Nursing Self-Development in Placement

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The purpose of this paper is to reflect on my understanding and critically demonstrate my awareness and self-development as a student nurse all through my recent placement experiences. This paper comprises of three patches which reflects on different placement experiences, and this experience narrates how my placement practices influenced my knowledge as a student nurse.  In relation to the patches, the purpose of patch one is to demonstrate my critical understanding of the meaning of health and its influences, also it explored a patient’s experience in healthcare treatment of a condition in relation to the biopsychosocial influences of health. In addition to this, patch two will critically analyse the nursing intervention of a patient using various theoretical approaches which underpin the nursing practices towards managing a condition, also it shows how the practice influenced my learning experience. Furthermore, the patch three of this paper will be critically examining the policies which influenced the nursing practices which I observed whilst on placement. Finally, the paper critically reflected on the awareness and knowledge which I developed in different areas of nursing practice through the period of my placement in various hospitals and community nursing experiences using Gibb’s model of reflection. The specific areas of my development which I critically reflected on were the multidisciplinary team (MDT) approach used, holistic care approach and the effective communication system that was relevant in most patient treatment whilst on placement. The following paragraph provides detailed analysis of the patches and their influences on my knowledge development as a student nurse.

In this patch one section of the paper, I critically examined the meaning of health based on different perspectives, also I examined the LHS poster presentation carried out on Crohn’s disease (CD), furtherly I explored some of the biopsychosocial factors which influence health. With regards to health factors, chronic disease such as CD is said to hugely impact an individual’s health and wellbeing. Therefore, to attain a quality state of health, prevention of chronic diseases is said to be very important. World health organisation (WHO,1948 p.5) defined health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”, however, this definition has been criticised because it is proven to be unsuitable for a vast number of the world population (Charlier et al., 2017).  On the other hand, Card (2017) argued that the absence of disability and diseases is not sufficient enough to describe good health rather it should be viewed as an experience of psychological and physical health and wellbeing of an individual. In addition to this, Woodgate and Skarlato (2015) furtherly added that the mental, social and emotional state are all crucial factors when referring individual’s health and wellbeing. However, because the meaning of health has been interpreted from different perspectives, therefore, the meaning of health should depend on an individual’s overall personal experience and life situations.

CD has been identified as one of the numerous condition which impact the health and wellbeing of an individual, that is the reason this assignment will explore the causes, signs, symptoms and the available treatment for this disease which is based on the national institute for healthcare excellence (NICE, 2016) standard of treatment guidance. In addition to this section, it will further explore the biopsychosocial factors that impacts the life of an identified patient suffering from CD. The patient, Jane (Pseudonym) Nursing and Midwifery Council confidentiality policy (NMC, 2015), used for this study is a 36-year-old white British woman, she works as a school teaching assistant and lives at home alone with her two children. Jane was diagnosed with CD ten years ago and her BMI was 17.5, as a result of this issue, she is on several medications for her condition such as corticosteroids, antibiotics, immunomodulators, amino-salicylates and biologic therapies, however, as the symptoms of CD differs so does the treatments and pharmacological therapies depending on the severity of the disease (De Mattos et al, 2015).

Furthermore, this condition is viewed as a chronic gastrointestinal (GI) tract disease which affects all parts of the digestive system that invariably impacts the health and wellbeing of Jane. Although any segment of the GI tract can be affected, the intestine, however, is frequently the most diagnosed affected area (Irwin et al, 2017). In addition to this, Shen (2017) described it as a progressive and destructive disease because it causes a persistent inflammation that evolve into fibro-stenotic strictures, which if poorly managed may lead to advanced bowel damage. Consequently, there is no surgical and medical cure for CD, rather the available treatment aims to change and prevent the course of the disease, this helps reduce disability and increase the quality of life of the sufferer (Shen, 2017). The treatment involves using Immunosuppressive agents or steroid medications such as infliximab which is a biological drug to control the condition. Infliximab is an anti-tumour necrosis factor (TNF) drug, which targets the protein referred as TNF-alpha in the body. The human body produces TNF-alpha naturally which helps to fight infections as part of the immune response, however, overproduction of this protein is said to be the cause of the gastric inflammation in patients who have CD. Therefore, the infliximab treatment functions by attaching itself to the TNF-alpha which helps to relieve the symptoms and prevent inflammation (Stoppino et al, 2016).

