This assignment will reflect on and critically analyse my personal and professional development in the domain of care management over the last three years. It will additionally outline how I plan to continue to develop in this domain once I have qualified as a registered nurse. My development so far will be analysed from the perspective of the skills, knowledge and values required of a registered nurse. Through this reflection I hope to confirm that my practice meets the standards for entry onto the nursing register as outlined by the nursing and midwifery council ((NMC) 2008).
Due to the nature of this assignment and for the purpose of reflection, as supported by Fulbrook (2003), I will adopt a narrative approach that conveys thoughts, feelings and experiences that examine my nursing practices, and support it with professional commentaries. Biber et al (2002) agree with the use of first person narrative for reflection in academic writing. Care management, according to Weety et al (2001), is a process of collecting information through assessment, to enable the nurse to make a series of clinical judgements and subsequent decisions about the nursing care each individual needs.
Fedoruk and Pincombe (2000) explain that modern health care settings are complex and the registered nurses’ ability to effectively manage care requires highly developed skills. Peate (2006) suggests skills in prioritisation and delegation are essential to care management. This is supported by Sitivier (2004) who adds the ability to effectively manage care will impact on staff, resources and the setting and achieving of goals. In order to structure my reflections I will use the Rolfe et al (2001) framework for reflective practice model which is based around Bortons’ (1970) developmental model.
Pryce (2002) states this is a simplistic cycle composed of three questions which asks the practitioner; what, so what, now what. Through this analysis I will give a description of the situation which then leads into scrutiny of the situation and construction of knowledge that has been learnt throughout the experience. Subsequent to this, ways in which to personally improve and the consequence of my response to the experience will be reflected on. Burton (2000) states this model of reflection can stimulate reflection from novice to advanced levels.
This directly connects to Benner’s (1984) model of skill acquisition which offers a framework to define the development from novice through to clinical expert. I will use Benner’s stages of clinical competence, which incorporates the Dreyfus and Dreyfus (1986) model of skill acquisition to provide evidence and define how I progressed in the development of care management skills. The Dreyfus and Dreyfus (1986) model posits that in the acquisition and development of a skill, a student passes through five levels of proficiency: novice, advanced beginner, competent, proficient, and expert.
In my initial placement I worked on an elderly care ward and I had no previous experience of managing care. I had experience of being a functional nurse as I had worked as a health care assistant on a hospital ward for several years before starting the nurse training programme. Kozier et al (2008) describe functional nursing as a mode of organising by being task-orientated which is defined by Corning (2002) as being focused on getting specific things done, rather than paying attention to the whole situation surrounding the patient.
On my first day my mentor and I went through the daily task orientation; serving breakfasts, helping feed those unable to feed themselves, assisting with personal hygiene and then recording vital signs of each patient. This schedule of events is a prime example of rule-governed behaviour according to Dracup (2004), as the rules, in this example being task related, are context-free and independent of specific cases; they can be applied universally to all elderly care wards.
I had past experience of this task orientated rules, therefore the following day I was able to perform these tasks without being told to do so and without unneeded help or supervision. Hogston and Simpson (2002) describe this traditional task-orientated method of nursing care as contrary to the nursing process, compromising the concept of individualised patient centred care. Price (2006) supports this view, suggesting that patient-centred care requires the nurse to be flexible and not confined to set care pathways or task-orientated methods.
I complied with functional nursing and completed tasks assigned to me which Higginson (2006) states many first year nursing students do as they are preoccupied with worries about their ability to perform nursing duties. However, through this I found that I did not engage completely with the patients which according to Squire (2001) would have built a good, therapeutic and interpersonal relationship with the patients. Reflecting using Benner (1984), in terms of starting to become a proficient and capable staff nurse, I was a novice.
Rather (2007) states that novices are taught rules to help them perform, and although I was not taught these rules within my first placement I still adhered to them and reflecting back I would consider my practice as limited and inflexible due to these rules. Consequently I saw managerial skills such as time management, prioritising and delegation beyond my capabilities, Hill and Howlett (2005) state feeling incapable of managing patient care is normal for a first year student nurse. During my second placement in Theatre Recovery is when I started to become an advanced beginner according to the Dreyfus and Dreyfus model (1986).
