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Foundations of Nursing Practice Essay

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A reflection on how the module content and associated practice experience has contributed to the student’s development as a nurse.

This essay is a discussion on how the module content and practice experience has contributed to personal development as a nurse. Therefore it will focus on firstly the concept of individualised care and its relevance to nursing assessment and care delivery, secondly the ethical and professional issues that impact nursing such as confidentiality, consent and dignity. The essay will also focus on exploring the various communication models and the development of the therapeutic relationship between the nurse and the service user, and finally the organisation and delivery of care within the practice environment. With particular reference to a recent placement, at a palliative care nursing home, this essay will discuss Harriet, an 88 year old lady with chronic bronchitis and suffers with multiple sclerosis. For confidentiality purposes the names of service users have been changed to comply with the Nursing and Midwifery Council, Code of Conduct (NMC 2008).

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This assignment will firstly discuss the individualised approach to nursing, which developed in the USA during the 1950’s and 1960’s, which coincided with the development of the nursing theory and models of nursing which began to challenge the medical model of health care (Lloyd, Hancock, Campbell 2007). The nursing process can be carried out successfully by implementing a popular model used extensively in the UK originally by Roper et al Activities of Living model in which it is based loosely upon the 12 activities of daily living; however Henderson acknowledges 14 activities that people engage in (Kozier, Erb 2008). This model identifies any deficit in their care usually upon admission; it is reviewed as the care plans of the service user evolve; after which an intervention may be given to the service user. The nursing home that was attended for placement had person centred care plans in which they based them on the 12 activities of daily living from sleeping, eating and drinking to mobility and communication; these were short term care plans that were reviewed monthly.

Another model that is frequently used described by Ellson (2008, pg22) is the Nursing Process, when it was initially identified; Yura and Walsh (1978)
showed that it is a four stage cycle that begins with assessment. Harriet was assessed by the Doctor as the registered nurse in charge (RGN) noticed a change in her health; she had developed a wheeze when talking and had a chesty cough, the RGN suspected a chest infection. A care plan was then devised to follow up the assessment. Harriet was to be started on a course of antibiotics for a week, and was to be resumed on her nebuliser. The care was then implemented the following day during the morning drugs round. An evaluation of that care completes the cycle; in which Harriet was to be seen by the Doctor the following week after completing her course of antibiotics and was to remain on her nebuliser.

Additionally, more than one stage can be occurring at the same time, for instance assessment may coincide with implementation (Carpenito-Moyet 2007). If goals are achieved after the first cycle, care maybe terminated or in some cases modified and the service user reassessed. (Ellson 2008, pg22) This process is designed to enhance systematic care, drive communication amongst team members and encourage continuity (Mason 1999 cited in Habermann, Uys 2006).The RGN wrote in Harriet’s daily report and updated her care plans, identifying her change in medication and change in her health.

Throughout nursing there are many ethical and professional issues that impact on it from confidentiality, consent to respect and dignity, to clear and accurate records and working as part of a team. The Nursing and Midwifery Council Code of Conduct (NMC 2008) clearly states that nurses should ensure they gain consent (NMC 2008) from the service user this can be anything from examining, providing care and giving treatment. Consequently a nurse has to be prepared if a service user declines their help as they have a right to refuse treatment based on knowledge of the outcomes and risks (Wilkins and Williams 2008). Informed consent is a communication process between the provider and the service user; this is now recognised as a professional standard of conduct (Westrick and Dempski 2009).

However if there is a case where the service user does not have the mental capacity to give consent, they are protected by the Mental Capacity Act 2005 in which during the decision making process their rights and interests are accounted for (Griffith and Tengnah 2010). My first task at placement was to try and feed Harriet, I introduced myself alongside a health care assistant and asked if I was able to feed her lunch, I was refused, on the grounds that I was a fresh face and that she did not know me so I let the health care assistant feed her. The following day after assisting the RGN with Harriet’s medication, she kindly said to me that she would let me feed her today if I was able to; so at lunch time I went along with another health care assistant to feed her.