The biopsychosocial model of health implies that behaviours, thoughts and feelings influences a patient’s physical state, therefore this model is said to impact the factors which influence the quality of life of patient’s  (Mc Inerney, 2015). In relation to CD, these factors alter the impact of medical interventions and therapies needed for treatment of this disease (Dam et al, 2013). An individual’s age, genetics and gender are an identified biological factor which impacts the health and wellbeing of Jane. Research showed that CD is often diagnosed early in line because it usually manifest before the age of 35 among half of its sufferers (Law and Li, 2013), however, Stoppino et al (2016) study shows that the adverse effect of the treatment which leads to its high mortality rate occurs mainly in older patients, therefore Jane’s  age may have impacted the pathogenesis of her condition. In relation to the genetic factors, Jaźwińska-Tarnawska, et al (2015) study shows that genetic factors contributes in determining the susceptibility of the CD in patient’s, this is because of the mutations of multi-drug resistance (MDR) -ABCB1 gene affects the pathogenesis of this disease and further impact on how the patients respond to the drug treatment. Additionally, Parkes (2012) study shows that CD can be hereditary, this is evident as the Jane’s mother still suffers from the same condition.  In terms of gender influences to CD, Mills et al (2011) study shows that women are more likely to develop CD than men because of the hormonal factors which lead to perianal manifestations that usually occurs before the other GI symptoms develop.  This may be possible as Jane explained that she always experiences female hormonal changes before the onset of her condition. However, Parke et al (2013) argued that no substantial genetic screening and developmental testing have yet linked genotyped biobanks to the clinical information and therefore can not insist on this  CD’s biological influence evidence.

Social factors such as alcohol and smoking, poor dieting and exercise lifestyle is said to impact the health of patients suffering from CD. This is because these factors disrupt the adaptive and innate immune system, also the structure of the intestinal microbiota (Dam et al, 2013).  In relation to Jane, she still smokes and drink alcohol which may be the main reason why her condition is deteriorating as against the prognosis of the disease. However, Pescud et al (2015) research show that lifestyle practices such as alcohol use and smoking, physical inactivity, poor nutrition can lead to development of serious health issues which significantly impact on individual health and wellbeing. Additionally, studies proved that this disease have a severe earlier outcome for patients who continue to smoke after diagnosis, than those who quit smoking (Pinxteren and Jong, 2014; Wang et al, 2016). This may be applicable to Jane, because she does not live a healthy lifestyle and does not get enough physical activity as required, therefore it is suspected that unhealthy lifestyles have influenced the degeneration of her disease.

Evidence have suggested that psychological issues such as stress, mood disorders, depression and anxiety have a significant effect on inflammatory process and the immunological function of the gastrointestinal mucosa which consequently have an adverse effect on CD activity (Todorovic, 2012). This is evident as Jane shows signs of depression because she is not in control of the progression of this disease, and she is constantly nervous about the results of the medical tests such as stool, urine, blood test and the endoscopy scan. Targownik et al (2015) highlighted that CD’s can be related with symptoms of depression, feelings of hopelessness and sadness, loss of interest in people or activities one used to enjoy, changes in sleep habit and appetite. Additionally, he highlighted that anger, fear, low self-esteem and stress could worsen the condition, thereby triggering the diarrhoea and abdominal pain of this disease. However, Jordan (2011) insist that although stress and depression impacts the system of remission and flare-up of this disease, but it is the life events which lead to the long-term stress in conjunction with the style of coping, links it to the poorer perception of greater disease concern. Therefore, nurses should encourage patient’s who are affected by this factor to adopt an effective coping skills in order to adequately manage the progression of this disease.

The overview of patch one shows that the concept of health was analysed from different perspectives, and it was described as a positive dynamic state of health experience rather than the absence of disease. Patients suffering from CD requires adequate health in order to fulfil their lifetime goal and ambitions.  Biopsychosocial factor such as genetics, smoking, infections, anxiety and depression is highlighted to impact the prognosis of CD. Additionally, there is currently no cure for this disease rather there are medical treatments to reduce or maintain remission of the symptoms so that patients can have an improved quality of life.  Although the issues of health and wellbeing have been debated by different biopsychosocial perspectives which conclusively depended on a patients life experience and situation, however, a patient cannot obtain an adequate health experience without effectively  taking care of oneself, therefore nursing intervention is crucial in providing adequate health care need  by the nurse practitioners, and these practices is embedded on some theoretical models which will be analysed below.

