Essay on Nursing

Introduction

The objective of this essay is to reflect on my progress in relation to the four domains of care stipulated by the Nursing and Midwifery Council (2010), throughout my second year of practice. These are Standards of Competence that are mandatory to be attained by progression point 2. As a second year student nurse, one is expected to work with less direct supervision, progressing towards autonomy and confidence regarding the four domains: professional values, communication and interpersonal skills, nursing practice and decision making, and leadership, management and team working within clinical practice, something which has to be achieved through rigorous areas of practice.

I will select one area from these domains and will explore my progression in clinical practice, whilst connecting this with authoritative theory which links with practice. In order to achieve this, I will utilise Driscoll’s (2007) model of reflection, ‘what?’, ‘So what?’ and ‘Now what?’. The simplicity of this model (found in the appendix), made it useful for reflecting on my thoughts and feelings and contemplate what I had learnt, considering what I would do differently if the situation happened again. Furthermore, it enables me to identify any personal and professional areas which I am deficient in, empowering me to make suitable alterations to my future practice.

Regarding confidentiality, anyone who is mentioned throughout this assignment will be assigned a pseudonym to maintain anonymity as required by the University and NMC code of conduct (2008).

Professional values

Under this domain, I am expected to practice in a caring and sensitive manner within professional boundaries, whilst respecting people’s rights and choices (NMC, 2010). I found this experience (see Appendix 1) I encountered in a community placement to be quite challenging on a personal level, possibly because I knew the patient’s wife, which made me aware of how fast I acted. By not disclosing any information regarding Jack, I kept confidentiality as I am required to by the NMC Code of Conduct (2008) and shown respect for his choices. I feel I did not jeopardise the relationship between Jack and the nurse (my mentor), so that his needs and wishes were catered for. McCormack and McCance (2010) and Barret et al. (2009) observe that being irresponsive to patients’ needs and wishes can result in a failure of care, which could even result in litigation procedures being issued.

Retrospectively, if this situation happened at the beginning of my training, I would have looked for guidance from my mentor on the correct course of action, due to lacking in experience. By acknowledging the patient’s wishes and considering the context of the information that Jack was disclosing, I feel I acted in the most appropriate manner. As I progress in my University study, I will continue to interact with patients to ensure that their needs are being met sufficiently.

Communication and interpersonal skills

This domain stresses the importance of caring for patients in a compassionate, empathetic manner whilst simultaneously using effective communication to alleviate anxiety and distress that the patients may experience (NMC, 2010). My experience with a patient Nick (refer to Appendix 2), indicates how I used my communication skills to gain his cooperation and trust.

Holland (2008) argues that we communicate our feelings and thoughts though the manner in which we speak, write, touch and gesture in a range of different social, personal or formal situations. In this case, the use of interpersonal skills was appropriate, through non-verbal and verbal communication. When I first entered Nick’s room, his body language communicated the tension and anxiety that he was experiencing. He was twitching, agitated, and looking around. I felt comfortable in approaching him, as I knew he had no history of aggression.

To engage with Nick, I used Egan’s (1990) SOLER acronym. This enables one to focus and actively listen through body language. I positioned myself squarely to Jack and was able to display empathy towards Nick by showing understanding of his feelings and his position, through smiling which portrayed warmth and employing verbal cues to show that I was listening such as ‘ahh’ and ‘ I see’ (Baillie, 1996). I explained that he did not have to have a wash if he did not wish, although I needed to check his dressing and wound site for signs of infection. This allowed me to gain co-operation from him.

I feel that if the nurses took the time to explore why Nick was behaving inappropriately and being uncooperative, rather than being labelled ‘difficult’, his attitude towards staff would have been different. Nicotine withdrawal symptoms such as irritability and anxiety which he was presenting with had not been considered. Nicotine Replacement Therapy, in the form of patches (NHS, 2014), could have been discussed with Nick and could have aided his recovery. Due to a lack of communication, a therapeutic relationship between Nick and the nurses was not viable, so no respect and dignity was shown towards him.

On reflection, past experiences and theory have informed my practice. In year one, I did not have either the confidence or experience to approach a patient as I do now. As I progress in my training, I hope to enhance my communication and interpersonal skills, so that patients receive safe and competent care at all times (NMC, 2008).

Nursing Practice and Decision Making

As a student nurse I needed to have the ability to recognise when a patient’s physical condition and act appropriately to signs outside of normal range (often known as Early Warning Signs) (NMC, 2010). On an acute placement I identified that a patient’s (Mary) condition was declining (see Appendix 3).

