The journey for parents, from suspected to a diagnosed hearing loss for their child, can be difficult and stressful. The first few months are described to be like a jigsaw puzzle, where lots of pieces of information are needed to be joined together before confirmation and parents begin to understand their child’s hearing loss. Not only do parents have to understand why diagnostic assessment are repetitive, but once confirmed need to make choices around the ongoing management of hearing loss for their child. This paper aims to provide an insight to a parent(s) journey as they move from suspected hearing loss to confirmed hearing loss, seek support and learn about the community as they move forward on a pathway for their child.

In Australia annually, there are over 297,900

[1]
births (ABS, 2018). On average in Australia, 1 in 1000 babies born has a confirmed hearing loss (ABS, 2018).Overall in Australia by pre-school age, 2 in every 1000 children tested are identified as having a hearing loss, and by the end of secondary school, more than 3 out of every 1000 children will require assistance because of hearing loss(ABS, 2018).

2016 in South Australia, approximately 20069 babies were born, of that number, 1 in every 100 birth did not pass the

initial

hearing screening and needed further diagnostic assessment with a paediatric audiologist and were referred to the Universal newborn hearing screening (UNHS) which is a part of the Women and Children Health Network (WCHN) in South Australia (UNHS- WCHN, 2016). Of early screening 50 newborn babies were diagnosed with varying degrees of hearing loss within six months of being born (UNHS- WCHN, 2016). In additional, a further 45 children 6months-5years were also diagnosed with hearing loss who initially passed at birth (UNHS- WCHN, 2016). Of the age range 0-5 years 1 in every 6 children live in a rural area (UNHS- WCHN, 2016). With 11.6 per cent of children who have hearing impairment are from non-English speaking backgrounds (UNHS- WCHN, 2016).

In 2012 the Health Hearing Early Intervention Working Group (HH-EIWG) was

established as a national group with representatives from each state to establish and

set practice standards for hearing intervention pathway for all newly diagnosed

children 0-5yrs in Australia (Australian Institute of Health and Welfare, 2013). In 2013, a national framework (Australian Institute of Health and Welfare, 2013) is developed and outlines the new standards for Practitioners working within the area of hearing screen, audiological management, Family or Hearing Coordinator and early intervention services (Australian Institute of Health and Welfare, 2013). The guideline provides a national standard to improve the journey for families from first screen, diagnostic assessment thru to treatment pathway and ongoing connection into a community for children and families (Australian Institute of Health and Welfare, 2013).The standard, aimed to improve upon previous difficulties of cases where parents of same suspect diagnosis received different levels of service support depending on which state the child had been diagnosed, which in turn affected overall long term quality of intervention from communication development, language acquisition social and emotional development, and education for the child, this was Australia wide issue (Australian Institute of Health and Welfare, 2013). The new standard embraced an Australian wide hearing intervention pathway that incorporated the broad diagnostic pathway and management that spoke to each other highlighting the importance of continuum of care to keep a family engaged (Australian Institute of Health and Welfare, 2013).

In SA like other states, the Hearing Coordinator’s role was established in accordance to the HH-EIWG national standards, and strives to support families to access and continue engagement with all services, in order to optimise the developmental outcome of all children diagnosed with a hearing loss (Australian Institute of Health and Welfare, 2013). A key criteria the Hearing Coordinator, is to provide an unbiased pathway that supports parents to make informed choices around their child (UNHS- WCHN, 2016). The pathway management support is ongoing and includes the broader pathway of such as Ear’s Nose Throat specialist (ENT) & paediatrician for medical management (i.e. Cochlear implant pathway), audiologist from both Women’s and Children’s health network children’s audiology service and Australian Hearing who provide information about technology assistance (i.e. hearing aids) and specialist early intervention programs that cover communication spectrum(UNHS- WCHN, 2016). It was worth noting that the Hearing Coordinator role only becomes involved with families once a confirmed diagnosis of hearing loss is established.

