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Library of Congress Cataloging-in-Publication Data
Peate, Ian, author.
Medical-surgical nursing at a glance / Ian Peate.
p. ; cm. -- (At a glance series)
Includes bibliographical references and index.
ISBN 978-1-118-90275-2 (pbk.)
I. Title. II. Series: At a glance series (Oxford, England)
[DNLM: 1. Perioperative Nursing. 2. Nursing Care. 3. Nursing Process. WY 161]
RT41
610.73--dc23
2015024293
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover image: © Getty Images/David Leahy
Medical-Surgical Nursing at a Glance is the ideal revision and consolidation book for undergraduate nurses and other healthcare workers. The text breaks down complex aspects of medical and surgical care in an accessible and inviting way against the backdrop of continually changing surroundings.
There have and there will continue to be many changes that will have an impact on the care that nurses offer patients in medical and surgical care settings. Key trends that may emerge over the next ten years or so are related to the socioeconomic and political environments, the health and care sectors, regulation concerning health and social care, the nursing and midwifery sectors as well as education and training provision for nurses and healthcare assistants. These changes will affect the ways in which nurses deliver care in the various health and social care settings. Rapid technological progress has the potential to alter the dynamic between the nurse and the patient. Telehealth is being increasingly used in providing healthcare along with the implementation of the electronic patient record.
Despite these changes, caring, kindness and compassion remain central to the role of the medical or surgical nurse. The use of an evidence base to offer care that is safe and effective is now a prerequirement of any healthcare provision.
This is a user-friendly, accessible aid for study and revision for preregistration nursing students. There are 77 chapters with 4 parts divided into medical and surgical nursing. The text adopts a concise and simple approach and is accompanied by detailed illustrations. The chapters are presented in bite sizes, in a double-page spread with colour diagrams, tables and line drawings. It is a practical text that addresses issues from a number of perspectives including anatomy and physiology, where relevant, and associated pathophysiology.
This book has been written to meet the needs of those working in the dynamic and ever-changing medical and surgical setting. The key aim of the book is to orientate and guide readers through the important and salient issues that they may face when providing safe and effective medical and surgical care. This text is offered at an introductory level, capturing all that the healthcare practitioner needs to know during their initial education and beyond. The approach used provides a better understanding of the issues related to medical and surgical nursing, walking the reader through the key issues and the significant points. The text reminds readers that there are physical and psychological issues that must be given careful consideration as well as recognising patient safety and the legal and ethical issues that must be taken into account when providing contemporary and up-to-date care.
The text builds on the strengths of existing 'At a Glance' titles already published; it is more accessible and less intimidating than other revision aids related to medical and surgical nursing. The At a Glance approach incorporates images and text, appealing to a number of learning styles.
I have enjoyed writing this text and I hope that you enjoy reading it.
Ian Peate
I would like to thank my partner Jussi Lahtinen for his enduring encouragement and Mrs Frances Cohen for her ongoing support. I acknowledge the help given to me by the library staff at St Bernard's Hospital, Gibraltar. Finally, I am indebted to my talented brother Anthony Peate who contributed to the illustrations.
Ian Peate
We acknowledge with thanks the use of material from other John Wiley & Sons publications:
Davey, P. (ed.) (2014) Medicine at a Glance, 4th edn.
Nair, M. and Peate, I. (2013) Fundamentals of Applied Pathophysiology, 2nd edn.
Nair, M. and Peate, I. (2015) Pathophysiology for Nurses at a Glance.
Peate, I. and Glencross, W. (2015) Wound Care at a Glance.
Peate, I., Wild, K. and Nair, M. (eds) (2014) Nursing Practice.
Wicker, P. (2015) Perioperative Practice at a Glance.
Nursing practice
What is Nursing? To care safely and effectively for a person, the nurse must understand what nursing is, the role of the nurse and the function of the nurse. Attempting to do this, however, brings with it challenges.
The International Council of Nursing suggests that nursing encompasses the autonomous and collaborative care of people of all ages, families, groups and communities, be these sick or well and in all settings. Nurses in undertaking their work promote health, prevent illness and care for those who are ill or disabled and people who are dying. Central to the nurse’s role is advocacy, the promotion of a safe environment, research, participating in shaping health policy in patient and health systems management and education.
The American Nurses Association explains that nursing is concerned with the protection, promotion and optimisation of health and ability, preventing illness and injury, and relief from suffering. Nurses do this through diagnosis and treatment of the human response; nurses also act as advocates caring for individuals, families, communities and populations.
The Royal College of Nursing (2003: www.rcn.org.uk/__data/assets/pdf_file/0003/604038/Defining_Nursing_Web.pdf) professes that nursing can be described as the provision of care that is underpinned by clinical judgement, enabling individuals to improve or maintain health or recover from illness. Nurses assist people to cope with health problems; they contribute to enhancing the quality of life regardless of the person’s disease or disability until their death.
