This paper reflects on my experience with a patient in community practice. Community nursing is a branch of nursing that aims to provide care and treatment to patients in their homes (Lubbers and Rossman pg. 142. 2017). As a student nurse, I will adhere to the Nursing and Midwifery Council’s (NMC) code (2018). The patient’s name will not be revealed during this assignment for confidentiality purposes (Leigh & Roberts, pg. 1070. 2018). Nursing associates, nurses, and midwives must maintain confidentiality for all patients who receive care (NMC 2018).
The patient that I will discuss is a 67-year-old male living on his suffering with bilateral venous leg ulcers (VLU). VLU are open wounds that usually appear between the ankle and the sheen and tend to affect the older population mostly (Vasudevan, pg. 8. 2014). The patient has worked as a chef all his life, meaning he spent most of his working life standing. He reported that he always had pain in his legs, but he did not pay any attention to it. However, since his retirement, his pain has gotten worse, and he has now developed VLU.
For this assignment, Driscoll’s What Model will be used. This model brings the ”what” cycle, which refers to: ”What”, ”So What”, ”Now What”(Driscoll et al., pg. 6, 2007). This interpretation describes what happened, analyses the event, and foresees future practice using the knowledge acquired from the reflection.
I have attended the patient’s home along with one of the district nurses working for the community team. The patient has been on the team’s caseload for about one year, so the nurses were familiar with the patient’s condition. It is also important to mention that the patient suffers from depression. I had also visited the patient a few times before and was familiar with the patient’s condition. Despite the nurses’ attempts to heal the patient’s legs, every time a nurse saw the patient, it looked like his legs got worse and he had now developed an infection.
Before this visit, there was a multi-disciplinary meeting (MDT) to discuss the healthcare team’s plan to aid the patient’s treatment and care. The purpose of the MDT meeting is for healthcare professionals from different specialties to meet and discuss a specific patient’s condition by bringing different skills and views (Raine, pg. 7, 2014). This aims to provide a tailored person-centered approach through holistic and continuous assessment.
Following the MDT meeting, the team decided that a detailed and extended discussion with the patient was needed so he could get the proper treatment and get better before any drastic outcomes would arise. At this point, it is essential to mention that the patient finds it difficult to follow the nurses’ instructions, which also means his legs started to get infected.
We found the patient in a very low mood as we arrived at the property. Talking to him, I discovered that the patient was feeling quite depressed, not wanting to keep on fighting and get better, as he could not see the point. Unwrapping the bandages, we also discovered that his legs got worse, and the infection started to spread. The patient did not report, but we could see that he was in a significant amount of pain. As leg ulcers become infected, they cause severe patient pain (Leren et al., pg. 472, 2020).
First, we carried out the leg care per the trust’s protocol and changed the dressings. After, as planned, there was a need for a professional-patient conversation for us to enhance and promote health and wellbeing. As a student eager to learn, I have asked if it would be okay for me to lead the conversation. Even though I am a student, I felt confident carrying out the discussion, purely because no matter what, I knew I had the team’s support if needed or for any lack of knowledge that could have been encountered, and the nurse was there to support me.
I started by asking the patient’s permission to discuss it and whether he was happy to discuss it with me. Informed consent is a process in which the care staff can discuss, highlight, and educate the patients about the benefits and complications of illnesses (Shah et al., pg. 8, 2023).
As the infection is the leading cause of concern, I have adopted a motivational communication approach. Motivational communication allows healthcare professionals to discuss changes they might need to implement with the patients without making them feel pressured about making those changes (Bischof et al., pg. 3, 2021). I have adopted this approach as I thought that in this particular situation, the patient would benefit and accept more of the information passed through an interview rather than just talking at him. As mentioned above, the patient did struggle to follow the plan put in place by the nurses, which could be due to the way information was passed to him.
I have discussed with the patient the impact of the infection from his ulcers on his overall health. Leg ulcers represent around three percent of the disease that affects people over 60 worldwide (Bui et al., pg. 32, 2017). One-third of the ulcers do not heal earlier than six months (Rondas et al., pg. 578, 2015), so our patients must know this fact. I explained how important it was to heal the infection because, as Parker et al.(2015) stated, the longer the VLU, the more impact it will have on his physical health and quality of life. The patient said that he was aware of that fact, but he struggled as he felt lonely, and except for the DNS, he did not have much help (Parker et al., pg. 1830, 2015).
