From the 16th Century mental health patients were contained in asylums until mental health hospitals were introduced during the 1950’s. Sometimes people who were a disruptive or were only reacting in a normal way to difficulties in their lives were ‘put away’. Often patients were excessively medicated and subject to treatment which would be totally unacceptable today such as ‘muffling’ or being put in a ‘swing chair’. In the 1960’s, inadequacy and cost resulted in mental health hospitals closing and care moving to general hospitals. Patients who were allowed home at the weekends recovered more quickly and therefore care increasingly moved to the community (Hannigan and Coffey 2003), where most people with mental health problems are cared for today (NHS 2010). Legislation such as the 1959 and subsequent 1983 Mental Health Act, and the Care Community Act (1990) are relative to modern community mental health nursing. In 1999 the Government confirmed mental health was a top priority in the Health Service (Jackson & Hill 2006). Since then guidelines such as the Department of Health guidance (2003), the National Service Framework for Mental Health (1997) and the NHS Plan (2000) (cited in Jackson et al 2006) have been introduced to reform and improve services for people with mental health problems and their carers. The Department of Health have also investing significantly in inpatient mental health settings due to issues such as a not enough beds being available, the lack of privacy and dignity of patients and wards not supporting provision of self care (DOH 2009). As a result many new opportunities have been created for mental health nurses over the last few years, for example the modern matron and nurse consultant, and new skills have been developed, such as nurse prescribing and psychosocial interventions (Brimblecombe 2009). Mental health nurses will work with children and adults who suffer with various mental health problems. The primary role being to form therapeutic relationships with patients (sometimes called clients) and their families to help them recover from their illness and promote independent living (NHS 2010). Mental health nursing is varied and complex, for example treatment may include conventional nursing interventions such as administering drugs and injections or it may be to encourage patients to take part in art, drama or occupational therapy. In order to care for people in a fair and anti-discriminatory way and deliver care holistically, mental health nurses need to have good knowledge of the theories of mental health and illness, psychological and biophysical sciences and personality and human behavior (Hannigan et al 2003). One in four people will suffer with a mental health illness at some point during their life and one in twelve will require medical intervention (Mind 2010). Women are 1.5 times more likely to suffer with anxiety and depression whilst men are more likely to suffer from substance abuse and anti social personality disorders. For some patients a mental illness is triggered by a crisis in their life, which they can’t cope with, such as depression following the death of a partner (NHS 2009). Some of the more familiar mental health illnesses are anxiety, depression, schizophrenia, eating disorders, drug and alcohol addition, personality disorders and impulse control such as gambling. Some of these illnesses will require treatment in hospital but many will be treated in primary care settings, such as outpatient clinics, schools, community mental health centres, residential facilities, prisons and day treatment centres (Hannigan et al 2003). Care is person-centered and mental health nurses will work within a professional multi-disciplinary team which will include GP’s, psychiatrists and social workers and other health care professionals. A mental health nurse will require good interpersonal and communication skills. They will to demonstrate sensitivity when caring for patients, for example there is still some stigma attached to people with mental health problems and it is important for a nurse to help the individual and their families deal with this (NHS 2010). Dealing with the human mind and behavior is not an exact science and sometimes people with mental health problems can be violent, one skill a nurse will be required to have is to recognise building tension and diffuse it when necessary to maintain the patient’s and others safety (NHS 2010). Sometimes nurses may find themselves faced with awkward situations, and be required to apply ethical principles, such controversial issues which cannot be disclosed and where confidentiality needs to be maintained (NMC 2008). On the other hand if someone is at risk of serious harm, have an infectious disease or criminal activity is involved they may have to inform the appropriate bodies (Hannigan et al 2003). Nurses may find themselves giving care or treatment which is against their beliefs, for example someone addicted to drugs may request a supply even though medically it is not in their best interest or an anorexic patient might protest when food when the nurse tries to care for them (Hannigan et al 2003) . In practice, mental health nurses will come across difficult situations were an assessment of the capacity and ability of a person to consent will be required. People with mental health disorders have the same rights to consent or refuse treatment as those with physical illnesses unless some mental health issue means they are unable to make a decision. Nurses need to support patients to take responsibility for their own well-being and make informed decisions by providing information which is accessible and understandable (Mind 2010). This may mean working with the clients, advocates and carers to ensure it happens. Although giving certain treatments might be in the client’s best interest it not enough to impose treatment without consent. In some circumstances a small number of people with mental health problems will be detained under the Mental Health Act (1983) (Hinchcliff et al 2003). To conclude mental health care has developed considerably over the last few years. Mental health nursing is not an exact science but is varied and complex and is about building therapeutic relationships with people and understanding and reacting appropriately to individual circumstances and needs to promote recovery and maximise life potential.
