Health care is continually transforming and evolving with emphasis on quality and patient safety which is embedded in the Code of conduct for nurses and midwives (NMBI, 2014). It is vital that staff play a meaningful role in achieving quality improvement and this can be achieved through achieving the domains of competencies required and reflection. Reflective practice are techniques that facilitates individuals to reflect on experiences and actions in order to enhance nursing care by engaging in a process of continuous learning through understanding of emotions (Caldwell & Grobbel, 2013). Therefore, aids in the provision of safe, quality patient care through learning from experiences (NMBI, 2015). Gibbs reflective cycle is an important tool in reflection process as it encompasses six stages of reflection, description, feelings, evaluation, analysis, conclusion and action plan (Sherwood et al., 2017).
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The domains of competencies are a multidimensional broad enabling framework that consists of five domains that students must achieve all to assure that they have the abilities and the skills of critical evaluation, problem-solving, decisiveness and reflective skills. The completion of the domains of competences indicate that the nurse has the ability to achieve their professional responsibility and accountability within their scope of practice while practicing safely and efficiently (NMBI, 2005). Therefore, each domain is equally as important.
This assignment will critically reflect on an incident I was involved in during the course of internship placement that contributed to the development of my professional nursing competencies. Gibbs reflective cycle will be used. For the purpose of this reflection assignment, Domain. 2 Holistic Approaches to Care and the Integration of Knowledge will be used as this was appropriate domain relevant in my incident. For the purpose of confidentiality as outlined in the Code of professional conduct and ethics for nurses and midwives, a pseudomonas will be used.
On my internship placement I was placed on a busy medical ward. I was feeling stressed already starting internship. Literature has articulated that while internship is a valuable experience in preparation for being a qualified nurse. However, the transition process from a student nurse to intern nurse can be challenging and stressful (Deasy et al., 2011; Duchscher Boychuck, 2009). On this particular day I had my alocation of six patients, all needing complex care. One patient, a lady called Mary, was an eighty two year old female. Mary was admitted for Comprehensive Geriatric Assesment (CGA) for frailty, after a fall at home. Frailty is an umbrella term for individuals experiencing sedentariness, fatigue, slow gait speed, falls and weight loss. Consequently, frailty is associated with disease, increased morbidity and mortality (Cornel, 2017). As a result, it is vital for the individuals holistic care to have a CGA. CGA is a multi-dimensional, interdisciplinary diagnostic process which involves the directed provision of treatment and services (Health Service Executive, 2016). CGA is also a gold standard in the appropriate assessment in diagnosing and treating frailty as it includes therapeutic processes which determines the medical, functional and mental problems of frail older people. Therefore, it incorporates a person-centred approach to care (Westgård et al., 2019). On admission Mary was assessed using the nursing model Roper, Logan and Tierney which is a holistic assessment of an individuals’ activities of daily living (ADL’s), this nursing model is a complete assessment which aims at promoting independence by using interventions that aid the service user in areas that they may have difficult in to promote maximum independence (Petiprin, 2016). Therefore, I should have known Mary’s capabilities. On this particular day, Mary was alert and appeared aggitated sitting at her bedside. I asked in passing was she all right. Mary communicated she needed the toilet. As I was preoccupied with my other tasks of the day. I offered Mary a commode due to the fact that I was busy and I did not do an appropriate assessment to establish whether she was was capable of walking out to the toilet. I presumed she was a falls risk due to her having a previous fall and she must have poor mobility. In actual fact I was to busy to mobilise her out to the toilet. I also feared she would fall and I would have more work to complete. Research by Shaw, et al, (2017) and Westgård, et al., (2019) found person centred, holistic care is more than just task orientated. It is critical in developing a concept of care that values the patients personhood and autonomy. Which I did not apply to this incident. Consequently, Mary was upset that I offered her the commode, she quiered as to how is she to get better and regain her independence if I would not allow her to walk out to the toilet herself. That’s when I realised Mary was right.
Prior to this incident, I always prided myself on delivering high quality care, in line with the code of professional conduct and ethics for nurses and midwives. After the incident I felt a range of emotions of embarrassment for offering a mobile, independent woman a commode, stressed due to all the work I had to complete and afraid in case she would fall. However, I mainly felt so disappointed in myself as I was not delivering the care I should have been. I was instead following the paternalistic culture of the ward. This incident also made me reflect and question all care that I had delivered. I realised I was to quick to judge individual’s ability without undertaking the proper holistic assessments, analysing and implementing the data as incorporated in the Domain of competencies. I also felt I was patronising her by assuming she wasn’t safe to mobilise as this was a woman that was living independently prior to admission. Therefore, impeding on her plans for discharge and follow up care.
