills. This process of facilitated reflection can be referred to as clinical supervision. Clinical supervision has been highlighted by the Department of Health (DH) and other international health agencies as significant to creating and providing safer clinical practice (DH 2001, Haggman-Laitila et al 2007, Staun et al 2010).
Using Gibbs (1988) model of reflection this paper details the discussion from a clinical supervision session following a perioperative death.Description of eventThis event is centred on a patient requiring an emergency oesophagogastroduodenoscopy (OGD). The theatre team consisted of a consultant endoscopist, endoscopist registrar, theatre sister, two staff nurses, a 2nd year nursing student, anaesthetic registrar and anaesthetic nurse. The patient was a fifty two year old man, William Brown, (pseudonym) who had presented with bleeding oesophageal varices. When I entered the theatre the procedure to band the varices was already underway. My role was to try and provide reassurance and support to William as he appeared very distressed.The anaesthetic team began implementing the massive transfusion protocol and were in the process of administrating packed red cells.
The consultant said he had spotted an active bleeder and within seconds of this William quickly desaturated and became very hypotensive. The consultant then withdrew the gastroscope and stated he felt this was a peri-arrest situation. The anaesthetic registrar began to manually ventilate William whilst I commenced chest compressions. The resuscitation attempt carried on for some time, but unfortunately the outcome was unsuccessful and William was pronounced dead.William had last offices attended to; he was then taken to the recovery side ward to allow his family to be with him.
Once the theatre had been cleaned and restocked the nursing team were sent to assist in another theatre.FeelingsI had never had the opportunity to nurse a patient with bleeding oesophageal varices before. During my training and as a ward staff nurse I had experienced cardiac arrests and the death of patients, however this was my first experience of death in theatre and my first cardiac arrest in approximately three years. Furthermore it was my first experience of massive and difficult to manage blood loss, which made for quite a devastating scene afterwards.Ads by GoogleAcademic Journals in U.S.Submit & Publish Papers, Journals. Faster Review & Rapid Publication.
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aiu.eduFollowing the cardiac arrest and unsuccessful resuscitation attempt I felt a mixture of shock, disbelief and dissatisfaction: shock and disbelief that William had died, the blood stained bed and floor, and dissatisfaction that resuscitation efforts had failed even though they were implemented quickly and effectively. Onstott (1998) and Gazoni et al (2008) acknowledge that theatre nurses are often under prepared to cope with an intraoperative death, consequently Onstott (1998) advocates that nurses need time to recover physically and psychologically from a sudden patient death. This could be achieved through having supervisors and peers available to turn to and by team debriefing.
My colleagues who were also involved in this event appeared not to show emotion or stress, however on reflection perhaps this was their method of coping despite their greater years of theatre experience. Onstott (1998) further outlines four areas that have been highlighted following debriefing sessions: occurrence of a sudden death, story telling, grief process and skill self-assessment. I can identify with the fourth area in particular as I questioned my skills, could I be of any use Would I know the things the consultant asked for Should I have been doing something other than helping to support William in position Was my CPR good enoughIn addition to these feelings at the time of the event, it was the following morning when I realised that I was being distracted by images of the previous days events. Onstott (1998) identifies that there is often a lack of time for nurses to process sudden death; there is pressure to attend to last offices and necessary paperwork and then to get ready for the next surgical case.Whilst attending to last offices I felt sadness. It became apparent that William was only in his early fifties; he had a wife and two children and this was his first presentation with alcoholic liver cirrhosis and varices. It was upsetting as his death did not appear to be comfortable and peaceful and I found the bloody scene slightly distressing, as maintaining haemostasis is such a vital part of surgery. Wilson et al (2010) suggested that attending to last offices can present a unique challenge to nurses: they are one of the few health professionals to care for people in the period leading up to death and immediately afterwards, and this final act of care involves a wide range of emotions that affect nurses.
However it remains imperative that nurses can deliver dignified, respectful and appropriate care at this time of transition from life to death.Onstott (1998) also emphasises the importance of the nurse recognising these feelings and emotions as this can help the nurses own grieving processes afterwards, to know that they provided care for this patient in a professional and compassionate way. Domrose (2011) and Gazoni et al (2008) indicate that evidence on how nurses cope with patient death is scarce. From the evidence available they conclude that nurses go through a unique grieving process when patients die and how they manage this process is crucial to their wellbeing. Also they agree that talking with co-workers is probably the most helpful coping strategy in getting through a difficult death.
In addition Martin (1993) acknowledges that healthcare practitioners often put their own needs on hold and move on to the next task without taking the time to assess and confront their own vulnerabilities.EvaluationIn the evaluation stage Gibbs (1988) suggests that the good and the bad of the event should be evaluated. Firstly, I tried to focus on what was good: William received treatment quickly and in keeping with the trust protocol for the management of bleeding oesophageal varices.