Figure 1.1 provides an overview of three definitions of nursing.
The fact that there are so many definitions of nursing (not to mention what it is that nurses do) would suggest that the term is elusive and is difficult if not impossible to define. When working in a variety of contexts, for example, a hospital ward, person’s own home or general practice, the role and function of the nurse will change in response to the context in which care is being offered. However, there are still central components of the nurse’s role that will never change, for example, offering support, providing information and making decisions that are in the best interests of the person. What must be remembered, however, is that different kinds of definitions are needed for different purposes.
Nursing is a dynamic activity and as such it is constantly developing to meet the needs of people. Nursing and what nurses do take account of new knowledge from a variety of disciplines, for example, the social (psychology, social anthropology, sociology) and physical (chemistry, biology, physics) sciences. No one definition of nursing will ever suffice due to the complex nature of the human being. Trying to define nursing could be too limiting but without a definition, it would be difficult to formulate policy, specify services and develop educational curricula and therefore some specification is required.
Just as it is a challenge to attempt to define nursing, it is also a challenge to describe the role and function of the nurse. Figure 1.2 provides some elements that are associated with the role of the nurse.
This aspect of the role has traditionally included those activities that assist the person from a physical and psychological perspective while preserving the person’s dignity, providing comfort and respecting the person. The notion of care giving embodies physical, psychosocial, developmental, cultural and spiritual aspects; this is often referred to as a holistic approach.
The most important aspect of the role of the nurse concerns communication which is central to all nursing roles. The nurse communicates with the person, the person’s family (as well as those who support the person), a variety of health professionals and others in the community. Communication takes many forms, non-verbal (i.e. body language, the ability to actively listen, and written communication) and verbal. The quality of a nurse’s communication (efficacy) is an important element in nursing care.
The role of an advocate is to protect the person; when required, the nurse represents the needs of the person, assisting the person in exercising their rights and helping them speak up for themselves.
The nurse as teacher/health promoter helps people to learn about their health and what they need to do to restore or maintain their health. Assessing the person’s learning needs and readiness to learn, the nurse working with the person sets learning goals, performing teaching strategies and measuring learning.
The nurse acts as a change agent when assisting others, helping them to make modifications in their own behaviour. Nurses also work with others to make changes in the healthcare system.
The nurse as leader influences others to work together to accomplish specific goals. This is often carried out at different levels: individual person, family, groups of people, colleagues or the community. The nurse manages the nursing care of individuals, families and communities, appropriately delegating activities to others, supervising and evaluating their performance.
Nurses use and conduct research to enhance care. As researchers and consumers of research, they must be aware of the process and language of research.
As the role of the nurse continues to expand, there are a number of new aspects developing alongside the function of the nurse.
Consultant nurses and clinical nurse specialists have usually completed a doctorate or Master’s degree in a specialty and have a considerable range of clinical expertise in that specialty. These nurses provide expert care to individuals, participate in educating healthcare professionals and undertake research.
The nurse practitioner is skilled at making nursing assessments, performing examinations, counselling, teaching and treating minor and self-limiting illness.
A nurse educator teaches in clinical and educational settings, teaches theoretical knowledge and clinical skills and conducts research.
The 6 Cs Care is at the centre of all that nurses do. Being a nurse brings with it a number of privileges; it is an extraordinary role. What the nurse does every day can have a tremendous impact on the health and well-being of the people we are privileged to provide care for. Nurses are central in helping people keep themselves independent, healthy and well for longer. Helping people to recover from illness and supporting them in living with illness from a medical and surgical perspective is a part of this.
The provision of care and comfort when a person’s life comes to an end, the compassion and humanity that nurses show are the hallmarks of our care and support system. Nurses provide care for everyone, regardless of their background, their gender or their age, from the beginning of a new life to the end of a life. This care is provided to people in their own homes, in their local general practice, in the community, in residential and care homes, in hospices and in hospitals. Nurses support people and their families often when they may be at their most vulnerable.
The Chief Nursing Officer for England and the Director of Nursing at the Department of Health have drawn up a 3-year vision and strategy for nursing, midwifery and care staff – Compassion in Practice – introduced in December 2012. The vision is underpinned by six fundamental values: care, compassion, competence, communication, courage and commitment (Figure 2.1).
The Chief Nursing Officer’s vision acknowledges that the context for healthcare and support is changing and always in a state of flux. In particular, people are living longer, there are a greater number of older patients and people who require and will continue to require support, there are a growing number of people with multiple and complex needs as well as people with higher expectations of what healthcare and support can and should provide. Offering people health and care support and services requires the nurse to work with people in a new partnership, engaging with people when they make choices about their health and care.
No one of the 6 Cs is more important than the other five; each one (the values and behaviours) carries equal weight. The 6 Cs instinctively focus on ensuring that the person being cared for is at the heart of the care they receive.
