Student Nurse

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    Reflection - Handover

    Introduction

    The purpose of this essay is to reflect upon an aspect of my professional practice or development that I have encountered throughout my time as a student nurse. For the purpose of reflection the essay shall be written in the first person. In accordance with the NMC (2002) Code of professional conduct, confidentiality shall be maintained and all names have been changed to protect identity. The purpose of reflection as stated by John's (1995) is to promote desirable practice through the practitioner's understanding and learning about his/her lived experiences. I have decided to reflect upon the first time that I gave a nursing handover and in order to structure my reflection I have decided to use John's (1995) model of reflection. This model encourages practitioners to work through a series of reflective cues, the last of which is concerned with personal learning. John's (1995) model provides a good example of an approach to reflection on action (or reflection on practice). Reflection on action, which takes place after the event, allows the practitioner to revisit an experience with the intention of exploring and learning from an activity. Reflection on action is particularly significant to nursing students, as it is often the basis of formal assessment.

    Bengtsson (1998) suggests that reflection can be understood and used as thinking and self-reflection. Self-reflection helps nurses to learn about the actual practice of the profession and help them to evaluate their own practice and performance. Bengtsson (1998) further suggests that nurses need to learn from these experiences and by doing so, they may acquire the competence that is needed to teach others. According to Maggs and Biley (2000) evaluating practice through reflection can bring advantages. The challenge is to recognise and use these advantages, together with the knowledge they generate. When nurses rely solely on factual, research-guided models, they fail to integrate the intuitive principles that complete the healing process. In a study by Gustafsson and Fagerberg (2004) it was found during interviews with nurses that nurses tended to focus on situations, which they regarded as poor nursing care and on occasions where they regarded the care as good nursing care the situation seemed to pass unnoticed without reflection. The authors further go on to write that reflective practice involves learning alone, to see situations in different ways and from different perspectives. Conscious reflection can be used this way, and systematic nursing care supervision, can be a way to use reflection as a tool for improving professional development. However according to Platzer (1997) knowledge about reflection does not necessarily enable nurses to use reflection in a meaningful way in practice. The UKCC's report Fitness for Practice (1998) reaffirmed support for the idea of reflection declaring that students should be able to demonstrate critical awareness and reflective practice.

    Context

    It was my final placement of my course in a children's ward. I was working towards performance level 5 which involved working independently within a supervised environment. I had been caring for one patient during my shift, a 12 year old girl Claire who had been admitted for treatment of her diabetes. Although I had been caring for her for the duration of my shift I was unprepared to give the next shift a nursing handover. I assumed that my mentor would do it as she had been doing it on all of my previous shifts. However on this occasion my mentor said to me to do it at the last minute. I listened to her giving the handover for her patients then when it came to mine I panicked and got information mixed up. I started with basic information about Claire such as name, date of birth and reason for admission. Unfortunately I became flustered after that and it was clear to both my mentor and the other staff nurse that I was out of my depth and needed help. My mentor then took over and continued the handover.

    I therefore decided to action plan to develop my nursing knowledge in this area. I looked at various nursing journals detailing how to give effective handovers. I also used the advice that I found in the nursing journals to plan out how I would give handovers. I also continued to give handovers on the ward. At first I wrote down all the information that I wanted to convey to the receiving nurse and explained to the nurse the reason that I had written the information down.

    At first I found that I had to rely heavily on my notes and I felt as though I was merely reading out a summary of the patient rather than giving a summary of care that had been given. Once when I had built up a small bit of confidence I still used the notes but instead of writing down everything that I wanted to say, I wrote down the key items that I wanted to say to ensure that I didn't forget. I found this to be extremely helpful and continued to do this until I felt ready to give a handover without writing anything down. The first time that I gave a handover without any notes I was extremely nervous, however I also felt more confident in the knowledge that if I did forget a piece of information or become flustered I simply referred to the patients folder and used this as guide. Another reason that I feel more confident now is that I feel more comfortable with the other members of the nursing team and do not feel as self conscious as I did when giving a handover the first time.

    Aesthetics

    The nursing handover was defined in 1969 by Clair and Trussell as the oral communication of pertinent information about patients. This was supported by Thurgood in 1995 who adopted the view that patient centered care is central to any definition of handover and that it is its primary function.

    John's (1995) describes an aesthetic action as concerned with the practicioner's response to a particular clinical situation. In my case I was concerned with trying to remember all the information about Claire that I wanted to hand over. However as I was not feeling confident I became very nervous and I feel that this was portrayed to my mentor and the other staff nurse. I was grateful that my mentor took over from me and continued the handover however I also felt embarrassed, as I was worried that the other staff nurse would think I was incompetent as I felt that being in third year I was expected to be able to give a handover correctly. Akinsanya (1987) and Leonard and Jowett (1990) found that generally, student nurses anxieties are due to a lack of knowledge and preparation. This was most certainly the case in my situation. The only knowledge of handovers that I had gained was from observing other staff nurses. Whilst I recognise that there is a wealth of knowledge to be gained from observing staff nurses I also feel that as third year student nurses close to qualifying, my university could have prepared us with some background knowledge in this area. In 1998 the NHS Executive claimed that pre-registration nursing programs are not equipping nurses with the knowledge and skills to deliver high quality care. However Fitness for Practice (UKCC 1998) states that the sequencing and balance between theory and practice should promote an integration of knowledge, attitudes and skills. I also felt worried about giving my next handover. I had prepared for the handover during the last part of my shift and had the whole handover written down on a sheet of paper. Reiley and Stengrevics (1989) believe that a written handover cannot only reduce report time but can also serve as a valuable catch up tool for part time staff and agency staff. Writing the report beforehand has also been proposed by Donaghue and Reiley (1981). The staff nurse that I was handing over to was just recently qualified witch helped to ease my nerves. I gave the handover as best I could and was relieved when it was over. The staff nurse told me that what I had said was fine and that he was worried about doing handovers when he was a student, which made me feel better as I thought that I was the only student nurse who was unable to give a handover correctly.