When a child is suspected to have a diagnosed hearing loss, parents feel a range of feelings from sad, angry, confused, to vulnerable, and guilty this is a natural reaction (Moeller et al. 2013, p146). Most will cry at the thought of what is the future for their child and are overwhelmed at the illogical thoughts they experience (Thornton, 2013).These feelings continue to confirmed diagnosis where most parents have little or no prior knowledge about deafness, deaf culture and have little to no knowledge of the types of intervention services that focus on listening and spoken language development (Moeller et al. 2013, 148). Most parents assume their child will have to use sign language and wear bulky hearing aid (Thornton, 2013). Quite commonly, parents fear an inability to communicate with their child, and that their child will develop deaf speech, a limitation in their life not being able to hear (Australian Institute of Health and Welfare, 2013). Parents see hearing aids as an identification of bullying from other peers and prolong making a choice to accessing hearing aids or cochlear implant (should it be needed) (FirstVoice, 2016).Like any parent, they want to do the right thing and give their child the best opportunities available, but struggle to commit, are overwhelmed by the opinions/conflicting information about choices present and decisions they are expected to make in a very short period of time (FirstVoice, 2016). This sense of urgency for parents to make life long decisions about their child’s hearing future has long divided the deaf community and questioned the human rights of the child by forcing parents to prematurely make choices on behalf of their child (Thornton, 2013). The term

audism

is often used by some within the deaf community to describe the medical community’s view of managing hearing loss (Thornton, 2013). It is suggested, that parents are lead to believe the ideals of the medical community who convey the notion that hearing is better, and scare hearing parents with the idea that their child’s hearing loss management should not include Australian Sign Language (ASL), should they want their child to succeed in learning to talk (Thornton, 2013). Moreover, the deaf community consider ASL to be the first option presented to parents before other intervention such as hearing aids/cochlear implant or auditory verbal communication, this belief does not take into account the range of hearing loss a child has and is confusing view for parents to understand (Early Childhood Intervention Australia, 2014). In contrast, medical community, have a goal to recreate hearing and provide the child with an opportunity to be as successful as hearing child and this includes accessing hearing aids/cochlear implants, broad types of communication services which includes auditory verbal & ASL as options(FirstVoice, 2016). In addition to the confusion parents face post hearing diagnosis; the recent introduction of the National Disability Insurance Scheme which changed how families access services and provided a new layer of urgency, confusion and economic choice to parents (NDIA, 2017-2018). The NDIS is a scheme by which the Australian government has applied neoliberalist ideals of free-market principles to disability support services (NDIA, 2017-2018). It was a move from the old way in which government gave money to particular disability services and people with a disability where expect to ‘fit’ what was offered, and move to where people with a disability and their families where able to exercise ‘choice’, essentially it allows for participants get a ‘NDIS funded plan’ which they could spend at competing services providers (NDIA, 2017-2018). They were now consumers, with purchasing power in a market of social services (NDIA, 2017-2018).

The role of the Hearing Coordinator is to support parents on their journey to connect with the broad medical/deaf community and encourage the parent, to develop their own knowledge base on how to support their child in a way that identifies with their own values and ideals (UNHS-WCHN, 2016). The Hearing Coordinator’s role is unbiased and challenges the oppressive of ideals of long held views of both sides of the community in a way that does not reject nor accept either sides ideals/values, but rather just support parents with neutral provision of information that allows them to develop their knowledge and understanding (UNHS-WCHN, 2016). Despite the divide, the Hearing Coordinator promotes and encourages engagement as a positive benefit for parents to learn they are not alone, there are other parents who are on a similar journey and importance to sharing their experience and just be connected (UNHS-WCHN, 2016). For parents, the positive opportunity to speak with other parents of children with hearing loss provides them with a strong support network, that gives insight to real-life information as they learn to understand the variety of ways a parent can support their child (UNHS-WCHN, 2016). Moreover, it provides the child the opportunity to meet other children with a hearing loss (Moeller et al. 2013, p158). Positive identification of hearing loss is the aim all around (UNHS-WCHN, 2016).

The method: Photovoice 300 words

Photovoice was first introduced by Wang and Burris in the early 90s, originally as photo short story, that enable them to assess health and socioeconomic needs of women living in rural farming communities of Yunnan province China (Liebenberg, 2018). Since then this theory –informed action based research method has continued to grow and be utilised by social workers to therapeutically highlight a wider range of social problems their clients may be struggling with (Liebenberg, 2018). The method helps to raise basic human right awareness within communities on issues such as, poverty, living conditions families and elderly, homelessness, domestic violence, and child bullying to name a few (Luttrell & Chalfen, 2010). Photography, becomes the narrative for clients to be empowered and motivated to document their own story through actively taking pictures of images significant to them, which in turn allows for reflection of the issue (Luttrell & Chalfen, 2010).Part of honouring the wisdom and expertise of clients experiences, requires a skilled social worker to facilitate critical reflection of their clients experiences, and in turn use the knowledge emerging from the reflection, as a platform from which their voice is amplified in ways that are able to be heard (Budig et al, 2018, p 6).

