This essay willattempt to explore and analyse some of the key building blocks to what makes a good nurse. Hero to most nurses,Florence Nightingale said that a good nurse is to be a good woman, that is sheshould have the following qualities: Quietness, gentleness, patience, enduranceand forbearance (Nightingale, 1881). In 2015, the NMC (Nursing & MidwiferyCouncil) published their annual equality and diversity report and stated that36% of the UK nursing workforce are now male (NMC, 2015) making the infamousFlorence Nightingale’s definition rather dated and inapplicable to today’spracticing nurses. McLean (2011) gave his definition of a good nurse to NursingTimes by comparing it to the film “The Wizard of Oz”; Dorothy’s threecompanions in the film represent her anxieties that she does not have the”heart”, “nerve” or the “brain” to be the person she wishes to be. He suggeststhat being the good nurse that you wish to be requires that you have heart,brain and courage.
Many people would agree that today’s frontline nurses havethese qualities. The first half ofthis essay will focus specifically on communication within nursing, one of thehighly-valued ‘six Cs’ of nursing that came about after the Francis report ofthe Mid-Staffs hospital and its disgraceful quality of care delivered by its healthcareprofessionals. Infection control, another essential element of the nursingprofession will also be analysed, including its importance, relevance and varioustechniques to achieve it. A staple book forany student nurse; The Royal Marsden Of Clinical Procedures answers the task ofdefining communication as a universal word with many definitions, many of whichdescribe it as a transfer of information between a source and receiver (KennedySheldon, 2009). In nursing, this communication is primarily interpersonal; theprocess by which information, meanings and feelings are shared through theexchange of verbal and non-verbal messages between two or more people (Brooksand Heath, 1993, Wilkinson, 1991). Sully et al, (2010) shares similar views onwhat communication is, they say that ‘all of us practise skills incommunication.
Communication skills are transferable across different walks oflife and different practice circumstances. Communication is a complex process.It involves a number of interacting factors: (1) physical, e.g. someone withdementia; (2) psychological, e.g. an anxious student and (3) social, e.g.
a newmother in her home. How we as practitioners respond in each unique situationrequires skilled thought. Effective communication, therefore, requiresself-awareness, attention to the unique nature of this episode and awillingness to respond sensitively and flexibly by the use of verbal andnon-verbal skills.’ These definitionsclearly highlight the importance of effective communication in the nursingprofession. Even from the get go, such as introducing yourself correctly andcompetently to a patient is essential to build a trusting and effective nurse-patientrelationship. A project called ‘#Hellomynameis…’ was created by Dr Kate GrangerMBE & her husband; Chris Pointon to improve compassionate care inhealthcare after she received poor communicative care herself when she wassuffering with cancer. She felt like her care wasn’t very personal and didn’tknow the names of the healthcare professionals caring for her.
An extension ofthe campaign is how a simple introduction is the first step on the ladder of atherapeutic relationship (Granger and Pointon, 2014). Hellomynameis was evenmentioned in the Government response to the Francis report (Granger andPointon, 2014). In the requiredreading of the NMC Code that all nurses and midwives must follow, point sevenis ‘communicate clearly’. To achieve this, you must: ‘7.
1, use terms that arein your care, colleagues and the public can understand. 7.2, take reasonablesteps to meet people’s language and communication needs, providing, whereverpossible, assistance to those who need help to communicate their own or other people’sneeds. 7.
3, use a range of verbal and non-verbal communication methods, andconsider cultural sensitivities, to better understand and respond to people’spersonal and health needs. 7.4, check people’s understanding from time to timeto keep misunderstanding or mistakes to a minimum.
And finally, 7.5, to be ableto communicate clearly and effectively in English’ (NMC, 2015). One particular, interestingmethod of communication to aid young people with learning difficulties is Makaton.Makaton is the UK’s most popular recognised communication system for peoplewith learning difficulties and it is used by more than 100,000 children andadults. Makaton is a language programme using signs and symbols to help peoplecommunicate. The programme is designed to support spoken language, and thesigns and symbols are used with speech in spoken word order (Makaton Charity,cited in J, Vinales 2013).