Care is central to the work of our core business and that of our organisations and the care that nurses deliver can help the individual person and improve the health of the whole community. Caring defines nurses and nursing. Those who receive care should be able to expect it to be right for them, always, throughout every stage of their life.
This concept concerns how care is given through relationships that are rooted in empathy, respect and dignity. Compassion can also be seen as intelligent kindness and is crucial to how people perceive the care they receive.
All those who provide care must have the capability and capacity to understand a person’s heath and social needs along with the expertise, clinical and technical understanding to deliver care that is effective and treatment that is safe and based on research and evidence.
Nurses are at the heart of the communication process, ensuring that care and support planning is in place based on the identified needs of the person being cared for.
This concept is key to effective caring relationships and successful team work. In order for ‘no decision about me without me’ to become a reality, listening is just as important as what we say and do. Communication is the key to a good workplace with benefits for those in our care and staff alike.
Being courageous empowers the nurse to do the right thing for the people we offer care to, to make it known when we have concerns and to mobilise our personal strength and imagination to innovate and welcome new ways of working.
Commitment is a cornerstone of what nurses do and what people expect. Nurses are committed to improving the care and experience of the people they care for, in order to meet the health, care and support challenges that will lie ahead.
Along with the 6 Cs go six areas of action.
Person-centred care in the NHS requires the nurse and other healthcare workers to look at all the elements of care a person experiences – from the clinical care they receive to how the person is greeted by a cleaner or receptionist, or how easy it is to find their way round a hospital or health centre. Often, it is the little things that make a big difference to how people feel about the way their care needs are met. Together with the 6 Cs and the six areas of action, nurses can work towards the ultimate aim of ensuring that the patient is truly at the heart of all that is done.
Accountability and ResponsibilityThe role of the nurse is complex and is in a constant state of flux and because of this the nurse must be acutely aware of responsibility and accountability. The two concepts of responsibility and accountability are often discussed together but at other times they are seen as two very distinct entities.
Some healthcare professions that involve the potential risk of serious harm to people are statutorily regulated; the law requires this regulation. This regulation is carried out by regulatory bodies with legal responsibility for ensuring that registers of people entitled to practise in the United Kingdom are kept. They also set appropriate standards and take action when these standards have not been met.
The regulatory body for nurses and midwives is the Nursing and Midwifery Council (NMC). There are nine health and care professional regulatory bodies in the UK. Other regulatory bodies regulate other professions; for example, the Health and Care Professions Council (HCPC) is responsible for regulation of 17 health and care professional groups. Doctors are regulated by the General Medical Council (GMC) and the General Dental Council (GDC) regulates seven dental professional groups (dental nurses are included here).
The various health and care regulators have been set up with one overriding aim and that is to protect the public. The Professional Standards Authority (PSA) has responsibility for overseeing the UK’s nine health and care professional regulatory bodies. It has oversight and scrutiny of the regulators, which is important in order to protect users of health and social care services and the public.
There are around 676,547 nurses and midwives on the professional register. In the UK, the NMC is the regulatory body that sets the standards for nurses and midwives to meet in their working lives.
Nurses have a code of conduct that they must adhere to. This states how they must work and behave without exception, regardless of whether the nurse is involved in hands-on practice or is a manager, an academic or researcher.
The NMC also sets and monitors the national education and training requirements needed to qualify as a nurse. The standards make sure that nurses have the right skills and qualities when they start work. Standards are also set for education throughout nurses’ careers, after they initially register with the NMC. Nurses are required to continually take part in learning activities to demonstrate that their skills and knowledge are up to date.
By maintaining a register of all nurses in the UK, the NMC decides who is able to call themselves a registered nurse. It is illegal to work as a nurse without being on the NMC register. In order to be on the register, nurses must pay a yearly fee and provide evidence that they fulfil requirements for keeping their skills and knowledge up to date.
The NMC sets requirements for nurses and midwives to help them to provide safe and appropriate care, taking firm but fair action where those obligations have not been met. If an allegation is made about a nurse or midwife that they do not meet the standards for skills, education and behaviour, or that there is a problem with their work, the NMC will investigate, calling the nurse to account and, if necessary, removing a nurse from the register permanently or for a set period of time. They may also place restrictions on the nurse’s right to practise in the UK.
Codes of professional conduct, also known as codes of ethics, are regularly updated and renewed (an ethical code for nurses in the UK dates back to 1983). The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives (the Code) guides nurses with regard to their professional behaviour, helping to ensure that nurses work within ethical and moral frameworks.
The Code is not law; it is a guide informing the general public and other professionals of the standard of conduct that should be expected from a registered nurse. Codes of conduct do not solve problems; they reflect professional morality, operating to remind the nurse of the standards required by the profession. An overview of the purpose of the Code can be found in Table 3.1.
