Nursing Relection

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This essay will reflect on my personal and professional development during my first year on the nursing diploma programme. I will do this by discussing my experience with the five essential skills clusters which include care, compassion and communication, medicine management and nutrition and fluid management. I will relate the five skills by showing an understanding of a recognised model of reflection. Reflection, is a way of analysing past incidents to promote learning and improve safety, in the delivery of health care in practice.

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For the purposes of this essay I have chosen the Gibbs reflective cycle model (Gibbs, 1988, cited in O’Caroll & Park, 2007, p86), will be followed, as it gives an opportunity to produce a structured account of the discussion. Gibbs (1988) consists of six stages to complete one cycle which is able to improve my nursing practice continuously and learning from the experience for better practice in the future.

The cycle starts with a description of the situation, next is to analysis of the feelings, third is an evaluation of the experience, fourth stage is an analysis to make sense of the experience, fifth stage is a conclusion of what else could I have done and final stage is an action plan to prepare if the situation arose again.

In order to respect the patient’s and staff member’s confidentiality (Nursing Midwifery Council, (NMC), the code of standards of conduct, performance, and ethics for nurses and midwives, 2008), the precise location of this placement will not be named. Consent (NMC, 2008) has been obtained from patients mentioned within this essay, although in the interest of maintaining confidentiality (NMC, 2008) of the patients, therefore pseudonyms will be used.

Both of the placement areas I was allocated were general children’s wards which both included a day unit and inpatient beds for surgical and paediatric patients. A children’s ward provides health care for children aged from birth to seventeen. The role of any nurse including children’s nurses is to play a major role in promoting healthy behaviours (Moules and Ramsey, 1998). Nursing a child is not just a question of caring for a miniature adult. You have to understand how a healthy child develops towards adulthood and know how to minimise the impact of illness or hospital admission on the child. This involves working in partnership with the parents, or whoever looks after the child at home.

Another factor that complicates treatment of the younger child is that of communication. While adults can express what they feel and need or identify the severity and nature of pain a child may not be able to communicate in such detail and the nurse needs to interpret behaviour and reactions intelligently. Children’s nurses need to be able to spot when a child’s health takes a turn for the worse, which can happen rapidly. (NHS, 2011)

Health problems can have an effect on a child’s development and it’s vital to work with the child’s family or carers to ensure that he or she does not suffer additionally due to the stress of being ill or in hospital.

I was both excited and apprehensive about starting my placement on this ward. I was excited because this was going to be a new experience and the opportunity to gain an insight into different illnesses and conditions, but I felt apprehensive because I was unsure of what to expect in terms of how illnesses affect an individual and their parents and what challenges they may face and how I would respond. I was conscious of my lack of experience and knowledge of illnesses and viewed this as a potential weakness, which I thought it was imperative to be self - aware of my personal strengths and weaknesses before I commenced my placement. Self – awareness is also essential to be able to interact effectively with patients. Personal beliefs and opinions can influence either negatively or positively, in the way of viewing other individuals.

Understanding strengths, weaknesses, and the ability to reflect on personal characteristics, are necessary for remaining non – judgemental. The NMC (2008, code of conduct), states as nurses we must make the care of people our first concern by treating them as individuals and respecting their dignity. I know it is imperative to focus on treating the patient and not the behaviour. My mentor gave me an overview of the different types of patients we would see, which included their different health diagnosis, and also their individual rehabilitation and recovery plan, which helped me to have an insight into the needs of each patient and how illness can impact on an individual’s life. I felt more confident after my mentor had given me this information to be able to approach each individual patient and to be able to start to build a nurse patient relationship. Brown & Eby (2005, p63) suggests that a nurse - patient relationship has three phases: - these are the orientation phase, the working phase, and the termination phase.

Many people including myself believe first impressions usually form a lasting impression so I am very conscious on how I introduce myself to others. On introducing myself to the patients on the unit I wanted to establish a rapport, which is the foundation of the nurse patient relationship (Timmins, 2007, p438). I wanted to show a warm, caring and compassionate person to enable trust and respect to develop with each patient which is an essential requirement of caring. Caring and compassion is a natural warm, informal communication skill, which is an important part of social exchange (Baughan, Smith, 2008, p3). Roach (Roach, 1987, cited in Eby & Brown, 2009, p50) suggests there are 5 attributes of caring which are “the 5 C”s.

