This essay is going to focus on the nursing skills that I developed during a period of placement simulations and in the community, placing emphasis on oral care, communication and bed bath. It will outline the fundamental aspects of clinical nursing skills that I have begun to acquire. This will also highlight the learning processes which took place and how it helped me to enhance my knowledge, and ethical values in order to deliver quality and safety of care. Using other sources of current literature, I will use a reflective model to discuss how I have achieved the necessary level of learning outcome. By utilising this model I hope to demonstrate my knowledge and understanding in relation to these skills as well as identifying areas with scope for learning.
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Reflection is the process of reviewing an experience in order to describe, analyse, evaluate and so inform learning about practice (Reid 1993). There are many reflective models that I could have used, including Johns (2004), Driscoll (2000), Atkins and Murphy (1994), Kolb’s (1984), and Gibbs (1988).
However, Gibbs (1988) model of reflection was selected, as a framework, because it focuses on different aspects of an experience and allows the learner to revisit the event fully. By contemplating it thus, I am able to appreciate it and guided to where future development work is required.
Skill 1: Oral Care
I was part of a placement simulation group which went to the multi-skills laboratory to practice delivering and receiving oral hygiene. I was assigned a colleague to brush his teeth using a toothbrush and paste. I put on gloves to prevent contamination (NICE 2003). Seeking his consent, I undertook a briefÂ visual assessment ofÂ his mouth’s health. I then put him in a comfortable position so that he could tolerate the wash. Thereafter, I cleaned all-round the mouth, gums and tongue. I finished off by helping him to rinse his mouth with mouthwash. I treatedÂ my partner as though he was physically unable to hold the brush himselfÂ to scrub his own teeth, but he was able to communicate with me and was able to assist me in terms of spitting and gargling with water at the end of the procedure.
When first informed that I was expected to undertake this task I felt anxious and concerned. I was aware that I had not brushed anyone’s teeth outside of my family before and that the mouth is an intimate and personal part of the body which is not usually exposed to anyone other than me or the dentist. I was concerned about how my partner (whom I did not know well at that stage) would react to me examining his mouth. Writers have described such intimate physical assessments as creating a potentially intrusive situation (Lewis 2006, Sturdy 2007) which might cause the patient to feel uncertain and inadequate. I was also concerned that my own anxiety was shared by my partner who also appeared embarrassed and awkward at the time.
This anxiety was increased when during the procedure my partner began to cough as though distressed. This caused me to feel hesitant about continuing- a situation recognised by Millon (1994) as a common response for carers to such an experience, although I persevered with his cooperation. When the task was completed I felt comfortable with my performance overall.
What was good about the experience was that, despite being aware that this role is often delegated to health care assistants (Kelly et al 2010), I was able to deliver a fundamental component of essential nursing care (Essence of Care 2003) quite effectively. The experience helped me to appreciate that oral care provides any nurse with an ideal opportunity to undertake a thorough physical, emotional and cognitive assessment of a patient (DOH, 2001). I was satisfied delivering this aspect of care without harming the patient as no injuries were sustained (having I checked his mouth prior to and after cleansing). Also, I was pleased to have an opportunity to improve my communication skills through the delivery of this skill and to understand the impact that this might have on the development of a therapeutic relationship with future patients. From my colleague’s reaction and feedback, I understood how feedback is an important learning tool. Despite my discomfort during the undertaking of this task, the experience highlighted the potentially complex problems I might have to solve in the provision of care needs to patients for whom I may not have had contact with before.
Administration of this clinical skill involved undertaking an assessment of my colleague’s mouth before delivering any care in order to help determine the most appropriate means of delivering oral care. Malkin (2009) asserts that this is a critical component of the procedure and was one I was keen not to overlook. The World Health Organisation (WHO 2010) describes a healthy mouth as being free of chronic mouth and facial pain and in the situation described; this is the condition I found my partner’s mouth to be in. I was therefore happy to proceed with cleaning his teeth as instructed. I selected to use a soft bristled toothbrush and toothpaste. The use of these adjuncts are described by many writers as being the most appropriate in terms of removing plaque and preventing trauma to the gums (Holman et al 2005,McCauliffe 2007).Despite this it has been identified that they are also most often not selected by nurses who appear uncertain about most effective evidence based practice ( McAuliffe 2007).
Clearly, mouth care is important and that, nurses have a role in assessing and maintaining it (Malkin, 2009).The task identified the role of the nurse in providing encouragement to the patient whilst delivering oral care. His weakness created a sense of dependency upon me and necessitated the utilisation of good communications skills on my part to complete the task properly. It has raised my awareness the effects of nursing interventions on others within my practice.
At the moment, I read more books a day than practice. My aim is to be proactive in the future by promptly opening up through total participation and doing more practices by brushing my teeth on regular basis. I would consider brushing others also and allowing them to brush mine in order to become familiar with areas that are often not well attended to. Keeping up to date with evidence based principles of practice will be maintained through the scrutiny of journals that refer to this aspect of care.
