Reflective account of a significant event in practice: a student ODP's perspective.
Abstract: This is an account of a significant event that occurred in clinical practice. The incident highlights issues that can arise from a breakdown of verbal and non-verbal communication between members of staff. It also demonstrates how professional conduct and effective team working can overcome such breakdowns to elicit a positive outcome. Using Johns (2009) model of structured reflection (MSR), this article reflects on the student operating department practitioner's (ST/ODP) role as anaesthetic support, exploring the impact on the care received by the patient, whilst examining the ethico-legal (governing body and legislation) considerations involved. Furthermore, the ST/ODP proposes to identify environmental and intra-operative factors that are potentially damaging to the patient's well being, through understanding the principles of negligence, emphasising clinical governance, vicarious liability and risk management issues.
Subject: Medical personnel (Practice)
Medicine (Practice)
Medicine (Analysis)
Author: Wishart, Karl
Pub Date: 04/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: April, 2012 Source Volume: 22 Source Issue: 4
Topic: Event Code: 200 Management dynamics
Product: Product Code: 8010000 Medical Personnel NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 293545452
Full Text: McGuinness (2009) states that reflection is a tool which allows us to make sense of an experience and/or situation. With the experience being central to any reflective process, it is the experience that has the potential to change one's future practice, and to shape the student practitioner into the professional practitioner. Jasper (2006) agrees that reflective practice assumes that the student will develop their ability to make informed decisions, based around experiences, identifying skills and knowledge that are deficient in each experience. Ultimately 'reflective practice informs our decision-making as functioning professionals' (Jasper 2006 p2).

I decided that Johns (2009) Model for Structured Reflection, best suited my reflective thought process. McGuinness (2009) unashamedly admits that the model is basically a step by step guide for the uninitiated reflector, and for those at the start of their professional career.

Johns (2009) model is well known for being based on his interpretation of Carper's (1978) 'Four ways of knowing'. Johns (1995) adapted Carper's (1978) Four patterns of knowing, by adding the 5th element entitled 'reflexivity' - the ability to draw upon previous experiences in enhancing personal and professional growth. This has been criticised by Rolfe et al (2001) for referring only to a situation which has been resolved. However Rolfe et al (2001), supplement their own 'Framework for reflexive practice' with John's cue questions. This, suggests Freshwater, cited in Rolfe et al (2011), is an optimal approach and structured system of reflection for practice development, advocating the benefits of clinical supervision to enhance reflective activity in practice.

Johns (2009) designed his first MSR in 1991, by analysing dialogue patterns framed within Strauss and Corbin's grounded theory model: encouraging the practitioner to split the description of the experience into different parts. However Johns and Freshwater (1998) believe that this impedes the practitioners' story telling:

'The risk is that practitioners will fit their experience to the model of reflection rather than use the model creatively to guide them to see self within the context of the particular experience'; Johns (2004 p19).

Johns has reviewed and modified his MSR since 1991, which suggests that it is adaptable not only to the individual's own perception, but also to the changing world. With this in mind, I have tailored Johns (2009) model to maximise my understanding and learning, and to allow me to answer questions in a way that works for me, a strategy that is championed by Jasper (2006).

The Health Professions Council (HPC) (2009) 'Guidance on conduct and ethics for students' clearly defines that any information regarding a patient is confidential and should be used only for the purpose for which it was given. Anything that may identify the person should not be disclosed. Furthermore, it advises you to follow local hospital policies and guidelines in line with the Data Protection Act (HMSO 1998), and Department of Health (2009) and Health Protection Agency (2010) guidance. With this in mind, the patient will be referred to as 'Monica'.

Brief background of patient

Monica was a mother of two in her twenties. Both previous deliveries were by caesarean section (CS), the last being particularly difficult due to blood loss and a perforated bowel. This quite rightly left her feeling anxious about the impending CS. It also impacted on surgery due to scar tissue, with muscle and tissue fibres sticking together.