    Personal

    Career (1978) describes the personal as being concerned with the knowing, encountering and actualisation of the individual self. My personal response was that I am glad that I had the chance to practice my nursing handover as it is an important role of the registered nurse and an aspect of nursing care that I will be expected to be able to do once I am qualified. Footitt (1997) writes that the delivery of handovers are key to the overall delivery of high quality nursing care. At all times during the learning experience I felt well supported by my mentor and considered her input to be of great help to me during the experience. I am glad that this experience happened during this placement and not any of my previous placements as in the past I have not felt as supported by mentors as I should have been. Morrow (1984) defines a mentor or preceptor as a person, generally a staff nurse who teaches, counsels, inspires, serves as a role model and supports the growth and development of an individual for a fixed and limited amount of time with the specific purpose of socialising the novice into the new role. This is further supported by Gray et al (2000) who writes that good mentors spend quality time with students and value their contribution to patient care and are good role models. Good mentors incorporate feedback when teaching students. Feedback is seen as one of the key roles of the mentor in a study by Phillips et al (1996). Little or no feedback is said to delay the development of self-confidence (Cahill 1996). I especially agree with Cahill (1996) as I have gone through previous placements without sometimes receiving feedback until the last week of the placement. This has led me wondering about how I am getting on, and whether I am doing things correctly. Although sometimes I find it hard to accept praise for my actions I also welcome it as it gives me confidence and lets me know that I am doing things correctly. I feel that once I am qualified and acting as a mentor to student nurses I will always let the students know how they are getting on and give them appropriate feedback as necessary. I feel that I will also support the student rather than breathe down their neck and allow the student independence in order for them to use their initiative and become self motivated.

    Ethics

    John's (1995) refers to ethics as knowing what is right and wrong and being committed to act on this basis. As a pre-registration nursing student and an autonomous practitioner I must consider my actions carefully. It is now upon reflection that I realise that during my initial handover I may have breached patient confidentiality. I feel that I may have done this by giving my handover at the patient's bedside. This allowed the other patients and visitors in the ward to overhear what was being said. The Nursing and Midwifery (NMC) Code of professional conduct (2002) clearly states that as a registered nurse you must protect confidential information. The handover has traditionally taken place in an office where patients do not have the opportunity to overhear what is being said. It is only in recent years that nurses have begun the practice of handing over care at the patient's bedside (Greaves 1999). The current practice has changed from the type of round where the purpose was purely to check standards of care overnight, to today's efforts to involve patients more. This shift in emphasis is a move forward in changing traditional nursing practices and has accompanied efforts by nurses to individualise patient care (Johns 1989). However Webster (1999) wrote that the bedside handover results in better nurse-patient communication and a sense of partnership. On the other hand Smith (1986) suggests that the correct location is somewhere private, away from patients and without distractions. I feel that the best place is away from the patients so that confidential information cannot be overheard and indeed in all of my other handovers I ensured that I maintained patient confidentiality at all times.

    Empirics

    John's (1995) states that empirical knowledge is for describing, explaining and predicting phenomena of special concern to the discipline of nursing. Van manen (1990) states that Empirics cannot stand before practice to dictate its outcomes. In other words much empirical knowledge cannot be foreseen to be required and it is only through experience in a clinical situation that the knowledge can be seen to be useful.

    Upon reflection I feel that I should have been better prepared for the handover. This therefore prompted me to look at nursing journals and the literature to see if there were any articles that could help me become more efficient.

    A report by Malestic (2003) stated that if done poorly a verbal report wastes time and can even jeopardise patient safety. The article goes on to provide a useful guide to verbal reports and I found the article extremely helpful and allowed me to see where I had gone wrong and to prepare properly for my next handover. By using the report by Malestic (2003) I constructed my handover by starting with basic information about my patient such as her full name, age and date of birth, date of admission, the consultant looking after my patient and the reason for her hospitalisation. I then followed by describing my patient's diet and any restrictions that she had plus any allergies that she had, I then described what treatment my patient has had including IV solutions and followed this by accurately describing the patients status including any medications that had been prescribed. I then finished by describing the family circumstances and whether a parent or family member is resident and including any family visits. Another article that I found to be of immense help was that of one by Hansten (2003). In Hansten (2003) article she suggests that in order to give an effective verbal report, the nurse should include the four P's. These are Purpose where you describe why the patient is here and any priorities that they have, Picture where you describe any results that are being sought both long and short term and asks you to imagine how you can picture the patients condition, Plan which includes treatments that did or did not work and part which asks what part can you play during the next shift.

    Reflexivity

    Reflexivity is the final stage of John's (1995) model, which enables practicioners to identify, confront and resolve contraindications between their aims and actual practice, with the intent to achieve more desirable and effective work.

    On the whole I found this to be a valuable learning experience. Although the initial handover did not go to plan this in turn has prepared me for future handovers. I feel that my confidence has increased in this area and will continue to increase once I am qualified and gaining experience on a daily basis. I also feel that this experience has helped me become more aware of other aspects of my nursing care that does not always go to plan. I now realise that it is possible to turn an unpleasant experience into a positive one. I feel more secure in the knowledge that it is acceptable for me to get things wrong and to use reflection as a tool in order to turn an unpleasant experience into a positive one.


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