People with learning disabilities have been treated as second class citizens for many years, once being seen as possessed by evil spirits or being punished by God for a sin they may have committed. In the 19th century they were removed from their families and lived in purpose built institutions, treated as sick and in need of treatment (Brown & Benson 1995). During the 1970’s care moved to the community (Brigden & Todd 1993) where it largely remains today. Approximately 1.5 million people have a learning disability, the majority of which live at home with their families or in community care settings (Mencap 2009). Relatively few live by themselves or with a partner (Emerson, Davies, Spencer, & Malam 2005). Turnbull and Chapman (2010) describe a learning disability as being a lifelong condition, which may be genetic or environmental and vary in degree of impairment. Sowney (2006) suggests all learning disabilities have common features including impaired intelligence and social functioning which has a lasting effect on development. According to Mencap (2009) people with learning disabilities live an average of 50-55 years and sometimes up to 70 years old. A learning disability nurse can therefore expect to nurse a range of patients from birth to the elderly and will need to demonstrate a patient centred approach and work in partnership with the patient to help them meet their health, social, emotional, developmental and behavioral needs (NHS 2009). Although a learning disability is not an indication of a physical disability or ill health, people with learning disabilities generally have more complicated problems and require more nursing interventions than the general population. In the young person some of the more common problems include respiratory problems, epilepsy, sensory and motor impairments, hypertension, thyroid disease and cancer and in elderly adults common problems include loss of hearing, vision and mobility, heart conditions, diabetes, fractures and osteoporosis (Davis 2008). Generic issues include communication difficulties, conditions relating to specific syndromes, challenging behavior and delayed development (University of Nottingham 2010). A learning disability nurse needs the skills to work within both simple and complex health areas. Communication is a vital skill for the learning disability nurse, hospitalisation for a patient with a learning disability can be very distressing and it is important to build therapeutic relationships based on trust and understanding. In the past access to healthcare services for patients with learning disabilities has sometimes unintentionally been denied. A learning disability nurse can help to overcome these prejudices by ensuring people with learning disabilities are not discriminated against and have the same opportunities as the rest of the population (Brittle 2004). People with learning disabilities are the most vulnerable and socially excluded in our society (DOH 2001). A learning disability nurse works in partnership with both the patient and family carers to provide healthcare, and should recognise each person’s uniqueness, individuality and differing abilities. The learning disabilities nurse’s main aims will be to support the well-being and social inclusion of people with learning disabilities, their rights, choices and independence by improving or maintaining their physical and mental health so they can pursue a fulfilling life whatever their ability (DOH 2009). For example teaching someone the skills needed to find work can help them lead an independent life with equal opportunities (NHS 2009). Many complex issues working with patients with learning disabilities relate to ethical aspects of care, and may be related to an individual’s rights and welfare, public welfare or inequality. For example a learning disability nurse may need to assess the capacity and ability of a person to consent to treatment (Hinchcliff, Norman & Schober 2003). Every effort should be made to provide information in a format the patient can understand, which might be in the form of pictures, alternative communication methods, using short sentences, repeating explanations and giving them time to make a decision (Brittle 2004). Previous experience may mean a person with a learning disability has not been given the opportunity to make their own choice regarding their individual treatment and care (Turnbull et al 2010) and involving family, friends or an advocate, where possible may help them understand the care and treatment offered to enable them to make their own decision (DOH 2001). In some situations people with learning disabilities may have the capacity to consent to straightforward nursing activities but may lack capacity to consent to more complex procedures (DOH 2001). Other ethical issues may involve the family or carer, for example, a person with learning disabilities may receive some benefits which they may wish to have control over and decide how it is spent. The carer on the other hand may see it as part of the household income and wish to control of it. Or maybe the parents or carers, due to ill health are unable to continue with full time care of a person with learning disabilities in their own home. Nurses will require good negotiation skills to support individuals and carers through dilemmas such whilst working within ethical guidelines, with the person being supported remaining the central focus (Thomas & Woods 2003). Other ethical issues might involve psychosocial and lifestyle issues such as overeating or drug abuse which might raise concerns about control and freedom of choice (Davis 2008). Opportunities for learning disabilities nurses exist in both hospital environments and the community. They will specialise in many areas which might include education, sensory disability or the management of services (NHS 2009). They will work within the multi-disciplinary team of their preferred environment, for example a learning difficulty liaison nurse will work with other staff, patients and carers to develop therapeutic relationships and ensure people with learning disabilities have a positive healthcare experience (Brittle 2004). To conclude people with learning disabilities have very similar health issues to that of the general population. However it is important that the learning disabilities nurse exercises a person centered approach, develops a therapeutic relationship and understands a person with learning disabilities personal needs in order to support their wellbeing and promote social inclusion, rights, choices and independence to enable them to enjoy the same health care rights as everyone else.