I will take care to remember my feelings when providing and receiving oral hygiene before delivering it to patients in the future. Recognising the potential for embarrassment and awkwardness I will ensure that I treat the patient with sensitivity and discretion at all times.
Skill 2: Communication Skills
I accompanied my mentor to attend to a consultation with R, in persuading him as a non-compliant patient, in taking his medication. He had refused to communicate with anyone, and had been violent and very suspicious of nursing interventions in the past. He would not open his door and started shouting. When he appeared quiet he let us in. I thought it would be nice for him to have some interaction after seeking his consent. I pulled up a chair next to my client so that I was closer to him and was at a similar eye level. I engaged him in a conversation about football. When I mentioned Arsenal, he became interested in the conversation. I realised he was a fan of the club and told me more about the club. I listened attentively, nodding and contributing. I ceased this as an opportunity to explain the need for taking medication and side effects of non-compliance. He understood and pledged to take his medication daily. He took some to our surprise.
Throughout the whole experience I felt terribly nervous as I knew I was being judged on how well I could achieve the skill. My initial perception was that R was a difficult patient and considered withdrawing but I felt emotionally concerned about meeting a professional obligation. I understood that I owed him a duty of care (NMC, 2008) and simply withdrawing was not professional in my view.
I was pleased to have an opportunity to improve my communication skills through which, I was able to convince him in taking his medication without confrontation. It was good that I sat in the chair next to him and did not just stand over him to show I valued him and that I was not in a hurry. I used good body language and facial expressions as stated by Egan (2002). I understood the impact that this skill might have on the development of a therapeutic relationship with future patients. Ironbar et al (2003) stresses that, therapeutic relationships can be stressful. This requires insight, self-awareness and ability to cope effectively with stress. The downside was that the patient initially felt that I was being nasty as I was persistent in having him take the medicine. Also, I found it difficult to communicate with the patient initially because I did not understand his condition. Barker (2003) reports of how in recent times empathy has been shown to enable nurses to investigate and understand the experience of persons experiencing a state of chaos as a consequence of psychiatric order.
There are many reasons why somebody may refuse to communicate. Wilkinson (1992) cited in (Kluijver et al, 2000) defined communication as an open two-way communication in which patients are informed about the nature of their disease and treatment and are encouraged to express their anxieties and emotions. Sheldon, (2009) expands this further by saying in nursing; communication is a sharing of health-related information between a patient and a nurse, with both participants as sources and receivers. The nature of health care demands expertise in interviewing, explaining, giving instructions and advising (Williams, 1997). In this instance, this was exactly what I did. The use of therapeutic communications in nursing, particularly empathy, is what enables therapeutic change and should not be underestimated (Norman and Ryrie, 2004). Egan (2002) argues that empathy is not just the ability to enter into and understand the world of another person but also be able to communicate this understanding to him. Nurses should be aware that patients, who are paranoid and suspicious of staff interventions as was the case of patient R, might not readily accept support from staff. O’Carroll et al (2007) contended that in our professional roles, nurses do not have the same option as we do in our personal life by withdrawing from difficult relationships. I began to feel tearful, but then quickly reminded myself that there must be a reasonable explanation for him refusing to communicate or cooperate with everyone. I felt my client needed a choice and giving him a choice will give him back some of his independence when he could be feeling helpless and vulnerable; and his self-esteem could be decreased (Child & Higham, 2005) as his cooperation could be inhibited.
The need to build therapeutic relationship with the patient is paramount in gaining trust and respect (Rigby and Alexander, 2008). McCabe (2004) argues that the use of effective interpersonal skills, a basic component of nursing, must be patient centred. If I had been tense and negative, my client would not have enjoyed the conversation and would have felt uncomfortable and rushed (Kozier, et al 2008).
Communication is without doubt the medium through which the nurse-patient relationship takes place. The skills of active listening and reflection promote better communication and encourage empathy building. Caring for acutely mentally unwell patients requires of the nurse sensitivity, conveying warmth and empathy. Engaging meaningfully and actively listening to patients makes them perceive the practice as valuing rather than punishing, therapeutic rather than custodial. Communicating with patients is in itself nursing and therefore should be encouraged at all levels of nursing care. I feel my caring skill went well, because we were both relaxed and comfortable. As no problems occurred, I would do most things the same again.
My goal for the future is to develop my knowledge by reading about long term conditions like schizophrenia so as to give me insight into those conditions before administering care. If patients appear distressed, I would get other members of staff to help give reassurance to them. I will also use reflective discussions with mentors and peer groups about managing similar situations. Finally, I will be taking the initiative and not being timid about challenging situations- the more times I meet the challenge, the better equipped I become at learning to manage them.
Skill 3: Bed Bath
I was asked with a colleague to bath a dummy patient during a placement simulation.
The procedure was outlined by the lecturer present. I prepared the trolley with soap, bowl of warm water, soap and towel.I explained why I was going to give him a bath and gained consent. I drew the curtains to maintain patient’s privacy and dignity at all times. I washed my hands, put on apron and gloves to prevent infection and contamination and bathed him all round (front, back and sides including crevasses and folds) using separate towel for the private area. I covered the patient with the bath blanket to prevent chilling for his comfort. Whilst carrying out the bed bath I assessed his skin condition for any sores or broken skin.I treated the patient as if confined to bed or he is too unwell to attend to his own hygiene needs but able to communicate with me and reassured him everything was alright.
