64 Clinical Notes [.(I i

In summary, the data obtained through the measure-ment of the daily practice of nurses has wide-rangingbenefits. It provides:• evidence of patient/relatives' involvement in nursing care,• clear objectives for staff development/training needs,• targets for individual performance review (IPR),• data to reflect the individual patients care, as well as an

overall picture,• continuous evidence of the quality of patient care,• statistical evidence on the provision of care which may

be used to fulfil purcha.ser provider contracts.In conclusion, it seems imperative that, as nurses, we

provide continuing and concise evidence of the quality ofpatient care, as reflected in something so fundamental asnursing care plans.

Questioning the assumption that urin-ary catheterization is a pain-free eventfor women "' ''*''• ^-'̂ iwaJ•^/: ini.H n-ji.A

JENNIFER MACKENZIE BSc (Hon.s), Dip N, (Lond), RGN, RN'l'Part-time Clinical Lecturer Department of Nursing, University ofManchester; also Part-Time Lecturer, School of Human & HealthSciences, University of Huddersfield 111 n i j ; .

Often, a break from clinical practice provides an oppor-tunity to reflect on aspects of nursing care and exploresome of the assumptions which underlie certain nursingprocedures. Of the many questions I have consideredregarding the assumptions I made in my own practice, oneis particularly challenging. That is, why do we as nursescontinue to delude ourselves that urethral catheterizationis a pain-free event for women.'

It appears to be accepted convention that if a man is tobe catheterized he is given the benefit of having a localanaesthetic gel inserted into his urethral meatus 2-minutesprior to the insertion of the lubricated urinary catheter(Brunner & Suddarth, 1982; Pritchard & Mallett, 1992).However, through my own experience the benefit ofanaesthesia does not appear to be extended to women.Indeed the literature supports this observation; for ex-ample in Brunner & Suddarth's description of femalecatheterization they write only of introducing the '. . . welllubricated catheter 5-7 cm . . . into urethral meatus . . . ' . Incontrast Pritchard and Mallett suggest nurses 'lubricatethe catheter with sterile anaesthetic lubricating jelly'. Thisat least tries to redress the balance, although even though itis well known that local anaesthetic gel applied to a mucousmembrane can take at least 2 minutes to achieve reductionin sensation, rendering their suggestion ineffective.

It could be argued that as the male urethra is approxim-

ately 20 cm in length, in comparison to the female urethrawhich is an estimated 3 cm (Tortora & Anagnostakos,1990), then men are more likely to experience pain anddiscomfort during catheterization and for a longerduration. In response to this might I use the oft-quotedadage that 'size is not important'. Women I have catheter-ized in the past and women I have questioned all reportedsome pain or discomfort. Common phrases used to de-scribe the experience have consisted of a 'sharp stabbingpain', 'a burning sensation' and 'a painful irritation'. It isclear that in reality women are experiencing unpleasantsensations during catheterization.

Despite the differences in dimension, the urethra inboth sexes serves as a channel for expelling body fluid, it issurrounded by circular fibres which form the internal andexternal sphincter, and shares a similar nerve supply. Theinsertion of a catheter causes the urethra to dilate beyondits usual capacity and is, therefore, a traumatic event. Asnurses we are taught to advise all patients to take deepbreaths during the procedure as a means of aiding relax-ation and reducing the risk of sphincter resistance. Thistechnique combined with the use of a lubricating gelminimizes the risk of tissue trauma and subsequent infec-tion. In this way we demonstrate an awareness that traumaexperienced during the procedure is related to an increasedrisk of infection in patients of both sexes. However, whilewe acknowledge that the use of local anaesthetic gel canfurther reduce sphincter resistance, trauma and discomfortin men, we continue to put women at risk.

Some critics may suggest that anaesthetic gel is moredifficult to insert, as a woman's urethral meatus is differentto a man's in appearance and is sometimes relativelyinaccessible, especially in older multiparous women. Reas-oning such as this needs to be questioned, particularlybecau.se if patients need to be catheterized, they will hecatheterized despite their gender, or the difficultiesencountered during the procedure. More significantly,although male and female urinary catheters are manufac-tured to differ in length, the catheter tips remain the same.Therefore it must be deduced that if the catheter tipswhich penetrate the urethras of both sexes are the same,then the nozzle used to insert anaesthetic gel into the maleurethra must also be appropriate for women, only thevolume of gel required will differ.

In conclusion I would like to suggest that we shouldcritically examine the assumptions about female catheter-ization as a pain-free procedure. In this case we appearto be allowing patient comfort to be guided by theassumptions we have made about the anatomical dif-ferences between men and women rather than patientexperience.