The Children’s branch of nursing is relatively new, in 1959 The Minster of Heath first recommended that children have the right to be nursed by specially trained, qualified staff who understood children’s individual needs but it wasn’t until 1988 dedicated training courses were set up to provide nurses with the specific skills and knowledge to nurse children whose physical, physiological and social needs are different to that of adults (Hubbard & Trig 2000). Sick children’s rights have only recently been acknowledged despite children making up 25% of the population. But now many reports and policies are aimed at improving children’s services and recent statute law has given children increased rights (Hubbard et al 2000).The Children’s Act (1989 & 2004) highlights their rights; Every Child Matters endorses working in partnership with other organisations to ensure children are safeguarded and receive the best care available and The National Service Framework (NSF) 2004) outlines a vision to provide a high quality child centred care for both children and their parents (Chambers & Licence 2005). These policies give direction today and will shape the future of children’s nursing. Nurses need to understand how they apply and what implications there might be when caring for children. For example, one of the most common reasons for children being admitted to hospital is due to injury from accidents, however if the injuries cannot be explained and physical or mental child abuse is suspected, the nurse will have an ethical duty to work with other agencies and professionals such as the Child Protection Services (Hubbard et al 2000). Children’s nurses work with children from birth up to 18 years old in many settings from special baby care units to adolescent services (Chambers et al 2005). In order to provide care in a fair and anti-discriminatory way they need to understand the effect age and development has on a child’s health and how the delivery of treatment and care will need to be modified accordingly. This will differ considerably from a newborn baby to an adolescent. For example when assessing medication the weight and development of a child, will need to be taken into consideration as well as which drugs come in a form which can be easily administered. Appropriate care plans will need developing and updating for evaluation and referrals made as necessary for Doctors to review (Robertson & South 2006). The age and development of a child will influence ability to cooperate with procedures; a young child may become bored, tired or hungry and their capability to concentrate may be limited and procedures may therefore take more than one attempt (Robertson et al). The DOH (2006) promotes optimal care for young people who have illnesses which previously wound have been fatal in childhood but are now surviving. Children’s nurses work in both hospital and primary care settings such as schools, GP’s surgeries and in the community. Children’s nurses specialise in many areas, a few examples are; intensive care, child protection, cancer, diabetes, pediatric emergencies, infections, neonatal problems, burns and plastics, respiratory, cardiac or skin disorders (Robertson et al). Children’s nursing is very much centred on the family (NMC 2008). Nurses should provide a safe, secure and comfortable environment and form good relationships with both the child and their family (Hinchliff, Schober & Norman 2003) and support both children and their families to make informed decisions regarding treatment and care options (Chambers et al 2005). Hubbard and Trig (2000) declare the family is central to a child’s wellbeing, and whilst respecting and promoting the rights of a child, should also be sensitive to the needs and views of the parents wherever possible during the treatment and care of children. This may sometimes result in conflicting situations and the NMC (2008) imply the importance of understanding the personal, socio-economic and cultural influences surrounding a child’s welfare. A nursing model often used to assist the nursing process is the Casey Model of nursing which focuses on working in partnership with both children and their families (Smith 1995). Lansdown, Waterston and Baum (1996) suggest children’s nurses should avoid jargon, use age appropriate language and in a child friendly way give children information they need in order for them to make informed decisions. Hubbard and Trig (2000) agree and suggest that play is used to communicate with a sick child, with the aid of toys, diagrams, picture books, photos and videos applicable to the child’s age and cognitive levels to clarify images and gain trust and understanding. For example in order to alleviate fears for a child who has a needle phobia, the injection technique could be demonstrated with the aid of an orange. Consent is an area where conflict may arise; English common law is vague about the age of consent to medical treatment (Alderson 1990). According to Dimond (2005) Children under16 can give valid consent to treatment if they are considered to be Gillick competent. If they refuse to give consent, parents may give consent against the child’s wishes, if the benefits outweigh the risks, for example a child who is suffering with cancer, refuses chemotherapy (Chambers et al 2005). Generally consent for young children is given by the family, but parents might have difficulty giving consent for someone other than themselves. In line with the Children’s 1989 Act, children’s nurses should ensure children are not cohersed into giving or refusing consent and their views should be taken account of where possible following the Fraser guidelines in respect of consent and confidentiality (Dimond 2005). Under the family reform Act of 1969 children over the age of 16 can give or refuse consent, unless they lack capacity, for example in emergency situations (Dimond 2005). Reducing costs for the government is key and one of their main priorities is to increase primary care for children in their own homes and reduce hospital admissions. In addition it is believed that care in the home is better for both children and their families, primary care was first recommended in the Platt Report (1958) (Hubbard et al 2000). Increasingly children are being cared at home by their parents supported by the community children’s nurse (NMC 2008) whose role is to provide guidance, care and to teach parents the skills necessary to provide care for their child, for instance administration nutritional requirements via a nasogastric tube (Hubbard et al). NURSING DISCIPLINE – ADULT BRANCH Prior to the influences of Florence Nightingale, hospitals were often unclean and contaminated by infection and nurses were seen as the ones to do the Doctor’s