I undertook a full assessment on a patient with a sacral pressure sore. The patient had limited mobility, dementia and does not speak. I completed the assessment using observation as a primary source. The care assistants were reluctant to engage with the nursing process rendering some specific measurements as ineffectual compromising the eventual Waterlow score.
I conducted the assessment with my mentor and gave a logical explanation how I administered the wound and gave rationale for the dressings I chose. I spoke to the care assistant to reiterate my action plan as it was pivotal to a successful wound healing.
Initially I felt confident. I had observed pressure sores before and I had prior knowledge of dressings and pressure relief. When I discussed about the patient with the care assistant, I ensured we were outside the bedroom as it unprofessional to talk over a client. The health records were of poor quality and had not been updated. When I mentioned this, the carer’s attitude became abrupt and I began to get defensive and made an inconsequential remark, “It does not matter”, just to reengage the carer. This remark I regretted as it undermined my authority and I appeared amateurish. Care records are a legal working document in progress. Poor record keeping will be detrimental to a client’s recovery and must always be challenged. I felt overwhelmed and looked to my mentor to support me.
My role in the nursing process enabled me to evaluate the patient’s wound and give an accurate descriptive account to my mentor. I provided evidence that consolidated my evaluating skills and put my basic wound knowledge into practice, within a safe nurturing environment. I rushed the assessment and regretfully completed it away from the nursing home. I found this frustrating as I could not explore the holistic process in greater depth and it simply became a checklist without breadth to the other client’s needs; dementia and poor communication, which I acknowledged fleetingly.
Payne (2000) identifies that professional partnerships are at risk if a nurse has insufficient knowledge required to perform ethically, thus undermining their own authority. The care assistant knew I was a student nurse and treated me, not as a partner in care but as a learner.
I failed to develop the partnership more and relied on my mentor too much when I conversed with the carer. I was looking for affirmation which was lacking within me. If I had communicated how significant the carer’s role was, this would have earned me more respect and empowered the carer.
Crawford et al (2005) believe empowerment inspires the self determination of others, whilst Fowler et al (2007) identifies listening skills and the encouragement in the participation of care motivates nurses to actively support changes in patient care. Entwistle and Watt (2007) remind practitioners that participation requires communication skills that are not universally possessed so nurses must be flexible in their approach to champion the participation of others. Using these concepts I could have built a rapport with carers, praising them for the care they provide, promoting partnership in care whilst emphasising the importance of the care plan.
I found it difficult to disengage from the patients many problems and only to focus on the wound. When choosing a suitable nursing framework, Roper et al (2000) describe care planning as a proposal of nursing intervention that notifies other nurses what to do and when. This model is used throughout the community and is thought to be a simplistic, easy to use everyday tool that enables nurses to identify actual and potential problems. Page (1995) had reservations about Roper, Logan and Tierney’s model, comparing it to a checklist which, if not used as the authors intended, can be restrictive in clinical practice as fundamental problems can be missed.
I used some of Page’s model as a checklist and not as a holistic assessment due to time constraints, the patient’s profound dementia, poor record keeping and being a novice assessor; however I was directed by my mentor to focus on the wound alone. It could be argued that community nurses working within care homes only prioritise physical needs from adapted assessments, as the care home provides the patient’s psychosocial needs. I identified from the patient’s assessment she was at the end stage of the dependence continuum, but I still recognised the importance of holism when completing the package of care and I identified that the promotion of comfort was as important as healing.
The main strength of my care plan was in identifying specific measurable outcomes exclusive to the client that were adaptable. I used evidence from reputable sources to identify suitable dressings to promote granulation and healing by sourcing up to date journals from the Cinahl and current trust policies. My weakness was relying on my mentor too much to confirm the evidence I collated on pressure care to the carer’s. Prioritising delegation and assertiveness as part of my learning needs I will now create an action plan that will ensure my future mentors will recognise the effort I extol to succeed in practice.
I conclude my implementation of the care plan was successful. The wound healed and the patient was discharged from the community case load. I demonstrated I can assess patients holistically, but require further practice when addressing client and carer concerns. To use nursing frameworks effectively nurses have to create an inclusive partnership with the client, family, professionals and care providers and demonstrate a broad knowledge of basic nursing care. Successful care plans are universal tools that empowerment others, giving them the direction to advocate safe holistic care based on evidence.
To encourage the participation of others I will become conversant in wound care. I will learn to identify the stages of healing by researching the biology of wound care. I will disseminate this to peers, as the sharing of knowledge is a fundamental part of holistic nursing care. As I develop from a supervised participant to a participant in care delivery I will continue to read research and reflect my practice on a daily basis. Creating new action plans that identify my learning requirements will address my limitations and by acknowledging them I will generate achievable goals to become a competent practitioner.
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1. Client pen portrait.