In hindsight this incident was challenging for me as it made me evaluate all care I deliver. The experience had both good and bad components which led me to have an increased understanding of the patients needs and how my attitude may contribute to the patient’s recovery and experience. I realised the importance of the therapeutic relationship as this is not only fundamental for providing person centred care (PCC) but also in improve health-related outcomes through thorough assessments, planning and implementing care and evaluation of care delivered (Nursing and Midwifery Board of Ireland, 2015; Kornhaber et al., 2016; NMBI, 2005). I learnt the importance of respecting the patient’s autonomy. It is a nurse’s role to promote independence, which I failed to do. The benefits of the nurse paying vigilant attention to hospital process such as attentive to the patient’s continence needs, nutritional needs and early and frequent mobilisation in order to prevent further deterioration of health needs, has been extensively researched (Hogan et al., 2017). On reflecting on the incident, I was not achieving the domain of competence as I was not incorporating applicable research findings into the care I was delivering.
Irelands population is steadily getting older and more dependent according to the Central statistics office (2017). It is projected that people aged 65 years and over are increasing by over 20,000 a year (Central Statistics Office, 2017). This is due to new research and evidence-based practice emerging (Stevens, 2013). However, is this postponing the normal biological age-related disease process, giving rise to increasing levels of frailty in later life (O’Neill, 2006). This demographic change has major implications for government, health care, economic growth and welfare and most importantly the elderly individual. Therefore, this highlights the need for nurses to provide high quality, holistic care in this area (Nursing and Midwifery Board of Ireland, 2015).
The Nursing and Midwifery Board of Ireland (NMBI) published guidance for staff working with older people in order to facilitate safe, competent and ethical nursing practice. This guidance articulates, reflective practice is an essential part of self-assessment and decision making, it encourages continuous development of practice and promotes continuous quality improvement through regular monitoring and evaluation in line with policy. The working with older people guidance also incorporates the domains of competencies in this guidance. Articulating the Domain 2. Holistic approaches to care and integration of knowledge has a performance criteria of, a systematic holistic assessment based on nursing theory and evidence-based practice, of the older person’s needs, identifies needs, plans integrated care and where necessary incorporating the needs of the family, implements care and interventions and evaluates (Nursing and Midwifery Board of Ireland, 2015). This is in-line with NMBI requirements and standards for nurse registration education programmes.
A fall is an unintentional, sudden event which results in a person to land on the ground, on the floor or at a lower level as a result of multiple factors (Feder et al., 2000). Globally, falls are the result of 646,000 injury deaths per annum with adults over the age of 65 experiencing the greatest number of falls. Therefore, posing substantial risk to the quality of life of the person, health and healthcare costs (World Health Organisation, 2018). As individuals at risk of falls increase with age, this is an important health issues that affect older people and are multifactorial conditions associated with adverse health outcomes (Health Service Executive, 2008; NHS, 2014). However, falls can be anticipated and prevented through assessments, clinical judgement and preventive measures (Nowak & Hubbard, 2009). This is also articulated in the domain of competence Holistic approaches to care and integration of knowledge in addition to guidelines published. Guidelines published by the National Institute for Health and Care Excellence (2013) recommends every individual over the age of 65 in acute care should have a falls assessment completed that is comprehensive and multifaceted. A study by Dykes et al (2010) demonstrated that the use of a falls assessment to determine individuals at risk of falling significantly reduced the number of falls. According to the Health Service Executive Incident Management Framework (2018), it is vital that incidents of falls are reported. This can ensure data is analysed accurately and methodically, leading to appropriate identification of factors that influenced the fall therefore preventative initiatives can be implemented (Health Service Executive, 2018; NMBI, 2005). However, the patient’s autonomy should be respected at all times, with the patient in the centre of care provided.
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The nursing process is a systematic guide defined as a patient centred approach to patient care based on critical thinking, evidenced-based practice, goal orientated tasks and intuition. The five sequential steps are assessment, diagnosis, planning, implementation and evaluation. The first step – assessment requires critical thinking and subjective, objective data collection while incorporating and promoting relevant research to improve into nursing practice. Diagnosis, the second step requires clinical judgement to format a nursing diagnosis that assists in the panning and implementing of care to be delivered. Planning, the third step is achieved in conjunction with the patient and establishes goals that are specific and timely. The fourth step – implementation, is the step where nursing care is delivered according to the plan of care whilst providing and maintaining patient safety. The final step evaluation, is a vital step as it assess to ensure the desired outcome is met and if not, reassess and determines further interventions (Toney-Butler & Thayer, 2019; Abdelkader & Othman, 2017). The nursing process is incorporated in the Domain of competence Holistic approaches to care and the integration of knowledge and is delivered in a holistic manner (NMBI, 2005). However, there are many barriers that impede the implementation of the nursing process, factors such as insufficient information, lack of sufficient motivation in undertaking the nursing process and lack of cooperation or skills among the nurses (Abdelkader & Othman, 2017).
