In the following piece of writing I will discuss how the Foundations of Nursing Practice module and my first placement experience have assisted in my development as a nurse. The unit where I spent my four weeks is a day surgery centre. Using experiences from the placement I will discuss the concept of individualised care and its relevance to nursing assessments and care delivery. I will also look at the professional and ethical issues that impact on nursing today, primarily focusing on the aspect of dignity and obtaining patient consent from the Nursing and Midwifery Council (NMC) Code of Conduct (NMC 2008).
Another area I will cover is the development of the therapeutic relationship between myself and a patient, exploring various models of communication. I will reflect on the organisation and delivery of care I observed on my placement and the impact the care delivery may have had on a patient whom, for the purposes of confidentiality, I shall call Lily. All names used have been changed and consent gained as per NMC code of conduct (NMC 2008). During my placement I met Lily. She is a 75 year old lady who attended the centre for cataract surgery.
Following a consultation with an ophthalmologist, Lily attended a preoperative assessment with a nurse whom I shall call Rose. Kozier and Erb (2008) suggest that “the nursing process is a systematic, rational method of planning and providing individualised nursing care”. The process is a problem solving approach using the four stages of assessment, planning, implementation and evaluation (Yura and Walsh cited in Brooker and Waugh 2007). For Lily, the assessment involved baseline physiological observations being taken and then answering a series of questions.
These questions included information such as name, date of birth and religion, and any current illnesses, including regular medications, complaints, disabilities and allergies? They also included previous medical history, family medical history and nutritional history such as eating and drinking habits or problems, religious or dietary preferences. The assessment, in essence, follows the nursing model set by Roper Logan and Tierney’s Activities of Daily Living. This framework is used to identify the needs of an individual by using factors that are all interlinked with each other, individuality,
Activities of Living, a dependence-independence continuum, progression during a life span and influencing factors such as biological or psychosocial factors (Hinchcliff, Norman and Schober 2008). Nursing models work effectively when used in conjunction with a nursing framework such as Ropers (McCabe & Timmins 2006). As assessment is an on-going process, they are an essential tool for the multi-disciplinary team to utilise, ensuring patient care is consistent. However the quality of an assessment plan is determined by the standard of nurse completing the assessment.
Experience and interpersonal skills will have an impact on assessment skills. Poor communication may also impact on the thoroughness of the plan (Spouse, Cook & Cox 2008). This relates to Bradshaw (1972) and the theory of listening to the expressed needs of a patient as opposed to the normative needs of the health care professional (Bradshaw (1972) cited in Naidoo & Wills 2009). There are many nursing models. If we look at Orem (1971) in comparison the Ropers it can be seen that while Orem’s theory is systematic and has an emphasis on self-caring it is very illness based (Current Nursing 2012).
Roper’s framework is more widely used; it takes a more holistic approach, the concepts are easily understandable, and if used in a comprehensive assessment, a nurse can gain more detailed information. However the model requires information regarding a person’s regular living patterns and any influencing factors and so a person must be able to communicate effectively for information to be collated (Spouse et al, 2008). At the clinic every patient has a care plan; these plans are devised using guidelines from the National Institute for Health and Clinical Excellence (NICE 2012).
Lily has a history of asthma and hypertension for which she takes prescribed medication. In using the care plan, this can be seen throughout Lily’s admission. She also has problems mobilising as she suffers with arthritis and has had bilateral knee replacements. A note was made on the care plan for extra pillows to be available so to ensure her comfort during the procedure. Working in partnership with Lily we were able to identify her needs, in using the answers Lily gave and in applying Ropers odel, an individualised care plan was implemented. Effective communication is one of the most fundamental tools in building healthcare relationships (Bach and Grant 2011). Prior to the assessment, Lily attended a consultation with the ophthalmologist. Lily appeared very anxious and though the ophthalmologist explained the procedure he adopted a biomedical approach meaning he was focused on the physical condition rather looking at Lily’s overall wellbeing and treating her holistically (Brooker and Waugh 2007).
Had the ophthalmologist adopted a more person centred approach, he may have been more sensitive to Lily’s anxiety and been able to reassure her. A person centred model is where a person is cared for with all aspects of their life being addressed and not focusing entirely on the medical condition (Koubel and Bungay2009). During the preoperative assessment, I was very aware of how differently Rose and I communicated with Lily. I’d introduced Lily to Rose and asked for her consent to carry out a blood pressure check.
Lily was still visibly anxious and so as I carried out the check, we spoke about how she was feeling and I discovered that this was not her first time having cataract surgery, and unfortunately the experience hadn’t been pleasant as she’d suffered a great deal of pain during the operation. Due to time constraints and in having to complete the care plan on a computer, Rose was not fully focused on Lily. This had a huge impact on the way they communicated with each other with Rose asking questions and Lily giving short answers. Had Rose used the aspects of Egan’s SOLER (1986) I feel the experience for Lily would have been very different.
