Reflection on Nursing Competence Standards - Essay Example

 Reflection on Nursing Competence Standards Introduction Nurses play an important role in any health care system. They play a major role in the assessment and treatment of patients. They promote the emotional well being of a patient because of their sense of empathy and caring feeling. They work with people suffering from various types of illnesses in diversity of roles and actions demanding expert skills and professional knowledge. The situations are many a times complex requiring an understanding of the complexity of the situation. Every nurse-patient encounter is unique and there are no fixed solutions to many nursing problems. Due to these demands and requirements, some professional standards and skills are expected from the nurses. The peak national nursing and midwifery organization, the Australian Nursing and Midwifery Council Incorporated in conjunction with the regulatory authorities of state and territory midwifery and nursing has set some national standards for the midwives and nurses to assist them in safe and competent delivery of care (ANMCI, 2005). The standards are used to assess professional competency levels both for obtaining and retaining license to practice as a registered nurse or midwife in Australia (ANMCI, 2005). It is very important for a registered nurse to maintain standards of competence to survive in the profession and also to do justice to the patient. One of the methods to maintain standards of competence is reflective practice. In this essay, I aim to reflect on my clinical practice with respect to national competency standards for registered nurses. Competence for nurses in the clinical setting Competence for nurses is important for the kind of profession it is and the expectations that the profession arouses. Nursing profession involves complex combinations of performance, knowledge, attitudes and skills (David, 2005). Developing professional knowledge, skills and competence is a way of meeting the demands of modern professional practice. Currently, in many parts of the world, education, assessment and training in nursing are based on competency-based approach (David, 2005). According to the NMC, (cited in Somerville, and Keeling, 2004), nurses have a duty bested upon them to provide care that is to the best of their ability to the patients. In order to impart this duty, they need to have good knowledge, possess good skills and display appropriate behavior during their interaction with patients and their colleagues. They are obliged to act as per the expectations of their profession. These expectations are the core of competence. There are basically four domains under which the National Competency Standards for Registered Nurses are organized (ANMCI, 2005). They are professional practice, critical thinking and analysis, provision and coordination of care and collaborative and therapeutic practice. Professional practice domain relates to ethical, legal and professional responsibilities of the nurse which are imparted through adequate knowledge, accountability of practice, protection of the rights of individuals and groups and also functioning as per the guidelines and expectations of legislations of healthcare and nursing (ANMCI, 2005). Critical thinking and analysis refers to research for practice which is possible through thorough professional development and value for evidence (ANMCI, 2005). One important aspect of this domain is reflective practice which helps in individual and professional development. The domain pertaining to provision and coordination of care refers to daily chores of the nursing profession wherein nurses are required to perform certain activities like assessment of patients, planning, evaluation and implementation of care. These activities demand organization and also good and coherent coordination. The domain of collaborative and therapeutic practice is concerned with standards for establishment, sustainance and conclusion of professional relationships with various individuals and groups. The domain also covers those competence aspects which are related to interdisciplinary health matters (ANMCI, 2005). Clinical experience is an essential component of nursing education and one of the methods of development of clinical experience is to place the nurses in different quality clinical placements. The rotation through these venues helps the nurses assimilate competence and grow into a confident professional (Levett-Jones, 2006). The most important aspect of expert clinical practice is clinical decision making which is a complex phenomenon and the thinking process varies from one nurse to the other (Higuchi and Donald, 2002). Reflective practice Advances in the 21st century are seeing many new developments in the field of healthcare forcing the nursing faculty to reinforce effective and appropriate education. This becomes of primary importance by virtue of the nature of the profession nursing is. As such, the primary goal of nursing is to provide quality health care to patients. Though reflective practice is an old-model of teaching and education in nursing, it was not much in vogue. However, its use is now widely spread and infact