The National Institute for Health and Clinical Excellence (NICE, 2007) expects that physiological observations should be performed on patients upon admission, so it works as baseline data of reference, and a profile of the patients’ general condition. In an acute setting the frequency of these depends on appropriate ‘track and trigger’ tools. These are also known as The Early Warning Score (EWS) assessment tool and it was used in this ward. It amalgamates vital signs such as blood pressure, pulse, respiration, oxygen saturation and temperature to give a quantifiable indicator of how the patient is doing (Dougherty and Lister, 2011). This was devised so that nurses can intervene and make changes to the care of a patient whose physiological condition has changed.

I recognised that Mary was quiet and she did not look well. When I undertook a set of observations, they constituted a final score of 5 in the EWS observation chart. I knew that these were not within normal ranges and when compared with earlier observations, indicated that she was deteriorating and needed swift intervention. As a second year student nurse, one of my roles is to measure and document vital signs, responding appropriately to abnormal signs (NMC, 2010). My progression during this year has entailed me becoming more familiar with abnormal physiology signs and their meaning. Mary was given oral paracetamol, oxygen and an adjustment to the frequency and level of monitoring also occurred. As I learn more, I hope to accentuate my knowledge on the different evidence-based risk assessments which are on offer in an acute setting, so that the care I provide is commensurate with the patient’s needs.

Leadership, Management and team working within clinical practice

Under this domain I am expected to be responsible for my own actions. Therefore, I must work within my own skills, knowledge and professional boundaries (NMC, 2010). When I am qualified I will be expected to work autonomously, adeptly and safely; this means that this is an area which I need to become competent in. Appendix 3 demonstrates how I accepted a delegated task to care for a patient and monitor her condition with less supervision and more autonomy from my mentor. I was fully aware that as a student nurse I must only accept tasks that fall within the limitations of my role and knowledge (NMC, 2010).

This experience has enabled me to undertake, accurately record and apply my knowledge and understanding on the interpretation of Mary’s physiological observations (Clarke, 2011). I acted appropriately in relation to my competence level, in that I was reporting the signs to a more experienced staff member who would then be able to institute what procedures needed to take place from there. At this stage of my development, I reported to a more senior colleague what Mary’s readings were after she had been observed to be clammy and showing signs of deteriorating in her condition and she subsequently re-assessed Mary and decided that she needed a different course of treatment (See Appendix 3). Presently, I am in the stage of being mentored by someone more experienced than myself as I am only a trainee halfway through their degree, but with time and experience, I will progress to being able to work autonomously.

Conclusion

Within this assignment, I have explored the four domains of competency which nurses are required to achieve and satisfy prior to becoming registered. It is clear that I have made significant progress in meeting each of the four domains, however I also need to further enhance my competency, as illustrated by my lack of experience (i.e. in the ‘Leadership, Management and team working within Clinical Practice’ where I am still a trainee which makes it hard for me to satisfy the leadership component of this standard). The different and contrasting experiences which I have had of both learning in an academic setting at University and a clinical venue on placement have enriched my understanding of the role played by a nurse. I am excited to further enhance my competency throughout the final year of my course, so that I can become a nurse who has developed holistically throughout their practice and provide an exemplary standard of care to clients and patients, which is assisted by my dedication towards my profession and also the variety of placements I have encountered.

References

Bach, S. and Grant, A. (2011) Communication and Interpersonal Skills in Nursing. 2nd edn. Exeter: Learning Matters.

Baillie, L. (1996) A Phenomenal Study of the Nature of Empathy. ‘Journal of Advanced Nursing’ 24, 1300-8.

Barret, D. Wilson, B. and Woollands, A. (2009) Care Planning: a Guide for nurses. Harlow: Pearson Education.

Clarke, D. and Ketchell, A. (2011) Nursing the Acutely Ill. Basingstoke: Palgrave Macmillan.

Dougherty, L. and Lister, S. (2011) The Royal Marsden Hospital Of Clinical Nursing Procedures. 8th edn. The Royal Marsden Hospital: Blackwell.

Driscoll, J. (2007) Practising Clinical Supervision: A reflective Approach for health Care Professionals. 2nd edn. Edinburgh: Elsevier.

Egan, G. (1990)The Skilled Helper: A Systematic Approach to Effective Helping. 4th edn. California: Brooks/ Cole.

Holland, K., Jenkins, J., Solomon, J. and Whittam, S. (2008) Applying the Roper, Logan, Tierney Model in Practice. 2nd edn. Churchill Livingstone: Elsevier.

McCormack, B. and McCance, T. (2010) The Theory and Practice of Person- centredness in Nursing. Oxford: Wiley-Blackwell.