SOLER adopts the principles of sitting relaxed, squarely in relation to the person, keeping an open position, leaning slightly towards the person and maintaining reasonable eye contact (Egan (1986) cited in Counselling Central 2009). Actively listening to a patient means that not only do you hear what is being said; you also hear how it’s being said. In the case of Lily had Rose been actively listening she would have picked up on the fact that Lily was extremely anxious about the procedure even though it was something she’d experienced before.
If we look at Burnard’s theory and zones of attention, Rose could have been perceived as being in zone 2, “attention in” whereby she was only aware of her own feelings and the task at hand (Burnard 1997). One of the NMC’s standards is that all nurses should have good communication and interpersonal skills (NMC 2008). The Johari Window (1969), developed by Joseph Luft and Harry Ingham, is a model to help a person to increase their self-awareness. It can help a person learn skills that affect the ability to communicate effectively and therefore become better nurses.
It shows the way we think of ourselves may not be how people perceive us and that there are areas of one’s self that remain undiscovered (Koubel and Bungay 2009). Having good interpersonal skills or self-awareness means I can understand how my own responses can affect others. By knowing my strengths and weaknesses, and by demonstrating a willingness to learn and develop I will ultimately improve as a nurse. This will enable me to work collaboratively more efficiently and ensure that my approach to care will always be patient centred.
By talking to Lily about her procedure and previous experience and by implementing Carl Rogers’s theory of positive regard, using the aspects of empathy, genuineness and respect, I was able to build a rapport and the basis of a person centred relationship. (Rogers 1951). The therapeutic relationship was identified by Hildegard Peplau with results showing the importance of individualised care (Stein and Parbury 2005). The goals of this were to help patients and for them to be more involved in their own care. There is also emphasis on the nurse’s role in the relationship as a teacher, counsellor, resource and leader (Hinchcliff et al 2008).
This relationship is usually initiated by the nurse. At the base of every relationship should be an element of trust. This is essential for a relationship to progress. Trust helps with confidence between patient and nurse, without it there is little chance a patient will share their experiences or feelings (Stein and Parbury 2005). The NMC code (2008) states that as a nurse we should “make the care of people your first concern, treating them as individuals and respecting their dignity. ” One aspect of this area is to always ensure you gain consent before beginning any treatment or care.
Consent may be given in two ways, by expressed consent which is usually spoken or written down and implied consent where a person’s actions imply they are agreeable to treatment, for example when a patient holds out their arm for a blood pressure check (Griffith and Tengnah 2010). Where a person id deemed to not have the capacity to consent, they will require an advocate as per the Mental Capacity Act (2005). In the treatment centre there was a huge emphasise on gaining consent with signs and posters throughout the unit. After agreeing to a procedure, the individual is asked to sign a consent form.
This states what their procedure will be and outlines the benefits and also the risks which the consultant should have already discussed with the patient (NHS UK 2010). The patient is given a copy of this and a copy goes in the patients notes. The patient will be shown this consent form at pre assessment and asked to confirm that it is indeed their signature and that they are happy to proceed. During Lily’s treatment at the centre she had interaction with many members of the multi-disciplinary team. As a small centre, it is primarily team nursing with a ward and surgical nurse divide.
Team nursing consists of a ward manager or clinical sisters who are responsible for the running of the ward, with staff nurses accountable for a specific area or task (Watson & Wilkinson 2001). The ward nurses are responsible for a clinic rotation, admission, postoperative care and discharge of a patient; the surgical nurses are responsible for ensuring patient safety within the operating theatre. There is an essence of task allocation within the setting for example with only ward nurses administering medications but as it is such a small team continuity of care is undertaken by everyone.
This, in my opinion, could lead to a limited continuity of care, with the risk of a breakdown in communication Lily for instance, was nursed by as many as 6 or seven different nurses. Repetition was also frustrating for Lily. The questions asked in clinic were then asked again on admission and then again by the person taking her to theatre. This may have been because of the different staff members or for absolute insurance that Lily was aware of everything pertaining to the procedure and that there had been no significant change in her health between pre assessment and admission to the unit.
I believe primary nursing may have been advantageous in the unit with one named nurse being responsible for Lily throughout her treatment at the centre. This would have given Lily an opportunity to develop a therapeutic relationship with one nurse, improving their communication. Documentation would have been completed by one nurse and therefore reduced the need for repetition. Unfortunately primary nursing in this setting is not feasible. For this approach to work, the nurse would have to see the patient in clinic and then be on shift on the day of scheduled surgery and then again for post-operative care.
The need for shift patterns to be completed in advance and surgeries booked around a surgeons timetable makes primary nursing impossible. There isn’t a one size fits all way of organising nursing care with all approaches having advantages and disadvantages, however a team nursing approach with emphasis on individualised care seems the most effective (Brooker and Waugh 2007). In the four weeks I was at the treatment centre, I was able to put into practice what I have learned during the module.