Another important ethical issue is maintaining a person’s dignity as Watson (1994) citing (Watson 2008) states that maintaining human dignity is a vital nursing duty and function, that needs to be recognised and respected in which people make to their own care and well being (NMC Code 2008). This can be associated with many aspects of care such as bed bathing, stoma care, peg tube care as Westrick and Dempski (2009) go on to say that it is down to the service user to say what is to be done with his or her body. Fenton and Mitchell (2002) cited in Franklin, Ternestedt and Nordenfelt (2006) argue that elderly people receiving care regarding dignity is a state of physical, emotional comfort, subsequently when this is not always adhered to it can leave the service user feeling embarrassment, shame, humiliation, foolishness and degradation (Mairis 1994 cited in Watson 2008).

However nurses themselves can become emotional if the standard of care given is not sufficient this is supported by the Royal College of Nursing survey (2008) asking nurses for their views on dignity in care in which over 80% said they sometimes or always left work distressed due to not being able to deliver the quality of care they thought they should give (Gallagher, Tschudin 2010). When asked to give a bed bath to Harriet, I made sure that only the area being cleaned was exposed thus covering up other private areas in case anybody was to enter her room. When Harriet was seen by the Doctor regarding her chest infection I treated the information sensitively and maintained confidentiality with all her health records.

The presence of the therapeutic relationship lies at the heart of patient centred nursing. However the nature of this one to one relationship is very dependent on the context in which nursing care is delivered (McCormack 2004 citing O’Connell 2008). Therefore the building blocks for this relationship should focus on genuineness, empathy and respect, which should leave the service user feeling supported as well as listened to, whilst the nurse feels value in their role (Dossey, Keegan, American Holistic Nurses Association 2008) Whereas Bynum-Grant and Travis–Dinkins (2010) go on to say that whilst the therapeutic relationship is at the core of nursing it is the knowledge and skill along with the caring attitudes and behaviours applied that build the foundations of this relationship. I spent a lot of time with Harriet getting to know her, and building a relationship of trust with her, in order for me to attend her personal care needs, give her medication orally under direct supervision.

This assignment will now discuss the effective communication skills throughout nursing that helps practitioners to engage with the service user, by making sure arrangements are met for people’s language and communication needs (NMC Code 2008) Studies have shown that the relevant communication means given to an individual can improve well-being (Bell 1996, Happ 2001 cited in Batty 2009). Means of communication that have proved successful are non verbal techniques such as writing, drawing or by gesture, therefore communication aids have been made available such as providing a pen and paper, or alphabet charts (Batty 2009).

Effective communication is seen as a fundamental competence required for registration as a nurse (Nursing and Midwifery Council 2004 cited in Timmins 2009) Timmins and Astin (2009) also goes onto explain that continuity of care supports high quality communication as it builds up the relationship between nurse and service user and is a main feature of patient centred care. Crouch and Meurier (2005) cited in Cox and Hill (2010) defines communication as a two way process in which information is transmitted and received.

However listening to service users and their families is central to the communication process (Timmins and Astin 2009) Harriet could communicate easily, her hearing was slightly impaired therefore you had to speak loudly and clearly; she was on eye drops as her sight was deteriorating and she was very well spoken and if I was to say something incorrectly she would be very quick to correct me. Harriet however was slightly confused and sometimes repeated things she had said a few moments ago, she also had imaginary friends she would refer to whilst talking to me.

This essay will now explore the delivery of care in nursing which is very important as this can impact the service users’ experience. There are three ways in which care can be delivered; this is by primary care, task allocation and team nursing. Primary nursing began in the 1970’s as a way to overcome dissatisfaction with functional and team nursing’s emphasis on tasks that directed nurses’ attention away from holistic care of the client (Huber 2006).

Walsh and Crumbie (2007) explain that primary care nursing involves one nurse being liable 24 hours a day for all care delivered to a patient. However Thomas (2006) identifies this is not always necessary as care can be delegated to other nurses or health care assistants … yet the primary nurse carries responsibility for writing care plans and ensuring that long term goals are met. Skelton (2001) cited in Timmins and Astin (2009) suggest that this approach fosters autonomy and gets them involved with their care rather than health professionals dictating their care to them. Within the nursing home the primary nursing approach to care was not suitable as there were too many service users for one nurse to focus all their attention to at one time.