dirty work. Nursing schools were set up in the 1880’s, although it wasn’t until the 1950’s that the nursing profession was governed by the regulation body, UKCC. Today nurses are accountable to the NMC (2008) and must work within the code of conduct, demonstrating that they are able to deliver, manage and develop an excellent standard of evidence based nursing care (Abel-Smith 1960)(NMC 2008). Adult nurses primarily nurse sick and injured adults back to health and have a prominent role in the provision of health care, whilst working closely with other professionals, patients and their families (NHS 2010). Traditionally nursing was task oriented and patient care focused on specific illnesses and conditions. Today nursing is much more patient centred. An adult nurse will provide holistic care to number of patients 18 years and above at any one time to meet their physical, psychological, social and spiritual needs, using the nursing process which will include assessing, planning, implementing and evaluating the care delivered (NMC 2008). Adult nurses care for adult patients with a wide range of acute and long term illnesses and are involved in many different health arenas such as health promotion and disease prevention or they may specialise in specific diseases or disorders, such as diabetes, respiratory problems or cancer care. Others may specialise in accident and emergency, practice nursing or care of the elderly (NHS 2010). Although purposely trained to nurse adults, adult nurses will almost certainly be required to care and treat other groups of patients such as children, people with learning difficulties and patients with mental health issues, for example if they present in an accident and emergency unit, or are admitted to a ward with diabetes issues (Hinchcliff, Norman & Schober 2003). Adult nurses will work within a multi professional team to deliver care to patients, which will include other health professionals such as doctors, pharmacists, healthcare assistants, physiotherapists, occupational therapists and radiographers (NHS 2010). Adult nurses work in a range of settings which can be hospital based or in the community where more and more health care is being delivered such as GP surgeries, clinics, occupational health services, schools, nursing and residential homes and voluntary organisations such as hospices. The government is driving health care towards a primary health care led service within which nurses roles are expanding and developing (DOH 2010). Opportunities are also available in the armed forces, prisons, and leisure, eg cruise ships (NHS 2010). Adult nurses all cover the same programme even though their work destinations differ considerably and it has been suggested that it is time to consider a new branch of nursing that equips people to work in primary care (Smith M 2003). Adult nurses will need to demonstrate many skills such as problem solving, flexibility, caring, counselling, managing, teaching and interpersonal skills to maintain and improve the quality of patients’ lives, sometimes in difficult situations (NHS 2010). They may find themselves caring for patients who are the same age as their family, friends or themselves and it is important not to get too personally involved with patients or they may find themselves in discussions regarding ethical issues such as euthanasia where clearly legally it is unlawful but the patient may feel it is in their best interest (Hinchcliff et al 2003). To assist the nursing process, nursing models are used such as the Roper, Logan and Tierney’s (2000) 12 activities of daily living, often used in acute settings and the Orem’s model (1985) which promotes self care, particularly useful in rehabilitation setting. An adult nurse must comply with legislation and obtain consent before any treatment can be given, this may be verbal for routine nursing procedures, or written for more complex ones. Nurses must allow the patient to have autonomy when making decisions regarding care and treatment, respect that decision and always act in the patient’s best interest (Dimond 2005). The government’s agenda and The Human Rights Act (1998) have had significant impact on how adult nursing has evolved to meet people’s needs in an ever changing environment. New jobs are being created to extend the nurses role and get them involved in advanced procedures such as the modern matron, consultant nurses, nurse practitioners and chief nursing officers. The DOH strategy for nursing recommends consultant posts, for example care of older people and pain management taking nursing to another level (cited by Sines, Appleby & Frost 2005). According to the NMC (2007) nurses now carry out roles previously carried out by Doctors, for example theatre nurses now perform surgery and community care nurses co-ordinate packages. Changes in the way care is delivered has taken place in accordance with the government directive which laid down a plan to make primary health care accessible to people in the community, at work and at and home (Hinchcliff et al 2003). New opportunities are being created to meet the needs of older people. Older people are living longer and are the largest group of people using health services (Hinchcliff et al 2003). Common health issues for elderly patients are strokes, falls and mental health problems. The NHS Plan (2000a)(cited by Sines et al 2005) promotes independence and encourages them to have support in their home environment rather than residential homes. The government also recognises the need to increase and improve services for young adolescence patients to address their individual needs. For example as child moves into adulthood they may take risks, take part in anti-social behaviour, or they might be vulnerable and frightened (Hinchcliff et al 2003). Nurses have a role to play providing care, treatment and information to help them stay safe and healthy. To conclude adult nurses work with a wide range of patients with many different health issues across numerous health arenas. Nursing has developed considerably since it was first regulated and as patient care is a key government priority today’s adult nurses need to have the necessary skills to deliver appropriate care and treatment in an ever changing environment whi
This reflective account will discuss the role of a rehabilitation nurse in a community hospital. I am going to use the Gibbs (1988) Reflective Cycle which encompasses 6 stages; description, thoughts and feelings, evaluation, analysis, conclusion and action plan which will improve my knowledge of nursing practice and develop my self confidence in relation to caring for others (Siviter 2008). To comply with the NMC Code (2008) and maintain confidentiality all names have been changed.