For this paper, photovoice is utilised to raise awareness of the overwhelming struggle parent’s face when told of suspected to confirmed hearing loss for their child (Thornton, 2013). The application of photovoice is to highlight to the board hearing loss community a parent(s) journey as they struggle to learn and understand both sides of the hearing impairment community (FirstVoice, 2016). Photovoice has been a way for parent(s) to express the impact of shock of suspected and confirmed diagnosis and the learning curve that follows (Moeller et al. 2013, p 147).

Careful collaborating when working with vulnerable populations requires the research to demonstrate creativity, mutual respect, flexibility, compassion, cultural competency, and patience (Luttrell & Chalfen, 2010). For parents of children diagnosed with a hearing loss using photovoice method exposes the vulnerability they feel as they come to terms with their grief and loss of the diagnosis needs to be ethically considered (Early Childhood Intervention Australia, 2014).Of particular concern is marginalization parents feel as a result of communication, cultural, social, and language barriers that their child will face in the future (Early Childhood Intervention Australia, 2014). These challenges have historically divided the hearing loss community from a variety of beneficial health education and outreach programs resulting in health inequities and limited health care access (Early Childhood Intervention Australia, 2014). De-identification of participants is done by referring to participants as parent 1, and so on.

Parent 1

At 18mths my child was diagnosed with a progressive hearing loss. This was my third child, having two older siblings with no loss or family history. I was surprised by the diagnosis, and I cried. My child was a bright beautiful child and I didn’t want hearing aids or a cochlear implant; I didn’t want my child to be excluded from play because of a disability; I didn’t want my child to talk differently or not at all. I didn’t want my child to be deaf.

After the diagnosis, as a parent I am overwhelmed with appointments—there was audiologist doing hearing tests, diagnostic tests at the Womens & children’s hospital and then appointments with the ENT doctor. For the first six months there were an average of two appointments a week and I had to stop working just to fit it all in. The focus in all of these appointments was to try to fix my child. It felt like they were trying to squeeze my child into a box. We meet with all the early intervention providers and a big focus was on acquiring clear speech and I was advised early on by my provider to not use any signs, as they believed that this interfered with my child’s ability to learn spoken English and I believed them. My child was fitted with hearing aids, my heart broke a little more.

The Fish bowl

I took this picture because little did I know how many months I would be sittig in here hoping that they (audiologist) testing had got it wrong……Each time I entered I pray they tell me they had got it wrong…..But instead each time I entered I learnt my child hearing was progressively worse…..

I took this picture because I remember it sitting in the audiologist room as they explained to me if the hearing worsens and hearing aids don’t work that an implant will be my child’s pathway…..I cried and prayed that they were wrong…..

I took this picture because it symbolises the countless hours I sat in the waiting at my child’s appointments….praying, begging ,believing they had got it wrong…..

Photovoice provided an alternative way for professionals from the hearing community to understand the parents perspective of the journey they go on when their child is either suspected of or confirmed with a hearing loss (Moeller, et al. 2013, p 156 ). The research method provides insight into how exposed a parent feels dealing with sensitive topics such as hearing aids, methods of communication, an often under-acknowledged emotion professional within the hearing community overlook (FirstVoice, 2016). Parents seek support from the hearing loss community and professionals within as they deal with powerful emotions of denial, shock and upset they experience when facing diagnosis of hearing loss (Early Childhood Intervention Australia, 2014). The connection to community provides parents with a sense of hope to be understood of what they are feeling (Thornton, 2013). At this time, parents see the need for support from professional as important, positive support is perceived to empower parents to provide well for the child even when the diagnosis is confirmed as a loss(FirstVoice, 2016). Parent reflects on the time it takes to get final diagnosis following the screening process can leave them feeling isolated and unsupported in what is described as a drawn-out delay before a diagnosis of hearing loss is finally confirmed (Moeller, et al. 2013, p 156). Parents understand delay was due to difficulties with testing the individual child, difficulty with interpretation of test results obtained, and the need for multiple repeat tests over prolonged periods of time resulting in diagnosis delay(UNHS-WCHN, 2016). Parent describes this time as frustrating as feeling helplessness and anxious and isolated(FirstVoice, 2016). Parents reflect on how important the need for support from the professionals within the hearing community was to avoid feeling isolated and not belonging(FirstVoice, 2016).