Clinical Notes 65

References

Brunner L.S. & Suddarth D.S. (1982) The Lippincott .Mamial ofMedtcal-Sttrgical Ntirsing. Lippincott Nursing Series, Volume 3.Harper & Row Publishers, London.

Pritchard P. & Mallett J. (eds) (1992) The Royal Marsden HospitalManual of Clinical Nursing Procedures, 3rd edition. BlackwellScientific Publications, Oxford.

Tortora G.J. & Anagnostakos N.P. (1990) Principles of Anatomy andPhysiolog)!, 6th edition. Harper Collins, London.

Cardiac arrest: a differing perspectiveon an ethical dilemmaJAN DEWING BA, RGN, Dip Nurs, Dip Nurs EdLecttircr Practitioner

KATE BUTCHER BSc, RGNAssociate NurseBurjord Community Hospital and Nursing Development Unit, SheepStreet, Burford, O.xon, UK

A female patient was admitted from an Oxford bospitalfollowing treatment for an acute illness. She had been inthe hospital for less tban 2 hours when sbe reported feelingunwell and having what appeared to be epigastric pain.The nurse contacted the patient's general practitiotier atidasked him to come and assess her. Suddenly, and in tbepresence of a primary nurse, the patient became unrespon-sive. The nurse, seeing this as a cardiac arrest, actedimmediately, with tbe assistance of an associate nurse, tocommence cardiopulmonary resuscitation (CPR). Afterabout 10 minutes the nurses discontinued the unsuccessfulresuscitation attempt. There had been no information withthe patient about her resuscitation status either from thehospital or from the GP. For the associate nurse tbis hadbeen ber first experience of handling a resuscitation.

The following afternooti the patient's GP visited thehospital to talk to the nutsing staff. It seetned an idealopportunity for tbe GP to discuss tbe events of tbeprevious day and to ofTer his support to the nurses for thedilemma tbey had faced. However, the conversation wasone-sided. The GP informed the nurses that be thoughtthe resuscitation was wrong and that tbe patient would notbave wanted it to happen. No attempt was tnade to discusswitb the nurses the events and the reasons for the decisionstbey made. Tbis lack of awareness even to acknowledge tbedifficult situation the nurses found themselves in left onenurse in particular very upset atid tearful.

That afternoon the nurses made time to have a groupdiscussion to reflect on the events of the previous day and

the GP's views. The purpose of the group was to sbowsupport for the tiurses involved atid for all the nurses toreflect on tbe situation and see if anything could be learnedfor the future. Tbe primary nurse felt tbat as the patientbad arrived in the hospital, was unknown to the nursingstaff, had not been assessed by her GP, had no availableinformation with her regarding her resuscitation status andhad suddenly become unresponsive in her presence, thatthe situation was a cardiac arrest. She felt angry that shewas placed in the situation of deciding wbat to do, whenfrom her training it was not ber responsibility to decide notto resuscitate. For these reasons she decided to initiate aresuscitation attempt. Tbe primary nurse believed tbatgiven the particular context sbe bad acted rightly.

The nurses felt that the attitude of the GP showed a lackof sensitivity to his colleagues and in particular a lack ofawareness of tbe personal trauma to tbe associate nurse.The primary nurse also felt that if the GP had informationabout the patient it should bave been sbared with tbenursing staff prior to her admission. The nurses com-mented on the fact that it was inappropriate for the GP tocome iti and isSue his judgement of tbe situation when hebad not been involved and be was not aware of the nurse'sdecision-making rationale. Through the omission of medi-cal infortnation the pritnary nurse had been placed in tbesituation of having to make a decision but tbe GP thencriticized her for making a wrong one. ' "

There are two main issues that arise from this nursingdilemma. Firstly, tbis situation demonstrated how messypractice can be. Tbe theory from books cannot alwaysadequately prepare nurses for their real-life experiences.Tbis situation had several important contextual factorsthat needed to be taken into account. Tbere was nodocumented or known resuscitation status for the patient.The events took place in an isolated community hospitaland there was no medical support available on site. Tbeevents happened very quickly following the admission ofthe patient who bad appeared well and the event happenedit! the presetice of a nurse. Tbe second issue that arises isthat tbe approach adopted by tbe GP for dealitig with thisethical dilemma does not take account of the philosophy ofnursing practice or tbe contextual factors. It is meaninglessto attetnpt to apply theory to practice when tbe practiceexperience has been significantly different to the standardtextbook accounts. It is also meaningless to try and applytbecrry and ignore the real-life dilemma and its contextualfactors. This devalues tbe experiences of those involvedand may prevent them from learning positively from thesituation.