Reflecting on Individual Professional Practice with Gibbs
For the purpose of this essay, I will use Gibbs (1988) Reflective Learning Cycle to reflect on an aspect of individual professional practice, which requires development in preparation for my role as a Registered Nurse. Gibbs (1988) Reflective Learning Cycle encourages a clear description of a situation, analysis of feelings, evaluation of the experience and analysis to make sense of the experience to examine what you would do if the situation arose again.
To keep within the Nursing and Midwifery Council (NMC) Code of Professional Conduct guidelines (2008a) and to maintain confidentiality the use of names or places will not be used throughout this essay.
Whilst on placement working on a general ward during my third year I was asked to research a drug I was unsure about by my mentor. On my way to research the drug I was approached by a health care assistant who asked me if I could assist her with a patient who was lying in a soiled bed. I chose to help the health care assistant as I thought this was priority as I could look up the drug at any point in the day as it was for my own learning and development and wasn’t urgent. After I had helped the health care assistant, my mentor asked if I had researched the drug. I explained that I had gone to help the health care assistant and would now look up the drug, which I then did. My mentor then told me that I needed to improve on my time management, as I had not looked up the drug when she asked me to. She carried on explaining that when I become a Registered Nurse I would need to know drugs and what they are used for. This situation left me questioning which was the priority, the patient’s needs or my own professional learning and development.
I automatically assisted the health care assistant in making the patient comfortable as I felt that this was the priority over researching the drug. I remember thinking that I could do this at home if the ward became busy. I felt annoyed with myself for not speaking up to my mentor about the issue as I had thought I had made the right decision to help the patient. I was concerned about the patients comfort and felt I could not justify leaving the patient lying in a soiled bed because I had to research a drug. Nurses need to be able to justify the decisions they make (NMC 2008a).
After the incident, being told by my mentor that I needed to improve on my time management skills because I chose to assist the health care assistant confused me a little. This practice experience made me feel as though I needed to learn and develop more regarding my time management skills. I decided I would have to research into the meaning of ‘time management’ as I thought that my time management skills were fine. I was always on time for my shift and I would make a list of the jobs I needed to do and prioritise them. This experience made me question how I was prioritising my workload at present.
I chose to assist the health care assistant in ensuring the patient was clean and comfortable and felt that this was the priority in this situation. As an accountable practitioner the NMC (2008a) states ‘you must make the care of people your first concern, treating them as individuals and respecting their dignity’ which I did. I could understand what my mentor was explaining to me, that as a Registered Nurse I must be able to know what different drugs are and what they are used for. As an accountable practitioner, I must have the knowledge and skills for safe and effective practice when working without direct supervision, recognize, and work within the limits of my competence. I must also keep my knowledge and skills up to date throughout my working life and I must take part in appropriate learning and practice activities that maintain and develop my competence and performance (NMC 2008a). Post-registration education and practice (Prep) is a set of Nursing & Midwifery Council standards and guidance, which is designed to help you provide a high standard of practice and care. Prep helps you to keep up to date with new developments in practice and encourages you to think and reflect for yourself. It also enables you to demonstrate to the people in your care, your colleagues and yourself that you are keeping up to date and developing your practice. Prep provides an excellent framework for your continuing professional development (CPD), which, although not a guarantee of competence, but is a key component of clinical governance (NMC 2008b). Following this experience my concern was which is the priority and which was not and that if I had have researched the drug I would have been leaving the patient in a soiled bed until I had done it.
As Individuals, we do not invent the concept of time, but we learn about it, both as a concept and a social institution, from childhood onwards. In the Western world, time has been constructed around devices of measurement, such as clocks, calendars and schedules (Elias 1992). A study by Waterworth (1995) explored the value of nursing practice from the viewpoint of practitioners, she identified that time with patients is important, but raises the question of how nurses manage their time.
The importance of time management will strike me at some point in my career as a Registered Nurse. I will be inundated with work and I will need to evaluate how to manage my time effectively. Time management is a dynamic process. It is constant actions and communications between you and your goals and dealing with changing situations (Brumm 2000). Time management tends to go hand in hand with good prioritisation skills, which mean managing your time, deciding upon priorities and planning accordingly, this can be one of the most difficult skills to acquire (Hole 2009). Managing time appropriately will reduce stress and increase productivity.