The patch two section of this paper theoretically analyses the care provision and the nursing intervention of a patient with a long-term condition which I observed whilst on placement. The patient, Paul (Pseudonym) Nursing and Midwifery Council confidentiality policy (NMC, 2015), is a 28-year-old man who was diagnosed of ulcerative colitis (UC) at the age of 22. This condition mainly affects the large intestine (colon) and rectum of the gastrointestinal tract, by causing sores (ulcers) and inflammation in the inner layer of his colon and rectum.  Because of this, Paul was presenting signs and symptoms of chronic abdominal pain, bloody diarrhoea and weight loss (Stansfield, 2014). Additionally, I became aware of UC being chronic disease which if left untreated, can have a remitting and relapsing course. Furthermore, I understand that most patients with UC have a normal life expectancy, also that the aetiology of this condition is still unclear (Stansfield, 2014). However, Ford et al (2013) study related its pathogenesis to the change in the environment which affects a person who is genetically susceptible to this disease.

According to Williams (2015), nurses use developed frameworks to provide strategies for an effective nursing intervention. They tend to carry out a holistic patient assessment which serves as a basis for a care plan development, and this was described in the nursing process of Roper, Logan and Tierney theory (Roper et al, 2000). This process, on the other hand, is the planning and setting of goals for a better patient’s outcome, whilst nursing intervention is the actual treatment and actions performed by nurses to support patients in reaching their health goals (Park et al, 2013). Realistically, nurses cannot function independently in terms of providing effective intervention without involving other MDT’s, for instance, they need doctors for prescribing medications, social workers for safeguarding purposes etc (Stein and Miclescu, 2013). Based on this framework, Paul’s previous medical and social history was obtained on admission, and this showed that he was diagnosed with long-term UC which is associated with a chronic abdominal pain.

Nurses diagnosed the need for an effective pain management plan, this is because of the severe abdominal pain complained by the patient.  For them to achieve this, an evidence-based pain management intervention was put in place which includes adequate assessment of pain, setting up a care plan, use of pharmacologic and non-pharmacologic pain management intervention, monitoring the side effect of the administered analgesic, inform the patient about the nursing process of pain management (Song et al, 2015). The intervention involved using a pain assessment scale on the national early warning scale (NEWS) chart to rate the intensity of the pain. And the assessment was based on the patients’ self-reporting pain rate. The nurses scored his pain rate 6 out of 10 on the NEWS chart, and this indicates that the condition requires an immediate pain management intervention which entails determining the required approach for reducing the factors affecting Paul’s abdominal pains.

Based on the pain rating which was derived from Paul’s description, the nurses saw the need for an effective pain management approach. This is because inadequate management of pain can lead to a poor outcome affecting both physical and psychological well-being of the patient (Voung et al, 2015). Whilst applying the pharmarlogic pain management strategy, the nurses administered the oral morphine as prescribed by the doctor, this medication was used for initial management of his pain followed by the routine observations for any side effect such as vomiting, nausea and drowsiness which can adversely affect the patient outcome (Poonai et al, 2014). In addition to this, I realised that 1000mg of paracetamol was being given to him four hours in between each last dose as a PRN for supporting the morphine because studies show that longer intake of opioid-based medicine is not suitable, especially considering the comorbidity of Paul’s  condition (Bryce and Gomez, 2015).

For nurses to carry out the required caring roles which is crucial for Paul’s treatment, they need to have a good therapeutic relationship and mutual understanding. This is why Peplau’s theory (Peplau, 1997) of interpersonal relations was applied on Paul’s nursing intervention because it emphasises on the need to develop a trusting relationship between nurses and patients, and this relationship is said to influence the outcome of care by enabling patients to participate in their treatment which significantly reduce unnecessary anxiety (Penckofer et al, 2011). Therefore, to obtain a better patient’s outcome, nurses tend to develop a therapeutic nurse-patient relationship in which patient’s holistic care is based on (D’Antonio, et al, 2014). However, Miller and Cameron (2011) study highlighted personality differences between the patients and healthcare workers sometimes hinders the successful outcome of this approach, thereby suggesting a joined-up working environment to enhance patient-staff relationship which promotes confidence.

Empowerment towards self-management was deemed to be vital aspect of nursing interventions. Based on the self-management model (Jahn et al, 2010), nurses educate Paul on how to manage his pain using different non-pharmacological strategies such as cognitive behaviour therapy (CBT) (Kalinowski et al, 2015). This type of non-pharmacologic pain management approach is a form of talk therapy which the nurses used for Paul to develop skills that will enable him to change negative thoughts and behaviours, they did this by encouraging him to focus on the experiences which entails less awareness of pain and develop better-coping skills, such as progressive relaxation and deep breathing skills even if the actual pain persists (Kendall and Hollon, 2014). The nurses applied CBT on Paul because of its effectiveness towards improving his ability to cope with pains. Additionally, this strategy aims to prevent the pains from interfering with his daily functioning, sleep and mood more than reducing the severity of the pain (Bryce and Gomez, 2015). However, patient’s knowledge, activities and attitude to pain management was observed to affect this skill needed to adequately cope with pains (Voshall et al. 2013). Because of this, the nurses extensively educate Paul on the importance of adopting a positive thought attitude which will enable him to manage the pain efficiently and they continue to review the current analgesic regimen for promotion of patient’s safety and to reduce its side effects. Therefore, a CBT approach and therapeutic relationship have been shown to be necessary whilst providing nursing care, and there should be constant encouragement of the patients towards participating in their treatment by the nurses.

