The health professions

Introduction

The Department of Health (DoH) (2003) highlighted the importance for all professions currently regulated by the Health Professions Council to demonstrate competence through continuing professional development (CPD). CPD is a systematic, ongoing, structured process that encourages the development and maintenance of knowledge, skills and competency that assists us in becoming better practitioners (Chartered Society of Physiotherapy (CSP), 2003). As a result of the Health Act (1999) and for registration with the Health Professions Council (HPC), CPD is a legal requirement (HPC Standards of Proficiency, 2007) that must be completed in accordance with the (HPC) Standards of Continuing Professional Development (HPC, 2006). This essay allows for demonstration of life-long learning using evidence from clinical practice and critical evaluation to contribute to my CPD.

Learning outcome 5 will be demonstrated throughout this essay. Throughout this essay the reader is directed to the appendices to support theory with evidence of practice. I considered my motivations for undertaking CPD before writing this essay and reflected upon them again on completion (Appendix 1).

Demonstrate professional behaviour with an understanding of the fundamental, legal and ethical boundaries of professional practice

Beauchamp and Childress (2001) identify four ethical principles; Autonomy, Beneficence, Non-maleficence and Justice. These ethical principles can be used to morally reason whether an action or decision is right or wrong when used in conjunction with a set of guidelines (Kohlberg et al, 1983). Professional codes of conduct are developed within moral, ethical and legal frameworks to help guide and regulate practice (Hope et al, 2008). Every practitioner has clinical autonomy, therefore they are professionally and legally accountable for their actions. The following will discuss the importance of consent and duty of care for both legal and ethical reasons with regards to case 1 (Appendix 2), encounterd on practice placement 6 (PP6).

Rule 9 of the HPC standards of conduct, performance and ethics (2008) states you must gain valid consent from a patient for any treatment you may perform or else you could face trial for assault, battery or negligence under civil or criminal law (Hendrick, 2002). It is a fundamental ethical priniciple that every person has a right to exercise autonomy (Article 9; Human Rights Act, 1998) and is reflected in the Core Standards of Physiotherapy Practice (CSP, 2005). Performing a procedure without gaining consent, undermines the moral priniciple of respect for patients autonomy and human dignity (Sim, 1986). However, inability for Patient X to conform to the Mental Capacity Act (2005) meant he was treated in his best intrest in adherance to section 1.5 of this act and Rule 1 of the HPC (2008) standards of conduct, performance and ethics.

Assuming the medical management of Patient X, a legal and professional duty of care was established (Rule 6; HPC, 2008). As part of this duty and in accordance with standard 2 of the CSP Core Standards of Physiotherapy, all interventions were explained to patient X despite his inability to consent. Had I not treated Patient X on the basis he had swine flu, this would have been failing to do justice to him, acting outside of the Disability Discrimination Act (2005) which states everyone should have equitable access to and utilisation of services regardless of disability and also Article 14 of the Human Rights Act (1998) in that no one should be discriminated against based on their health status. The Bolam Test (1957, cited in Dimond, 1999) states if duty of care to a client is breached and subsequent harm to the patient occurs, professional standards have not been kept and therefore negligence can be assumed. Although not legally binding, the CSP rules of professional conduct effectively have the same status as law and failure to comply with them means they may not only be used in disciplinary hearings but also in legal proceeding as a civil case under the tort law of negligence (Dimond, 1999; Hendrick, 2002).

In summary, a sound understanding of the legal implications surrounding consent and duty of care can help avoid unwanted litigation, however they should not undermine the ethical implications. Appendix 3 demonstrates how I have learnt from this experience.

Assess the needs of a range of service users and, with reference to current professional knowledge and relevant research, apply, evaluate and modified physiotherapeutic intervention

A service users is anyone who utilises or is affected by a registrants service (HPC, 2008). The complex needs of a service user encompass a range of issues including social, environmental, emotional and health related, the extent of which varies from person to person. For the purpose of this essay, the physiotherapeutic management of two patients treated whilst on PP6 with differing severities of chronic obstructive pulmonary disease (COPD) exacerbations (Appendix 4) will be discussed.

The National Institue for Health and Clinical Excellence (NICE) guidelines (NICE, 2004) in conjuntion with the guidelines for physiotherapy in respiratory care (British Thoracic Society (BST), 2008) advocates the use of active cycle of breathing technique (ACBT) with expiratory vibrations on the chest wall for the treatment of COPD to help aid airway clearance.

Inability for patient A to comply with ACBT indicated the use of manual hyperinflation (MHI) to passively inflate the lungs and aid mucocillary transport (Ntoumenopoulos, 2005). As identified by Finer et al (1979), atelectasis is a common problem observed in mechanically ventilated patients for which MHI has been found to be beneficial in reducing it in a well controlled clinical trial by Stiller et al (1996), scoring a PEDro rating of 6/10.