On my second week of my placement, I met my associate mentor for the first time. She asked if she could look at my placement documentation and personal development plan. We then discussed the skills and knowledge I want to achieve during the placement which is on a community rehabilitation ward. After our discussion, my mentor suggested to that I spend some time reflecting on the role of a community hospital rehabilitation nurse.
Although my associate mentor did not require a formal piece of reflection, I thought it would be good to document my reflection for my personal development. When she asked me if I would reflect on the roles of nurse in a community hospital, I had already been thinking how different is was from that of a nurse in an acute hospital during my first week so I welcomed the challenge, although I had some reservations about what I could say on a positive note about community nursing. From what I had seen during my first week I was skeptical about the skills of nursing in a community hospital as the pace seemed much slower with less opportunity to practice clinical skills than in my previous acute placement. I was feeling quite disappointed and whilst I appreciate personal health care is an important nursing skill, the majority of my first week I had been left to work with nursing assistants and not invited by my mentor to be watch or carry out any clinical skills, who as a sister spends less time than staff nurses on ‘hands on’ nursing and more time on office tasks. This really worried me as I don’t want to just ‘cruise’ through my nursing training, I want to take every opportunity to broaden my knowledge and skills in all aspects of nursing. However I was now feeling more positive as my first impression of my associate mentor was that she was extremely knowledgeable, committed and caring and I hoped I would find her inspirational as I got to know her.
Being left for a whole week working without any real mentorship was demorilising for me and having no support or guidance the first week resulted in me having a negative view of the rehabilitation ward and community nursing in general (Taylor 2008). However, meeting with my associate mentor for the first time was a good experience. She was interested in me and committed to developing my knowledge and skills and by the end of our conversation had a good understanding of what I wanted to achieve from the placement and was able to challenge my knowledge on the current placement. Taylor (2008) states an inspirational mentor is a necessity to assist student nurses with their learning and development needs and nurture them to become first-class nurses. Understanding the skills and knowledge required by a community hospital rehabilitation nurse will build on my current knowledge which has been in the acute sector and be good for my personal development and future nursing career.
Rehabilitation is an important aspect of any nurse’s role, but more prevalent for nurses working with the elderly in community hospitals (Brooks 2010). It is the nurse’s role to promote independence and to empower patients to carry out the activities of daily living adopting new skills and knowledge where necessary. Many different models of nursing are used for rehabilitation purposes, two popular ones are the Roper, Logan and Tierney’s (2000) 12 activities of daily living and the Orem’s (1985) model of self care. Sinclair and Dickinson 1998 define rehabilitation as: ‘A process aiming to restore personal autonomy in those aspects of daily living considered most relevant by patients or service users and their family carers’. Many patients find themselves on a rehabilitation ward as a result of a traumatic incident or disease and rehabilitation nurses will work with the patient, family and other member of the multi disciplinary team to support and encourage patients to maximise their independence with physical functioning (White and Johnstone 2000). They are very often the coordinators of a patients care as they are the ones in contact with patients 24 hours a day. Nursing interventions will include supporting and reinforcing the care devised by other health care professionals such as occupational therapists and physiotherapists (Low 2003). They will need to have underpinning knowledge about adjusting to life changes and understanding of anatomy and physiology, health promotion and illness prevention (Chilvers 2002). To provide holistic care for the patient, nurses will be required to apply their knowledge and skills through the nursing process. The first stage of this process is assessment to identify a patient’s impairments and disability in order to develop care plans. Identifying emotional effects is as important as physical disabilities, as these are likely to have an effect on patients’ rehabilitation progress (Vohora and Ogi, 2008). These may include anxiety, grief, depression, frustration, and anger (Stroke Association, 2008). Many of the care plans aims will be to increase a patient’s independence so that they can resume responsibility for personal care. Amongst many others these might include washing and dressing, elimination, mobility and nutrition. Care plans will be updated and amended as care or treatment is no longer relevant, for example when a patient with a fracture is able to mobilise better, they may be encouraged to walk with a frame rather than use a wheel chair (Low 2003). Whilst implementing care plans a nurse will concentrate on helping the patient to live with as much freedom and autonomy as possible therefore will assist a patient wherever necessary but also encourage and empower them to be as independent as possible. In rehabilitation, cure is not usually the aim, for example a patient who has had a stroke a cure is not an option but will require intensive rehabilitation to obtain maximum functionality (Low 2003). Being able to communicate well is important for the rehabilitation nurse at it is important to identify patients’ psychological needs. Good communication can open up and highlight non-physical care aspects such as cognitive issues, hope, motivation and depression. As in any nursing role, nurses might need to use alternative methods of communication with patients who have speech difficulties (Miller 2002), for example may have to use eye contact, sign language or write things down for a patient who has suffered a stroke. Rehabilitation patients are not usually acutely ill, therefore community hospitals do not generally have 24 hour medical cover, with Doctors on site a limited number of hours (Dobrzanska 2007). Therefore out of hours, when there are no other health professionals around, a staff nurse has totally responsibility for patients within their care. In the event of an emergency nurses will need to request a doctor who may have to travel many miles from another hospital. It is though that patients recuperate better in community settings, and have said they appreciate community hospitals for location, atmosphere, accommodation, greater sense of freedom, quality of food and staff attitudes (Green, Forster & Young 2008).