Parents give insight to initial experience with professionals within hearing community and reflect on communication difficulties and misunderstandings had negatively impacted their child’s care(FirstVoice, 2016). Parents felt that at times some professionals who overlook parental reactions also did not explain findings clearly enough and parents would leave appointments feeling confused and disconnected from a community they are trying to navigate (FirstVoice, 2016). Parents found some professionals had mislead and provided incorrect advice which sometimes had been based on the professionals own knowledge and personal experience rather than fact (Early Childhood Intervention Australia, 2014). Moreover, misleading information at times had contributed to parents disconnecting from the hearing community prematurely which had led to impacting the overall development of children as final diagnosis was not achieved(Early Childhood Intervention Australia, 2014).

Photovoice applied to the journey of parents as they navigate hearing loss diagnosis in their child provides a valuable way for expression of parents’ thoughts, feelings, and experiences (FirstVoice, 2016). It gives an insight at a time when the future direction of hearing community from medical to early intervention has been questioned and where at a national level has moved towards a model of partnership where inclusion of parents with the support of the Hearing Coordinator are more active in the pathway decision making for their child(Australian Institute of Health and Welfare, 2013). The use of photovoice provides a tool for listening collectively to parents’ insights. As a Australian wide hearing screening programmes become established, inclusion of photovoice as a research in the programme evaluation and application of the findings to future programme planning and development will enable providers to better meet the needs of children with hearing loss and to adequately support and inform parents(Australian Institute of Health and Welfare, 2013). Professionals from the hearing community need to be trained in specific communication skills when delivering abnormal test results, and in identifying and dealing empathetically with likely parent reactions such as shock and denial(FirstVoice, 2016). Professionals from the hearing community need to ensure that apart of positive engagement with parents they are allocate sufficient time to communicate effectively and clarify questions for parents (FirstVoice, 2016). Verbal communications about audiological findings need to be supplemented with written information using simpler language, diagrams, and clearer explanations of the implications of hearing loss for language development(Australian Institute of Health and Welfare, 2013).

The aim of this paper was to show through photovoice the journey parents go on when their child is diagnosed hearing loss. Time and time again the essay attempts to highlight just how difficult and stressful diagnosis was and how important the need for emotional support and connection to the hearing community becomes for that parent. Moreover it provided an understanding of communication deficits often felt by parents of newly diagnosed child and professionals from the hearing community, particularly as providers attempt to explain a child’s hearing loss diagnosis and misinterpret when a parent experienced intense emotional reactions. Consistent support from the hearing loss community once a diagnosis was established is the constant highlight of parents as they go on a journey to learn about hearing loss, the and move forward with what is “best” for their child.

References

• Australian Bureau of Statistics, Births Australia 2018, cat no.3301.0,ABS, Canberra.
• Australian Institute of Health and Welfare. (2013). National framework for neonatal hearing screening. National performance indicators to support neonatal hearing screening in Australia. Cat.no. 73, ABS, Canberra.
• Budig, K., Diez, J., Conde, P., Sastre, M., Hernan, M., & Franco, M. (2018). Photovoice and empowerment:evaluating the transformative potential of participatory action research project.
  
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• De Lange, N.,Molestsane, R.,& Mitchell, C., (2015). Seeing how it works: A visual essay about critical and transformative research in education.
  
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• Jarldorn, M. (2016). Picturing creative approaches to social work research: using photography to promote social change.
  
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• Liebenberg, Linda. (2018). Thinking Critically About Photovoice: Achieving Empowerment and Social Change. International Journal of Qualitative Methods. 17. 160940691875763. 10.1177/1609406918757631.
• Luttrell, W., & Chalfen, R. (2010). Lifting up voices of participatory visual research.
  
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• Moeller, P., Carr, G., Seaver, L., Stredler-Brown, A., Holzinger, D. (2013). Best practices in family-centred early intervention for children who are deaf or hard of hearing: An international consensus statement.
  
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• Early Childhood Intervention Australia. (2014). Early intervention best practice discussion paper. Viewed april 20th 2019,<
  
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• National Dissability Insurance Agency (NDIA) 2017-2018 Annual report. Viewed April 23
  
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• National Performance Indicators for neonatal hearing screening in Australia (2013). Viewed April 23rd 2019,<
  
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• Thornton, G. (2013). Early Intervention & Education for deaf & hard of hearing children. Viewed April 23rd 2019, www.deafaustralia.org.au >.
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The purpose of this assignment is to conduct a literature review on a chosen topic which is a healthcare/nursing intervention related to a chosen clinical setting. A rationale will be given on why the particular intervention was chosen and also a brief description of the intervention will be outlined. The author will also identify the search strategy used to give the readers understanding of how the literature was researched and chosen. This will be followed by a summary of the findings from the relevant literature in relation to the chosen intervention.