is currently the corner stone of the professionalism of nursing. Hence many nursing educators have incorporated reflective practice as a part of nursing education. Reflection is nothing but an evaluation and examination of thoughts and actions of oneself. For health practitioners, reflection means focusing on the interaction of oneself with colleagues and environment in a particular situation so that they are able to evaluate their own behavior. “Reflection gives scope for better understanding of oneself so that existing strengths can be used to build-up for future actions "(Somerville and Keeling, 2004). “Reflective practice is essential for clinical practice because it provides a retrospective look at current clinical experience and questions the reason for doing so” (Alexander, Fawcett and Runciman, 2006, pg.2). This is also an opportunity for professional growth and development to increase competence in the nursing practice. According to Burns and Grove (1997), “reflective practice is a good way of learning and it enables the practitioner to assess, understand and learn through their experiences.” Reflecting of what happened in the past, the performance of our profession can be considered a lifelong learning. “Systematic and deliberate use of reflection as one of the learning tools needs to be done consciously with all efforts over a period of time” (Bulman and Schutz, 2004, pg.25).As professional learners, nurses are motivated to enhance their knowledge as they perform their daily tasks and responsibilities independently in their chosen fields. They also need feedback in the workplace from their colleagues in order for learning to be complete. It is in a way, to be able to refine their abilities and confidence as a person and as a professional. The meaning of reflective practice is to take one's experiences as the starting point for education and leaning. In my experience, thinking about some experiences in a purposeful way using various reflective processes can help understand the experiences in a different way so that appropriate and necessary actions can be taken. Practical knowledge gained through reflective practice is totally different from theoretical knowledge which provided knowledge for practice. Skills in reflective practice are acquired through watching others and by imitating what they do by the process of active decision making and conscious thinking. Thus it can be said that reflective practice bridges the gap between practical experience and pure theory (Jasper, 2003). In the author's view, this happens through strategical understanding and learning which is provided by reflective practice There are many frameworks which make the process of reflection easy. One of the commonly used framework is the John's model of reflection. John's Model of reflection is based on five cue questions which help in breaking down the experience to be reflected and also understand the process of reflection and outcomes of the actions (Bulman, & Schutz, 2004). The five cue questions are: 1. Description of the experience: Through this question, the experience and significant factors of the experience are described. 2. Reflection: Here the aims of the action and the consequences of the actions are analyzed. 3. Influencing factors: Any internal and external factors and the knowledge and skills possessed which affected the process of decision -making are analyses 4. Could I have dealt with it better? Through this question, other alternative modes of action and their possible consequences are analyzed. 5. Learning: Here changes that are implied from the analyses of the experience are noted and how they have affected the scientific, ethical, personal and aesthetic thinking are analyzed and understood. Reflection of clinical practice with reference to nursing competence I was posted in Accident and Emergency Race Track-Majors department as a part of nursing postings rotation. There were several situations I was confronted with which are worth reflecting upon. However, in particular to competence in clinical practice, I chose to discuss about management of Mrs. E who attended the Accident and Emergency Race Track-Majors department on a Saturday evening. With respect to this situation, I will be reflecting upon 2 domains, namely, critical thinking and analysis and provision and coordination of care which I personally feel are critical to the management of this patient. I will be using John's model of reflective practice for reflection of this particular situation. The name of the patient and the place will not be disclosed throughout the assignment for the purpose of anonymity and confidentiality. Description of the experience Mrs. E was brought with complaints of feeling ill for 3 days associated with intermittent abdominal pain and repetitive vomiting. She looked pale with dry cracked lips and appeared very weak. The A&E Department was as usual very busy and bustling with activity, the patient waited for 30 minutes before being assessed by myself. Temperature was 37.3 degree Celsius, blood pressure 109/67, pulse rate was 89 per minute and respiratory rate was 28 per minute. Blood sugar level was 22.7 mmol/l and urine dip stick revealed plus 3 ketones, plus 