Ferris-Taylor (2007) suggests that the importance ofbeing able to communicate with healthcare service users and families is paramount.Nurses can do much to reduce the impact of communication difficulties. Mencap(2004) highlighted the importance of communicating with individuals withlearning disabilities in their published ‘TreatMeRight!’ document which foundthat three quarters of healthcare staff in the UK had no training incommunicating specifically with people with a learning disability, and thereforecould not understand them. Vinales (2013) established that during theevaluation after an introductory lesson of Makaton to second year nursingstudents in a university in Birmingham, the students were asked whether or notit would have been beneficial to have had a Makaton session in their firstyear.
Eighty-five per cent of respondents said they would have liked a Makatonsession in year one of their training, to help when meeting clients, families andcarers who use the system. My first placementas a student nurse was with the charity mentioned, Mencap. I was placed in twosites: a two-female household with varying learning disabilities and a muchbusier five-male house. I did some research into Makaton prior to the placementin case any of the tenants used it as a form of communication or as an addedlayer of language on top of verbal communication. Once on placement, Idiscovered that none of the tenants used Makaton, but on reflection I am veryglad I did some research into the topic as I now have a few basic words andhand signals I could use in the future if I came across a Makaton-user and I’velearnt it is not a form of sign language but it’s a visual prompt forparticular words to assist people with learning disabilities to communicate iftheir verbal communication is affected by their learning disability. On placement withMencap, I very quickly adapted and learnt how to read non-verbal communicativesigns from the individuals under their care from my four weeks.
I readeveryone’s health files and care plans to get a basic understanding of theirlearning disabilities and any accompanying mental, physical or medical issuesthat needed to be addressed. Toocaram (2010)supports and further enhances Mencap’s ideology by saying that every consciousperson can communicate regardless of the severity of their disability. She goeson to suggest that if nurses can embrace and practice a total communicationapproach with vulnerable groups of people including the elderly, children,people with learning disabilities, people with mental health problems, thephysically disabled and people with sensory deficits, then they should be ableto communicate well with everyone else. Within the practiceof communication, barriers and challenging issues sometimes arise. Onedifficult issue to address is communicating with a patient displaying anger,aggression and violence.
Duxbury and Whittington (2005) suggest that nurses arelikely to be exposed to anger and aggressive behaviour during their practice.Anger is felt or displayed when someone’s annoyance or irritation has increasedto a point where they feel or display extreme displeasure (Adams andWhittington, 1995). Gudjonsson et al (2004) proposes that people often getangry when they feel like they’re not being heard or when their control of asituation and self-esteem are compromised. He suggests that many healthprofessionals are unfortunately renowned for failing to acknowledge patients aspeople and this can stimulate an angry and arguably legitimate behaviouralresponse. Dougherty and Lister (royal marsdennnnn page 220) suggest that people can become angrywhen they feel they have not been communicated with honestly or are misledabout treatments and their outcomes.
To prevent people’s frustration escalatinginto anger or worse, health professionals need to ensure that they arecommunicating with people openly, honestly and frequently. Infection controlis certainly a well-discussed topic in the world of healthcare. According to Hayleyet al (1985, cited in Wilson, 2006), ‘infection is a common but often avoidablecomplication of healthcare which has a major impact on the patient and thehealth service. It has been estimated that up to one-third of hospital-acquiredinfections could be prevented by improved infection control practice.’ TheHealth and Safety at Work Act (1974), a document that every organisation/businessmust adhere to and display advises that patients are most at risk buthealthcare staff are also legally obliged to take reasonable and practicableprecautions to protect themselves, other staff and anyone else who may be atrisk in their workplace. Therefore, infection control is an area of healthcarewhich helps to protect everyone and is a critical part of care delivery. TheRCN (2010) define infection prevention and control as the clinical applicationof microbiology in practice. Wilson (2006) suggests that ‘patients receivinghealthcare are at an increased risk of acquiring infection due to invasiveprocedures, devices or conditions that impair normal defences againstinfection.