Anaesthetic team and management

Team: Anaesthetist A (consultant), anaesthetist B (CT1), registered ODP and ST/ODP.

Pre-Anaesthesia: At approximately 09.30, Monica was brought into theatre by the ST/ODP, and 'checked' in for surgery with the RODP and scrub nurse. Routine monitoring was set up in the form of continuous pulse oximetry, non-invasive blood pressure monitoring and ECG - for induction/regional injection, maintenance and recovery (AAGBI 2008). Monica was positioned seated sideways on the operating table with her feet on a stool. Intravenous (IV) access was secured with a cannula in Monica's left hand prior to anaesthesia, and IV fluid was attached. Whilst anaesthetist B washed her hands (maintaining asepsis), the RODP prepared the spinal trolley with the necessary equipment.

Anaesthetic technique and airway management:

09.40 Monica was asked to sit forward and flex her spine, so that anaesthetist B could locate the area in which to administer an effective subarachnoid block (spinal). She remained agitated throughout the administration of local anaesthetic (to eradicate further pain from the spinal needle).

09.46 After successfully locating the dura and injecting Marcain Heavy 0.5% (bupivacaine) to induce an effective block, the patient was asked to lie down on the operating table. It was noticed that even with the local anaesthetic, Monica felt pain.

09.48 The midwife introduced a catheter to maintain patient dignity throughout the perioperative and postoperative stages.

09.50Monica's friend (birth partner) was then brought in to sit beside her.

09.51 Once scrubbed, the surgeons and the scrub nurse took up position, asked if everyone was ready and then proceeded with the surgical cut to perform the csection.

09.52 It was noted that Monica felt considerable discomfort. Surgery ceased.

09.53 Surgery resumed. Monica was clearly distressed. Anaesthetist A made the decision that surgery should cease temporarily, and that a general anaesthetic was necessary to prevent further distress. Her friend was reassuringly escorted to the recovery room.

It is national protocol that a rapid sequence induction (RSI) be performed on the pregnant patient undergoing a general anaesthetic, as they are prone to reflux due to the anatomical shift in pregnancy. The ST/ODP was to perform their first RSI on a pregnant patient under the guidance of both anaesthetists and the RODP.

All the necessary (and emergency) equipment was located and put within reach.

09.54-09.56 Cricoids pressure was explained to the patient and the cricoid located prior to the induction agent (thiopentone) and muscle relaxant (suxemethonuim) being given.

Anaesthetist B took the laryngoscope and attempted tracheal intubation. The view of the laryngeal anatomy was not good and a bougie was used 'successfully'. Oxygen saturation was 97%.

Anaesthetist B connected the endotracheal tube (ETT) to the breathing circuit on the anaesthetic machine to ventilate. No CO2 trace appeared indicating that the ETT was in the wrong place. Anaesthetist B asked the ST/ODP if they had felt the ETT pass under their fingers. The ST/ODP had, and continued maintaining cricoids pressure. With no CO2 trace, anaesthetist B listened to both sides of Monica's chest with a stethoscope, and reported that no sound could be heard. This confirmed incorrect placement of the ETT (which had been placed in the oesophagus). Oxygen saturation was 91%.

09.57-09.59 The ETT was removed and an airway (guedel) inserted to begin manual ventilation with the view to raising oxygen levels to facilitate a second intubation attempt. Oxygen saturation rose to 98%.

10.00-10.02 The second attempt was performed by anaesthetist B. The ST/ODP asked if the view was sufficient, and was told it was 'not a good view'. Another bougie was used, yet the ETT could not be inserted. The alarm was sounding on the anaesthetic machine as the oxygen level was dropping at a considerable rate and by now was in the region of 70%. The second attempt was aborted and anaesthetist A stepped in.

10.04-10.06 Anaesthetist A re-inserted the guedel while the Ambubag was fixed together for manual ventilation. Monica's lips were now blue, and oxygen saturation was no longer visible on screen. The RODP had the cricothyroidotomy kit to hand. The ST/ODP maintained cricoids pressure. Anaesthetist A managed to raise oxygen saturation to 97% ready to attempt the third and final tracheal intubation.