Aveyard (2008) describes a literature review as the comprehensive study and interpretation of literature that relates to a particular subject.

The authors elective placement was spent in a surgical theatre in a large hospital trust. The theatres largely comprised of gynaecological procedures and Gastro-intestinal surgery where up to 25 procedures could be performed each day dependent upon the number of available beds within the trust. The age range of the patients that were seen were 16 years of age and above. For more than a century, surgery has been an essential component of public health. As longevity increases worldwide, its role is increasing rapidly (WHO 2009) with around 230 million people undergoing surgery each year.(Lancet 2008). Surgical complications are common and data suggests that many deaths and injuries due to a surgical procedure are avoidable.(Gawande AA et al 1999). Therefore the author has chosen to review a tool from the initiative ‘Safe Surgery Saves Lives’, known as the ‘Who Surgical Checklist’. The checklist has been chosen as it was used in the authors surgical placement area.

For this literature review a literature search of electronic databases using The Cumulative Index of Nursing and Allied Health Literature (CINAHL) and OVID Medline was conducted the search was limited to English Language articles and date limitations were set between 1990 – 2010 using Key words including ‘Patient safety in surgery’ which resulted in 493618 papers, this search result was too broad and so then was started using the words ‘Surgical safety’ which resulted in 44 papers some of which weren’t relevant to the chosen topic so the phrase ‘Safety checklists’ were added in to the search which resulted in nine papers. I found it difficult when searching for literature on the chosen subject as it is a fairly new initiative and only became mandatory in 2010.

Data recorded from 56 countries identified that in 2004 the annual volume of major surgery was an estimated 187-281 million operations, or approximately one operation annually for every 25 human beings alive. (Weiser TG, et al).

Surgical care very often can prevent loss of life or limbs, it is also associated with posing a considerable risk of complications and death (Haynes AB et al). Major morbidity following surgery occurs in 3 to 25% of patients being treated in a hospital setting and mortality rates following surgery range between 0.4% and 10%. It is not just the morbidity rates that are affected , health-care costs increase substantially for patients with surgical site infections. In the United Kingdom alone, the excess cost has been calculated to be about £1594 per infection (Coello R et al 2005).

Confronted with evidence from countries all over the world of the substantial public health harm due to inadequate patient safety, the World Health Assembly (WHA) in 2002 adopted a resolution urging countries to strengthen the safety of health care and monitoring systems across different areas of healthcare systems and surgery was one of the areas listed. The resolution also requested that WHO take a lead in setting norms and standards and supporting country efforts in preparing the patient safety policies and practices. (WHO, 2009)

The goal of the intervention is to address safety issues within the surgical setting, this includes improving communication within a surgical team, improving anaesthetic safety practices, avoiding surgical site infections and ensuring correct site surgery. The tool can be applied to accommodate all countries and health settings and is a step by step reminder of important safety checks.

The WHO launched the challenge in June 2008 The challenge was launched in 2007-2008 by the World Health Organisation (WHO), guidelines were published identifying multiple recommended practices to ensure the safety of patients worldwide (WHO 2008) and the National Patient Safety Agency (NPSA) made it mandatory that all NHS hospitals in England and Wales implement an adapted version by 1 February 2010. (NPSA 2009)

The guidelines were set in the form of a checklist, set out to be similar to an operations manual which most small and large organisations have. Often Checklists, used at a crucial point to confirm that vital actions are complete, are familiar to many high pressured occupations such as pilots, who assume that such actions have already occurred as part of clearly defined procedures. A member of a surgical team can be compared to a pilot and surgical procedure compared to a flight – both need important checks and validations to ensure a smooth ‘flight’.

The WHO based checklist consists of an oral confirmation by surgical teams of the completion of the basic steps for ensuring safe delivery of anaesthesia, prophylaxis against infection, effective teamwork, and other essential practices in surgery (Hynes AB et al). With three stages to the checklist – ‘sign in’ – Before operation, ‘Time out’ – Before skin incision and ‘Sign out’ – Before the patient leaves the operating room. (DoH)

Through 38 interviews Giles et al (2006) found that most surgeons had experience of wrong site surgery. Wrong site surgery and near misses are not as uncommon as maybe they should be. Between September 2007 and August 2008, 728 cases of wrong site patient safety incidents were reported to the Reporting and Learning System (RLS) database (Catchpole et al 2009). And in a different study there were 427 reported wrong site surgery near-misses or interventions found that patient positioning, anaesthesia before a time-out, verification of consent or site marking and a proper time-out process are all frequently not done (Clarke, Johnston & Finley 2007).