I was fortunate to have been in clinic on my first day as this meant I was able to meet Lily and so could follow her journey from admission to discharge. In retrospect, had I had more confidence on that first day I may have felt able to communicate more effectively with the ophthalmologist. As a student on my first day I felt unable to challenge his choice of communication though I am now aware that it is crucial that nurses are considered equal partners if a collaborative relationship is to be established (Jane Day, 2006).
Throughout my time at the centre I was able to increase in confidence and my communication skills improved which I am sure will continue to develop through to registration and beyond. After finding out Lily had a relatively traumatic experience previously, I felt we should give Lily more support but time constraints meant Rose was very task orientated and unfortunately didn’t build a therapeutic relationship with Lily. Upon Lily’s admission she appeared to be significantly calmer than she had previously and I believe this was because my presence meant there was someone there she had already began a therapeutic relationship with.
Using the tools learned through the module my self-awareness had changed and I believe this helped me to achieve better relationships with patients and colleagues. Whilst I have previous experience working in a clinical setting, I was unaware of how the NMC Code of Conduct guides how a nurse practices and that as professional body they are bound by the aspects to ensure patients are treated equally with dignity and respect (NMC 2008). Throughout the module and familiarising myself with the Code, I have found that whilst I always gained consent, I now understand why it’s so important.
I have learned there are various approaches to organisation and delivery of care with team working playing an essential role in achieving a good patient experience. Overall the module content and practice experience have had a major influence on my character, not just as a nurse. I am more confident and self-aware and I am able to communicate more effectively. I am conscious of how body language could be misinterpreted, and that actively listening to someone determines how they will respond. I will take all that I have learned and experienced and use it to underpin how I behave and practice in the future.
Throughout this essay I have talked of the learning outcomes and how each has had a positive effect on my development as a nurse. Looking at nursing processes and nursing assessments it became evident how they related to the delivery of care witnessed at the treatment centre; showing the importance of individualised care and that effective planning and evaluating can improve the quality of care delivered. I have explored various models of communication and how active listening is essential when treating a patient holistically.
I also looked at how developing a therapeutic relationship with a patient can improve my own communication and interpersonal skills. I have read and understood the impact ethical and professional issues have on nursing. I have studied the NMC Code of Conduct with emphasis on the aspect of consent, applying them to my practice experience (NMC 2008). Exploring the organisation and delivery of care at the treatment centre I have understood how the structure of team working and task allocation can improve organisation and care delivery and that whilst one approach may be more eneficial to patients, staffing and time constraints make them implausible. Throughout researching and writing this essay I have read various published literatures around each outcome and referenced accordingly. In summary I have found that the module content has been essential in my development as a nurse and has underpinned the experiences I underwent in practice. References. Bach, S and Grant, A. (2011) Communication and Interprofessional Skills in Nursing. 2nd Edn. Exeter: Learning Matters. Berman, A. Snyder,S. Kozier,B. & Erb,G. 2008) Clinical Handbook for Kozier & Erbs Fundamentals of Nursing. 8th Edn. New Jersey: Pearson Prentice Hall. Brooker, C, & Waugh, A. (2007) Foundations of Nursing Practice. Edinburgh: Mosby Elsevier. Burnard, P. (1997) Effective Communication Skills for Health Professionals. 2nd Edn. Cheltenham: Nelson Thornes. Counselling Central. Gerard Egan and SOLER. Available at http://counsellingcentral. com/gerard-egan-and-soler/ (Accessed: 08 February 2012). Current Nursing. (2012) Dorothea Orem’s Self Care Theory. Available at http://currentnursing. com/nursing_theory/self_care_deficit_theory. tml (Accessed: 08 February 2012). Day, J (2006) Interprofessional Working. Cheltenham: Nelson Thornes. Hinchcliffe, S, Norman, S & Schober, J. (2008) Nursing Practice and Health Care. 5th Edn. London: Hodder Arnold. Griffiths, R & Tengnah, C. (2008) Law and Professional issues in Nursing. Essex: Learning Matters. Koubel, G & Bungay, H. (2009) The Challenges of Person-Centred Care. An Interprofessional Perspective. Basingstoke: Palgrave Macmillan. NHS Choices. (2010) Consent to treatment. Available at http://www. nhs. uk/conditions/Consent-to-treatment/Pages/Introduction. spx (Accessed: 08 February 2012) National Institute for Health and Clinical Excellence. (2011) About Clinical Guidelines. Available at http://www. nice. org. uk/aboutnice/whatwedo/aboutclinicalguidelines/about_clinical_guidelines. jsp (Accessed: 08 February 2012) Nursing and Midwifery Council (2008) The Code- Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC McCabe, C & Timmins, F. (2006) Communication Skills for Nursing Practice. Hampshire: Palgrave Macmillan. Naidoo, J & Wills, J. (2009) Foundations for Health Promotion. 3rd Edn.