There are a number of key facets incorporated within Code – see Table 3.2.
Being accountable for actions and omissions is a central tenet of the Code. All healthcare professionals in carrying out their duties have the potential to do good as well as to harm the people they offer care to. To be accountable, the nurse needs to be in possession of up-to-date knowledge and to have the appropriate nursing skills.
Professional accountability is constant; the nurse is accountable at all times for their actions or omissions and the first section of the Code makes this clear. The nurse is personally accountable for their own practice and may be called to account for actions and omissions. There are four spheres associated with accountability (Figure 3.1).
This occurs through the criminal courts as defined by criminal law. Where accountability is in question, the police are likely to investigate and a decision may be made to prosecute the nurse for a criminal offence. Public accountability is generally associated with a social contract between the public and the profession.
The injured party may seek a civil remedy via the criminal law in the courts. The person making the complaint or bringing the action for negligence may also sue the NHS for the nurse’s negligence (indirect liability).
The nurse is accountable through the contract of employment. In some cases, the nurse may be in breach of contract if they have not acted with due care and skill and disciplinary action may ensue.
The nurse is accountable to the NMC through its Conduct and Competence Committee. The NMC determines if a nurse is deemed incompetent through their actions or omissions.
Risk and Safety In all aspects of health and social care there will always be elements of care that are associated with risk and issues concerning safety. We can never guarantee that patients will never be harmed by the system that is meant to look after them. Issues concerning risk and safety may be associated with people being cared for or those who are delivering care. Healthcare systems are complex so preventing adverse events and improving patient safety require a multifaceted approach. Patient safety is seen as a priority in most organisations. Nurses have a key role to play in the investigation and implementation of improvements in patient safety.
Nurses are required by law and from a professional perspective to manage risk, be aware of risk and help to ensure that everyone is kept safe in the places where they are receiving healthcare. Patient safety is a key component of high-quality healthcare; it is something that patients have a right to expect. Nurses need to know how to manage patient safety and risk in all care settings.
Risk management can be considered from many perspectives; it is not a one-off event but rather a process that can help to raise the quality and safety of services provided. It focuses on occurrences where patients may have been harmed by their treatment or where that treatment had the potential to cause them harm. It is the collective responsibility of healthcare organisations and an individual responsibility of those who work in them to manage risk and improve the safety of care. Nurses need to understand that it is not just the harm that is caused to the patient but also the knock-on effect this has on families, loved ones and friends.
In organisations as large and as complex as the NHS, things will sometimes go wrong and as such patients will suffer unintended harm. When this does happen, an opportunity to learn and not to blame should be taken.
There are several resources available to help nurses deliver high-quality, safe and effective care (Table 4.1). The pace of change in contemporary nursing practice, the introduction of policy statements and the amount of new evidence emerging have the potential to lead to frontline staff such as nurses feeling swamped.
A variety of assessment tools are available. For example, the Waterlow score is a pressure ulcer risk assessment tool that can be used to alert staff to the need to implement certain actions to prevent a deterioration in the patient’s condition. Other examples of risk assessment tools include those for malnutrition, suicide and falls.
Regardless of the risk assessment tool being used, these are only as good as the nurse undertaking the assessment. Risk assessment tools can help to predict the probable degree of risk to the patient. Risk awareness is associated with understanding risk-prone situations and having the skill to anticipate or predict hazards, risks and incidents and reduce the ensuing personal and organisational risk.
Early warning scoring systems proactively help nurses and other staff to identify those patients at risk of deterioration. Using these systems has the potential to lead to fewer cardiopulmonary emergencies and deaths.
The Modified Early Warning System is a simple scoring system that routinely measures patients’ physiological vital signs to identify those who are likely to deteriorate. It prompts nurses to notify medical staff and other care givers when appropriate and take other essential steps in order to prevent further decline in condition. A score is allocated to each vital sign and these scores are combined to provide the patient’s overall score. Table 4.2 identifies some of the components of a Modified Early Warning System.
A surgical safety checklist has been devised by the World Health Organization (WHO) with the intention of reducing the number of surgical deaths across the world. The checklist addresses important safety issues, including inadequate anaesthetic safety practices, avoidable surgical infection and poor communication among team members. These factors have proved to be common, deadly and preventable problems.
The checklist is not a regulatory device nor is it a component of official policy; it is intended to be used by nurses and others interested in improving the safety of surgical procedures and reducing unnecessary surgical deaths and associated complications. There are three areas that the checklist addresses; these can be modified to meet local needs.
Improving the safety of patient care is a weighty challenge for the NHS; patient safety is at the heart of the healthcare agenda. The provision of healthcare relies on a range of complex interactions between people, skills, technologies and drugs. Sometimes things can and do go wrong. Adverse events that do occur can be avoided, if lessons from previous incidents are learned.