Wong et al (2006) found 1,627 problems in 464 procedures and although most problems were perceived as having been resolved, one-third were never discussed with the operating team so nothing could be learned about the cause or correction for future cases to prevent re-occurrence. De- Briefs were not common practice within the trust where the authors placement due to time constraints, surgeons would usually send for the next patient before the current patient had finished therefore leaving no time in between as surgical staff were getting the theatre ready or scrubbing up. But it has been cited that briefing and de-briefing can give team members the chance to share knowledge of a case and resolve discrepant assumptions of how a case would proceed. A percentage of staff also felt that the checks duplicate checks already undertaken by others eg anaesthetic room pre op checklist by anaesthetic nurse, but the lack of communication and briefings within an operating theatre and staff actually highlights the need for a checklist that involves the whole team.

Another barrier with the implementation of a checklist is duplicity. Many of the team members are unsure of when some things should be done eg some anaesthetists thought that many of the items in time-out should be done in sign-in.

It has been identified by the author after reading the relevant literature that those furthest from surgical practice seem to be the ones who are embracing the new WHO surgical checklist most enthusiastically. Thus, it is ironic that Atul Gawande’s book The Checklist Manifesto is reviewed by a physician rather than a surgeon

Although it has been promoted internationally by WHO and in the UK by the National Patient Safety Agency the surgical staff still believe is little more than a distraction and in fact it does little in the way of ensuring the surgical staff are capable of performing their roles in an adequate way. However, results from a thousand patients in eight separate pilot sites worldwide has shown that use of the checklist has actually increased adherence to these standards of care from 36% to 68% and in some hospitals to levels approaching 100% resulting in reductions in complications and death in this group” (DoH)

A study of the preintervention and postintervention periods was conducted across 8 hospitals which represented a wide variety of economic circumstances and diverse populations between October 2007 and September 2008. Data was collected on clinical processes and outcomes from 3733 enrolled patients who were all 16 yrs and over. During the study data was also collected on 3955 enrolled patients after the introduction of the safety checklist. The end point was the rate of morbidity and mortality during hospitalization within the first 30 days post operation. Once the study was completed data was collected and the rate of death was 1.5% of patients before the checklist was introduced this declined to 0.8% after the introduction. Complications occurred in 11.0% of patients at baseline and in 7.0% after the introduction of the checklist. Results of this pilot project showed significant reductions in the mortality and morbidity rates. (Haynes AB et al 2009)

A growing body of evidence also links teamwork in surgery to improved outcomes, with high functioning teams achieving significantly reduced rates of adverse events. Hogg and Vaughan (1995) believe that individuals occupying different roles in a group need to co-ordinate their actions through communication but putting this in to action within a busy surgical environment is not an easy task.

In 2008 a UK pilot experience was carried for 6 months in which two operating theatres from one hospital were selected to represent the bulk of procedures carried out within the NHS. Operating theatre staff were interviewed individually, in small groups and through a wide hospital forum.

During this pilot it was proposed that the checklist process should be led by nurses to flatten hierarchy and support shared teamwork. The Nursing and Midwifery Council (NMC) Code (2008) emphasises that nurses need to deliver care based on the best available evidence or best practice. Sackett (1996) described evidence-based practice as ‘conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’ (Aveyard, 2008 p7).

It has been argued that interpersonal dynamics and steep hierarchical structures in the operating room contribute to error by creating an environment in which persons who could prevent an error are reluctant to speak up (WHO 2009). With Nurses being given the role of enforcing the checklist and being the only constant through complicated pre, during and post surgical procedures.

In the first two weeks of the pilot a representative from the research team was present to train and encourage staff and to also answer any questions. After the first two weeks compliance fell resulting in the return of the research team to further promote use of the checklist, this reflects the fact that the use of the checklist has to be actively driven by the research team (lingard l et al 2005) By helping teams work together, the checklist establishes a higher standard of baseline performance in the Operating theatre.(Hales BM et al 2006)

At the end of the study no significant changes in overall morbidity or mortality were found but there was noticeable improvement in timely use of prophylactic antibiotics which rose from 57% to 77% of operations after the checklist was introduced.

Modification needs to be done as some participants thought that some of the items were not relevant to UK operating theatres. However it is important to prevent the list from becoming too exhaustive as too many items to check may result in things being overlooked.