The overview of patch two highlighted that nurses play important roles in helping patients manage any acute or chronic health conditions, specifically complex diseases such as UC which has no known aetiology and its treatment depends on patient’s factor. Nurses used a holistic approach in managing the abdominal pain associated with this disease, and their skills involves having the physiological knowledge of the disease, being aware of the required pharmacotherapy and non-pharmacological approach specifically CBT in management of pain which generally promote patients’ health. However, nurses cannot apply any intervention without adopting the principles and policies which regulates individual nursing practices necessary for diagnosis and treatments in every clinical setting and these policies and their influences in nursing practice will be analysed below.

In this patch three section of this paper, I critically examined the influences of health care policies in a day to day nursing practice of patients whilst on placement. This is because the implementation of infection control and prevention policy have become one of the critical issues in healthcare services in the UK. Therefore, my focus on this section is based on the experience obtained from the infection control policy carried out within the hospital ward and the influence of this policy on the nursing practices. Additionally, I understand that the purpose of this policy is literally to minimise the risk of cross-infection through adoption of aseptic non-touch technique (ANTT), accurate hand hygiene and appropriate use of personal protective equipment (PPE) during any medical treatment. Furthermore, I critically analysed this policy in relation to its influence to nursing practice.

I understand that implementation of the infection control policy by nurses is a crucial aspect of nursing practice. Health and Social Care (HSC Act, 2008) Regulations 2014 provided the guidance of the code of practice and control of infections within all the healthcare services. The objective of this regulation is to mandate all the clinical practitioners specifically registered nurses to the precaution and standards that is necessary to prevent infection or minimise the exposure and transmission of possible micro-organisms which may arise from any source (Department of health, 2015). In the UK, the national infection prevention and control manual provides guidance for hygiene practice which should be adopted by all care practitioners, specifically nurses (NICE, 2014).  By applying this policy, the nurse practitioners aims to reduce the risk of the infection of the patients in the ward and everyone who may be in contact with the patient which includes all the staff and visitors (Bowden, 2010).

The national evidence-based guidelines for nurses provides directives for adequate patient protection which involves an effective clinical infection control and prevention practice which enhances safety of patients and reduce the risk of hospital and healthcare-acquired infections (HCAI’s) (Loveday et al, 2014).  I understand that this clinical procedure is mandatory for all registered nurses because the training focuses on reducing the complication that occurs as a result of poor hygiene practices within the hospital wards (Ellis, 2012). Additionally, NICE (2014) guidelines outlined the processes for appropriate hygiene practices which helps to minimise the risk of infections. However, to prevent transmission of HCAIs by nurse practitioners, adequate hand hygiene, appropriate use of PPE and aseptic technique is said to be an essential practice (Farrelly, 2014). Therefore, the policy mandates the nurses to carry out these precise cares because it is very important in reducing the risk of infection-related diseases.

Nurse practitioners are expected to carry out adequate hand hygiene as a standard requirement which was outlined by the local hospital policy whilst on placement. This practice is required to be carried out before and after having contact with any patient in all the healthcare services (Stephen-Haynes, 2014). For this to be achieved, hand hygiene routine training was introduced for all nurses in my placement wards. The training involves using liquid soaps and alcohol-based handrubs to disinfect the hand. This practice is beneficial because nurses developed the skill of appropriate washing and disinfecting their hands in order not to transfer infection from one patient to another (Williams et al, 2016). However, I observed that factors such as cultural influences, availability and location of hand washing equipment’s in the hospital ward impacts the implementation of this policy by some nurses.  Furthermore, owing to cultural ideologies and religious principles, some nurses deem not to use alcohol-based handrubs to disinfect their hands as it is forbidden for them to have any contact with alcohol because they believe it can be absorbed through the skin which is against their beliefs (WHO, 2009). Therefore, I suggest the need to educate some nurses who have different views on this system of infection control practice within the hospital ward to adopt this practice to avoid the legal, ethical and professional consequences of not practising an effective hand washing each time the need arises and to reduce the risk of infection transfer. Additionally, the location of the hand washing equipment’s such as hand washing sink’s and alcohol hand rub gel was observed to be situated far away from individual patients’ beds, therefore making it difficult for some nurses to immediately wash their hands after each patient contact. However, research viewed this practice to be time ineffective because nurses spent more time washing their hands instead of carrying out their caring roles (Azim et al, 2016). Therefore, the washing hand equipment should be sited closer to the patients’ beds in the hospital wards for easier accessibility and effective time management by nurses. Also, there should be an audit of hand hygiene practices, education, improvement of water and soap availability, reminders and performance feedback carried out on all the nurse practitioners on the ward.