Absence of a cough reflex in patient A, resulted in sputum retention and the increased risk of infection indicating the use of suctioning (Pryor and Prasad, 2002) by which, copious amounts of viscous secretions were cleared. Shorten et al (1991) supports the use of saline instilation to loosen secretions prior to suctioining however, conflicting arguments by Blackwood (1999) and Kinloch (1999) question its effectiveness. Patient Bs compliance with ACBT replaced the need for MHI and suctioning.

Patient A developed bilateral shoulder subluxations due to his lengthy intubation for which subluxation cuffs were applied, as suggest by Zorowitz et al (1995) with positive effect. Despite this study being on stroke patients, the results can be generalised to other patient groups as proved.

The importance of mobilising patients with regards to respiratory function is highlighted by Ciesla (1996), however mobilisation of critically ill patients is restricted as they are often non-ambulatory. A high quality, randomised control trial using fifty-six participants by Mackay et al (2005), identified mobilisation as superior to other respiratory techniques, therefore Patient B was encouraged to sit out and treated using a graduated walking program. In the case of Patient B, mobilisation constitutes any change in position therefore the use of postural drainage positions and positioning into the cardiac chair setting on the bed were used (BTS, 2008).

The range of problems service users present with means practitioners need to be adaptable, drawing on current evidence, professional knowledge from different fields of physiotherpy practice and experiences through CPD to deliever indiviualised patient-centred care.

Appraise self management of a caseload and modify practice accordingly, demonstarating effective teamwork and communication skills

Caseload management typically refers to the number of cases handled in a certain timeframe by an individual for which they have a duty of care towards (Scottish Executive, 2006). It is the management of time effectively through appropriate priority-setting, delegation, and allocation of resources to meet the service demand of its users (Curtis, 2002). Self-management of a caseload and adaptability to changing circumstances is expected of a registrant (HPC, 2008).

Well developed time management skills can make a workload more manageable and improve the effectiveness of treatments and quality of time with patients. Prioritising patients to the order in which they will be seen based on their needs is encouraged by SARRAH (2010), however Nord (2002) argues whether it can be justified to prioritise those in most need if their potential benefit may not be as great as those in less need. In my experience prioritisation is dependant on a variety of factors for example, the trust where PP6 was completed, enforced protected meal times which did not run alongside staff meal times. Therefore, to prevent there being a void in the day, patients were still prioritised according to need but considertation had to be given to see patients that would be eating first and treat those that would not be during protected meal times.

It is essential to consider that a therapists workload includes not only patient care, but also admistrative and research tasks in which delegation to others can be a valuable stratergy to assist with workload mangement. Curtis, (1999), identifies the need for practioners to show greater awareness of other disciplines competancies so delegation can be more effective. Feedback systems should be enforced to ensure task completion and objectives are being met (Curtis, 2002).

Inter-professional collaboration refers to the process by which different disciplines work together to improve healthcare (Zwarenstein et al, 2009). Poor collaboration amongst healthcare professionals contributes to problems in quality of patient care and consequently poorer outcomes (Zwarenstein and Byrant, 1997). Liaison with members of the multi-disciplinary team (MDT) is encouraged by Shortell and Singer (2008) as practitioners are less likely to work off their own autonomy, ensuring patient safety, as demonstrated during handover in (Appendix 5).

The learning objectives on PP6 to develop MDT collaboration and caseload management have been achieved as demonstrated in the feedback from my educator (Appendix 6) which identifies that improvement in self confidence will allow further development of the skills discussed.

Demonstrate partnership with more junior students and/or appropriate others through the development of mentoring skills

Mentoring is a process aimed at transfering knowledge, skills and psycological support from a more experienced person to a less experienced person, where the desired outcome is for both persons to achieve personal and professional growth (Anderson, 1987). An effective mentor facilitates, guides and empowers the mentee in becoming an independent learner (Coles, 1996) in which the relationships developed are based upon mutal respect, trust, confidentiality and shared beliefs and values (Lyons et al, 1990). The CSP (2005) acknowledges the importance of intergrating mentorship into CPD, in which the mentor develops a range of skills transferable to other CPD activities. This section focuses on peer mentoring as a concept, its practice and clinical application on an informal basis.

Having identified the characteristics of a mentor (CSP, 2005), a SWOT analysis (Appendix 7) was completed to assist recognition of my personal learning needs.

There are four stages to the mentoring life cycle (Appendix 8), in which the mentor needs to adopt and develop new skills to accommodate the mentee and guide them through the process.

A qualitative study using a moderate sample size by Chan and Wai-Tong (2000) encourages the use of learning contracts (Appendix 9) to help establish rapports and facilitate autonomous learning which aids progression to stage two of the cycle. This is further supported in a recent review of the literature by Sambunjak et al (2009).

Gopee (2008) recognises the importance of analysing the mentees needs. Foster-Turner (2006) states that different people approach the learning process in different ways therefore, matching the learning styles of the mentor and mentee will produce a more productive and successful relationship (Mumford, 1995; Hale, 2000). Honey and Mumford (1992) suggested people tend to have a predominant learning style and can be classified as activists, reflectors, theorists or pragmatists (Appendix 10). Boud (1999) identifies raising self-awareness as an essential tool used in lifelong leaning and through analysis of learning styles using Honey and Mumfords (1992) questionnaire, this allowed for reflection on the style of learning that would best suit the mentee to help meet their learning needs (Foster-Turner, 2006) (Appendix 11).