Everyone in the team remained calm and understood their roles and responsibilities. There was an anaesthetic registrar in theatre on standby even though William had not had a general anaesthetic. This meant that when William went into cardiac arrest there was no delay in intubation and airway management. Having the anaesthetic team on standby also allowed for the massive blood transfusion protocol to be implemented quickly and managed effectively. Furthermore, I was impressed with how quickly the arrest team arrived, which included a consultant anaesthetist who efficiently took charge of the situation and led the team during this emergency.
Everyone who participated in cardiopulmonary resuscitation (CPR) did this effectively, alternating when appropriate to deliver stronger and more effective chest compressions.I then tried to reflect on what was bad: obviously the outcome was not desirable. It was very unsettling to be sent to another theatre straight away and to be expected to continue with another case. There was no talking over what had happened, no explanation of why, no praise for everyone trying their best and no one was asked if they had any questions or needed to discuss anything.AnalysisGibbs (1988) describes this stage as what sense you can make of the situation. The analysis of this situation is focused on briefing and debriefing. Mitchell (1983) developed a model known as the critical incident stress debriefing (CISD).
The model entails seven phases and is intended as a supportive crisis intervention process which aims to reduce distress and restore group cohesiveness and unit performance. The seven phases are: introduction, facts, thoughts, reactions, symptoms, teaching and re-entry. This model is the preferred choice of facilitators working with groups such as firefighters and military personnel (McNally 2004). However, there is limited evidence to determine its effectiveness amongst hospital staff (Ireland et al 2008).Ireland et al (2008) recognise that debriefing originated in the military and is used as a form of psychological first-aid. Interestingly with regards to the hospital setting a Cochrane review, first published in 2002 and then updated in 2006, concluded that there was no evidence to suggest that a single session of psychological debriefing was a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents (Rose et al 2006).
However Ireland et al (2008) argued that this review has not truly looked at Mitchells model.A Canadian study by Western Management Consultants (1996), undertook a cost benefit analysis with a sample of 236 nurses who had experienced a traumatic critical incident. The nurses attended a critical incident response programme where CISD facilitation was implemented. There findings concluded that there was a dramatic reduction of sick time utilisation, turnover and disability claims in these nurses. The benefit to cost ratio was calculated at $7.
09-1.00 indicating that the introduction of this type of programme was beneficial in financial terms. This study has not been replicated within the health service in the UK. However, it would seem reasonable to suggest that the implementation of a similar programme in the UK could have the same cost effective and positive staff outcomes as observed in this Canadian study.Papaspyros et al (2010) highlight that communication failure is one of the contributing factors to adverse events. They suggest that the health industry may benefit from embracing the briefing-debriefing technique as an adjunct to continuous improvement through reflective learning, deliberate practice and immediate feedback, as is used in industries such as aviation or the military.
Papaspyros et al (2010) further state that communication weaknesses in theatre may come from a lack of standardisation and team integration. They suggest that, rather than having a culture of blame where errors are seen as failures, this should be replaced by a culture where errors are seen as opportunities to improve the system. It has been suggested that a debrief as simple as a positive comment about something done well, can become very powerful when repeated after each case, and can lead to a more positive working team (France et al 2008).Awad et al (2005) also acknowledge that debriefing establishes a platform for common understanding and gives people permission to be frank and honest. It gets all members of the team working together and provides a structure for collaborative planning. Baverstock & Finlay (2006) concur that briefing and debriefing provide an opportunity for reflective practice: review, learn and congratulate, or time to look at an event emotionally, physically and clinically.
Had this happened in Williams case, would it have allowed me to leave the room feeling more confident and reassured that we had tried our best and that everyones input had been of value Could I have forgotten the images faster and been able to move on to other cases without interruption Had we have been given the chance to talk things through with our more senior and experienced colleagues would the event have seemed less of an ordealOther healthcare areas such as the hospice setting advocate that, as part of any new staff induction plan, self awareness, a chance to look at grief, loss and anticipatory grief should be included, as well as clinical supervision and preceptorship as an important means of supporting staff (Baverstock & Finlay 2006). The introduction of this type of grief and self awareness training may have benefit in other areas such as theatre and acute clinical settings. Whilst perhaps death does not occur quite as often in these areas, when it does it can have a deep impact psychologically.On a personal level I believe that, had I have been slightly better prepared, I could have dealt with the situation with less self doubt. Nelson (1999) states: When it is not possible to save a life I have learned and have begun to teach how to save a death. This statement reinforces that as nurses it is a privileged position to care for patients even in death, and although life has ended our patients should still receive care with the utmost dignity and respect.
I am confident that William received this.I became aware of the hospital policy on the management of bereavement during this clinical supervision session. The policy outlines four main points which are summarised as:* Staff should have access to training in all aspects of bereavement care.
