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Why Critical Thinking is Essential to Nursing Associate Practice

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According to Loughlin (2018) respiratory rates are arguably the most important vital sign often being missed or inaccurately recorded, which can often lead to poor outcomes for the deteriorating patient. The importance of counting for a full minute allows the practitioner to fully assess the patient using the four-step process. This involves, Inspection, looking at the whole person colour and appearance. Palpation, the position of the person looking at the area the trachea is fond, seeing there is a distortion to the wind pipe or neck. Percussion, how the person sounds on inhalation and exhalation and Auscultation which looks at the quality and rate of the respiratory effort. Following these guidelines allows the practitioner to look for any abnormalities.

When I chose this subject, I felt I had a relatively good knowledge of respiratory rates. However, when reading the articles and reports I found I only had a basic knowledge. This left me feeling a little lost with where I wanted to go with this essay. This led me to question my ability as a Nursing Associate Apprentice as to whether I really had what it takes to qualify in two years’ time. I suddenly had this realisation that maybe my experience was not as in depth as I had originally thought it was, and that maybe it was too soon after my level three qualification to be thinking about the next stage in my nursing career.

My anxieties crept in the more I read, the more out of my depth I felt, some of these articles were so in depth I didn’t fully understand them. I have somehow remained positive throughout these doubtful weeks. Reflecting on my learning journey, I must admit has been an extremely difficult few weeks. Learning how to use the Digital Learning Environment (DLE) or Moodle and finding my way through the site, gaining access to the library (Primo) has gradually become easier. I can easily manoeuvre through the site finding relevant items when I need to. I am aware it is a professional obligation and continual learning is part of our standards of proficiency in our employment contract with the trust as a Nursing Associate Apprentice. This is vital to my growth as I continue my learning journey.

The Nursing and Midwifery Council (NMC 2018) state requires that nurses and midwives use feedback as an opportunity for reflection and learning to improve practice. I must admit as a Doctors Assistant admitting patients to the Medical Assessment Unit, when we were completely overstretched I would take a respiration rate by counting for 30 seconds and multiplying by 2 to get a full reading. Since becoming a Nursing Associate Apprentice and reading the articles and papers I now have a new-found passion and regardless of constraints facing me I now do a full reading, having a new understanding in to the importance of respiration rates. I have also found that as we are going to be accountable and regulated I comply with clinical guidelines in every aspect of my role. That’s not to say I didn’t beforehand, I feel I have a growing sense of pride in what I do now. I also feel more able to help others who perhaps do not understand the implications as I am now equipped with more knowledge to back up my findings. I now work more in adherence to the clinical guidelines and have found counting the respiratory rates for a full minute also allows me to observe the patient based on a holistic approach.

I have never been academically minded and always struggled with putting in to words what I can do. However, whilst researching the importance of critical reflection, it was reassuring to find that I am not alone in this I made the mistake of hand writing all my guided learning pack rather than typing straight on the pack, this used to be my preferred method of doing this type of activity. However, with the depth of knowledge needed for this I now know that note form hand written is the way forward as I have unintentionally doubled my work load. I now feel competent and confident to educate others the importance of accurately recording respiration rates, enhancing the patients experience.

I need to be more confident that I do know what I am doing, and that I deserve to be on this course. I need to approach each task positively, that is ok to have a basic knowledge, that’s a foundation for me to work on. It is an honour to be on this course and I can do it no matter what my anxieties tell me. I need to open up a bit more, let people know that I’m struggling with aspects of it too. Many of my peers think I have a good understanding of this project, when really, I had no idea either. I’m seen as the mum of the group so felt like I need to be strong and help everyone, neglecting my worries and struggles at the same time. I know realise that there is support out there for me and I need to stop being so stubborn and ask for help when I need it, as this ultimately hinder my learning journey.