At the beginning of this placement I was still very much a novice and would not go near an unconscious patient unless having direct orders. Kenworthy et al (2001) state the majority of student nurses become nervous at the prospect of caring for an unconscious patient. My mentor and I made a plan to start with the basics and put theory behind the actions so that I would understand evidence based practice behind caring for an unconscious patient. Irani (2001) states evidence-based practice is essential to ensure the effective and efficient management of patients.
In addition my mentor used both cognitive and behaviour modelling, which is promoted as good teaching methods by Ziegler (2005), to give me confidence in breaking out of the rule governed behaviour and allow me to start making care management decisions. Benner (1984) explains that advanced beginners start to show situational perception and by the end of this six week placement I was able to efficiently manage an unconscious patients’ airway care, including administering oxygen and deciding when to wean the oxygen whilst maintaining oxygen saturation levels.
I would analyse my practice using Rolfe et al (2001) reflective model part ‘so what’, by stating that I was unable to prioritise efficiently and although I had started to show situational perception, I still treated all aspects of care management with equal importance. I was unable to distinguish whether monitoring vital signs was more important than airway management due to my lack of experience and knowledge.
Sharif and Masoumi (2005) qualitative study of nursing student experiences showed that the students experienced anxiety as a result of feeling incompetent due to lack of professional nursing skills and knowledge. To overcome this feeling Stuart (2003) suggests using care protocols developed by the Primary Care Trust (PCT). Eraut (2004) states competence starts to develop when the student nurse begins to see his or her actions in terms of long-range goals or plans of which he or she is consciously aware. Competence is defined by Pearsall (2008) as the ability to do something successfully or efficiently.
There is considerable debate as to what is needed to achieve this, Musk (2004) argues it is just technical ability to perform a skill whereas Falvo (2010) states associated knowledge and the appropriate attitude is also important. However the NMC (2008) defines competence in nursing as having the knowledge and skills for safe and effective practice. I feel that during my first placement in my second year I started to show competence. I was on an acute cardiac ward and I was able to manage the care of two to four patients’ in a bay.
This was the first time I had experienced primary nursing, this, explained by Kozier et al (2008), is where individual nurses’ are allocated patients. Drach-Zahavy (2004) state this allows the nurse to assess, plan, implement and evaluate the care they provide to the patient and a consequence the nurse has full responsibility and accountability for the care provided and managed. I felt I had the competence to organise care needed for my patients’ by setting priorities, establishing patient goals or desired outcomes, selecting nursing interventions and using previous experiences to increase situational perception.
Schroeder (2004) states this organisation helped me establish and achieve patient goals or desired outcomes. According to White (2007), workload prioritisation is essential when a nurse has several patients to care for whose needs differ in terms of urgency. This skill also helped me use the nursing process which Alfaro-LeFevre (2002) states includes the ability to undertake and document a comprehensive, systematic and accurate nursing assessment of the physical, psychological, social and spiritual needs of patients, clients and communities.
The nursing process is central to many key government papers, such as the Department of Health’s ((DoH) 1999) document Making A Difference, the United Kingdom Central Council for Nursing ((UKCC) 1999) document Fitness For Practice and The NHS plan (DoH, 2000), and is governed by the standards of proficiency outlined by the NMC (2008), and embedded in parliamentary statute. One of my priorities on the Cardiac ward was to make sure all the patients ho needed care intervention checklists completed for afternoon catheter labs were done in the morning which then allowed time to rectify any issues and implement care needed such as handing out theatre gowns, checking vital signs and delegating tasks beyond my capabilities such as cannulation and venepuncture. When delegating these tasks to one particular health care assistant I encountered some hostility from her.
Higginson (2006) suggests that this role conflict between student nurses and health care assistants is a common experience for student nurses. When using Rolfe et al (2001) ‘what now’ stage of reflection I would describe my response as inappropriate and confrontational towards the health care assistant. Although I was able to step into an authoritative role, which Campbell et al (2008) state is imperative skill to employ by a student nurse, I think I intimidated her with the tone, pacing and volume of my voice.
McCabe and Timmins (2006) report to communicate effectively, I must use all three components to send clear and concise messages. Druskat and Wolff (2001) advise that while it is important to voice concerns over other team members’ behaviour rather than allowing concerns to remain hidden, this should be done in a manner which does not intimidate the other person. Gartland (2008) agrees and furthermore states that to verbally communicate effectively it must be in a manner that is not offensive to the receiver.