* Staff involved should have access to a range of formal and informal support including clinical supervision, critical incident review and down time to allow for peer support.* Specialist training should be offered to staff that may have had exposure to sudden and traumatic death.* Staff should be aware of the procedure for contacting the 24 hour staff care line.While I feel this policy is consistent with the evidence I have reviewed, in practice on that day, I do not feel that this was implemented, largely because of the fact that I was sent straight to another theatre. As Petherbridge (1996) states, perioperative practitioners are often denied the opportunity to grieve following the death of a patient.Gazoni et al (2008) also states that The Royal College of Surgeons of Edinburgh in 2001 (RCS 2001) published guidelines recommending that, subsequent to an intraoperative death, surgeons, and perhaps the entire OR team, avoid further elective surgery that day.
They further conclude that it would be unrealistic to set rigid guidelines on how to handle a death as the circumstances surrounding each case vary (Gazoni et al 2008). It is once again stressed that, although debriefing is considered to be very helpful, in reality it is carried out in few cases.Vashdi et al (2007) also highlight that implementing a system of briefing-debriefing in hospitals requires overcoming resistance to change at both team and organisational levels. This resistance to change may be related to individuals viewing such a system as posing a direct threat to their own professional status and wellbeing.
However, the process of debriefing does not have to be a long psychoanalytical process and healthcare organisations could be cognisant of the success of this standard procedure within the fire service and military organisations.Vashdi et al (2007) reveal that military debriefing follows a predetermined pattern consisting of three questions: What happened Why did it happen What can we learn from this so as to do it better next time Sexton et al (2000) suggests that surgery and aircraft combat are comparable. Both professions have a high degree of stress generated by the fact that lives are at stake; they need to be prepared for the unexpected, and operational performance is contingent on close and continuous attention to detail. Vashdi et al (2007) suggest that perhaps one of the obstacles in implementing briefing-debriefing in the surgical setting is interand intra-occupational status differences. In a military debrief there are no differences made between ranks, but the same cannot always be said for the surgical team.
The introduction of the WHO checklist has helped to develop interprofessional communication in the theatre setting. The time out session includes all members of the theatre team. This may provide the opportunity to introduce debriefing as part of the routine following a traumatic surgical event.ConclusionReflecting upon clinical practice has links with improving quality of care, professional development and personal growth while closing the gap between theory and practice (Glaze 1998). The development of regular clinical supervision sessions has proved beneficial as it encourages the practitioner to take time out to explore events and to understand how improvements can be made to practice. By using a reflective cycle it has been possible to analyse and learn on both a personal level but also to raise an issue for other theatre practitioners.
Dealing with sudden patient death presents many challenging emotions for healthcare practitioners and it is recognised that theatre staff are often under prepared to deal with intra-operative death (Petherbridge 1996). It is imperative therefore that theatre staff recognise the value of the briefing-debriefing as part of their daily routine. However it is also important that we acknowledge and appreciate the obstacles tackled by hospital surgical teams in implementing this process (Vashdi et al 2007).Self awareness and a chance to look at grief, loss and anticipatory grief should be introduced as early as staff induction (Baverstock & Finlay 2006).
However, staff need to take responsibility for their psychological well being and to recognise when to get support from their peers or staff support networks. As theatre practitioners we often put our own needs on hold and move on to the next task without taking the time to assess and confront our own vulnerabilities.Action planFollowing this supervision session I now try to implement debriefing and I recently witnessed a particularly effective example:Whilst I was assisting with a bronchoscopy, the patient had a sudden bronchial bleed. The team received clear instructions from the consultant in charge, and as soon as the bleeding was under control but before the procedure was finished, the consultant thanked everyone for their hard work in helping to get the bleeding under control.
Once the procedure was over she again thanked the team, explained the rational for certain instructions, explained why she thought the bleeding had occurred and what she thought the patient outcome would be. This simple thank you and explanation allowed the team to finish the shift knowing that they had tried their best and were valued as team members. Receiving a rational for her instructions will help me to remember what to do should this situation occur again.ReferencesAwad S, Shawn P, Bellows C, Albo D, Green-Rashad B, De La Garza M, Berger D 2005 Bridging the communication gap in the operating room with medical team training The American Journal of Surgery 190 (10) 770-774Baverstock A, Finlay F 2006 A study of staff support mechanisms within childrens hospices International Journal of Palliative Nursing 12 (11) 506-8Department of Health 2001 Building a safer NHS for patients. Implementing an organisation with a memory London, DHDomrose C 2011 Good grief: nurses cope with patients death Nursing 24 (4) 14-15France D, Leming-Lee S, Jackson T, Feistritzer N, Higgins M 2008 An observational analysis of surgical team compliance with perioperative safety practices after crew resource management training American Journal of Surgery 19 (5) 546-53Gazoni F, Durieux M, Wells L 2008 Life after death: the aftermath of perioperative catastrophes International Anaesthesia Research Society 107 (2) 591-600Gibbs G (1988) Learning by doing: a guide to teaching and learning methods Oxford, Further Education Unit, Oxford Brookes University