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In order to reflect upon my learning throughout this module, I will identify and critically discuss three Module Learning outcomes that reflect the range of possible issues of the Nursing and Midwifery Council (NMC) Proficiencies (2004). I will then identify appropriate literature and reflect on my learning and experience. This will enable me to identify personal strengths and areas for further development.
The first learning outcome is: ‘Recognise the importance of reflective practice and understand the process of reflection’. The second outcome chosen is: ‘Discuss the difference between data and information?’. The third outcome is: ‘Demonstrate appropriate non-verbal and verbal skills, including the use of silence, open and closed questions and summarising, to gather information’.
*Please note that the names of the patients mentioned in this essay have been changed in order to protect their identity for confidentiality reasons.
1 – Recognise the importance of reflective practice and understand the process of reflection
This outcome relates to the NMC Proficiency of ‘Demonstrate the responsibility for one’s own learning through the development of a Record of Achievement of practice and recognise when further learning is required’.
‘Reflection’ is a new method of learning for me. With regard to nursing, the term ‘reflection’ and ‘reflective practice’ has been defined by many academics, resulting in various models and theories being developed.
The Oxford Mini-dictionary for Nurses (2008) describes ‘reflection’ as the ‘careful consideration of personal actions, including the ability to review, analyse and evaluate situations during or after events. It is an essential part of the learning process that will result in new methods of approaching and understanding nursing practice’. Johns (2000) defines reflection as ‘a window through which the practitioner can view and focus self within the context of his/her own lived experience in ways that enable him/her to confront, understand and work towards resolving the contradictions within his/her practice between what is desirable and actual practice’. Schon (1983) proposed that reflection occurs ‘on action’ or ‘in action’. The first occurs after the incident whereas the latter occurs during the incident and is said to be the ‘hallmark of the experienced professional’ (Somerville & Keeling, 2004).
The more traditional theories and models base ‘reflection’ on critical incidents. Love (1996) states that a critical incident does not have to be negative or dramatic but should provide deep thought and raise a professional issue. Gibbs (1988) developed The Reflective Cycle. The model divides the reflective process into sections; Description, Feelings, Evaluation, Analysis, Conclusion and Action Plan (see Appendix 1). Johns (2000) developed a ‘Model of Structured Reflection’ (MSR) (see Appendix 2) As with Gibbs (1988) Reflective Cycle, the MSR uses a series of questions to guide an individual through the reflective process. Johns’ model is based on five cue questions; Description, Reflection, Influencing Factors, Could I have dealt with it better? and Learning.
The volume of studies and models on ‘reflection’ demonstrates the value that is placed on this tool. Newell (1992) described the process of reflection to be ‘a cornerstone of nursing professionalism’. Gustafsson and Fagerberg (2004) support the notion that reflection is a vital tool and advantageous in terms of the improvement of a nurse’s professional development and patient care.
Many consider journal writing to be an effective reflection strategy (Johns 2000; Paterson, 1995; Cameron & Mitchell, 1993; Lauterbach & Becker, 1996). Journal writing is considered to ‘offer writers the opportunity to become participants/observers of their own learning, to describe a significant experience and to reflect on that experience to see what they can learn from having had it’ (Weisberg and Duffin, 1995). While in clinical practice, I have written a journal of my experiences. I recognise its value to aid reflection as I feel that the act of writing things down is important. This is supported by Somerville and Keeling (2004).
To demonstrate my understanding of reflective practice, I will now reflect on an incident that occurred while on placement when I was feeding a patient, named Tom*. I will utilise Gibbs’ (1988) model as this is my first experience of using reflection and feel that it is concise and appropriate at this stage.
Tom had dementia and had recently suffered a stroke, which had left him confined to bed. As Tom had difficulty feeding himself, I offered to assist him; he smiled, agreed and appeared to recognise me. Halfway through the meal, Tom became agitated and asked if the food was mackerel. I told him that it was turkey. He shouted aggressively that he wanted mackerel and then became verbally abusive towards me. I was unable to calm him so I left the room with an assurance that I would be back soon. I then asked a senior nurse for help.