National Health Services (2007) NHS Choices: Stop smoking, coping with cravings. [Online]. Available at: http://www.nhs.uk/Livewell/smoking/Pages/Copingwithcravings.aspx (Accessed: 9 February 2015).

National Institute for Health and Care Excellence (2014) Acutely ill patients in hospital: Recognition of and response to acute illness in adults in hospital.[Online]. Available at: http://www.nice.org.uk/guidance/cg50/chapter/1-guidance (Accessed: 9 February 2015).

Nursing and Midwifery Council (2008) The Code : standards of conduct, performance and ethics for nurses and midwifes. [Online]. Available at: http://www.nmc-uk.org/Documents/Standards/nmcTheCodeStandardsofConductPerformanceAndEthicsForNurses

AndMidwives_LargePrintVersion.PDF (Accessed: 8 February 2015).

Nursing and Midwifery Council (2010) Pre-registration nursing education: section 2 Standards of competence. [Online] Available at: http://standards.nmc-uk.org/PreRegNursing/statutory/competencies/Pages/Competency-Framework.aspx (Accessed: 8 February 2015).

Appendix 1

In one of my community placements, myself and my mentor went on a home visit to a gentleman that needed personal support and assessing. Throughout the meeting Jack was disclosing very personal information regarding some thoughts and feelings he had been having recently and did not want this to be disclosed to anyone, even his GP. Suddenly, someone opened the front door, it was Jack’s wife.

Jack’s wife used to be my client when I used to work in a salon prior to commencing my university course of studies. Straight away, I felt extremely uncomfortable, I looked at Jack and his facial expressions suggested he was tense also. I worried about Jack. It was important I removed myself from this situation in an attentive, considerate manner. I wanted to ensure that Jack knew that I had not disclosed any information to his wife. I asked Jack and my mentor if they would mind if I exited the room so that I could chat with Jack’s wife, as I had lost touch with her, although this was only an excuse to leave the room, a subtle clue that I hoped my mentor might understand and explain to Jack after I exited the room that information would always be kept confidential. Later I found that she ensured that he fully understood this. I excused myself and went to chat with his wife in the kitchen. Whilst in the kitchen she attempted to ask personal questions about Jack, which I explained that I was not allowed to answer in the interests of confidentiality. I felt I acted professionally, by ensuring that she understood that because we knew each other it would be extremely unprofessional and illegal to disclose information without his consent. I showed sensitivity by explaining that I understood how she felt, explained that I am a student nurse and also asked the other nurse to talk to her. She smiled at me and apologised, and said that she did not want to make me feel uncomfortable, that she just worried about her husband, which is perfectly understandable.

In essence, I felt that I acted responsibly by considering the situation in an informed manner. My mentor praised the awareness I had demonstrated in this scenario. In the future, I may be best advised to read the patient’s notes prior to conducting a home visit and heed the name of the next of kin, so that I am not put in a position where the patient’s person centred care is compromised.

Appendix 2

In the orthopaedics placement, when beginning my shift, me and my mentor (Steph) were told that we were looking after a 71 year old gentleman called Nick, following a total knee replacement.

We were told in the handover that Nick needed his surgical dressing examined and possibly changing; in addition he needed a wash, as there was an odour in the room. It was clear during this handover that Nick has been difficult for the past 2 days. He had not been aggressive although he had been shouting, and had refused to let the nurse change his dressing which was wet, or have a wash and change his clothes. When handover was finished, Steph thought it was best to begin the rounds with Nick, helping with his personal care, then changing the dressing.

Therefore, I gathered everything which I required and placed it on a clinical trolley before entering Nick’s room. I introduced myself, asked how he was feeling this morning, he looked at me, and did not answer. I explained that we needed to check his dressing, and asked consent to change it as it was soaked. Then I asked if he would mind if we started with a wash, then the dressing? He replied loudly ‘’No, I don’t want a bath, when can I have a smoke?’. He seemed anxious; he kept looking around, moving his hands, twitching. Steph explained that he could not leave the ward just yet; therefore he was going to have show just a modicum of patience. Nick put his head down; this was not the answer he was expecting. He was sat on his bed, so I moved closer to him, and went down on my knees so I was on same eye level to him. I engaged in conversation with him, keeping a softer tone of voice, and explained that we really needed to see his knee. I asked if he was in pain, he said no. I noticed from his body language, that he was relaxing, he smiled at me. He replied ‘a very strong one’. Still maintaining a relaxed posture, I asked for his consent to assist him in washing and changing his dressing. He complied, managed to relax and I assisted him in washing, changing his clothes and his dressing with my mentor’s supervision.