2. Plan of care
3. Wound evaluation
4. Activities of Daily Living
5. Waterlow Pressure Score
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A REFLECTIVE ESSAY This is a reflective essay based on a event which took place in a hospital setting. The aim of this essay is to explore how members of the Multidisciplinary Team (MDT) worked together and communicate with each other to achieve the best patients outcome. Reflection is an everyday process and is very personal matter. Jasper (2003) suggests that reflection is one of the key ways in which we can learn from our experiences. Reflective practice can be defined as process of making sense of events, situations and actions that occur in the workplace (Oelofsen, 2012). There are a different models of reflection.
One of them is Johns (1994) model of reflection, this model is based on five cue questions: description, reflection, influencing factors, alternative strategies and learning. That enable practitioner to break down his/her experience. Gibbs (1988) is another common model of reflection which consists of six stages: description, feelings, evaluation, analysis, conclusion and action plan. The structure allows the reflection to be written in a clear way. In accordance with the NMC (2008) code of professional conduct, confidentiality should be maintain and all names will be anonymous.
Ii this essay I will use Gibbs (1988) model as a guide for my reflection. The first stage of Gibbs (1988) model of reflection requires a description of event. On the beginning of one of my shifts, my mentor informed me that I can participate in Multidisciplinary Team meeting. A Multidisciplinary Team meeting is a meeting of the group of professions from one or more clinical disciplines who together make decision regarding recommended treatment of individual patients (NHS 2012). I work on the ward on which these meetings are held every day.
On that day the meeting was attended by medical doctors, deputy sister, physiotherapist, occupational therapist, discharge coordinator, social worker and community nurse. Order of the meeting was as follows: at the outset a brief description of the patient was given by deputy sister. Then one of the doctors presented the patient current medical situation. At the end the other members of the team have time to take voice. They discussed medical and social situation of each individual patient. The team focused on planning and reviewing patients’ goals, they also made a joint decision about discharge plans and destinations.
I was given the opportunity to observe multidisciplinary team members working together and participated in the discussion about patients whom I took care of. The second stage of Gibbs (1988) model of reflection is a discussion about my thoughts and feelings. My feelings at the time were mixed. I felt welcome and accepted within the MDT meeting. Many of the professionals who took part in the meeting, I knew from my daily work, and this made me feel comfortable. The MDT listened to my opinion and asked further questions. I always thought of myself as a confident person.
However, when I stood and spoke in front of more qualified people then myself, my confidence vanished. I had no experience in speaking in front of large group and I was very nervous. For this reason my speech was not always consistent. In such a case, my mentor supported me and helped me by asking additional question that lead me to the right way. I found it very interesting to see how MDT cooperate and communicate well with each other . I am going to enter the third stage of Gibbs (1988) model of reflection which is evaluation.
There are many positive aspects of the MDT meeting. One of them is that the health professionals of different specialities are working as a team to achieve the same goals. The team members have different skills and knowledge. Their roles and responsibilities vary and are based on their professional experience. Thurgood et al. (2011) suggests that this skill mix is one of the most important benefits of working in MDT. Works in a team allows to collect informations from all its members which ensures that no important information about the patient will be ignored or missed.
Another big advantage of these meetings is that they are carried out every day. According to Whyte et al. ((2007) the most frequently team members meet face to face and have the chance to discuss issues and work together, the better communication will be. However, if effective communication among the team is not achieved, errors may occur. It is the major disadvantages of the MDT. The National Patient Safety Agency (2007) communication difficulties identified as a main factor influencing patient outcomes.
Stage four of Gibbs(1988) model is an analysis of the event. Communication is defined as a process that involves a meaningful exchange between at least two people to convey facts, needs, opinions, thoughts, feelings or other information through both verbal and non-verbal means, including face to face exchanges and the written word (DH 2010). For the MDT is important to effectively communicate with each other and overcome all communication barriers that may arise because poor communication among health professionals can negatively impact patient care.
Atmosphere during the meeting was friendly and thank to this that all team members knew each other from daily meetings effective communication was easily achieved. However, there was a few problems. A noticeable issue was that medical abbreviation used by the doctor were not understood by others members of the team. This led to interruption of his speech to find out about their mining. This is mainly related to the fact that different health care workers have different training and education. Another factor who had significant influence on the MDT meeting and extended it was partially not updated handover from previous shift.
The team had to correct the informations contained in it. In this case the handover missed its intended purpose because it was originally designed to transfer information concerning an individual patient with outstanding task from the outgoing to the incoming teams (Farhan et al. 2012). I think that I did well by participating in this meeting. As a student but also as a front line worker I could learn a lot from other professionals and I was able to inform the members of the team about the patients, whom I looked after, progress.
This is important because as a front line worker I interact more with patients during their hospital stay then any other health professional in the MDT ( Hamilton, Martin, 2007). If I had not given my opinion on the patients care, they could not benefit from the MDT as much as they did. Conclusion is the fifth stage of Gibbs (1988) cycle. The MDT give me the opportunity to work closely with other health professionals and better understanding their roles. I could clearly see that effective communication encourages collaboration, help prevent errors and can influence the success or failure of the patient care and treatment.
