Running Head: REFLECTIVE NARRATIVE ANALYSIS 1

Reflective Narrative Analysis of a Systems Issue

Jamie A. Meyer

University of Detroit Mercy

McAuley School of Nursing

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Clinical Outcome

During the clinical experience this semester many opportunities were had

to make an impact on patient, community, population, or system. The scenario that will

be reflected on in this analysis meets program objective four: Lead health care systems

and policy innovation with a focus on preventative care, quality improvement and patient

advocacy. As I spent time with the Director of Nursing at Heartland of Knollview to gain

knowledge about health policy to develop and implement effective system wide practice

initiatives that will improve quality of care delivery as situation aroused regarding the

ethical treatment of a patient with advanced dementia.

This situation involved a patient who started to decline due to his advancing

dementia to the point where he no longer talks or swallows making it difficult to feed and

administer medications. His DPOA continues to insist that he is a full code and that the

facility needs to do everything in their power to keep him alive. This patient ended up

being sent to the hospital for adult failure to thrive which resulted in a keofeed being

placed. Post discharge from the hospital, he pulled out the keofeed a total of 7 times and

needed to be transported back to the emergency room each time to have it replaced as the

DPOA was persistent not to transition to Hospice after several evaluations from speech

therapy to upgrade his diet. This patient failed two swallow studies as he was unsafe to

eat by mouth because he pocketed his food or just drooled it out of his mouth.

Furthermore, when he was in the hospital the first-time surgeons declined to put a long

term feeding tube in as he was not a candidate due to the fact he would most not recover

from surgery and the areas of tumors that most likely represented cancer. The DPOA

declined further workup of the tumors, though. Finally, after multiple visits to the ED and
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the DPOA being presented with the risk-benefits of having the tube replaced, patient

being fed by mouth, and potential outcomes the patient ended up re-admitted to the

hospital in ICU vented due to severe sepsis from aspiration pneumonia.

System Based Issue

Healthcare professionals encounter situations day in and day out that require

ethical behavior and decision-making. Due to the ethical and legal requirements that

affect the same situation it can be difficult to come to a solution. This situation as

described above exhibits two different ethical dilemmas: Do no harm and respect the

right of others to make their own choices. The decision of the DPOA to continue to have

the patient sent out to the ED after the patient would purposely pull out the feeding tube

was hard for staff members to support the DPOA right to make choices when it seems the

choice is a poor one. The patients demeanor would change each time he would pull out

the tube such as he would get out of bed, sit in his wheelchair and go around the unit with

a smile on his face, and be back to his normal self. Otherwise when his keofeed was in

his nostril he was in bed, tears running down his face, and very sad. After the 7th time the

feeding tube was removed the provider and unit manager had a lengthy discussion with

the DPOA about the situation, harm that is being done to the patient each time the tube is

replaced, the patients behaviors with and without the tube, and the risk-benefit of the

patient eating. Post lengthy discussion the DPOA wanted the patient to be fed orally

along with medications administered orally knowing the risk of aspiration and aspiration

pneumonia was very high. This patient ended up going into respiratory distress after 3

days of being fed and sent out to the hospital where he was admitted to the ICU on a vent.
REFLECTIVE NARRATIVE ANALYSIS 4

As described in the above paragraphs there is a demand for systematic ethics

work in the nursing homes. In a study by Bollig, Schmidt, Rosland, & Heller (2015)

indications that an implementation of special structures or places for systematic ethics

work must be based on awareness of ethical aspects in everyday work and

communication. To establish a culture of care in nursing homes, the attention for

everyday ethical issues and inclusion of ethics in everyday meetings and discussion have

to be more focused at this particular nursing home. To meet the needs regarding ethical

concerns an ethics team needs to be developed to be able to provide adequate resource to

patients, family members and health care providers. This team would be able to provide a

communication-based strategy aiming to assist health care providers in tackling moral

issues through improved deliberation with colleagues. Ultimately this would increase the

feeling of professional security and confidence in ethical dilemmas.

Finally, positive dialogue with the DPOA and finding time to listen to them can

assist in managing dilemmas and in reducing the emotional challenges associated with

disagreements with the DPOA (Preshaw & Frolic, 2015). In this case culture dynamics

played a part of the emotional challenges that the medical provider was faced with in

trying to follow through with what he felt was in the best interest of the patient. The

DPOA and patient are black whereas the physician is white. Tension grew between the

DPOA and physician due to the lack of cultural diversity. In this case once the unit

manager stepped in, who is also black, and had many lengthy conversations with the

DPOA and physician, tension decreased. The improvement of ethics needs to be focused

on communication, resources and quality of care provisions.

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Reflective Narrative Analysis

As a DNP student, I was able to use interprofessional collaboration to improve

patient and population outcomes. Being able to collaborate with the unit manager and

DON and meeting with the physician provided insight into the ethical dilemma among

providers and family in the care of this particular resident. Providing culturally

competent, compassionate, holistic and patient-centered direction to care and suggestions

to the provider human dignity was spared. In the future as a DNP prepared nurse I will

seek the expertise of individuals depending on the situation to provide culturally

competent and patient-centered care. Lastly this situation helped me understand that as a

APRN, I need to look at the whole picture and not go in with an agenda. Patient and

family members deserve to have their physical, social, spiritual and psychological needs

met by preserving integrity and dignity.

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References

Bollig, G., Schmidt, G., Rosland, J., & Heller, A. (2015). Ethical challenges in nursing

homes- staffs opionions and experiences with systematic ethics meetings with

participation of residents relatives. Scandinavian Journal of Caring Sciences.

DOI: 10.1111/scs.12213

Preshaw, D. & Frolic, A. (2015) Ethical issues experience by healthcare workers in

nursing homes: Literature review. Nursing Ethics. Retrieved from

http://citeseerx.ist.psu.edu/viewdoc/download?

doi=10.1.1.936.7416&rep=rep1&type=pdf