Many health care settings would deny using task orientated care however in reality it still goes on and tends to induce apathy and reduce team morale. Task allocation on the other hand may be the most suitable way of allocating the workload (Thomas 2006) especially during staff shortages or certain health care settings. Despite the nursing home having person centred care plans and making individualising the care needs, the nursing home still took on the task allocated approach as all the residents had breakfast by 8am and were washed and dressed by 9am. However as Harriet was unable to feed and dress herself due to having multiple sclerosis she was often left until last to have these needs addressed as two health care assistant’s were required.

Team nursing was developed in the early 1950’s it was designed so that staff strengths can be used to the maximum and aids group productivity and growth of team members. By using this system nurses should still be able to provide individualised nursing care (Lloyd, Hancock and Campbell 2007) therefore nurses take on certain roles such as temperature, medication or a nurse for the right side of the ward (Kalisch and Kalisch 1978; Reverby 1987 cited in Huber 2006).

Communication is therefore key for this model to be effective as the team leader continuously evaluates and communicates changes of the patient to the team members (Zerwekh, Claborn 2006). It also allows the nurse to delegate patients to the strengths of the staff with what their care focuses on (Tiedeman and Lookinland 2004 cited in Zerwekh, Claborn 2006). Unfortunately the care given can become fragmented and thus ineffective and productivity decreased among team members if there are staff shortages. Harriet’s care followed this approach, as she was bed bound the arjo hoist was the only way of transferring her from bed to chair; this required two people, as did log rolling Harriet for her bed bath so she was cleaned effectively and appropriately.

I feel the module content has contributed to my development as a nurse as it taught all the relevant information needed for my first placement. I was able to see how the theory coincided with the practice which also contributed to my development as a nurse. For example I was able to see how the individualised care approach was introduced into the person centred care plans used within the nursing home. I was also able to see how the therapeutic relationship was built amongst the nurses in charge, the health care assistants and other members of the multidisciplinary team, they each had their own style of approaching the service user in regards to their attitudes, body language and behaviour, this I was able to pick up and use myself which made me handle situations better.

The module content went into great depth and was given in a variety of learning styles which suited my learning pattern having come straight from school; I feel the type of learning given has strengthened my ability to learn and the relevant theory made me feel more confident when attending placement. Having learnt the theory I was able to put some of this knowledgeable experience into practice, as having had no previous experience within health and social care I felt uneasy at first but as more faith and confidence was put into me via my mentor and other staff members, this helped me feel more involved and more comfortable with working within this environment giving me the confidence boost I needed. Throughout the placement I was guided throughout every task that I had to carry out, I was taught it first by mentor and then throughout the weeks I had to improve on what I had learnt, the registered nurses I shadowed were very supportive and approachable which helped me greatly.

In conclusion this essay has discussed the concept of individualised care by incorporating the nursing process and models that evaluate the service user’s health and identifies the care needed and any deficits in their care. Nurses uphold a reputation in which the ethical and professional issues are the foundations of this. As explored throughout this essay it shows that confidentiality, consent and dignity are fundamental throughout nursing and need to be incorporated into the care provided by the nurses.

Various models of communication have been identified throughout this essay its relevance shows how the nurse must interact with service user, this is very important as the service user needs to be able to express their concerns of their health either verbally or non verbally. The therapeutic relationship is at the epicentre of nursing as this can impact a service users experience within a health and social care setting. The essay has also explored the organisation and delivery of care needed to be most effective throughout nursing. Overall the essay has focused on various fundamental aspects of nursing that contribute to the way care is delivered to service users.

Reference List
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* Bynum – Grant D and Travis Dinkins M,M. (2010) Schaum’s Outline of Psychiatric Nursing. [Online]. Available at: http://books.google.co.uk/books?id=ru57ujcVO6sC&printsec=frontcover&dq=schaum’s+outline+of+psychiatric+nursing&hl=en&ei=XcZmTeb7HZSyhAfUkJy4DQ&sa=X&oi=book_result&ct=book-thumbnail&resnum=1&ved=0CEUQ6wEwAA#v=onepage&q=therapeutic%20relationship%20is%20at%20the%20core%20of%20nursing%20&f=false. (Accessed:25 January 2011).

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