Patients with VLU experience loneliness and depression (Weir, pg. 1745, 2023), so I listened to what my patient had said about loneliness, and I have tried to use this as giving him an even more reason to help the staff heal the infection. If his infection heals, he can meet other people or support groups. Studies show that support groups have a positive impact on improving mental health and reducing the level of depression and loneliness. When I discussed this with the patient, it was clear that he did not follow the plan put in place by the care team. So another important thing that I mentioned to the patient was that due to the infection, his mobility was poor.
In most cases, VLU reduces patients’ mobility, forcing them to spend most of their time bed or chair-bound (Weir, pg. 1747, 2023. This also means an increased risk of isolation, which would also worsen his depression (Mushtaq et al., pg. 6, 2014).
Another subject that I discussed with the patient was his diet. Nutrition is essential in wound healing and fighting infection (Seth et al., pg. 7, 2024). At this point, it should be mentioned that my patient’s diet is inferior, so it was essential to educate the patient about the importance of having a balanced and healthy diet. Munoz et al. (2019) argued that the intake of macronutrients, micronutrients such as vitamins C and D, and proteins aid the wound healing process (Munoz et al., pg. 5, 2019). The patient reported that he did not eat cooked meals, and he did not eat a lot of fruit and vegetables, but mostly he eats take-out food or snacks. So, I explained that a healthy diet would help the healing process. Also, an unhealthy diet does not only affect their physical health, but it also affects their mental health, which might affect their depression even more. We have also discussed that dining can also be used as a social tool so he can meet other people, which would help with his loneliness. Using the motivational interviewing method we discussed, the patient admitted that there is a need to change his diet and, with the proper support, would do it.
The other thing we discussed was that there may be a need to use antibiotics to help with the healing of the infection. Topical or systemic antibiotics are generally used to fight leg ulcer infection (O’Meara et al., pg. 8, 2014). So, I discussed with the patient how he would feel about the possibility of antibiotic treatment and whether he would feel confident enough to self-administrate this. I have explained that untreated infection will worsen and severely impact the patient’s quality of life (The National Institute for Health and Care Excellence [NICE] 2020). I explained that if the patient does feel they need more port in, help him. We discussed how important it was for him to get the proper support.
Following the patient-professional conversation, the patient has realized how important all the proposed changes are. We have discussed how those changes can have a positive impact on his health and improve his quality of life. The nurse I was with stated that this conversation should have happened before, which could have impeded the infection.
On reflection, I am thinking from my perspective and the whole team’s perspective. The team should have looked at the patients’ needs because they are so complex, and an infection is present in the wound. This would have helped prevent the disease or even the infection from spreading. As healthcare professionals, our ultimate purpose is to ensure that patients receive the highest quality of care. Even though the nursing team had noticed signs of infection before, the MDT meeting and the treatment were delayed, and so was the abovementioned conversation. Delaying treating VLU can drastically impact patients’ healing process, which could result in hospital admissions (NICE, pg. 821, 2020).
It was clear that the patient was not educated enough, so he could not follow the plan put in place by the nursing team, which was somehow expected. The patient lacked the knowledge to understand how serious his condition was. On top of his lack of knowledge due to his depression, the patient often feels that there is not much point in living or fighting and that it would be easier just to stop trying (Lachance and Ramsey, pg. 111. 2015). So, maybe the team should have discussed a mental health referral with the patient. Identifying and holistically treating the patient would bring better benefits to the healing of VLU.
Another essential factor that needs to be mentioned is the DN’s patients’ caseload. Sometimes, caseloads get overbooked. On average, patients stay on caseload for about 123 days (NHS Benchmarking Network [NHSBN] 2020). From my practice experience with the DN team, I discovered that, at times, the nursing team is overworked due to a busy caseload. Despite their best efforts, this means that, at times, patients only get appointments less frequently than they would need. This can also mean that our patient’s infection could have been overlooked.
Being part of the DN team means you work mostly alone and must use your critical judgment constantly. Nonetheless, this does not mean that you do not belong to a team. During my practice, I found that the DN team always came together and helped each other. So, having a team behind me gave me the confidence to lead the discussion with the patient. I knew the nurse with me would support me if needed. That being said, the patient’s infection worsened before the conversation; however, during the MDT, everyone brainstormed using their knowledge and experience to create the most appropriate plan to help the patient improve. One last thing that needs to be mentioned is that, as highlighted above, the deterioration of the patient could be from different reasons. Nonetheless, there can be a long road following the conversation discussed above and with the patient’s involvement. Still, the infection could be treated, and the patient’s condition could improve his physical, mental, and social health.
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