Through my reflection of the role of a rehabilitation nurse I have a greater appreciation of the important and sometime undervalued work they carry out in helping patients to gain independence in both physically and emotionally. If I had carried out some research prior to my first day on placement I would have had a better understanding of the nurses role in rehabilitation and realise now that I should not have been as quick to form opinions regarding the nursing care delivered on the ward.
Through my research I have become very interested in the causes of strokes and the rehabilitation process. Therefore my action plan is to gain a deeper understanding on:
This reflective account is of something I observed during my second placement whilst working on a rehabilitation ward in a community hospital. I am going to use the Gibbs (1988) Reflective Cycle which encompasses 6 stages; description, thoughts and feelings, evaluation, analysis, conclusion and action plan which will improve my nursing skills and knowledge through continuous evidence based learning and develop my self confidence in relation to caring for others (Siviter 2008). To maintain confidentiality and comply with the NMC Code of Conduct (2008) all names have been changed.
I was asked by my mentor to admit a new patient to the ward, assess his needs and develop relevant care plans. The patient was a 78 year old male who required a period of rehabilitation before returning home after a fall in which he fractured his femur. I introduced myself to the patient and explained the admission procedure and gained his consent to collect the information required in respect of his physical, psychological, social and spiritual needs. The admission document used by the trust is based on the 12 activities of daily living (Roper, Logan & Tierney 2000). Observations are required as part of the process and after gaining the patients consent I collected the automated equipment to take his blood pressure. At this point my mentor arrived and asked me if I would take both lying and standing blood pressure measurements. I took the lying blood pressure measurement first and then repeated the procedure with the patient standing. This resulted in a reading off 20 mmhg lower than the lying measurement. I repeated this procedure a little while later with manual blood pressure equipment to confirm the measurements just in case the electronic equipment was faulty. However on this occasion the measurements were accurate and confirmed that when the patient stood his blood pressure significantly dropped. After accurately recording the measurements, I then informed mentor, who said it was probably as a result of ‘postural drop’. All other observations taken were in the normal range.
I have admitted a few patients before on the ward and am familiar with the Trust’s policy and documentation for the process. I felt confident that I have good communication skills and am able to ask the right questions in the correct manner to draw any concerns and obtain relevant information to identify appropriate care and treatment plans to assist rehabilitation reporting to my mentor any anomalies for further investigation. I have carried out vital observations on many occasions following a recognised procedure (Dougherty & Lister 2008), and I am confident of recognising measurements outside normal parameters, informing a staff nurse of any irregularities or concerns where appropriate. Therefore I was more than happy to have the opportunity to have the responsibility of caring for this patient. I have on occasions taken lying and standing blood pressure measurements and know it is to identify whether there is a drop in blood pressure as a result of the change in position. However I was not sure why a drop occurs or what it signifies when a person changes position, particularly in relation to older people. Therefore I have taken this opportunity to reflect and improve my knowledge in this skill to provide the best possible care and treatment for patients whose care has been entrusted to me.
On this occasion I realised that as a student I may be able to carry out the clinical skill of taking a blood pressure which can be done by anyone who is
trained to do so. However blood pressure monitoring is an important way of picking up irregularities which otherwise may go unnoticed. I correctly identified the anomaly and informed my mentor, but as a qualified nurse I will have responsibility of being able to interpret the information to enable me determine an accurate nursing diagnosis in order to deliver appropriate holistic care and treatment or make referrals to other health professionals.