Respiration is more than just the rate. Inspiration, the intake of breath. When you breathe in, or inhale, your diaphragm contracts and moves downward. This increases the space in your chest cavity, into which your lungs expand. The intercostal muscles between your ribs also help enlarge the chest cavity. They contract to pull your rib cage both upward and outward when you inhale. The Gas exchange takes place in the millions of alveoli in the lungs and the capillaries that surround them. Inhaled oxygen moves from the alveoli to the blood in the capillaries, and carbon dioxide moves from the blood in the capillaries to the air in the alveoli and then exhaled. Respiration is the production of energy, typically with the intake of oxygen and the release of carbon dioxide. Expiration, your diaphragm relaxes and moves upward into the chest cavity. The intercostal muscles between the ribs also relax to reduce the space in the chest cavity. As the space in the chest cavity gets smaller, carbon dioxide is forced out of your lungs and windpipe, and then out of your nose or mouth. These stages will enable us to see if there are any notifiable irregularities.

Respiration should be effortless, we need to be looking at ease, comfort, pattern and position. Although studies show there is no link between respiration rate and position. Whilst observing rate and rhythm we should also be observing our patients’ general colour and appearance, listening for any abnormal sounds. This will comply with what is recognised as the gold standard in EWS. The Early Warning score protocol was introduced in 2012 and updated in 2017 after several reports found there. was no one way to detect a deteriorating patient. It has been designed to systematically score each of the physiological measurements. Dependant of the score determines the level of observation needed, aiding the early recognition of those at risk of becoming critically ill.

The lower the EWS score the less likely the risk of catastrophic events. By recording all vital signs in accordance to the clinical guidelines EWS should be trended on an observation chart. Clinical guidelines state that every patient has to have a set of observations at least once a day, more if required. Each set must include Heart Rate, Blood Pressure, Respiration Rate, Temperature, sP02, Pain score and conscious level. It’s also recommended that at least one set should be performed manually. Therefore, providing a ‘track and trace’ system giving the practitioner a more accurate window in to the patient’s health, and possibly preventing further deterioration or even death. Normal respiration rates for an atypical adult is between 12-18 Breaths Per Minute, dependant on patient’s health requirements, however abnormal rates vary from 14-36 Breaths Per Minute. Patients with a Tachypnoea: 20 Breaths Per Minute, (fast but regular) or above are classed as unwell, patients with a rate of 24 Breaths Per Minute are classed as acutely unwell, this may the first signal a patient may be deteriorating. A patient with Bradypnoea which is less than 12 Breaths Per Minute (slow but regular) may be under the effects of sedation. A patient with an absence of respiratory rate for several seconds may have an apnoea if left untreated can lead to a respiratory arrest or if left untreated cardiac arrest. Treatments may include a continuous positive airway pressure device (CPAP). CPAP is a mask that fits over the nose and/or mouth, and gently blows air into the airway to help keep it open during sleep. If a patient is gasping for air (Dyspnoea) or having difficultly breathing, this may also be an indication of respiratory arrest and can lead to possible cardiac arrest. A high respiration rate is usually a marker for severe derangement elsewhere in the body.

Freshwater (2005) states that effective learning isn’t just the conceptual theory, to become a better practitioner a change of practice and reflection has to occur to enable us to grow and continue to learn. Looking at my role as a Nursing Associate Apprentice, it has become more apparent that critical reflection is essential to my becoming a better practitioner as will give the skills to look at the who, what, when and why, giving me the tools to make the right choices, and be able to make the appropriate moral and legal decisions regarding my patients care. Reflection is a method of using knowledge to provide professional and personal development whilst reinforcing continual learning. According to Schon et al 2010 reflection comprises of 3 components, Reflection before learning – Think about the task at hand, what is already known about the task, what achievement can be gained from the task?

Reflection in action – Thinking on our feet, how would we react in situations? Reflection on action- Looking back at what we did, why did we react or respond the way we did, how would we do it differently and what could’ve been improved? By using the ‘Gibbs Model’ I have effectively been able to deconstruct what I do, placing evidence-based knowledge as to why I am doing what I do, also identifying gaps in my knowledge. Giving me a Holistic view in to my patients care and enhancing their patient experience, also allowing me to better support colleagues and myself and embrace others views and opinions. Effective working relationships rely heavily on shared and mutually respectful experiences of who we the healthcare team are. If our team is to provide an effective and responsive service to patients, the team must have common purpose.

For future endeavours I now know not to do this, therefore reducing my stress levels. I was worried I wasn’t going to complete the work on time. I have found setting myself smaller targets and allocating a set amount of time to study, allows me to relax and unwind and enjoy being with my family and not have this nagging guilty feeling in the back of my head .

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