In addition, the healthcare environment provides plenty of opportunitiesfor micro-organisms to transfer between patients and for antimicrobialresistant strains to emerge and spread’. As mention above,the NMC Code (2015) which is adhered to by all nursing and midwifery staff inthe UK also contains its own guidance on infection control: ‘19.3 keep to andpromote recommended practice in relation to controlling and preventinginfection.’ Infection controlis so important and its need to be regulated that Ward (2016) states that everysingle NHS organisation in the UK has to have a team of people responsible forinfection prevention and control (IPC). This team has a variety of roles withinthe organisation, but work together to support its IPC infrastructure andservices, reporting results, findings and current legislation to the TrustBoard and the chief executive. Ward also informs us that within NHSorganisations, someone is designated as the infection control doctor. Thismight be the consultant microbiologist, public health doctor or an infectiousdiseases consultant. Whoever this is, they are seen as the lead for the IPCteam and often chairs an infection prevention and control committee and liaisesclosely with an appointed IPC nurse.
Evidently, infection prevention andcontrol is a highly regulated and practiced aspect of healthcare for the NHS. One of the mosttalked-about topics within infection control is hand hygiene. Wilson (2006)suggests that the hands of healthcare staff are the most common vehicle bywhich micro-organisms are transmitted between patients and hands are frequentlyimplicated as the route of transmission in outbreaks of infection.
Researchinto staff hand hygiene has been carried out multiple times through history.One particular case carried out by Gorman et all (1993) found that over aperiod of one month, the same type of Klebsiella pneumoniae bacteria wasisolated from the respiratory secretions of six patients in an intensive careunit. Four of these patients developed infections caused by this organism.
Thesource of the organism was found to be in the condensate from ventilator tubingwhich collected in a foil dish which was emptied by respiratory nurses whenfull. Although hands were washed after contact with tracheal secretions, theywere not washed after contact with this condensate, therefore, spreading thebacteria and infecting the other patients. Ward (2015)suggests that hand hygiene/decontamination (including both handwashing and theuse of alcohol hand rub) is the most important intervention in the control ofcross-infection due to the fact that most cross-infection in healthcaresettings is caused by the transfer of micro-organisms on staff hands.
The WorldHealth Organisation (WHO, 2009) identified five key moments when a nurse shouldbe decontaminating their hands, these are: Before touching a patient, beforeclean/aseptic procedures, after body fluid exposure/risk, after touching apatient, and after touching patient surroundings. It is clear that theseorganisations to protect the health of the people are wanting nurses toconstantly consider if their hand hygiene is kept. To efficiently washthe hands and kill any infectious organisms, Lucet et al (2003) suggest thatsimple mechanical washing of the hands with soap and water will achieve this.Ward (2015) outlines this process in the following steps: Wet hands underrunning water, apply soap, wash all areas of the hands, rinse soap off fullyand finally, completely dry hands.
Ward also summarises to us the commonly-usedspecific technique of fully decontaminating the hands, knows as the Ayliffetechnique, developed in 1978. The Ayliffe technique was developed after theknowledge that healthcare staff were missing certain areas during handwashing,in particular, the thumbs, tips of the fingers, between the fingers and thumbsand the wrists. The newly developed technique ensured that all areas of thehands are fully decontaminated. It is common place to see he technique printedand placed by the majority of hand-washing sinks/stations in NHS organisationfor staff, patients and family to follow to correctly decontaminate their handsand protect everyone from potentially harmful infectious diseases.