Looking through the relevant literature it does show that improvements have been made by using the checklist and it encourages team work and positivity for staff members who in the past may have been unheard by superior members of staff may now be heard.

Although not everyone within the surgical teams embrace the checklist instead they view it as more of a hindrance than a key component to every surgical procedure just as a flight check list is to a pilot. We wouldn’t be allowed to take off on holiday without the key flight checks having been made and most people would not really want to have a surgical procedure without a similar checklist being carried out? But implementation of the checklist seems to be key in ensuring it works, a proven way of achieving this is by utilizing a nurses’ role with the surgical procedure and opening lines of communication between all key surgical staff.

The WHO checklist is not a final product but an intelligent tool that can be adapted with time and effort (Lingard L et al 2005). Safety of surgical care can be easily accomplished with the checklist if proper planning and commitment from all members of the Multidisciplinary Team is given. The key factor is that it must be workable and acceptable to all staff

This annotated bibliography will discuss three pieces of literatures, which include a Department of health policy. Demonstrating an understanding of the chosen articles with the use of additional literatures to analyse identify and explore learning and how it will influence the nursing care of patient with stroke. Furthermore, the analysis of how the literature search was performed, the database used, search term used, the inclusion and exclusion criteria, the findings and exploration of why the literature was chosen will be identified.

Search Strategy

Database such as CINAHL plus, British Nursing Index and Department of Health policy was utilised to acquire relevant articles and guideline relating to stroke (Achterberg, Schoonhoven & Grol, 2008). This was searched using keywords such as; “self- care CVA”, “self-care management”, with the use of the Boolean operator “OR”, “AND “and “IN” which helped expand and narrow the search criteria (Petersen, 2010). To carry out the first search the keywords “self-care management” was inserted and it came up with 1878 hits, again Boolean operator “OR” was used to refine the search. However the hits were large at 40361 hits, the Boolean operator “IN” was inserted which gave less than 1657 hits. Moreover, when the search keywords “self-care stroke” was inserted to the database it came up with 1831 hits, however when the Boolean operator “AND” was added the number of hits had reduced to 51.

To further narrow the search to get minimum and relevant information relating to stroke, the writer used the advance search tools by limiting the search to UK only, publications dates within 6years and excluding international. As a result of this, the first article had 30 results, second article had 500 results and the third article had 321 results. From this, the writer read 10 abstracts each from the articles that were more suitable for the research. From the ten abstract read, the writer was able to come to conclusion by choosing 1 article from each search as it contains appropriate information regarding nursing care for patient with stroke.

However the policy was found using the DoH website as the database used to find the other articles were not appropriate for finding a guideline. This was search using keywords “SELF MANAGEMENT FOR STROKE”, in which gave the writer suitable information relating to stroke and how it influence nursing care (reference)

Annotated Article 1

Joice, S. (2012). Self-Management following Stroke.



Nursing Standard, 26



(22), 39-46

In this article the author defines the concept of self-management and describes psychological theories and emerging behaviour change techniques that nurses can use to promote positive self-care in patients who have had a stroke (McCabe & Timmins, 2013). They identify the importance that nurses are in the main position to combine a wide range of behaviour change techniques that can be modify to different patients (Egan, 2009). They also identify the importance of nurses creating a therapeutic relationship through communication as it enhances the delivery of care provided (Palmer, 2000). Additionally, by providing useful communication between the nurse and patient it encourages them to take more interest in their condition and develop greater understanding and confidence in self-care management (McCabe & Timmins, 2013).

Many authors such as Burnard (2003), Barrett, Komaromy, Robb and Rodger (2004) and Bach and Grant (2011) agree that communication is the most important therapeutic skill compulsory for nurses. Whilst Schuster (2000) highlights that nurses must also be able to appreciate non-verbal communication, through eye contact and touch, as it is a crucial method to creating a rapport and trusting relationship with their patient before verbal communication commences.

The article also identified the challenges nurses face when delivering self-management after stroke, as different policies, authors or researchers may not use same definition of self-management (Newman, Steed Mulligan & 2009). Therefore, nurses have to interpret documents and apply them in different environment. Lorig & Holman (2003) supports that self-management is poorly theorised, which means lack of knowledge restrict both the nurses and patients from facilitating self-care management (White, Duncan and Baumle, 2011)

Although it identifies the importance of individual’s attitudes and beliefs towards recovery and response to rehabilitation, the attitudes and beliefs of the nurse also plays a role (Young and Forster, 2007). However Daniel, Grendall & Wilkins (2008) states the importance of valuing people’s attitude and beliefs as it determines their motivation to participate in self- care. Therefore nurses have to be sensitive to that fact that all patients share different beliefs regarding health care issues. (Barker, 2009)

The overall article highlighted the importance of nurse’s usage of different behaviour change techniques to promote positive self-management after stroke. It also identifies nurses as the main provider in promoting self-care to patients and their families in order to improve the outcome.