If this situation were to arise again I would ensure that I used a more appropriate tone, pace and volume to try making myself understood whilst achieving the best practice from the health care assistant (or other team members) and best care for the patient. Ellis et al (2003) states this should be a calm, slow and normal volume voice. My first placement of year three was on an oncology and haematology ward and proficient nursing could be seen in my practice.
Mattu and Goyal (2007) state in critical care areas such as Oncology and Haematology where patients are unstable and their conditions can rapidly deteriorate, the nurse at the bedside needs both practical knowledge and theoretical knowledge to make rapid decisions in crisis situations. For this reason Berger et al (2006) assert it is impossible to be task-led or rule governed. Benner (1984) states the proficient nurse uses rules as guides which can mean one thing at one time and quite another thing later.
During one situation on this placement I was allocated the patients in the isolation room; this had five patients in. I was assisting a patient with washing, when he began to bleed per rectally (PR). Intuitively I pressed the emergency call bell to get assistance. Adams and Buckingham (2000) suggest that nursing intuition often occurs at a subconscious level, causing decisions to be based on hidden knowledge and previous experience. A health care assistant got to us first and I asked her to stay with the patient whilst I got the necessary equipment, informed a doctor and got a qualified staff nurse for guidance.
Benner (2001) describes the skills shown here as effective management of a rapidly changing situation and the ability to identify and manage a patient in crisis by grasping the problem quickly, intervening appropriately, and assessing and mobilising the help available. Reflecting back on this experience, I feel I was able to monitor the patient closely while maintaining the quality of care given to the other patients by delegating suitable parts of my workload to the health care assistant helping me.
Huber (2000) states delegation is an essential core skill of care management, and according to Peate (2006) delegation is a natural progression for prioritisation. In order to delegate effectively and in the patients best interests, Ellis and Hartley (2004) state that tasks and responsibilities should be allocated to the person most suited to fulfil them in order to ensure they can perform the task in a safe and effective manner. According to Curtis and Nicholl (2004), when a task is delegated the responsibility and authority are transferred to the delegate but the accountability for the task remains with the delegator.
This is supported by McInnis and Parsons (2009), who adds that it is essential to ensure that quality of care is maintained when nursing tasks are delegated to people with less experience or training. Based on the reflection of my development in the domain of care management, I can see that while I have gained experience in prioritising and delegation I need to continue developing these skills in order to gain experiential knowledge and advance on the journey described by Benner (1984) from novice to proficient and ultimately to expert.
This assignment has considered my personal and professional development over the last three years, and has brought to light areas which need further development in the remainder of my final year and in my first year of registration. By the end of training I hope to be an expert student nurse. Ruth-Sahd (2004) explains expert performers no longer rely on analytic principles (rule, guideline, and maxim) to connect understanding of the total situation to an appropriate action.
Lloyd et al (2007) state this allows the nurse to make decisions quickly without wasteful consideration of a large range of unfruitful alternatives, diagnosis, and solutions. To get to this standard King and Clark (2002) advise to continue to develop confidence in key care management skills by using past experiences and progressing in evidence-based practice. The Nursing and Midwifery Council (2004) requires all qualified nurses to engage in continued professional development to ensure that they are up to date with developments in their nursing area.
Continuing professional development (CPD) refers to formalised education that is designed to enhance the knowledge and skills of practitioners. According to Peate (2006), the nursing environment is one that is constantly changing and developing, and continuing professional development helps nurses to adapt to changes in their area of practice. During my first year post-registration I intend to enter the preceptorship scheme when I gain employment, Huggett et al (2007) state this will allow me to make the most of the learning opportunities and professional developmental activities available.
I will draw up an action plan, as advised by Cottrell (2005), for the first year of my registration, which will include such aims as completing my drug administration and intravenous drug training, and will outline action steps to completing these aims. Nurses’ are required by the NMC (2008) to show that they have met post-registration education and practice (PREP) standards in order to maintain their registration. I will begin a PREP portfolio which will include reflections from the five days of learning activity relevant to my profession during a three-year period that is required by the NMC (2008b) to maintain my registration.
Clarke and Donaldson (2008) state constant updating and growth are essential to keep abreast of scientific and technological change and changes within the nursing profession. I am confident that I will be able to continue my professional development once registered in order to ensure that I employ best practice at all times, and will be able to act in patient’s best interests by giving high quality, up to date care.