This was the first time that I had fed a patient but felt comfortable. I knew Tom well and felt that I had built up a rapport with him. I was pleased that he seemed happy and relaxed. When he shouted I felt shocked, worried and conscious of other people’s reactions; they may think that I had done something wrong. Even though Tom was disabled he did have some use of one arm so I was afraid that he might become violent. I was upset that I had to stop feeding him and leave the room. When I left I felt relieved but also anxious that I may have contributed to the way Tom was feeling.
When evaluating and analysing the incident, I was pleased initially with the way the task started as on admission he had a poor appetite. The negative side of the situation was that Tom became angry and didn’t finish his meal.
I realise that dementia is a complex progressive illness and there may be times when a patient experiences sudden mood changes.
I believe that I would now do things differently if a similar situation arose. With hindsight, I questioned whether I should have just agreed with Tom that the turkey was mackerel then this incident may not have occurred. However, this raises ethical issues such as whether it can be acceptable to not tell the truth. A report published by the Nuffield Council on Bioethics (2009) discusses the ethics of dementia care and states that ‘ethical dilemmas arise on a daily basis for all those providing care for people with dementia’. Research suggests that challenging someone with dementia could be detrimental and cause unnecessary distress (Shellenberger, 2004). Naomi Feil developed ‘validation therapy’ between 1963 and 1980 as a technique to communicate with patients with dementia by recognising and accepting their view of reality of people with dementia in order to provide them with empathy and respect (The Validation Training Institute, Inc). In the future I could use this technique; for example, when Tom asked if it was mackerel he was eating I could have replied by asking him if he liked mackerel which would have avoided giving a direct answer.
With regard to strengths and areas of development, I feel that I have reflected successfully on this incident. However I would like to strive to reflect ‘in action’ as opposed to ‘on action’ as this is the most effective. In terms of development, I believe that it would be beneficial to patients and myself to learn more about caring for patients with dementia. The Dementia UK Report (2007) published by The Alzheimer’s Society states that ‘there are currently 700,000 people with dementia in the UK. The report also predicts that by 2025 there will be over 1 million people with dementia so it is inevitable that I will be caring for many dementia patients in my career.
In summary, although the models of reflection span over 20 years and vary slightly, the principle of reflection is very similar, which implies that reflection is a robust tool and still applies to modern nursing. I have learnt that reflective practice is a vital tool, particularly when associated with journal writing. Continuous reflection will allow me to develop skills and knowledge to enable me to provide the best care possible for patients and their families.
2 – Discuss the difference between data and information
This learning outcome links to the NMC proficiency of ‘Demonstrate literacy, numeracy and computer skills needed to record, enter, store, retrieve and organise data essential for care delivery’.
As a student I’m not involved in using my computer skills on the ward but eventually will be involved in audit and data entry. My literacy and computer skills are demonstrated throughout my portfolio and assignment. I demonstrate my literacy and numeracy skills when writing patient evaluations, calculating fluid balance and assisting with drug calculations.
There are many examples of data and information used within nursing care. Due to the broad nature of this area I have focused on a particular type of ‘data’ and ‘information’ to demonstrate my understanding of these terms. My focus is data collected from patients’ vital signs and the ‘information’ that relates to this. I will demonstrate how the process of giving ‘information’ to patients rather than just ‘data’ is an essential part of nursing.
Gathering, giving and recording both data and information accurately is vital. ‘Data’ can be described as ‘facts and statistics used for reference or analysis’. The term ‘information’ can be defined as the meaning applied to the data (Concise Oxford English Dictionary, 2008).
Observation data collected from patients includes pulse rate and rhythm, blood pressure, respiration rate, temperature and oxygen saturate percentage. These measurements are taken on admission as it is important to gain base-line readings to which future readings can be compared. It is necessary to apply meaning to this data to form information to be able to judge a patient’s condition.
Throughout the module I have learnt what data means in terms of acceptable values. As I now have the information about the data I can make judgments about data. For example, I now know that the information I can get from the blood pressure data of 160/110 mmHg is ‘high’ (Blood Pressure Association). However, this information needs to be put into context to allow use of the information to make a judgement. For example, if a patient has just completed cardiovascular exercise, this may account for a high blood pressure reading. With this information, the plan would be to wait for 30 minutes before repeating to gain more accurate data. Readings can vary temporarily due to a number of reasons; for example, medication, an existing health condition, fluid intake, exercise and alcohol consumption. However, a change in blood pressure can indicate deterioration in condition, which alerts health care professionals to investigate.