Anaesthetist A asked the ST/ODP to adjust the cricoids pressure and with the aid of another bougie, Monica was intubated and connected to the anaesthetic machine where a CO2 trace was confirmed.

What are the significant issues?

Standing back from the incident, looking more objectively, there are many significant issues that require attention. Initially, Monica was conscious and talking to the members of staff caring for her. She was checked into theatre following the World Health Organisation (WHO) Surgical Safety Checklist (WHO 2009). Monica appeared nervous as this was her third caesarean section, a procedure that is ordinarily performed under regional anaesthesia. Hind and Wicker (2000) acknowledge that reassuring the patient is important, as is recognition and acceptance of the fact that patient attitudes may be irrational due to fear and anxiety. As Wicker and O'Neil (2006 p127) state: 'communication is the basic element of human interactions that allows people to establish, maintain and improve contacts with others'. This is a role to be undertaken by all team members in the care of the patient. For scrubbed practitioners, it is important to remember that face masks impede effective communication (Wicker & O'Neil 2006 p129).

The guidelines for caesarean section, developed by the National Collaborating Centre for Women's and Children's Health (NICE 2004), reported that 91% of elective CSs are performed this way. Monica was reassured and seated sideways on the operating table, with her feet on an immovable stool in line with The Manual Handling Operations Regulations (HSE 1992). For the pregnant patient, Wildsmith and McClure (2003) claim that this is an optimum position for administering a subarachnoid block (SAB), which is more commonly known in theatres as a 'spinal'. Intravenous access had been gained prior to anaesthesia, which allowed for a rapid conversion to general anaesthesia once it became evident that Monica was not enjoying the benefits of a successful SAB. Under the Guidelines for Obstetric Anaesthetic Services (AAGBI 2005), Monica should expect the same standards of perioperative care as all surgical patients, including appropriate anaesthetic assistance.

How do I interpret the way people are feeling and why they felt that way?

The tension in the clinical setting was evident throughout the incident. The level of stress however differed between individuals. The body language, followed by the actions of anaesthetist A for example, suggested initial confidence in anaesthetist B. However, this was rapidly replaced by her own knowledge and expertise, which brought about effective leadership and instilled confidence back into theatre. Alternatively, the actions of the RODP did not suggest total confidence. Acting within his code of conduct as outlined by the HPC (2008), the RODP gathered the emergency equipment as soon as the first intubation attempt had failed. He did so in a calm but effective manner, suggesting confidence in his own ability.

It was clear that anaesthetist B did not feel confident after the initial failure. This was made apparent by her body language and facial expressions. Hind and Wicker (2000) comment that even a frown or a raised eyebrow carries significance where speech is unwarranted.

Dyke (cited in Hind & Wicker 2000 p72) suggests that the difficulty in maintaining communication is due to hierarchy. Being lower in rank, and critical of the unfolding incident, the ST/ODP may have felt it increasingly impossible to communicate effectively. Hence, communication between anaesthetist B and the ST/ODP seemed to break down when the ST/ODP asked if their application of cricoids pressure was correct. The response was simply that the view was 'not good'. This visibly did not reassure the ST/ODP, whose facial expressions exhibited fear and worry as though the event was a direct result of their lack of experience in the management of the obstetric patient's airway. Communication is the primary psychological factor in Florence Nightingale's Environmental Theory (see Phillips 2007 p16), and a lack of communication can leave practitioners and patients feeling frustrated. This can have an adverse effect on practice claims Dyke, which certainly was the case during this incident.

The Perioperative Care Collaborative (2007), permit the minimum standards of obstetric theatre staffing as requiring only seven staff members, including one anaesthetist and one anaesthetic assistant. On the occasion of the incident there were three members of the anaesthetic team and one student.

How was I feeling and what made me feel that way?