Appropriate application of personal protective equipment (PPE) was observed to be a vital aspect of the infection control policy. Research shows that inappropriate use PPE while carrying out clinical procedures is said to hugely impacts on the quality of life of patients and increase the risk infection-related complications and diseases such as MRSA (Royal College of Nursing, 2012).  Whilst on placement, I observed that nurses do not bother much towards using PPE’s such as latex gloves and aprons. This is because they claim to have latex sensitivity which pose a huge challenge to their health. Research shows that latex allergy affects a higher percentage of health care workers, and this allergy is said to develop mostly during the period of their active career (Labergea, and Ledouxb, 2011). Therefore, it is vital that there should be options for constant provision of latex-free product for effective management of latex hypersensitivity among the nurses, this is because avoiding the exposure to latex-containing products is said to be the best treatment for this condition (Katrancha and Harshberger, 2012). In addition to this, Fisher (2010) study shows that less attention has been focused on the provision of the suitable protective equipment for supporting hygiene practice in hospital wards. This is evident because, whilst on placement, I noticed that nurses rather prefer not to work with an unsuitable PPE than using any protective equipment which poses risk to their health. Although Hübner, et al (2013), study show that adequate implementation of this hygiene practice has reduced the rate of reported HCAI’s. However, I suggest there is still a need for adequate provision of suitable PPE’s to help reduce risk of allergies and other health-related issues among the nurses.

Adoption of the aseptic non-touch technique (ANTT) was observed to be a vital aspect of infection control policy implemented by nurses whilst on placement. I understand that this practice mainly focused on minimising the introduction of harmful micro-organisms that may occur while preparing and administering certain medical procedures such as cannulation and catheterisation etc (Lavery, 2010). Although some hospital wards have specially trained side practitioners whose job is to carry out these procedures, the nurses still have the responsibility of occasionally carry out minor procedure which require ANTT as part of their nursing roles and responsibilities (Fisher, 2010). However, research shows that there were breaches with ANTT practice by some nurses as they do not strictly adhere to the rules of the procedure because of the difficulty memorising its extensive practice protocols and procedures (Rowley et al, 2010). Therefore, a development of audit tools and continuous education specifically on the principles of ANTT and asepsis procedures is crucial in providing adequate hygiene practices among the nurses.

Through the analysis of patch three, I understand that inappropriate practice of the infection control policy by nurse practitioners pose a significant health risk which have the potency of an increased risk of infection, longer hospitalisation and possibly death for the patients. This is the reason why my placement hospital policy outlined the standards for controlling infections for the nurses, and some of these standards I analysed include appropriate hand wash, adequate application of ANTT and use of PPE. Based on the reflection of the observable hygiene practice among the nurses whilst on placement, I think there is a need to educate the nurses more, on the ethical and professional issues regarding this policy and the importance of infection control practice towards providing adequate healthcare for continuous reduction of the risk of HCAIs.  As a student nurse, there is a need for me to adequately reflect on these principles and policies guarding the nursing practices, also the factors which influences health and well-being in order to develop an extensive knowledge needed to provide the required standard of healthcare whilst on placement. The following paragraphs provided the reflection of my knowledge development and qualities which I obtained through my placement experiences using the Gibbs (1988) model of reflection.