3 of Glucose and traces of protein. Blood ketone levels as determined by ketone strip were 5.8 mmol/l. I made a diagnosis of diabetic ketoacidosis and shifted her to the resuscitation room where further treatment was rendered. The patient was then treated according to DKA protocol. Soon after admission, blood samples were sent for serum blood glucose level, arterial blood gas analysis, serum sodium, potassium, phosphate, calcium and magnesium, blood urea and serum creatinine, glycosylated hemoglobin, full blood count, serum amylase, serum osmolarity and serum triglycerides. Urine samples were sent for urine glucose and ketone bodies. Pregnancy was ruled out. Mrs. X initial laboratory investigations showed hyperglycemia (23 mmol/L), ketonemia, metabolic acidosis with pH of 7.2, mild hyponatremia (129mEq/L), normokalemia, mild leukocytosis (15,0000 cells/ml), normal phosphate, calcium and magnesium levels, normal BUN and creatinine and, glucose and ketone bodies in the urine. The first therapy initiated after sending the blood samples was fluid and electrolyte therapy and insulin replacement. Two large bore venous lines, one in each arm, were placed; one was to facilitate fluid therapy, and the other to draw blood samples as and when required. The dehydration status of the patient was corrected over 24 hours after calculating the fluid deficit by clinical assessment. For initial resuscitation, 10 ml/kg of isotonic sodium chloride solution (0.9%) was administered over 30 minutes. This was repeated after 10 minutes. Thereafter, maintenance fluid therapy with isotonic sodium chloride solution was continued until blood glucose levels fell to 250-300 mg/dL (ie, 12-15 mmol/L). Once dehydration was corrected and there was normal urine output, potassium chloride was added to all the fluids. Maintenance therapy was started with glucose containing solution, 5% glucose with normal saline. This was continued until Mrs. X could eat and drink normally. The ongoing urinary losses were calculated on hourly basis and replaced along with maintenance therapy in the form of isotonic sodium chloride solution with the addition of 20 mEq of potassium chloride per liter of saline. The weight of the patient was checked regularly, twice a day. This was done to detect unapparent dehydration or fluid overload. After the initial arterial blood gas, venous samples were used to monitor acidosis. Brandenburg and Dire (1998) studied venous and arterial blood gases in DKA patients and opined that venous blood gas measurements accurately demonstrate the degree of acidosis of adult ED patients presenting with diabetic ketoacidosis. To bring down the glucose levels, continuous, low-dose intravenous (IV) insulin infusion was started. The patient's condition was reviewed atleast hourly until she stabilized. Insulin infusion was discontinued only after subcutaneous insulin was given once the patient recovered. Thereafter, the patient was continued on subcutaneous insulin therapy as per sliding scale. The initial daily dose was calculated depending upon the weight of the patient. This was divided so that one half was administered before breakfast, one fourth before dinner, and one fourth at bedtime. After selecting the initial dose, the amounts, types, and timing were adjusted depending on plasma glucose levels. The dose was adjusted so that the pre-prandial level of plasma glucose was 80-150 mg/dL (ie, 4.44-8.33 mmol/L). Also, the dose was adjusted with increments of 10% at a time, and the effects were assessed over about 3 days before making any further changes (Hussain 2007). Reflection Mrs. X arrived to the hospital in an emergency situation and she received appropriate treatment in the right time. I believe this is what helped the patient in fast recovery. Also, she received appropriate fluids in the right time and was never over loaded or dehydrated in the hospital. The urine out put and fluid intake were monitored correctly. Her sugars, ABG and urine ketone bodies were also monitored properly. Successful treatment of DKA requires frequent monitoring of patients, correction of hypovolemia and hyperglycemia, replacement of electrolyte losses, and careful search for the precipitating cause (Umpierrez & Kitabchi 2003). Privacy and confidentiality of the patient was maintained throughout. The Hippocratic Oath stresses on the privacy of the patient and the nurse must take all measures to protect this. She received appropriate psychological support. Influencing factors The knowledge I possessed about DKA though reading, listening to lectures and observation of patients helped me in my decision making. Diabetic ketoacidosis (DKA) is a life-threatening condition that frequently requires hospitalization in those with type 1 diabetes and is the most common cause of diabetes-related death in children (Della Manna et al, 2005). Diabetic ketoacidosis may be defined as a state of absolute or relative insulin deficiency aggravated by ensuing hyperglycemia, dehydration, and acidosis-induced derangements in intermediary metabolism (Rucker, 2006). It most commonly occurs in type-1 diabetes. It is characterized by hyperglycemia over 300mg/dl, low bicarbonate (15mEq/L) and acidosis (pH Read More