As this was a situation I had never before found myself in I had no previous experience to draw upon and I felt totally out of my depth. All I knew was that cricoids pressure must be maintained until the anaesthetist requested it to be removed. Time seemed to stand still, and the entire surgical team had backed away from the operating table. It felt like the longest 5-10 minutes of my life as there was nothing I could do but maintain cricoids pressure.

What factors influenced the way I was/am feeling, thinking and responding to this situation?

The Health and Safety Executive (2010), suggest that optimising Performance Influencing Factors (PIFs) will minimise the probability of all human failure types. Human factors encompass PIFs (Patient Safety First 2009) and are attributed to job, individual, and organisational factors (HSE 2010). The most common risk increasing human factors are: mental and physical workload, teamwork, distractions, environment and device/process design. The HSE (2010) agrees that stress can cause fatigue from an acute temporary situation such as this, especially where communication, clarity of roles, signals and instructions are diminished, or the competency and skill mix is insufficient to deal with the circumstances.

[ILLUSTRATION OMITTED]

The failure type from the anaesthetic side is a 'rule-based mistake', where the mistake is due to mis-application of a remembered rule, or the application of a bad rule (HSE 2010). The rules here are regarding cricoids pressure (Anaesthesia UK 2004), and difficult or failed intubation (Finucane & Santora 2003). Situations similar to the case of Elaine Bromiley, reported in the Clinical Human Factors Group (CHFG 2011a,b) founded by Martin Bromiley, occur in moments such as this. The CHFG was founded as a result of his wife's death following failed intubation 'So that others may learn, and even more may live' (CHFG 2011).

'Serious failures are uncommon. Where these occur, they are often due to weak systems rather than the fault of any one individual' (DH 2011). Patient Safety First (2009) recognises the need to achieve a positive safety culture within healthcare. This creates an open, just and informed culture, where reporting and learning from error is routine.

What knowledge did or might have informed me?

Before the surgical list commences it is imperative that the theatre is staffed appropriately. As previously noted, clinical supervision can support practitioners, enabling individual development for the delivery of clinical excellence (Wicker & O'Neil 2006). This in turn would highlight the individual's roles and responsibilities within the multidisciplinary team, effecting good communication, teamwork and leadership. In healthcare, Phillips (2007) understands that teamwork includes all personnel relating to the patient, recognising and achieving common goals. Philips (2007) acknowledges that all healthcare professionals were once novices and that, with the reality shock of the transition from student to professional, it can take up to a year to feel competent. However, Wicker and O'Neil (2006) protest that members of the perioperative team must merge their experience and qualifications in the care of the perioperative patient.

This merging of skills can be identified through the preoperative team brief, as outlined by the National Patient Safety Agency (NPSA 2010). This is sharing knowledge at the point at which concerns and risks can be isolated and dealt with. 'Trusts, team leaders and practitioners must ensure that the checklist is used as common practice' (Ly 2009, p3).

How do situations connect with previous experiences?

This cue invites reflection, to determine whether the experience being reflected upon is linked to past experiences. Johns (2009, p71), intimates a 'pattern of response' that elicits a certain response. This response is determined by past behaviour, especially if past actions were successful. However, such attitudes bring about complacency and resistance to change, leaving the practitioner stuck in a rut and resistant to change. Thompson and Thompson (2008) suggest that reflection-in-action and reflection-on-action should combine, meaning that past experience is detected (reflection-on-action), whilst reflecting during the incident (reflection-in-action). This ensures that practice is informed by theory, and theory is informed by practice. Informed practice should enable the practitioner to make effective decisions and clinical judgements.

What would be the consequences of alternative actions for the patient, others and self?