This experience helped me to learn the importance of sharing of skills and professional experience with others for the benefit of patient outcomes. This will help me to work effectively with others team members in the future. This situation showed me straights and weaknesses in my communication skills. As communication is a key building the relationship with others I need to continuously develop this knowledge. I also realized that speaking in front of large group of people is hard for me and this is the area which I have to improve. The final stage of Gibbs(1988) model of reflection is action plan.
If I find myself in this type of situation again I would be more confident in discussing about the patients and their needs. Communication is a skill that can be learned and continually improver (Webb, 2011). For this purpose I created an action plan that will help me to improved my this skills and gain self-confidence. The first objective in my action plan is to meet my mentor in order to discuses the whole situation and obtain feedback. The next point is to research further the appropriate literature to gain new informations and develop my knowledge.
I also want to attend a conflict resolution study day to learn how to resolve conflicts. Communication with others can be challenging (Webb, 2011) and conflicts may arise at any time, not only between team members but also between health professionals and patients or their families. Summarizing, reflection on this experience allowed me to identify gaps in my knowledge and establish my own learning needs. Gibbs (1988) model of reflection given me the chance to explore my thoughts and feelings, analyse the situation and draw conclusion for the future. This essay also enabled me to connect theory and practice.
Reflective Nursing Essay
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Case Study One
In this case study I will use Gibbs (1988) model of reflection to write a personal account of an abdominal examination carried out in general practice under the supervision of my mentor, utilising the skills taught during the module thus far.
During morning routine sick parade I was presented with a 21 year old male soldier experiencing severe acute, non specific, abdominal pain. Under the supervision of the medical officer (MO) I proceeded to carry out a full assessment and abdominal examination, using Byrne and Long’s (1976) model to structure the consultation. I requested the patients’ consent before conducting the examination, as is essential before commencement of any medical procedure, be it a physical examination or a critical surgical procedure (Seidal et al, 2006).
The patient was quite agitated on arrival and appeared to be in a great deal of pain, and so before continuing with the physical examination I reassured him and made him comfortable in the treatment room. On examination his abdomen was soft, palpable with no tenderness, on auscultation bowel sounds where normal, vital signs normal, with cramping centralised pain.
I was feeling confident in my ability to deal with the patient and perform the examination effectively as I had practiced this several times previously using the university resources and mock OSCE with my facilitator. As I am often solely responsible for the care and management of patients during out of hours (OOH) I felt comfortable assessing and triaging the patient. However, under normal circumstances I would assess the patient and refer them to the MO if I was concerned about their condition, in order for a decision to be made. I was also being closely monitored throughout which did increase the pressure to deliver the correct diagnosis and make appropriate decisions. However, by utilising the consultation model I feel I managed to keep a focused approach and ensure the correct questions where asked.
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I feel I gained a good history from the patient by using the SOLER principles (Egan, 1990) taught in the history taking presentation. Thus allowing me to form a differential diagnosis and rule out certain causes, such as; constipation, and indigestion. Subsequently, the physical examination enabled me to confirm a diagnosis of acute abdomen. As the patient was not experiencing any worrying (red flag) symptoms associated with abdominal emergencies, such as; appendicitis or pancreatitis. However, I did forget certain aspects of the physical examination and had to be prompted by the MO. Although with more practice such incidence would be reduced.
I was happy that I managed to rule out any distinct causes of the abdominal pain by performing the examination to collect data, analyse it, and use the results to make an appropriate decision (Schon, 1984). However, had I performed the examination without assistance I may not have gained all the information required to confirm diagnosis, as I did forget some aspects.
The MO seemed happy with my diagnosis and care plan, though he did highlight the importance of practicing the physical examination skills in order to become a more competent practitioner. Overall I feel gaining knowledge and skills in translating a patients’ history and physical examination results, has enabled me to become more confident in making a diagnosis and has improved my decision making skills.
In order to become a more capable and effective practitioner I must continue to perform physical examinations under the guidance of a more senior practitioner, and utilise their expertise during the decision making process.
Additionally, I will continue to develop my consultation and history taking skills by using Byrne and Long’s (1976) consultation model to assist my practice and aid future development.
BYRNE, P, S., LONG, B, E, L. (1976) Doctors talking to patients. London: HMSO EGAN, G. (1998) The Skilled Helper: A problem-management approach to helping. 6th edn. Pacific Grove, London: Brooks/Cole. GIBBS, G. (1988) Learning by doing: a guide to teaching and learning methods. Oxford: further education unit, oxford polytechnic SEIDAL, H, M., BALL, J, W., DAINS, J, E., BENEDICT, G, W. (2006) Mosby’s Guide to Physical Examination. 6th edn. Philadelphia: Elsevier. SCHON, D. (1984) The Reflective Practitioner: how professionals think in action. New York: Basic Books.