In order to show my understanding of the difference between data and information I will now give an example of an incident that occurred while on placement.
During observations of a 70 year-old lady named Eileen*, I noticed that her systolic blood pressure had dropped from 127 to 90 mmHg. Her other observations remained consistent. I informed a senior nurse who asked a doctor to review the patient. I discussed her fluid intake with her as this could have had an adverse effect on her blood pressure. As she had only drank a small amount I encouraged her to drink more and continued monitoring. Eileen’s blood pressure eventually returned to her baseline. This example shows how data, such as blood pressure readings, prompts gathering information which, in turn, enables problem solving.
As demonstrated, I need to have an understanding of the information gathered from the data but additionally I feel that it is important that patients understand what the data means. Bastable (2006) defined ‘patient education’ as the ‘process of assisting people to learn health related behaviours so that they can incorporate those behaviours into everyday life and achieve a goal of optimal health and independence in self care’.
I will now provide an example of my experience of patient education: During a blood pressure check on Paul*, who was hypertensive and took multiple medications, I asked him whether he would like to learn about blood pressures. He gladly agreed so I explained what the reading was and what can affect blood pressure. I explained that exercise, healthy eating, low salt intake and weight control would have a beneficial effect on his blood pressure. He was unaware of how his current lifestyle could have a detrimental effect on blood pressure and said that he now intended to make some lifestyle changes.
Research supports my thoughts about the benefits of giving patients information about aspects of their health rather than just the data. Florence Nightingale, who has been described as the founder of modern nursing, recognised the importance of educating about adequate nutrition, personal hygiene and exercise in order to improve well-being (Bastable, 2006). The Department of Health (2009) states that ‘giving people relevant, reliable information enables them to understand their health requirements and make the right choice for themselves and their families’. (Bastable, 2008). Partridge and Hill (2000) found that patients who are well informed are better able to manage their health, have improved psychological outcomes, have fewer exacerbations of their condition and less hospital admissions. Glanville (2000) states that ‘if clients cannot maintain or improve their health status when on their own, we have failed to help them reach their potential’. Abbott (1998) reported that by involving patients in their state of health by keeping them informed has been proved to improve patient satisfaction and concordance. However, there is research to suggest that providing information may not result in a change in health outcomes (Kole, 1995; Sherer et al. 1998). They found these reasons to be that patients don’t understand the information, are unable to absorb it due to pain, anxiety, or that they choose not to act upon it. Additionally, absorption of information is decreased when there is too much information; therefore health outcomes remain unchanged. The question is how much is too much information? This is difficult to determine.
In terms of personal strengths, I felt very satisfied that I had initiated this conversation which resulted in Paul considering lifestyle changes. On reflection, this incident highlighted the importance of patient understanding and has encouraged me to take time to educate patients where possible. It has emphasised the need for continuous learning so that I am able to answer questions and educate patients. Additionally, I am aware of my limitations and when to seek advice or refer patients to others. I also need to develop confidence in speaking to patients about sensitive issues such as weight management by researching this area.
3 – Demonstrate appropriate non-verbal and verbal skills, including the use of silence, open and closed questions and summarising, to gather information
This outcome relates to the NMC Proficiency of ‘Engage in, develop and disengage from therapeutic relationships through the use of appropriate communication and interpersonal skills’.
Communication is a ‘reciprocal process that involves the exchange of both verbal and non verbal messages to convey feelings, information, ideas and knowledge’ (Wilkinson 1999; Wallace 2001). In nursing, communication and information gathering is essential to provide quality care. Sheldon, Barrett & Ellington (2006) report that ‘Communication is a cornerstone of the nurse-patient relationship’.
Information gathering commences from when the nurse greets the patient. In order to communicate non-verbal and verbal cues are used. Non-verbal skills are portrayed with body language and impact on communication (Hargie & Dickson 2004). These include posture, facial expressions, head movement, eye contact and hand gestures showing active listening. Verbal skills include the use of silence, open and closed questions and summarising. The tone of voice and rate of response are significant.