Before starting, I had many emotions running through me. I expressed that I did not have much confidence in performing the task. This was because I: (1) lacked experience, (2) was concerned that I would not perform to the patients’ expectations and (3) was still trying to adjust to the laboratory environment. I therefore felt embarrassed that my lack of confidence was so obvious to present lecturer and colleagues. I later felt calm but a little apprehensive due to this. Despite all these, I persevered and finished the task successfully.
What was good of this experience was that, I upheld the reputation of the profession by maintaining it (NMC, 2008) as I did not speak over the client nor did I ignore him at any point during the procedure The instructions about what I needed to do was clear and I understood it and this give him the utmost respect, comfort and safety. By washing my hands thoroughly before coming into contact with the patient, Pirie (2010) explains that micro-organisms are easily removed through the process of hand washing. With supervision and comments from the lecturer present, I completed the task without harming the patient. Thomas et al, (1997), explains that, supervision is an important development tool for all learners.
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What was not good about this experience was when I redressed the client without allowing the client to choose the dress which I will prevent happening again. Nurses are taught to include family members where possible, keeping them well informed constantly about the condition and health care which is taking place. This helps make families feel more comfortable and also enables them to gain a clear picture of what is going on.
Again, the lecturer was concerned that I appeared to lack confidence, and explained that, being able to express opinions clearly and confidently was essential in my future career as a nurse. In the lecturer’s view, the only way to develop confidence was to participate regularly which Bulman & Schutz (2008) confirms.
Skin care is a fundamental aspect of basic nursing care, with the outcome of these interventions often used to gauge the quality of the care provided (Voegelli, 2010). . Bathing involves actions to keep the skin clean and is essential for healthy skin (Dougherty & Lister 2008). There are essentially two bed bath options available for today’s health professional. Option one is the traditional soap and water bed bath which is labour intensive. Option two is the use of pre-packaged specialist bed bath wipes that come already impregnated with skin-friendly cleansers and moisturizers (Massa, 2010). Bathing is an intimate activity which requires physical assessment. Writers have described such intimate physical assessments as creating a potentially intrusive situation (Lewis 2006, Sturdy 2007) which might cause the patient to feel uncertain and inadequate. I was prepared not to overlook this area.
The use of curtains and screens helped maintain the person’s dignity and self-esteem (Child & Higham, 2005). Despite this, dignity is seldom defined and there are few guidelines that nurses may use in their practice to safeguard individual patients’ dignity (Dignity in care (DOH 2006).It is true that healthcare assistants and auxiliaries can perform bed bathing and attend to patients’ hygiene needs; there are also important roles for the registered nurse, as it is often during the bathing of a patient that the nurse/patient relationship develops (Downey et al, 2008). In addition, the observation of a patient during the process of bathing provides excellent opportunities to make more detailed assessment and observation of the patient’s condition and progress (Pegram et al 2007).
Without doubt, provision of bed bath clients is to promote personal hygiene and to give them a sense of well-being and allows the caregivers to monitor changes in the client’s skin condition (Evans, 2001). My reflective experience was very basic although a lot of the experience was preparation, planning and assessing which prevented the experience from going badly in anyway. I will also ask if they want to brush their teeth so that they feel more comfortable and also help prevent dental decay or any sores from developing around the gums. I now feel confident and comfortable enough to assist bathing people.
If a situation like this was to arise again I think I would like to try to take out more time to talk to the client about how they are feeling and involve him at every stage of the activity. I also feel that it is important for me to work alongside more experienced members of staff to be able to learn more whilst on my placements. I think it is worth highlighting that as this procedure was carried out on a manikin, it did not reflect proper nurse / patient interaction and that I will now need to try and develop this skill and what I have learned from it to the wider clinical context when assisting patients who really do need help meeting their hygiene needs. I have learned something about giving the patient’s choice but it really won’t be until I apply this skill into practice that I will receive feedback about how effective I’ve undertaken the task, from the person that really matters or is in the best place to help me evaluate my actions, that person being the patient.
Administering oral hygiene, bed bathing and how these are combined with care, compassion and communication forms the basis of a holistic approach to care, and with the knowledge I got from supporting literature formed the foundation of my learning and practice. This experience has undoubtedly enhanced my critical thinking as a nurse and prepared me to move forward in my development and practice as a caring and competent nurse. I see myself as being in the right job which offers many opportunities for development and to improve upon my knowledge and skills. I have clearly demonstrated that by using a reflective model as a guide I have been able to break down, make sense of, and learnt from my experience during my placements
In spite of above, the processes of learning I went through are more complex than Gibbs suggests. It is not as cyclical as this model implies and I found myself jumping or combining some stages, before coming back. However, it has taken me out of my comfort zone, challenging my thinking.
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