A drop in blood pressure, when a person changes position is referred to as postural hypotension, which is also known as postural hypertension or orthostatic hypertension (Jevon 2001). Postural hypotension is when the systolic blood pressure drops 20mmhg or the diastolic blood pressure drops 10mmhg in response to a change in body position, such as standing from a sitting position, or getting out of a bath or bed (Jevon 2001). Postural hypotension can sometimes cause disruption of the automatic nervous system, resulting in problems with the respiratory and circulatory systems (Jevon 2007). The symptoms people may experience are fainting, dizziness, confusion, blurred vision and temporary black outs. Sometimes these do not occur immediately but several minutes after changing position (Jevon 2001). Postural hypotension increases with the aging process affecting up to 30% of elderly people. There can be a significant fall in blood pressure when the arterioles do not constricting quickly enough in response to changes in position. This may increase with certain conditions such as reduced blood pressure regulation or cardiovascular diseases (British Hypertension Society 2006). It can also be a symptom of illnesses such as Parkinson’s disease, anemia or diabetes and some drugs such as digoxin and furosemide can cause postural hypotension (Jevon 2007). Elderly people on prolonged bedrest and over 74 are at the highest risk of postural hypotension. Sometimes symptoms can present themselves after just 20 hours of bedrest which is thought to be because bedrest compromises blood volume and cardiac deconditioning (Knight, Nigam & Jones 2009
In healthy patients there is not usually much of a difference between lying and standing blood pressure measurements as when they change positions the drop in blood pressure is detected by the baroceptors in the aortic arch and carotid sinus which send messages to the cardiac and vasomotor centre to maintain blood pressure and circulation in the brain (British Hypertension Society 2006). Although postural hypotension may seem a minor condition it can affect a patient’s safety and quality of life. It is associated with increased morbidity and mortality, for example hospitals frequently treat elderly people for fractures who then return home, fall again which results in further injury (Carey et al 2001). As so many elderly people have the symptoms of postural drop it is recommended that lying and standing blood pressure measurements are taken routinely for this group of patients during the admission process. These should be taken in the morning preferably and on more than one occasion (Jevon 2007). Nurses have significant input into patients care including maintaining and promoting a safe environment and providing lifestyle advice for patients with postural hypotension. Treatment should be discussed individuals and tailored to their personal needs to improve their quality of life and reduce risk of injury (Jevon 2007). One common treatment is to increase blood volume by asking the patient to drink plenty of water. To reduce the risk of injury and maintain quality of life patients other treatments may include advising a patient to take care when changing from a sitting to standing position, raising the bed head so the patient is not lying flat or ensuring they are aware postural hypotension may occur as a result of a particular medication they are taking (Jevon 2007). Cary and Potter (2001) say it is important to understand postural hypotension is not a diagnosis but a symptom of an underlying cause which should be investigated, for example prolonged bedrest, medication or neurogenic failure. Sometimes non-pharmacological treatment is not successful and medication such as fludrocortisone and midodrine is prescribed (Mathias & Kimber 1999).
Although postural hypotension can seem relatively harmless, an elderly patients’ safety and quality of life can be seriously affected. Taking blood pressure measurements is a fairly short nursing intervention and I could easily take lying and standing blood pressure measurements routinely for all elderly patients upon admission to hospital, which for some might make significant improvements to their safety and wellbeing.
My action plan is to:
I have routinely taken both lying and standing blood pressure measurements on admission since writing this reflection. I have offered advice on a regular basis to patients who have had low blood pressure, with the agreement and supervision of my mentor. As yet I still have to research drugs which might cause postural hypotension, I have put this in my diary to do May 2010.
This reflective account will discuss the underpinning knowledge, practice and evidence of a skill I have become competent in practicing during my first placement on an acute medical ward which specialises in Diabetes. I am going to use the Gibbs (1988) Reflective Cycle which encompasses 6 stages; description, thoughts and feelings, evaluation, analysis, conclusion and action plan which will improve my nursing skills by continuously learning from both good and bad experiences, and develop my self confidence in relation to caring for others (Siviter 2008). To comply with the NMC Code (2008) and maintain confidentiality all names have been changed.
I was asked to draw up and administer insulin to a diabetic patient by subcutaneous injection by a staff nurse, whom I had not been supervised by previously. It is a method of drug administration frequently used on the ward. I had previously practiced subcutaneous injection techniques at university and observed and administered insulin by this method on the ward under the supervision of my mentor who ensured I was carrying out a safe and effective nursing intervention. Under observation, as requested I drew up the dose of Novamix 30 into an insulin syringe, taking care to undertake aseptic techniques to prevent contamination (Dougherty & Lister 2008). I then checked the validity of the drug card and ensured I had the right drug in the right dose and it was being administered at the correct time on the right date through the right route (Dougherty et al 2008). I then took it to Mr A and after introducing myself, explaining the procedure and gaining his consent; I checked his ID in compliance with the Trust’s policy and administered the insulin into his abdominal wall. Afterwards I documented the details on the patient’s drug card and disposed of the sharps and non-sharp waste appropriately (Dougherty et al 2008). What differed on this occasion from previous times was the qualified nurse observing questioned me in detail to determine the depth of underpinning knowledge I had of insulin and the technique used.
I have previously drawn up and administered insulin by subcutaneous injection on numerous occasions for several patients and felt confident to carry out the clinical skill correctly. However when the staff nurse asked me related in-depth questions I found myself unable to answer some of the rationale behind my actions. At this point I realised that although I could carry out the clinical skill on a practical level, gaps were emerging in my underpinning knowledge and I know how important it is to perform evidence based practice (NMC 2008). Although the nurse was supportive and not judgmental, and I did have some knowledge regarding drug administration and injection techniques, I felt to underpin safe and effective nursing practice I should further develop my understanding of diabetes type 1 and insulin administration which will enable me to give my patients the best possible care and maintain their safety (NMC 2008).