Annotated Article 2

Rowat, A. (2011). Malnutrition and Dehydration after Stroke.



Nursing Standard,



26 (14), 42-46

The aim of the article was to encourage nurses to identify the frequency and causes of malnutrition and dehydration, consider the complications it can cause and to be aware of the feeding strategies. They identify that patient presented with stroke should be assessed within the first 48 hours and swallowing should be assessed before giving any food, fluid or oral medication (NICE, 2008).

They identify the video-fluoroscopy test used to observe the patient swallowing process. However the test is not practical for assessing patient with stroke as they are unable to sit independently as well as endure movement of their head (Rowe & D’Antonio, 2005, Jacobsson et al, 2000). Although the video-fluoroscopy is used to detect dysphagia, it is believed to be an unreliable source as it does not identify how the patient should be fed when they return to the ward (Clayton, Jack, Ryall, Tran, Hilal & Gosney 2006).

The use of different trials carried out by Dennis, Lewis & Warlow (2005) supports decisions about feeding patients after stroke as it illustrates the significance of enteral tube feeding reducing risks of death at 6months. The article also identifies alternative evaluation tool; Fibre optic Endoscopic Evaluation of Swallowing (FEES) has been developed as it can be used at the bedside to establish the movement of fluid and food in the larynx (Ramsey, Smithard & Kalra, 2003). However it still requires a skilled operator to administer the swallowing test, therefore the person administering the tests must receive sufficient education and training in order to carry out the test accurately (Rodgers, 2005).

It identifies the importance of nurses using the Malnutrition Universal Screening Tool as it is a valid and reliable nutritional screening tool used in hospital setting, as high number of patient with stroke experience malnutrition (NICE, 2008). However the tool is not specific to stroke and would not identify reasons the patient is malnourished, but it enables the nurses to identify the patients who need to refer to speech and language therapist (Hickson, 2006).

The overall article informs nurses of the common complication arising from stroke and the tools used to examine. It also identifies the importance of teamwork between nurses and speech and language therapy in maintaining the nutrition and hydration status of the patient after stroke.

Annotated Policy

Department of Health. (2007). National Stroke Strategy. London: HMSO

The strategy has been put in place as it provide a quality framework against which local services can secure improvements to stroke services and address health inequalities involving stroke within ten years, provide advice, guidance and support for commissioners, strategic health authorities, the voluntary sector and social care, in the planning, development and monitoring of services; and inform the expectations of those affected by stroke and their families, by providing a guide to high-quality health and social care services.

The Department of Health (2007) established a national strategy for stroke facilities in England. According to DoH (2007), almost 110,000 people under the age of 65 in England have a stroke yearly and 20-30% of those people pass away within a month. They identified Stroke as the main cause of disability within adults and costing the NHS and economy £7 billion yearly as suggested by (Leatherman, Sutherland & Airoldi 2008). The DoH developed the strategy as a result of an evidence based practice (Keele, 2011), which suggest what needs to be done by recommending nurses to use the care pathway to deliver an effective care to patients with stroke (Barker, 2013).

The policy was implemented to remodel the services provided to the patients, ensuring they receive the best care using resources available. However due to some nurses lack of knowledge, it could limit the resources being used effectively (Rodgers, 2005).

Although the policy supports the involvement of patients and family with stroke by involving them in care planning (Benner, Kyriakidis & Stannard, 2011). However the policy identifies that this can prove to be less effective when communicating with the patient due to either physical disability or limited communication as a result of the severity of their stroke (DoH,2007).Therefore the policy identifies how to interact effectively with the patient by maintaining their dignity (Masters, 2014).

Overall the policy highlights the important of nurses being updated frequently on different tools available to use when caring for their patient. This ensures the patients receive an up-to-date care and restricts their stay in hospital.

To conclude, the writer has demonstrated understanding of the articles and policy chosen, by using literatures to analyse and explore further reading concerning how it influences the nursing care of the stroke patient. This has equipped the writer on how effective high quality care should be delivered to patients effectively.

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