These are commitment, which is to provide the care necessary for each patient, Compassion that involves sharing in the emotional feelings of another and showing empathy which means trying to understand how another person feels. Competence of understanding and applying the nursing process by problem solving and the decision making process. Confidence (believe in oneself), and self – confidence to enable to gain trust of the clients, and confidence of the clients to trust the nurse. Finally, having a conscience and having an ethical conviction or belief about what is right or wrong, and acting in accordance of the nursing profession.

I wanted to spend quality time getting to know each patient on an individual basis to enable each patient to be able to develop a relationship based upon trust, honesty and mutual respect. I wanted each patient to be able to trust me and have the confidence in my ability to offer the appropriate care and support to meet their individual needs. The ability to empathise and relate to each patient’s emotions is fundamental in showing care and compassion. The ability to understand and perceive feelings and their meanings are at the core of empathy. (Reynolds & Scott, 2000, 31, (1), p226). Having an understanding of what it would be like to be in a patient’s position enables interaction and engagement to be more supportive and motivated which I wanted to convey to the patients on the unit and show positive regard. I was looking forward to spending time speaking to each patient and getting to know them over the duration of my placement within an inpatient setting, as this would help me to further develop the communication skills that I learned in my first placement , which would also enable me to develop my nursing skills further.

Communication is an essential component needed for the nurse patient relationship and is at the heart of good nursing care (Stein – Parbury, 2009, p274), and therefore effective communication skills are crucial. May (2004, p488) suggests communication is a complex two way process that involves passing a message between people using verbal or non-verbal communication skills. Showing genuine interest and concern is necessary to allow the patient to speak openly and feel comfortable within the conversation. The tone and mannerisms ‘paralinguistic’ used during the conversation and the patient’s perception of this will either enhance the relationship or inhibit the development. A comment made can be damaging to self – esteem and identity (Miller, 2002, 17, 9, p46). I felt comfortable communicating with the patient’s and I feel I have good communication skills which is one of my interpersonal strengths, although I did feel a little cautious at times, for example if I was asked a question of which I was unsure of the answer.

I observed my mentor and other health professionals engage in conversation with the patients in these situations first before engaging in a meaning conversation, to ensure I was using effective and appropriate communication skills and remained objective. The level of interaction and communication I received from each patient did vary initially which reflected on the age of the individual and their parents understanding, and also on their ability to trust me as a student nurse.

Listening is one of the most important skills needed for communication. This non – verbal communication will establish a lot of valuable information to the patient’s wishes and concerns. The information given will also give an insight into the care needed and allow time to offer an appropriate reply. It is equally important to offer gestures of intense listening such as good eye contact, facial expressions, and appropriate nodding to acknowledge a general interest. Listening to the patient’s will also give the opportunity to observe their body language and to observe any conflicting areas of speech and movement that may suggest they are uncomfortable with certain topics or are experiencing symptoms of cognitive impairment.

I wanted to show I was listening to each individual and I was genuinely interested in what they were saying to me and to develop the patient’s trust so they could be open and honest with me and be able to disclose their thoughts and feelings based upon mutual trust and respect. The care, compassion, and communication skills I demonstrated to the patients on the ward were paramount for a therapeutic relationship to develop. A therapeutic relationship will be of mutual benefit to meet the holistic needs of the patient and for nurse to gather the relevant information to offer the appropriate interventions (McQueen, 2000, 9, p724).

I was particularly looking forward to being able to develop my knowledge and skills in medication management during this placement. Medicine management relates to the safe use of medicines to ensure patient’s get the maximum benefit from the medicines they need, while at the same time minimising potential harm. (Medicines and Healthcare Products Regulatory Agency, (MHRA), 2004 p3). I did have some opportunity in my first placement to administer medication to patients, so I did have some knowledge into how to administer medication correctly and also in accordance with the NMC medication guidelines (NMC, 2010). I gained some confidence in my ability to be able to administer medication to patients safely from my first placement and was able to demonstrate safe practices from the onset of my second placement.

I knew it was imperative that I adhered to the eight rights of medication which are the right patient, right medicine, right time, right date, right dose, right route, right preparation and the right documentation, which needed to be applied to each patient before I administered any medication. I was extremely conscious of the accountability nurses face in relation to medication management and therefore I wanted to learn as much as possible during this placement to ensure I was competent and also familiarise myself with the legislation that underpins medication management such as the Medicines Act, (1968), misuse of drugs act (1971). All administration of medication needed to be accurately recorded in accordance to the NMC guidelines and Trust () policy.