All through the period of my hospital placement, I developed knowledge of many nursing practices and skills which is vital and enabled me to function effectively as a student nurse. Foremost, I understand that multidisciplinary team (MDT) approach is very important system of patient’s treatment (Mason, 2012). This is evident because whilst on placement I realise that majority of the patients were always treated using this approach which involves team of healthcare and social care professionals combined as a team to plan, implement and evaluate the treatment for serious health conditions (Browne, 2014). Additionally, they work in a system of coordinated method of treatment with other health professionals who are chosen into the team and this depends on the patient’s condition or needs that is being treated (Mason, 2012). For instance, during Paul’s treatment in patch two, the nurses were not the only professional who provided care for him, he was also treated by team of doctors who were always prescribing and recommending most of the nurse’s actions and treatments necessary for his diagnosis. Whilst at the hospital, I realise that the MDT is mainly made up of doctors, registered nurses and other necessary healthcare professionals. This made me to understand that nurses are generally good team players because their practice requires them to work closely with both their fellow staff nurses and other professionals to enable adequate treatment coordination and enhanced an effective patient care (Karen, 2011). This means that they ensure that the treatment provided to patients are high standard and has a better patient’s outcome.  Furthermore, as a student nurse in a geriatric orthopaedic unit, I had the opportunity to work with other professionals such as the physiotherapist (PT), occupational therapist (OT), the social workers (SW) and other clinical practitioners. I understand the importance of their individual contributions towards providing the required treatment for every patient’s in the ward and this made me to develop some practical knowledge and enhanced my awareness of the functions of other individual professionals at the ward.  Evidently, Goodwin (2014) research shows that MDT work benefits all the parties involved because it enhances the knowledge and professional skills of other team members by providing a learning opportunity about the resources, approaches and strategies used by the team which is beyond the confines of each other’s speciality. However, I realise that the team sometimes experiences professional conflict during treatment delivery. In support of this, Ndoro (2014) highlighted that lack of trust, misunderstanding of role and responsibilities, unclear position description, unstable leadership, limited staff participation in decision-making, power issues and differences in frameworks guarding individual professional approach sometimes leads to professional misunderstanding which impacts on provision of high-quality patient-centred care. Therefore, I suggest an adequate clinical audit among the professionals to improve the functions of MDT’s in order to continue to achieve a quality patients treatment.

Additionally, I understand that nurses occupy a crucial position in MDT meetings because they provide consistent physical care to patients. Therefore, attending MDT meetings should be a necessary aspect of learning for every student nurse, however, I could not attend any of the meeting whilst on placement because it was against the hospital policy as they try to adhere to the confidentiality issues concerning the patients (Burzotta and Noble, 2011). Consequently, during each meeting, the nurses were mainly represented by the ward sisters or the manager. Therefore, this concept should be added as a standard requirement for all the student nurses to attend comprehensive MDT meetings and grant the opportunity to give their own opinion and views as a student towards improving and providing the required care for patients.

Practically, for adequate care provision of patients to be achieved, it most times requires an inter-professional approach. For instance, whilst on placement at the orthopaedic ward, I understand that most of the patients often requires appropriate moving and handling techniques for the treatment of their sustained fractures and enhancement of their recovery (Goodwin, 2014). And this made the PT’s relevant in giving directives for proper system of mobilising and transporting patients from one position to another, which every member of the clinical care will have to adhere to and follow their instruction for a better patient’s outcome.  Also, I had the opportunity of doing the ward round with the consultants because I learned that nurses have the most number of physical contact with the patients and stand the chance to explain every observable and documented vital information about the patients in their care to the consultants (Leary 2011).  However, I realise that some nurses most times tend not to be aware of their specific responsibilities and should know that they are partly responsible and accountable to any critical decisions made by the MDT (Feo et al, 2016). Therefore, I suggest that nurses should use their knowledge and patient’s experience to initiate improvement regarding their opinions in order to make the prescribed care correspond to the patient’s needs.

In my first placement at the gastroenterology ward, I learned the importance of application of holistic care to every patient admitted in the ward. Additionally, this form of caring approach is a system of treatment which recognises a patient as a whole and not as part of a being, and the process involves acknowledging a patients biological, psychological, social and spiritual values (Ziebarth, 2016). Furthermore, I understand that this system of care provision is achieved by complementary treatment, medication administration, education, empowerment towards self-care and appropriate communication system (Selman et al, 2013). Whilst on placement, I observed that most nurses consider all aspects of patients factors which may impact the process of their treatments such as the patients culture, opinions, emotions, beliefs, attitude and thoughts, and this factors is said to contribute to a patient satisfaction, happiness and quick recovery (Vincent, 2010).  However, I realise that effective factors such as the structure of health education system, personality traits and professional environment affects the adaptation of this approach (Selman, 2014). Therefore, I feel that establishing adequate holistic clinical system and appropriate education which promotes spiritual and physical values of the patients, will encourage the clinicians to provide an ultimately holistic and improved quality care.