There are three basic steps to time management. The first step requires time to be set aside for planning and establishing priorities. The second step requires completing the highest priority task whenever possible and finishing one task before you start another. In the final step the nurse must reprioritise what tasks will be accomplished based on new information received (Marquis and Huston 2009).
We use planning in all aspects of our lives. In nursing, we often call it a ‘care plan,’ and nurse’s use this process to guide their practice. The nursing process, or ‘Assess, Plan, Implement and evaluate (APIE),’ can be used successfully as a time management tool. ‘APIE’ is a systematic, rational method of planning and providing care but if you change, the meaning to read it is a systematic, rational method of planning and accomplishing a workable time management plan this can be a great tool for nurses to use to manage their time effectively (Brumm 2000).
Assess/Analyze – Collect and organise data and form a statement of actual or potential time management needs.
Plan/Prioritize – Formulate your plan. This involves devising goals and expected outcomes, setting priorities, and identifying interventions to help reach the goals.
Implement/Intervene – Put your plan into action.
Evaluate – Assess your outcomes and see how you measure up against your goals.
There will be constant demands on my time and attention and it may be difficult to identify exactly what my priorities should be. In patient care, priorities can change rapidly and I will need to be able to constantly re-assess situations and respond appropriately. Priority setting is the process of establishing a preferential sequence for addressing nursing interventions. The nurse begins planning by deciding which intervention requires attention first, which second and so on. Instead of rank-ordering interventions, nurses can group them as having high, medium, and low priority. Life threatening problems such as loss of respiratory or cardiac function are designated as high priority. Health-threatening problems, such as acute illness and decreased coping ability, are assigned medium priority because they may result in delayed development or cause destructive physical or emotional changes. A low-priority problem is one that arises from normal developmental needs or that requires only minimal nursing support (Kozier et al 2008).
The assumption is that priorities can be determined, and decisions made as to what is most important, and that this can be followed by appropriate nursing actions. To establish priorities is to question what will be the consequence if this is not done immediately.
During this experience questioning ‘what will be the consequence of not helping the health care assistant?’
The patient would have had to wait whilst I researched the drug and would have been left lying in urine and faeces. This could cause skin excoriation to the patient and they would have been left uncomfortable and undignified. I would not have been providing a high standard of practice and care as stated in the NMC (2008a) and I could be held accountable for this as a Registered Nurse. Urinary incontinence and faecal incontinence should be managed in a manner that is unobtrusive, reliable, and comfortable. The patient will need to be attended to quickly, in order to prevent skin damage, relieve discomfort and restore dignity. Nurses need to be aware of the potential skin problems that may result from incontinence (Baillie 2005). The presence of moisture from urine and sweat increases friction and shear, skin permeability and microbial load (Jeter and Lutz 1996). If a patient has been incontinent of urine and faeces, their interaction can result in the formation of ammonia, leading to a rise in pH and an increase in the activity of faecal enzymes that damage the skin (Baillie 2005). The importance of changing a soiled product promptly in cases of faecal incontinence to prevent skin excoriation has also been emphasised by Gibbons (1996). I must act at all times to identify and minimise risk to patients and clients (NMC 2008a).
A research article and news story about student nurses and bedside care produced a phenomenal response on nursingtimes.net. The study authors Helen Allan and Pam Smith (2010) speak out saying that given the current pressures, qualified nurses are unable to deliver bedside care. The perception is that technical care is valued over and above bedside care as a source of learning for students’ future roles, leaving them feeling unprepared to be registered nurses. Their research showed that students conceptualize nursing differently to qualified staff because of an intensified division of labour between registered and non-registered nursing staff. As students, we often observe health care assistants performing bedside care and registered nurses undertaking technical tasks. The absence of clear role models leads students to question bedside care as part of their learning and to put greater value on learning technical skills. In relation to my reflective experience my mentor suggested the technical task in researching the drug was the priority in relation to the bedside care of the patient therefore it is not surprising to find that student nurses are unclear as to what is a source of learning in preparation for our roles as Registered Nurses. Helping patients with personal hygiene is one of the most fundamental and crucial relationship-building skills available to nurses, regardless of their seniority and clinical experience, student nurses should embrace these opportunities while we do not have the other time pressures and we can then reflect on our experiences. These skills will prove invaluable in delivering, overseeing and evaluating meaningful, holistic care (Bowers 2009).