Nutrition and hydration is an important aspect of maintaining good health and childhood diseases can often be complicated by poor nutrition. Patient B has type 1 diabetes and is treated by insulin injections twice daily. Diabetes develops when the body is unable to produce the hormone insulin, which is produced by the pancreas (Diabetes UK, p4, 2008). Patient B is also overweight with a body mass index (BMI) of 27 and is considered to be clinically obese. Patient B also suffers from regular urinary tract infections (UTI). When Patient B was admitted to the ward in October, he received an initial baseline nutritional assessment following the clinical guidelines of the National Institute For Health And Clinical Excellence (NICE, 2006), Essence Of Care (DH, 2003, P89), and also implemented by .

An intervention plan identified for Patient B’s nutritional needs to be closely monitored and nutritional tools such as a daily food and fluid intake charts and a weekly food menu chart were to be used to record an accurate account of his diet and fluid intake. Patient B’s weight also needed to be monitored and recorded on a weekly basis. The intervention plan also highlighted that a poor diet and fluid intake was a trigger factor into why Patient B’s health was deteriorating.

Supporting Patient B to maintain a healthy diet and accurately recording the nutritional information became part of my daily routine while on shift, which gave me an invaluable insight into the importance of monitoring a patients daily diet and fluid intake, and also the importance of accurate documentation and continuity of care. Good record keeping is essential to the provision of safe and effective care (NMC, 2009). Due to monitoring Patient B’s fluid and diet intake, it became apparent to that Patient B was becoming reluctant to maintain a regular diet independently and also his fluid intake was slowly decreasing which was having an impact on both his diabetes and his physical health.

My mentor approached me and asked if I would like to carry out an assessment and formulate a care plan for patient B, I was excited and did feel I had gained enough knowledge and understanding of this process during my two long
placements. To formulate a care plan, I first needed to identify the current risks that were present or were likely to occur. A risk relates to a negative event or an adverse affect, which is likely to cause harm (, 2009 p5). I needed to use an evidence-based approach by ensuring all the relevant data relating to Patient B’s current health care needs were accurate and apply an evidence-based approach to minimize the risk. Once I obtained all the relevant information from Patient B’s care documents and nutritional assessment tools I was then able to plan an appropriate plan of care and intervention plan based upon the identified risks. The main areas of risk I identified were Patient B’s parents also needed guidance in helping him maintain a healthy diet and fluid intake.

During my placement I also administered an intra muscular (IM) cytotoxic injection to a patient A. During the administration process it was imperative that I applied infection, prevention and control procedures. The risk of infection is always present to both staff and patients and therefore Infection Prevention and Control procedures are aimed at breaking the infection chain (, 2011, P5). I initially felt overwhelmed by the process as there appeared to be a lot of precautions needed but after I had observed my mentor several times and understood the process, I felt more at ease with the procedure.

The process I followed was hand hygiene ensuring I washed my hands before starting the procedure and applying my personal protective equipment (PPE) such as my gloves and apron, the safe use and disposal of sharps ensuring the Needle was not bent or broken before use or disposal and the needle was safely discarded into a cytotoxic sharps container. All PPE along with items used which contained bodily fluid from the patient was discarded into clinical waste before washing my hands after completing the procedure.

On reflection of my experience on my placements, I think I would do exactly the same. I feel proud of what I have achieved so far and continued to develop my skills and enhanced my knowledge from my first placement. I feel I have become more aware and confident within the 5 key clusters of care I have discussed within this essay and I have demonstrated my willingness to learn and demonstrated a professional attitude throughout both of my placement settings. I feel my experience gained has been very positive and I have learnt new skills and have gained confidence in my ability needed to be a nurse. Although looking back on my experiences, there are areas I would change for future placements. I would prepare better for each placement by ensuring I research further around the specific client group and setting.

I feel that this would have been very beneficial to me in my second placement as I felt I was not fully prepared when I administered my first injection, and how each individual patient may be affected in different ways. My first week on placement I was still a little unsure how to communicate with some patients and although my communication skills will develop further with experience, I feel if I was better prepared I would have been more confident and relaxed with the patients and the environment and able to communicate effectively from the onset. Overall I feel this has been a positive experience and I have gained a good insight into the importance of developing and maintaining my nursing skills in relation to care, compassion and communication, medicine management, infection prevention and control, nutrition and hydration, and organisation of care.