As identified by the learning style inventory, the mentee and myself were both reflective learners, therefore we arranged sessions where we could dreflect on a clinical experience and discuss how new learning could be applied to future events.

A feedback form from the mentee (Appendix 12) an a SWOT analysis (Appendix 13) demonstrates how through increased self-awareness and review of the literature, I have developed a better understanding of the mentoring process, the skills required and its application in into clinical practice. Developing others is central to current and desired practice (DoH, 2000a, 2000b, 2001, 2002) in which mentorship offers all the key attributes to the process. Preparation of an individual for this role, through self assessment, is central to its success, in which the skills developed are lifelong and can enable development into management and leadership roles later on in life.

Demonstrate skills of career-long learning

Lifelong learning is used synonymously with CPD and is concerned with practitioners critically reviewing their skills and knowledgebase with the ultimate goal of providing a better standard of care to all service users (French and Dowds, 2008). A recent inquest into a practitioner who did not maintain his competencies, demonstrates the possible consequences of poor CPD (Appendix 14). Appendix 15 details a range of formal and informal activities that can be undertaken to contribute towards CPD, evidence of which can be documented in a portfolio.

The importance of staff development is recognised by the DoH documents (2000a, 2000b, 2001, 2002) which sets out the Governments vision of an NHS that prepares allied health professionals with the skills to take advantage of wider career opportunities and realise their potential. By using the competency based framework; The NHS Knowledge and Skills Framework (2004), physiotherapists can participate in development reviews which identify development opportunities and contribute to the fulfilment of personal development plans.

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What does the order in which I have prioritised my list say about me as a professional now?

I now appreciate the importance of CPD in helping to provide a higher quality of care to service users. Feer of litigation has moved down to the bottom of my motivations as through the development of CPD the maintainance of a portolio to meet the required standards I shouldnt fear litigation.

Patient X was being treated on ITU after being admitted following onset of Guillian Barre Syndrome. He was sedated, intubated, paralysed and unable to communicate. Despite being unable to respond vocally or physically he was still able to hear and to fulfil my duty of care to patient X and as a matter of common courtesty treatement he was to receive was explained to him indicating the potential benefits. This allowed for the development of a good rapport and trust which allowed for better compliance to treatments. Patient X had also been diagnosed with swine flu prior to admission.

Description:

Working as part of the respiratory team, I was treating patient X on ITU with Guillian Barre Syndrome. He was intubated, vented and sedated. On auscultation patient X had secretions he was unable to expectorate. Unable to communicate, patient X was unable to consent to the proposed treatment of manual tecniques and suctioning to aid airway clearance. I discussed with my clinical educator, and we came to the conclusion treatment was indicated. With regards to patient autonomy, I respected this however felt it would be it the best intrest of the patient to receive the treatment.

Feelings:

Having never been in a situation where a patient has been unable to consent to treaetment, I was overwhelmed by it. I was confident in my clinical reasoning that patient X needed manual therapy and suctioning to clear his chest yet I was concerned with possible clinical implications that may follow.

Evaluation:

The experience has made me confident that in the same situation I would be able to handle it independently. It made me stop and consider legal and ethical implications of my choice of treatment. The patient had no say in their treatment but then I was acting in their best intrest.

Analysis:

I feel I managed the situation well conidering my clinical inexperience and despite having never faced a situation as such before. The situation mad me stop and clinically reason why treatment was necessary.

Conclusions and personal action plans:

Despite being put on the spot, I feel I managed the situation well. I have learnt to appreciate the importance of taking a step back and weighing up all the information to come to a decision using my clinical judgement and professional knowledge. In the future I will make myself aware of the HPC standards of conduct, performance and ethics to avoid any unwanted litigation.

Gibbs (1988)

Two patients, Patient A and Patient B, were both admitted following an infective exacerbation of COPD. The following identifies their problems respectively and how treatment was altered in order to help alliviate their symptoms.

Patient A was in severe type II respiratory acidosis and was admitted to ITU where he was subsequently inutbated and ventilated.

Problem List

Treatment Plan

  1. Unable to comply with ACBT
  2. Retained secretions - absent cough reflex
  3. Copious amouts of viscous secretions
  4. Shoulder subluxation
  5. Non-ambulatory
  6. Poor saturation levels

Learning Styles Questionnaire

This questionnaire is designed to find out your preferred learning style(s). Over the years you have probably developed learning habits that help you benefit more from some experience than from others. Since you are probably unaware of this, this questionnaire will help pinpoint your learning preferences so that you are in a better position to select learning experiences that suit your style.

There is no time limit to this questionnaire. It will probably take you 10 -15 minutes. The accuracy of the results depends on how honest you can be. There are no right or wrong answers. If you agree more than you disagree with a statement put a tick by it

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