In 2005, theNational Patient Safety Agency told us that there is an ever-increasinginterest in the value of alcohol-based hand rubs for routine handdecontamination. They found that 60-95% alcohol solutions are rapidly micro-biocidaland active against Gram-negative and positive bacteria, fungi and some viruses.Although there is doubt about their efficiency against non-enveloped viruses.There is also evidence to suggest that alcohol gels are ineffective againstspores and should not be relied on for routine hand-washing after contact withpatients with Clostridium difficile (commonly referred to as C. diff) (Hoffmanet al 2004).
It was alwaysbelieved that to efficiently wash hands and kill off any potentially harmfulorganisms, the temperature of the water should be as hot as you can comfortablytake it, at least 38°C foreffective decontamination (National Restaurant Association EducationFoundation, 2006). But only last year, research was done into hand washing watertemperatures by Rutgers University and GOJO Industries. NHS Choices (2017)published a document with the findings that the study found using colder water(15°C) was just as effectiveat getting rid of bacteria as using hot water (38°C).
Contrary to current guidelines, which recommend using hot water when we washour hands, this study found using colder water (15°C) was just as effective atgetting rid of bacteria so perhaps guidelines and legislation will soon needreviewing. Prior to joiningthis adult nursing course, I was a dental nurse for three years in an NHSpractice and infection control was paramount in that setting too. The donningof gloves for every patient, sterilisation of instruments, the decontaminationof the surgery between patients and checking water lines for legionella werejust some of the infection prevention and control measures dental nursesundertake every day, but one incredibly important measure I took was to avoid aneedle-stick injury.
As the practice was an NHS service, I nursed patients fromall backgrounds and walks of life including patients with blood-borne virusessuch as hepatitis C and HIV (Human Immunodeficiency Virus). As dental nursesare constantly handling sharp instruments, anaesthesia needles, scalpels and areregularly aspirating blood from the mouth during dental procedures,needle-stick injuries are one of the top incidents to avoid. For this reason, asharps policy was in place. ‘Sharps’ includeneedles, scalpels, broken glass or other items that may include a laceration orpuncture. Sharp instruments frequently cause injury to healthcare workers andare a major cause of transmission of blood-borne viruses (Health ProtectionAgency 2005).
The National Audit Office (1999) tell us that sharps injuries accountto 16% of occupational injuries in hospitals but many more go unreported so thefigure is likely to be much higher. Ward (2015) tells us that for this reason,in 2010, European employment ministers agreed a directive aimed at preventingsharps injuries in the healthcare setting. This became UK law in May 2013 infor form of The Health and Safety (Sharps Instruments in Health Care)Regulations 2013.
The new regulations put most of the responsibility onto theshoulders of the employers, it said that those practicing with sharps such asnurses need to control the risk by practicing safely, including the following:Not resheathing or recapping needles, not bending or breaking needles, todispose of sharps immediately after use, wear gloves while handling sharps(while these cannot prevent injury, there is evidence that the glove actuallyremoves a significant portion of the blood from the needle prior to in enteringthe skin during an injury), disposing of needles/sharps and syringes/holders asone unit rather than disassembling after use and proper to disposal and finallyto use safer sharps devices where available and provided. If, unfortunately,a needle-stick/sharps injury does occur, there are procedures set in place bythe trust/organisation. The NHS’s procedure (2015) goes as follows: ‘If youpierce or puncture your skin with a used needle, immediately follow this firstaid advice: Encourage the wound to bleed, ideally under running water. Wash thewound using running water and plenty of soap.
Don’t scrub the wound whileyou’re washing it. Don’t suck the wound. And finally, dry the wound and coverit with a waterproof plaster or dressing.
‘ It is then recommended the injuredparticipant seek urgent medical advice either from occupational health or A.A risk assessment will need to be completed to assess possible blood-bornevirus contamination based on how, when it happened and who used to needle. Oncethis is done, usually a blood test will be required to check for HIV andhepatitis B and C.
Blood tests may also be required from the other person’sblood, with their consent.