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Reflective writing is a useful approach for nurses to learn from experience. In nursing, self reflection is essential to acknowledge own strength and limitation and to initiate necessary changes in future to improve the situation and for professional development. I have selected Gibb’s reflective cycle to reflect the incident as it helps to express both events and feelings generated by experience.
On placement, I was assigned to take complete care of 4 patients in a surgical ward of the Hospital Umum Sarawak under the supervision of senior nurse. The night shift new graduate registered nurse handed over to us that one of our post operative patients had an indwelling catheter (IDC) which was taken out a night before and patient voided after removal of IDC. The nurse reported that the patient’s incontinent aid was moderately wet at night,however the patient was still complaining of not being able to void which made the nurse think that the patient was confused.
Upon receiving a handover, I went to check my patients and I found that particular patient was restless and when asked she stated she had a lot of pain in her lower abdomen. A quick physical examination revealed distended lower abdomen. After reviewing her clinical notes I noticed patient received PRN (as needed) analgesia for abdominal pain early that morning however no further investigation and intervention were done for pain. Furthermore, I assessed the patient and found she was well orientated to time,place and person as there was no significant history of confusion or delirium in her clinical notes.
At that time, I felt the situation wasn’t correct and I reported immediately to my mentor. She appreciated my initiation and instructed me to perform an ultrasound bladder scan.
Bladder scan revealed a residual volume of 998 mls of urine in bladder.I immidiately noticed my mentor and the junior medical officer working on the floor who reviewed the patient and ordered for immediate insertion of IDC.While I was inserting IDC under supervision of my mentor I delegated the assistant in nursing staff (PPK) staff working on the floor to keep on close eye on my rest of the patients and answer their needs. Upon insertion of IDC a urine output was 1650mls within a couple of minutes and patient stated she felt much more comfortable. Patient thanked us for not ignoring her complaint of pain and not considering her as confused and undertaking prompt action to make her comfortable.
In my opinion, the night shift nurse changed her incontinent aid which was fairly wet thought the patient was confused when patient stated she can’t void. The patient might have incomplete bladder emptying or overflow incontinence which the night nurse might have assumed as patient voiding normally. Later, my mentor spoke to the night duty nurse about the incident and asked her either she attended bladder scan or informed any of the senior nurses or treating team about the situation. The nurse said she was really busy and she didn’t think about it. My mentor explained to her how important is to attend comprehensive and accurate assessment of patient rather than making an own judgement. My mentor discussed about legal requirement of nurses to fulfill the duty of care and how negligence can lead to harm to the patient. The night shift nurse assured my mentor that she will never ignore patient’s needs and always fulfill her duty of care in future.
Australian Nursing and Midwifery Council (ANMC) have outlined the competencies for nurses to provide safe and competent nursing practice adhering to the legal and ethical framework. ANMC competency for registered nurse requires nurses to perform a comprehensive and accurate assessment of the patient before performing any interventions (NMBA,2006). In this scenario,the night duty nurse should have performed comprehensive assessment (physical assessment and bladder scanning) when the patient was complaining of abdominal pain and discomfort. It is the responsibility of nurses to fulfill the duty of care for their patients. Based on ANMC competency standards, reflecting on this incidence has enhanced my understanding of the importance of duty of care,nurses role to advocate for their patient, critical thinking and analysis, comprehensive and systematic nursing assessment to identify actual and potential health problem and need of effective communication and care coordination with multidisciplinary team to achieve optimal level of health.Furthermore, with this incidence I have also learned that whilst providing care to the patient nurse must understand their own personal value and attitudes should never impose the care they provide to their patients.
Reflection on this incident in feel i performed fairly well however,I should have acted much sooner to alleviate my patient suffering. I now realize if I would have ignored the incident thinking the patient is confused I would have put my patient’s well being at risk. Retention of more than 800mls of urine in bladder increases the risk of bladder over distention injury (Nguyen et al,2016). Similarly, there are many other complications associated with acute or chronic retention of urine which may include infection, flaccid bladder, renal damage due to reflux and development of bladder diverticulum or pouching (Casey,2011). Hence,if the relevant action wasn’t initiated in time the situation might have been worst. Looking back on this incident,apart from fulfilling duty of care I realize nurses are legally obligated to recognize and respond promptly to unsafe and compromised care. Therefore, keeping patient well being at the forefront i also learn to challenge the practice of colleagues if their practice put patient’s health at risk. Furthermore,this incident helped me to understand the importance of comprehensive patient assessment in identifying actual and potential health issue. By conducting through patient assessment the exact cause of the problem was able to notify and with the involvement of multidisciplinary team the issue was easily resolved. This incidence provides me an insight of the importance of patient centred holistic care,effective communication and teamwork skills for smoother transition as a beginning level registered nurse.
Nurses are accountable to provide safe and competent nursing care (NMBA,2008). The national competency standards for registered nurses to fulfill duty of care and recognize and respond to unprofessional and unsafe practice. With this incidence I have learned to fulfill the duty of care carefully and to significantly improve the assertive skills. Similarly, effective communication is an essential attribute a new graduate nurse should have. Taking time to listen to the patient,recognize their unique need and involving them n their own care promotes patient centered care(Stein- Parbury,2012). Relating back to the incident,due to lack of effective communication a client needs was neglected therefore,in order to successfully transit into beginning level registered nurse i should develop competent communication skill.
The transition from a student into the professional graduate is often confronting and requires a wide range of knowledge and professional skills. In order to successfully adopt into the professional role, a new graduate nurses are expected to prioritize care,manage workloads,make an appropriate clinical decision,exert leadership skills and work within the interdisciplinary team. The other key competencies required for a new graduate nurse are practicing within the evidence based framework,mentoring,regularly monitoring patient progress,care coordinating and advocating for patient. Apart from other skills,a novice practitioner is also expected to have skills like leading, mentoring and delegating the task to other staffs based on their competence and scope of practice.