The emphasis is on effective communication; the way we communicate can hinder or enhance the information we gather. Sheldon et al. (2006) state that ‘the power of effective nursing care is strengthened and enriched by good communication’. Maguire and Pitceathly (2002) suggest that clinicians with good communication skills identify patients’ problems more accurately, patients are more satisfied with their care and are less anxious. It has been reported that that ineffective communication can lead to patients not engaging with the healthcare system, refusing to follow recommended advice and failing to cope with the psychological consequences of their illness (Berry, 2007).
The scenario below demonstrates my understanding of appropriate verbal and non-verbal cues. It is part of a conversation with a patient on admission regarding current medical history.
When meeting Arthur*, a 78 year old, I smiled, introduced myself and explained the purpose of our conversation. I asked Arthur ‘Do you have any chest problems?’ he answered ‘Yes’. I then asked ‘What chest problems do you have and how do they affect you?’ he answered ‘I have emphysema causing wheezing and a cough. I also get breathless when walking and have oxygen at night’ I left a brief silence at this point. Arthur then disclosed ‘I cough up a lot of horrible phlegm in the morning which is embarrassing’. He then asked ‘will I get a chest x-ray’. I asked ‘Have you any particular worries about your chest?’ to which he replied ‘well I am quite worried about lung cancer’. I told him that I would pass on his concern to the doctor and then summarised our conversation.
With regard to verbal responses, I initially asked a closed question as I wanted a specific answer. Silverman et al. (2005) supports the theory that closed questions are appropriate when wanting to narrow the potential answer. Due to Arthur’s response I asked an open question to encourage him to go into more detail. An open question often results in a lengthy answer, so I used fillers such as ‘mmm’ throughout, to show active listening and to encourage him to continue. The brief pause was successful as it enabled Arthur to disclose his embarrassment. I summarised his response in order to clarify what Arthur had said for my own benefit but also to give the patient confidence that I had understood and opportunity to correct me if not.
With regard to my non-verbal communication, I kept an open posture with eye contact and leant forward slightly to show that I was listening. I also ensured that my facial expressions were appropriate. For example, when greeting Arthur I smiled, but during descriptions of distressing symptoms my facial expression was one of concern. Egan (2002) supports the notion that conveying these non-verbal cues in this way will facilitate emotional disclosure and encourage the patient to talk more freely. Egan derived the acronym SOLER to portray awareness of the non-verbal responses; facing squarely, maintaining an open posture, leaning slightly forward, having appropriate eye contact and being relaxed. There are approximately 700,000 different non-verbal cues that may or may not have meaning (Birdwhistell, 1970; Pei, 1997). As nurses, we must be aware of our use of non-verbal cues as they can convey unintentional meaning.
In addition to awareness of our responses it is imperative to be aware of patient cues, as this is part of the information gathering process. Arthur’s hesitancy indicated to me to remain silent to encourage further disclosure.
Being aware of patients’ verbal responses is more straightforward than what their non-verbal responses convey and it may be that patients’ body language contradict the spoken word (Miller, 1995).
Barriers to communication include anxiety, language, hearing, sight or speech impairment. During communication, I would like to think that I am non judgemental. According to Underman Boggs (1999) most of us have personal biases regarding others that are based on previous experiences. In relation to my scenario, Fuller (1995) suggests that health care professionals may underestimate the verbal capacity or abilities of older people, which results in their conversations being undervalued.
In terms of personal strengths, I feel fairly confident with the use of verbal and non-verbal cues and how these can deter or catalyse communication. I feel that I used silence successfully as Arthur disclosed embarrassment and mentioned about an x-ray, which he may not have done otherwise. I was able to reassure him that we would provide a disposable sputum pot and acknowledged his fear of cancer. I realise that it can be difficult communicating about sensitive information and this is an area of development for me, which I feel will improve with experience. Although at this stage of training I would not be expected to lead consultations for diagnostic purposes, it was informative to research ‘consultation models’. I intend to become more familiar with these models in order to utilise some of the communication skills (Newell, 1994).
To form an overall conclusion, I feel that through theoretical learning and clinical experience I have demonstrated my achievement of the NMC Proficiencies (2004). I have critically discussed and concluded each learning outcome in turn throughout the essay but to summarise; patient focus and effective communication are paramount. I feel that in terms of reflection, self-awareness is key (Rowe, 1999). This will enable me to look at my skills to recognise strengths and areas of development to ultimately provide best practice in patient care. I realise that I will gain experience and confidence as my training progresses.
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