Holistic caring system additionally increases the understanding of the patients and their need by the clinical practitioners, where the patients will be provided the opportunity to discuss about their emotional wellbeing, social aspects and their physical health (Poulymenopoulou et al, 2013).  Based on my placement experience, I understand that this approach can be achieved using the information obtained through the patient’s assessment forms in order to ascertain the patient’s values, beliefs, knowledge and attitude that is needed to provide good health management and better patient outcome. However, I understand that these holistic assessments still have not been embedded in the patient care as it has not yet enabled the patients to take greater control in terms of managing and identifying definite areas where they believe the condition mostly affects them than relying on the subjective professional assessment outcome (Vincent, 2010). Therefore, I suggest that patients should be given reasonable autonomy towards their treatment as they tend to know more on their whole condition and its effects on them.

The meaning of health and the biopsychosocial influences of health was earlier explored in this paper in which the importance of holistic approach to Jane’s care was discussed.  In order to achieve this practice, a holistic assessment of Jane’s need was carried out, and this directs all health professional who were involved in her treatment to look beyond her Crohn’s disease condition and further explore other factors such as the social influences which includes  her smoking lifestyle, poor nutritional habits and her emotional well-being such as her marital problems, body image, her spirituality and cultural influences which impacts the healing of her physical illness (Selman et al, 2013). Additionally, I understand that holistic care approach increases the depth of care providers’ understanding of patients and their needs which involves educating patients about self-care, also helping them to perform their daily activities independently. For example, in patch 2, the application of CBT for Paul is regarded as a form of holistic care because it is an alternative pain management strategy which considered other factors which influences his health such as his psychological and emotional wellbeing. However, my findings show that some the elements of holistic care such as provision of adequate respect for human dignity, mutual respect, openness, equality and patient’s autonomy was not sufficient enough within the holistic approach required by the patients. Therefore, I suggest that nurses should always consider other elements of health which increases the chances of successful treatment outcome for the patients while providing their nursing care.

Whilst on placement, I developed an effective communication skill because I understand that an appropriate communication strategy is a vital skill required for me to carry out an adequate patient care. As a student nurse, I realise that an effective communication is very essential for me to provide a high-quality and compassionate nursing care which gears towards improving patient’s outcomes and satisfaction (Yardley et al, 2013).  For me to achieve this, I worked along my mentors and other registered nurses to enable me to understand the patients’ communication needs which involves demonstration of courtesy, sincerity and kindness that requires development and integration of clinical skills (Rutt, 2017). Also, I always took my time to communicate sensitive and vital issues with necessary confidentiality whenever the need arises. In addition to this, (Feo et al, 2016) agreed that an effective communication between patients and the nurse practitioners are very important tool for achieving a better outcome of an individualised care of each patient. For example, in patch 2 Paul was educated on how to self-managed himself in order to stabilise his condition. Evidently, the nurses were able to empower him to adopt the self-management strategy of care, and this plan was achieved because of the impacts of the effective communication skills they applied when interacting with him. However, I learned that some of the nurses does not have good elements of communication. In addition to this, Hafskjold et al (2015) research showed that empathy, mindfulness and emotional intelligence was noted to be lacking within the self-reported communication skills among the clinical staff. Also, the study highlighted that majority of the clinical practitioner’s experiences communicative challenges such as power distance, decision-making, preservation of dignity and respect, these are communication features established to be lacking among the care professionals. This is evident because some of the healthcare professionals I observed during my placement does not apply these qualities while communicating with patients. Therefore, there is a need to include application of emotion while communicating with patients into the training programme for healthcare students and other care providers for adequate management of the psychological influences of health (Eikey, 2013).

Along with my understanding of the importance of communication within the hospital unit, I realise that an effective communication is necessary for interventions which are required to improve health outcomes and staff performance. The need for a therapeutic conversation on which an effective interpersonal atmosphere is developed with the patients is vital, especially in this our current multicultural society (Wade, 2014). Whilst on placement, I was able to enhanced my communication skills which evidently improved the quality of nursing care which I provided to the patients because it created a ground upon which a meaningful and genuine relationship between me, the patients and other healthcare professionals is built (Roets and Maritz, 2013). Furthermore, Bacon (2012) highlighted that the complex process of communication involves several interacting factors which ranges from the social, physical and psychological influences, and these factors require skilled thought to respond to them. As a student nurse, this means that I must be aware of principles which underpins communication in care. For instance, the NHS 6C’s values of care which relates the concept of compassion in practice as one of the required elements of communication (Hardicre, 2014). However, I understand that there is still issues of trust and openness between the nurses and some patients. In addition to this, research shows that the outcome of an effective communication has not yet led to an increased influence in patient’s confidence and there is no favourable tendency for openness and trust from many patients (Eklöf and Ahlborg, 2016). Therefore, I suggest that nurses and other healthcare professionals should continue to strive for more openness and honesty in order to attain the required trust necessary for most successful treatment of patients to occur.