Leadership skill is one the essential in the nursing profession. Upon completion of graduation,a new graduate nurse is also expected to lead a team depending upon the organization policy and protocols. The new graduate nurse can demonstrate and built leadership capability by working within a small group of staff who has different competencies and skills such as enrolled nurse and assistants in nursing in order to achieve a common goal (Thoms & Duffield,2012). Leadership skill requires a nurse to clearly delegate tasks to other,provide recurrent feedback,communicate effectively within a team and involve in the professional development of self and others. Delegating a task to others is often a challenging job for a new graduate nurse.Before delegating a task to others it is essential to have a sound knowledge of skills and capabilities of other team members. In addition ,consistent supervision , support and mentoring are essential to ensure delegated task has been performed safely and accurate. Meantime, as a leader providing appropriate feedback is also important to motivate team members.
Hence, reflecting on this incident has helped me to get insight into my clinical practice, understand the importance of comprehensive assessment, assertiveness, holistic patient centered care,interdisciplinary team work,leading mentoring and delegating within the team for a successful transition into the role of registered nurse.
This reflective piece is on learning experience concerning the management of wound dressings whilst placement in aged care. The Gibbs reflective cycle is used, which will help to describe the incident, explore the feelings, make an evaluation, analysis of different components, finally conclude and action plan looking at what would be done differently if this happened again (Wain, 2017). The purpose of the reflection is to identify and use strengths and weaknesses during placement to direct learning. The reflection on wound dressing is chosen because this skill is more practised in aged care in the first clinical placement.
The wound dressing was conducted on an elderly resident with a skin condition bullous pemphigoid. The patient had fluid-filled blisters on both legs. The RN had asked the student nurse for assistance in wound dressing. The student nurse assisted the RN in removing the old dressing and cleaning the wound. She observed how the RN cleaned the wound and changed the dressing. The RN had used inadine as a primary dressing and then applied an appropriate secondary dressing over it. Moreover, the RN showed her the different dressings used in wound care.
The student nurse observed that infection control and hand washing principles were followed throughout the procedure. According to standard 6.1 and 6.5, hand hygiene and social hand wash are considered important to ensure infection control and needs to be done throughout the procedure (Nursing and Midwifery Board of Australia [NMBA], 2016). The student nurse got the chance to do the dressing on another leg under the supervision of the RN. After the procedure, she documented the notes that the legs had been washed and redressed as per the plan. Nursing documentation is important as it provides a reflection of nursing assessments, interventions, the record of patient care and is a basis of communication between health professionals (Alkouri et al., 2106).
When the RN removed the old dressing, the student nurse was very shocked to see the wound. It was the first major acute wound she had observed in her placement. It made her sympathize with the patient. She became instantly eager to help the RN in wound care. She also felt anxious when she was asked by the RN to perform the dressing on the second leg. The RN assisted her, and she felt confident in performing the skill. It made her feel like she is enhancing her skills as the placement goes on.
The clinical skill gave positive outcomes. The student nurse got knowledge about tissue viability, wound healing, wound assessment and became familiar with the different types of dressings. She followed the RN instructions and performed the skill using aseptic technique. She focused on aseptic principles of wound care and infection control. An aseptic technique is used to prevent the entry of micro-organisms from infected areas onto vulnerable areas (Denton & Hallam, 2020). She learnt how the nurse-built rapport with the patient and provide patient-centred care. However, the negative aspect was that she was lacking in communication with the patient. She communicated with the patient before the wound dressing, but during the skill, she did not talk to the patient as she was focused on her work. Effective communication is the key element in the health care setting and can improve patient satisfaction, reduce their anxiety and build their confidence (Negi et al., 2017).
The overall learning experience in age care was a positive one. The student nurse performed the wound dressing for the first time on a patient in a clinical setting. She learnt about wound assessment and the aseptic non- touch technique of wound dressing. The wound assessment needs to be done before the procedure. The wound assessment is important to find out diagnosis and appropriate treatment. Wounds should be regularly assessed to provide care to the patient. The wound assessment should focus on the position of the wound, aetiology, presence of blood, exudate, odour, colour, size of the wound and the level of pain experienced by the patient (Kleintjes, 2018). The student nurse learnt about different types of dressings. It is significant to choose an appropriate dressing for the wound. She got to know from the RN that the dressings should get maximum exposure to the wound bed, which can be achieved by a suitable dressing that decreases the spaces where the bacteria can thrive.
Moreover, the student nurse also noted that the RN was displaying excellent patient-centred care. The resident with leg blisters had been living in aged care for six years and during that time the nurse had learnt few words in Greek (as the resident was Greek) to better understand him and provide him comfort. She admires this attitude of the RN and would like to adopt into her practice in future.
The Gibbs reflective cycle has helped the student nurse to examine the incident extensively and encouraged to explore her feelings. She has achieved positive outcomes through this learning experience. Moreover, this learning experience will help her to enhance her clinical skills in wound management and encourage critical thinking. Furthermore, to provide more comfort and protection, she should have shown more interest in the patient, because communication is very necessary for good results to be obtained.
In future, the student nurse will plan to improve her clinical skills on wound management by keeping herself up to date about this topic, watching videos and nurses performing wound care in her next placement. She will learn more about different types of dressings that she is not familiar with and should get appropriate knowledge on the aseptic techniques of wound cleaning and dressing through research journals. She did not communicate with the patient throughout the procedure. Therefore, she will improve this by engaging in effective communication with the patient throughout the procedure and not just at the start and the end of the skill. Thus, the feedback given by the RN will help her to improve further in the skill in her next clinical placement.
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