PCC is internationally accepted and recognised as a model of quality healthcare worldwide. It is enabled by cultures of empowerment that promote a continuous approach to practice development It is described as, the formation and fostering of therapeutic relationships between all healthcare providers, service users and others significant to them. This is a unique approach to practice supported by values of respect for persons, mutual respect, individuals right to self-determination and understanding. It is enabled by cultures of empowerment that foster continuous approaches to improved practice development (McCormack & McCance, 2010). The core concept of patient-centred care is patient participation beneﬁts the patient (Tobiano, et al., 2016). This is also implied throughout the Domain of Competence number 2 (NMBI, 2005). However, it has been argued that the consistent deliver of PCC in practice is a challenge due to the learning environment, the care environment and the organisational culture (McCance et al., 2013). Organisational culture is a change-resisting element that emerges from shared beliefs, attitudes, values, norms of behaviour and judgement which is mutual between colleagues in a working enviroment (Davies, et al., 2000).
In order to evaluate and improve the quality,safety and culture of care delivered, Healthcare organisations monitor patient experiences through patient experience surveys. The aim of this survey is to measure patient feedback and experiences in a rigorous and systematic method to try to understand how patients interact with the healthcare system (Health Service Executive, 2017). Therefore, this initiates a change in how care is delivered (Davies, et al., 2000). This is also in-line with Slainte cares vision to improve individuals health by developing new models of health care and infrastructures in order to improve data and research thus to deliver more effective and integrated care (Government of Ireland, 2017). In this patient experience survey findings, it highlighted the need to improve in the delivery of dignity, respect and privacy in care delivered (Health Service Executive, 2017). These are vital elements of nursing care. However, these elements are not being met to the patients expectations according to the national patient experience survey findings. Patients expect to be offered choices, being involved in decision making, maintaining hygiene and personal appearance, aided if needed in toilet management and continence promotion. This can help patients to maintain their dignity (Logan, 2012). If these expectations are not being met, then it may be preceived as neglect (Reader & Gillespie, 2013). The term neglect is defined as to give little attention or not enough care to people that you are accountable for (Collins, 2019). The term neglect has been a key issue in high profile enquires. The Mid Staffordshire NHS Foundation Trust Public Inquiry Report which reported the failure of Mid Staffordshire NHS Foundation Trust to provide safe, quality patient care resulting in high mortality rates (Francis, 2013). However, not all inadequate care is deemed neglect, poor care may be delivered due to an error, lack of training or insufficient resources rather than neglect (Reader & Gillespie, 2013).
It has previously mentioned about the importance of offering patients a choice. This is supported by the Code of Professional Conduct and Ethics for nurses and midwives. The aim of the Code is to guide nurses in their standard daily practice and support them to understand the importance in caring for patients in a safe, ethical and effective way, working under their scope of professional practice. It encourages ongoing research to deliver evidence based pratice. The Code of Professional Conduct and Ethics has five guiding principals. Principle 1: respect for the dignity of the person articulates that the nurse should promote and protect patients autonomy while respecting the patients beliefs, choices and values (NMBI, 2014). Therefore, a nurse has a professional obligation to repect the choices the patient makes regarding their health. The nurse also plays an important role in the integrated discharge planning of a patient. The Health Service Executive has produced guidelines in the management of integrated discharge planning using a multidisciplinary approach. The aim of integrated discharge planning is to ensure a coordinated seamless transition from hospital to home is achieved using a person centred approach, multidisciplinary approach and education. This can lead to improved patient satisfaction with healthcare services, reduced length of stay and prevention of unplanned readmissions (Health Service Executive, 2008). However, patient education and participation is required as this encourages adherence to treatment reigemes, reducess anxiety and increases motivation (Tobiano, et al., 2016). This is highlighted in the domain of competency Holistic approaches to care and the integration of knowledge.
From this experience, I am more mindful of the care I deliver. I realise the importance of assessments and the role of the nursing process within the Domain of competence number 2. Holistic approaches to care and the integration of knowledge. The nursing process incorporates a person centred approach based on critical thinking, evidenced-based practice, goal orientated tasks and intuition, that influences nursing care. The five steps are assessment, diagnosis, planning, implementation and evaluation
I am aware the biggest challenge to the delivery of services for older people is the fact that Irelands population is steadily getting older and more dependent according to the Central statistics office (2017). This demographic change has major implications for government, health care, economic growth and welfare and most importantly the elderly individual. Therefore, this highlights the need for nurses to provide high quality, holistic care and continuing education in this area (Nursing and Midwifery Board of Ireland, 2015). I can now see how my quick judgement may impede on Marys discharge process.
Throughout this assignment it has been highlighted the importance of holistic assessments, building theraputic relatioships and PCC is key in the management of the elderly in the acute settings.
According to Gibbs reflective cycle (1988), an action plan is how one would deal with similar situations if they arose in future. In the future
- I aim to be more understanding,
- I aim to put more emphasis on building a theraputic relationship rather than be task orientated
- I will continue to reflect on my practice using Gibbs reflective cycle
- I aim to continuously and consistently deliver care according to the Code of professional conduct and ethics as set out by NMBI
- I will not assume that any service user is not capable without doing a full assessment
- I will liase more with the multidisciplinary team
- I will work within my scope of practice
- I will use evidence based practice to guide care delivered
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