Whilst on placement, I understand the importance of appropriate language acquisition, this is because different medical terminologies and abbreviations are always used while communicating within the hospital premises. I observed that some nurses tends to use difficult medical terminologies when interacting with patients, Wade (2014) insist that the language of communication must be understood by everyone who are involved in the treatment practice both the care provider and the patients.  Additionally, Bacon (2012) agreed that nurses should talk to patients in an informative and courteous manner, and in a meaningful personal communication system for easier understanding. He added that this should not based only on the nurse’s physical ability rather it should also take into account their education and healthcare experience (Bacon, 2012). Furthermore, I understand that communication is not just about the simple conversation, rather most of the patient’s communication transpires through different forms such as body language, changes in behaviour, movements and hand gestures, which most healthcare professionals always put into consideration while trying to communicate or assess a patient’s communication style (Laidlaw et al, 2014).  For instance, in patch 1, the nurses were able to address the factors which was affecting Jane’s health issues, by interacting with her using the appropriate form of her communication style. This practice led to a satisfactory outcome of Jane’s assessment because of her excellent communication ability and good nurse-patient interaction which existed between the two parties.

I understand that technology has taken over the realm of clinical treatment, with the use of emails, text messages, and use of electronic documentation and report writing, these are important aspect of communications system within the hospital units. I developed the skill of using the healthcare technology to communicate within the hospital unit. For instance, I have the knowledge to request for prescription and to request for doctors attention online. However, I observed that some the nurses still lack the capacity to engage in this current communication system because there is still a considerable imbalance in the number of attention provided to the current communication support compared to the outdated information system. Studies shows that over or under-diagnosis and treatment of illnesses in modern healthcare setting is often related to insufficient communication strategies used while providing treatment, such as poor online system of sharing information among the MDT’s for a deliberative method of treatments (Kirsten, 2016; Stonehouse, 2014). However, Wade (2014) insist that because communication technology improvement is one of the cheapest and most profitable intervention needed to improve the safety and quality of healthcare services, therefore it should warrant a bigger attention and concern than the attention that is currently being provided. In addition to this, I suggest a need for provision of adequate technical training and continuing education for nurses in the issues which relates proper use of communication which will incur the nurses to respond efficiently to the dynamic system of the healthcare service.

The documentation workload of nursing practice made me to understand the importance of education towards provision of the required health care and prevention of medical dilemmas, that means an adequate education is vital towards improvement of the clinical and professionals research practice. This experience made me to realise that all the healthcare professionals must receive formal education and knowledge development training such as the undergraduate education and basic healthcare training to improve their clinical practices and professional responsibilities (Bacon, 2012).  In support of this, MacLean et al (2017) reported that nurses are mandated to professionally practice within their ethics for promotion of care.  For this reason, education programmes which aims towards improving the nursing abilities and enhancing its professional standard in various hospital has been put in place. In terms of student’s development, Yardley (2013) agreed that effective nursing practice impacts students’ knowledge by distinguishing between the simulated and authentic patient’s care which tends to shape their learning. In addition to this, William and Song (2016) highlighted that this practice of knowledge development of clinical care facilitates students acquisition of the necessary healthcare skills for promotion and delivery of an effective healthcare.  However, I viewed challenges such as inadequate readiness of the mentors, limited learning opportunities and insufficient equipment to affects students learning abilities in a clinical setting (Jamshidi et al, 2016). Therefore, I suggest that students should be adequately prepared by their mentors with a specific focus on enhancing their healthcare practical ability and other knowledge development needs necessary for provision of the required healthcare practice.

In summary, this paper has reflected on many aspects of nursing practices which I developed whilst on placement. One of the vital concepts highlighted on this paper is the contradicting meaning of health which was addressed by application of different perspectives of health. The paper additionally examined the biopsychosocial influences of health and how these factors affect the health and well-being of patients. It further explored, the nursing interventions which I observed whilst on placement, this intervention was applied to a patient’s treatment in order to achieve the required healthcare treatment, by using the theoretical approaches which underpins the nursing practice.  Additionally, the influences of policies and principles affecting the nursing practices of the patients I observed within my placement ward was later analysed. Furthermore, the paper reflected on the qualities and skills which I developed so far on placement, and some these qualities includes awareness of the MDT system of intervention within the hospital units, the influences of holistic approach towards providing adequate patient care, and lastly, the importance of communication and education towards improvements of healthcare services. Judging from the extent of my learning development gained from my placement practice, therefore I agree that so far, it has been a great learning experience blended with a positive learning outcome.

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