Straight away in the hand over, I felt uncomfortable by the way that Nick was being portrayed as ‘difficult’ by the nurses. This made me question why he had been like this, as the nurses did not have a clear explanation for labelling him in such a manner. When I met Nick it become quite apparent to me why he was being ‘difficult’. He was in a single room; he was not mobile yet, as he had refused to listen to the physiotherapist. He also smoked and his last cigarette was 2 days ago which was bound to make him febrile. He lost his autonomy, he felt ignored and I understood his frustration, being an ex-smoker myself. I do understand the effects and symptoms of cigarette withdrawal can have in an individual. I thought was sad and unprofessional that the staff seemingly had not made an effort to look at why he was being like this. There seemed to be a lack of communication, relationship between the nurses and Jack, because of how he was portraying himself.

I feel the manner in which I communicated with John had a positive effect and his needs were met sufficiently. This experience again made me acknowledge the importance of effective communication in building a therapeutic relationship between a patient and a nurse. If I were to encounter a similar situation in the future, I aim to pose the question earlier of why nurses are acting towards the patient in such a manner, as it is clearly unacceptable and constitutes bad practise. Nurses should respect patients, and keep their dignity.

Appendix 3

On one of my placements, in an acute unit, my mentor decided that it would be a good idea for me to look after a bay that only had 2 patients, whilst she was working on the next bay. We learnt from the handover that one of these patients would probably be discharged later on the day, after the doctor had been to see her; she came through A&E with abdominal pain, with constipation, which she had a history of. The other patient Mary was also admitted during the early hours of that day, with complaints of abdominal pain to her right side. She was suspected of having an inflammation in her pancreas (pancreatitis), although she had not been given a formal diagnosis. Bloods were taken, with an ultrasound scan also imminent.

My mentor was reassuring, and encouraging explaining that I had demonstrated to her on numerous occasions that I had the capacity to monitor these patients, and that she trusted me. We introduced ourselves to both patients and informed them that I was a student nurse, and consent was obtained. I accepted this role, as I knew I had learnt the skills in monitoring patients and could identify changes that I must report straightaway, which needed to be act upon. I was also aware that the nurse would be in close proximity and intervene if anything arose that was not within my knowledge and competence.

Later in the morning I noticed that Mary appeared flushed and was very quiet. I asked how she was feeling, she replied ‘ok, just tired’ and still had a bit of pain; I asked her on a scale of 1-10, she said about 3-4. I did perform all her vital signs, and recorded on her personal observation chart. Mary was scoring 5, even though her blood pressure(BP) was within normal ranges (112/68), her respiration rate (RR) was 18p/minute and her pulse (PR) was 100, and her Temperature was 38.2, hence the scoring. In addition her Oxygen levels were only marginally below average at 94%. I asked her if she was hot, which she replied ‘a bit’; I asked her to take a few deep breaths, and her O2sats remained between 93 %-94%. I informed her I needed to call the nurse, to report this, and due to her Oxygen saturation, she may need to intake some oxygen, to bring her back to within a normal range. She asked what this meant, I explain to her that the importance of the Oxygen in the blood in simple terms; that oxygen levels should exceed 95%, so that it can be distributed to organs around the body effectively. She understood, and thanked me for my transparency in this case.

I informed my mentor, who came to see Mary. She reassessed Mary, and Mary was given paracetamol and put on 4L Oxygen, until her Oxygen Saturations (O2sats.) were at a normal level. When comparing to previous data, she only scored a 2, from her Respiratory rate, which could be attributed to the pain she was experiencing, and her Sats were 98%. Her condition had changed therefore the decision was made to monitor the patient closely, with observations taken at 30 minutes intervals. Her vital signs were assessed using the MEWS assessment chart and a record made, for revaluation so that further deterioration in the patient could be identified.

When the doctor visited Mary, and questioned how Mary had been, my mentor explained that I had been looking after Mary. I responded to the questions to the best of my ability and knowledge concerning the patient; and my mentor contributed to the discussion by explaining in more depth about Mary’s condition. An accurate record was made in Mary’s notes, so that any other professionals involved in Mary’s care would have a good knowledge of her recent interventions.

Compared to my first year, if I saw a patient looking flushed/ clammy, quiet; I would have reported this to the nurse, in order to receive guidance on what to do next. I feel I reacted well, and felt I was able to recognise that Mary’s condition had changed. I also employed the correct tools to measure and document her vital signs. I reported her change in condition promptly to the nurse so that further decline was prevented.