Registered Nurses hold a position of responsibility and other people rely on them. They are professionally accountable to the Nursing and Midwifery Council (NMC), as well as having a contractual accountability to their employer and are accountable to the law for their actions. The NMC (2008a) code states that ‘As a professional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions’.
The NMC (2008a) code outlines the standards that I must work according to, what is expected of me as a registered professional by colleagues, employers, and members of the public. It also outlines what my professional responsibilities and accountabilities are. I may sometimes be faced with situations, which will require me to challenge, and question things that they are asking me to do if I feel that these things are unsafe or are not in the best interests of the patient or organisation. It is well recognised that it can be difficult to address these issues due to factors such as fear of the consequences, embarrassment, and lack of support like in my experience as mentioned above. Semple and Kenkre (2002) point out that the UKCC (2001) [now the NMC] reported the research of Moira Attree, which highlighted that fact that nurses are often reluctant to raise concerns about standards of care because they feared either inaction or retribution from employers. Nurses may also be inhibited by fears of being ostracised by the team if deciding to speak out against poor practice. This is another aspect of my individual professional practice, which requires development, and I will try to question situations in the future if I feel they are not in the best interests of the patient.
Being overwhelmed by work and time constraints will lead to increased errors, the omission of important tasks and general feelings of stress and ineffectiveness. Time management is a skill, which is learned and improves with practice (Marquis and Huston 2009).
Literature on time management in nursing is mainly unreliable, providing a number of tips on ‘how to’ manage time, along with descriptions of processes or strategies. The order for thinking about the process varies, ranging from setting objectives as the first step to working out how time is being used with the aid of time logs (Waterworth 2003). Determining the importance of tasks or priorities is part of the process, although the stage at which this should occur varies between authors. The main theme in literature is that nurses need to think about their own time management, with the main message being that individual nurses can manage their time. The reality of time management in nursing practice has been subject to experimental investigations, although studies on nurses’ work organization have found time management problematic, with nurses compensating for lack of time by developing strategies in an attempt to complete their work (Bowers et al. 2001).
Time management is a dynamic process and tends to go hand in hand with good prioritising skills. If you cannot prioritise you, will waste time and be inefficient. This can cause stress to yourself and your fellow team members, as well as causing potential harm to your patients. An efficient way to organising your time can be to use the nursing process as explained in the essay to Analyze, Prioritize, Intervene and evaluate.
After my research into time management and prioritising, I believe that my mentor was wrong to question my time management skills. I had thought about which was the greater priority in this situation and I still believe that the patient was. The patient would have been at risk from skin excoriation and would have been left uncomfortable and undignified. As a Registered Nurse, I will be accountable for my actions and in the future, if the same situation arose again I feel that I would not do anything different other than to speak up and justify my decisions. I identified and minimised risk to that patient and as a Registered Nurse, I will hold a position of responsibility and other people will rely on me. Although saying this, my priorities as a Registered Nurse may be different to those as a student nurse and my continuing professional development will be extremely important. I must make the care of my patients my first concern at all times, treating them as individuals and respecting their dignity (NMC 2008a).
With the increasing emphasis on efficiency and effectiveness in health care, how I manage my time will be an important consideration. Time management is recognized as an important component of work performance and nursing practice. As a newly qualified Registered Nurse, I will have to have excellent time management skills and be able to prioritise care appropriately.
To achieve this I will:
- Break down my day to find out how long it takes me to do certain tasks.
- Using the nursing process as a tool, I will write a list in priority order and cross of tasks as they are completed and I will keep evaluating my list during the shift.
- I will delegate tasks to other members of the team where necessary.
Through the reflection of this experience, I am now aware that I also need more development to challenge and question things that I feel are not in the best interests of the patients.
To achieve this I will:
- I will speak up and justify my actions at all times.
- I will research more into assertiveness and confidence skills.