It was good to work with another staff nurse other than my mentor. It gave me an opportunity to maximise learning opportunities and evaluate the nursing care delivered. She was supportive and confirmed I carried out the clinical skill in the correct manner in accordance with Trust’s policy and general principles of drug administration as described by Dougherty and Lister (2008). In addition she made me realise practical skills need underpinning with evidence base practice and has motivated me to find out more into relation to the rationale behind the clinical skill. According to Dale (2006) finding, appraising and applying scientific evidence is well-suited to the nursing profession in the treatment and care of patients. On the negative side I felt as I was a first year student on my first placement, my mentor had a duty not only to show me the practical skills but to guide me in my learning and thinking in respect of the underpinning knowledge. Wilkes (2006) confirms my thoughts and suggests the mentor is paramount to enhance student learning. This was a clinical skill I had observed and practiced several times before, and felt embarrassed about how little I knew about the underpinning knowledge. It also made me think about the importance of my training and how I need to be more proactive to enable me to gain the maximum learning experience from placements.
I will now attempt to analyse and explore the skill and look at the evidence underpinning it. Mr A has Diabetes Mellitus Type 1, sometimes known as insulin dependent diabetes, which is a chronic condition caused by too much glucose in the blood (NHS Choices 2009). The condition occurs when there is little or no natural insulin to break down glucose to be absorbed by cells to maintain stable glucose levels (Dunning 2003). Currently insulin is the only treatment available to maintain life for patients with Diabetes Mellitus Type 1, (Wallymahmed 2006). Insulin is necessary to mimic the body’s natural insulin (NHS Choices 2009) and without it people will experience Hyperglycemia
(high blood sugar levels), the symptoms which may present are; thirst, polyuria, polydispsia and fungal infections. Longer term health problems might include retinopathy, neuropath and nephropathy. Without insulin the patient would eventually die (Wallymahmed 2006). The British National Formulary (2008) recommend insulin is stored in the refrigerator at a temperature of 4-8oC. It is important to check the insulin is the correct type and in date before inverting it to mix the solution without it breaking down (Dickinson 2001). The correct method of giving insulin is usually by subcutaneous injection and is paramount to ensure appropriate absorption and action (Dougherty et al 2008). Insulin should not be given by intramuscular (IM) injection as this method leads to unstable glucose levels (Dunning 2003) and it should not be given orally as it is inactivated by gastrointestinal enzymes (Wallymahmed 2006). Insulin is measured in international units and should be drawn into a syringe specifically designed and marked for this purpose, not normal syringes which are measured in millilitres. Using the wrong syringe could result in a lethal dose being administered, potentially killing a patient (Staines 2009). A short fine gauge needle ensures the injection is relatively painless and absorbed by the subcutaneous layer and not into the muscle (Dunning 2003). Needles are available in 5mm, 8mm and 12.7 mm. 5mm needles are suitable for thin patients which can be used without lifting the skin. 8mm needles are suitable for most adults, and 12.7mm needles are more suitable for obese people (Dickinson 2001). Mr A is prescribed Novamix 30 which is premixed insulin, containing 30% rapid acting and 70% intermediate insulin (Wallymahmed 2006). Typically the effects of this type of insulin last for up to 8 hours and should be administered twice a day before or after eating, usually at breakfast and evening meal to work together with food (Wallymahmed 2006). The main side effect of insulin is hypoglycemia, therefore the practice in an hospital environment is to check blood glucose levels regularly usually prior to meals, and more often if the readings are not in the acceptable range (Dunning 2003). The site of injection should be rotated to ensure that the insulin is absorbed correctly and prevent overuse of one area, to avoid causing lipohypertrophy (Dickinson 2001). Sites used are usually abdominal wall and thighs, although upper arms and buttocks can be used (Dougherty et al 2008). The injection site should be assessed for signs of inflammation and skin lesions to reduce of infection and possible trauma to patient (Workman 1999). A fold of skin should be pinched and the needle inserted at 45 degrees to avoid the IM route. According to Dougherty et al (2008) and Dunning (2003) this is common practice although Becton Dickson (2001) recommends insulin injections should be given at 90 degrees as short needles are available. The needle should then be removed and gentle pressure applied to the area to prevent possible haematoma formation (Dougherty et al 2008).
During this reflection I feel that my skills have developed both clinically and reflectively which has helped me to recognise that reflection is an important learning tool in practice. The Gibbs (1988) model of reflection has helped me to structure my thoughts and feelings and realise that I must be proactive to enable me to develop both on a personal and professional level. My knowledge in respect of evidence based practice, and its importance has increased during this process and my competence to carry out this skill improved. In future when administering insulin I will be more aware of the underpinning evidence to enable me to practice safely.
My action plan from this experience is to:
I have since been on my second placement. I now research any new clinical skills I am asked to carry out either on my placement or from home so I am able to reflect and understand the rationale behind my actions. I also familiarised myself with the Trust’s policies and procedures at the earliest opportunity.
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