There is a surgical 'Golden Rule' (Phillips (2007, p17) which defines the concept of a surgical conscience, 'do unto the patient as you would have others do unto you'. It is self-regulation, which practitioners should possess according to individual personal commitments in setting high values, moral obligation and intellectual honesty. Should anaesthetist B have followed the difficult intubation protocol following the second failed intubation as outlined in Tewari and Gautam (2006)? It is my belief that each professional acted within their codes of conduct and in the best interest of the patient. The outcome was positive in that both mother and baby were fine. Everything that could and should have been done, was done. Anaesthetist A especially, acted in the essence of Nightingale's words in that 'the nurse should keep a high sense of duty in her own mind, must aim at perfection in her care, and must be consistent always in herself' (Philips (2007, p17).

How do I now feel about this experience?

As an RODP, I am aware that I may face the obstetric patient many times during my professional career. Finucane and Santora (2003), profess that the majority of obstetric deaths are anaesthesia related, and airway problems feature prominently. This is due to diminished oxygen reserves and other physiological changes related to pregnancy. Having had this experience as a student however, I am already better equipped should a similar situation arise. This experience was physically draining and a major shock to my confidence, largely due to experiencing the tension and fear emanating from the anaesthetic team.

Am I more able to support myself and others better as a consequence?

I have already expressed that I feel better equipped to act accordingly if a similar situation arose in future. Patient Safety First (2009) advocate the use of 'debriefs' to review the team performance. Questions are asked such as: 'How did we do?', 'What went well?', 'What went not so well?' and 'What should we do next time?'. A team brief did ensue. This creates the safety culture previously mentioned, where the team is open, just and informed, and the reporting of and learning from error is standard. As part of an 'open culture' I feel able to discuss patient safety issues with colleagues and seniors. I felt supported during and after the incident, and feel more able to support others as a result. The trust actively promotes the reporting of incidents, and is dedicated to learning safety lessons from them. There are no barriers. A critical incidence form was completed following this incident. Having been involved, I am more aware of the process and can actively support others.

Am I more able to realise desirable practice?

Having had no prior experience of this situation, this reflection-on-action will in future, facilitate me looking back to the reflection-in-action and, look forward in terms of reflection-for-action. This will help me to plan ahead in the future. I am more able to anticipate difficulties and achieve more in the limited time available.

The clinical competence level of an inexperienced individual is categorised as 'novice' (Philips 2007). My confidence and competence has grown, and will continue to grow with experience and continuous professional development. This is a requirement to maintain desirable and efficient practice as outlined by the HPC (2008, 2009). To achieve and maintain clinical effectiveness, professionals should, and it is my goal to be 'applying the best available knowledge, derived from research, clinical expertise and patient preferences, to achieving optimum processes and outcomes for patient care' (Hind & Wicker 2000, p78).

Johns (2009) Model for Structured Reflection (edition 15A)

* Bring the mind home

* Focus on a description of an experience that seems significant in some way

* What issues are significant to pay attention to?

* How do I interpret the way people are feeling and why they felt that way?

* How was I feeling and what made me feel that way?

* What was I trying to achieve and did I respond effectively? (aesthetic)

* What were the consequences of my actions on the patient, others and self?

* What factors influence the way I was/am feeling, thinking and responding to this situation? (personal)

* What knowledge did or might have informed me? (empirical)

* To what extent did I act for the best and in tune with my values? (ethical)

* How does this situation connect with previous experiences? (personal)

* How might I reframe the situation and respond more effectively given this situation again? (reflexivity)

* What would be the consequences of alternative actions for the patient, others and self?

* What factors might constrain me responding in new ways?

* How do I now feel about this experience?

* Am I more able to support myself and others better as a consequence?

* What insights have I gained?

* Am I more able to realise desirable practice? (framing perspectives)

References

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About the author

Karl Wishart

Dip HE ODP

ODP, Peterborough City Hospital

No competing interests declared

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by Karl Wishart

Correspondence address: Karl Wishart, Perioperative Practitioner (ODP), Day Treatment Unit, Peterborough City Hospital, Edith Cavell Campus, Bretton Gate, Peterborough, PE3 9GZ. Email: karl.wishart@pbh-tr.nhs.uk
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