Essay: Reflection using Gibbs Reflective Cycle (nursing)

Description

I undertook a full assessment on a patient with a sacral pressure sore. The patient had limited mobility, dementia and does not speak. I completed the assessment using observation as a primary source. The care assistants were reluctant to engage with the nursing process rendering some specific measurements as ineffectual compromising the eventual Waterlow score.
I conducted the assessment with my mentor and gave a logical explanation how I administered the wound and gave rationale for the dressings I chose. I spoke to the care assistant to reiterate my action plan as it was pivotal to a successful wound healing.

Feelings

Initially I felt confident. I had observed pressure sores before and I had prior knowledge of dressings and pressure relief. When I discussed about the patient with the care assistant, I ensured we were outside the bedroom as it unprofessional to talk over a client. The health records were of poor quality and had not been updated. When I mentioned this, the carer’s attitude became abrupt and I began to get defensive and made an inconsequential remark, “It does not matter”, just to reengage the carer. This remark I regretted as it undermined my authority and I appeared amateurish. Care records are a legal working document in progress. Poor record keeping will be detrimental to a client’s recovery and must always be challenged. I felt overwhelmed and looked to my mentor to support me.

Evaluation

My role in the nursing process enabled me to evaluate the patient’s wound and give an accurate descriptive account to my mentor. I provided evidence that consolidated my evaluating skills and put my basic wound knowledge into practice, within a safe nurturing environment. I rushed the assessment and regretfully completed it away from the nursing home. I found this frustrating as I could not explore the holistic process in greater depth and it simply became a checklist without breadth to the other client’s needs; dementia and poor communication, which I acknowledged fleetingly.

Analysis

Payne (2000) identifies that professional partnerships are at risk if a nurse has insufficient knowledge required to perform ethically, thus undermining their own authority. The care assistant knew I was a student nurse and treated me, not as a partner in care but as a learner.
I failed to develop the partnership more and relied on my mentor too much when I conversed with the carer. I was looking for affirmation which was lacking within me. If I had communicated how significant the carer’s role was, this would have earned me more respect and empowered the carer.
Crawford et al (2005) believe empowerment inspires the self determination of others, whilst Fowler et al (2007) identifies listening skills and the encouragement in the participation of care motivates nurses to actively support changes in patient care. Entwistle and Watt (2007) remind practitioners that participation requires communication skills that are not universally possessed so nurses must be flexible in their approach to champion the participation of others. Using these concepts I could have built a rapport with carers, praising them for the care they provide, promoting partnership in care whilst emphasising the importance of the care plan.
I found it difficult to disengage from the patients many problems and only to focus on the wound. When choosing a suitable nursing framework, Roper et al (2000) describe care planning as a proposal of nursing intervention that notifies other nurses what to do and when. This model is used throughout the community and is thought to be a simplistic, easy to use everyday tool that enables nurses to identify actual and potential problems. Page (1995) had reservations about Roper, Logan and Tierney’s model, comparing it to a checklist which, if not used as the authors intended, can be restrictive in clinical practice as fundamental problems can be missed.
I used some of Page’s model as a checklist and not as a holistic assessment due to time constraints, the patient’s profound dementia, poor record keeping and being a novice assessor; however I was directed by my mentor to focus on the wound alone. It could be argued that community nurses working within care homes only prioritise physical needs from adapted assessments, as the care home provides the patient’s psychosocial needs. I identified from the patient’s assessment she was at the end stage of the dependence continuum, but I still recognised the importance of holism when completing the package of care and I identified that the promotion of comfort was as important as healing.
The main strength of my care plan was in identifying specific measurable outcomes exclusive to the client that were adaptable. I used evidence from reputable sources to identify suitable dressings to promote granulation and healing by sourcing up to date journals from the Cinahl and current trust policies. My weakness was relying on my mentor too much to confirm the evidence I collated on pressure care to the carer’s. Prioritising delegation and assertiveness as part of my learning needs I will now create an action plan that will ensure my future mentors will recognise the effort I extol to succeed in practice.

Conclusion

I conclude my implementation of the care plan was successful. The wound healed and the patient was discharged from the community case load. I demonstrated I can assess patients holistically, but require further practice when addressing client and carer concerns. To use nursing frameworks effectively nurses have to create an inclusive partnership with the client, family, professionals and care providers and demonstrate a broad knowledge of basic nursing care. Successful care plans are universal tools that empowerment others, giving them the direction to advocate safe holistic care based on evidence.

Action Plan

To encourage the participation of others I will become conversant in wound care. I will learn to identify the stages of healing by researching the biology of wound care. I will disseminate this to peers, as the sharing of knowledge is a fundamental part of holistic nursing care. As I develop from a supervised participant to a participant in care delivery I will continue to read research and reflect my practice on a daily basis. Creating new action plans that identify my learning requirements will address my limitations and by acknowledging them I will generate achievable goals to become a competent practitioner.

Reference List

• Allman, R. (1989) Pressure Ulcers among the Elderly. New England Journal of Medicine [on-line]. Available at http://gateway.uk/com/gw1/ovidweb.cgi[Accessed 22/07/07]
• Bale, S., Dealey, C., Defloor, T., Hopkins, A., Worboys, F. (2007) The Experience of Living with a Pressure Ulcer. Nursing Times. Vol. 103, No.15, pp42-43
• Benbow, M. (2006) Ethics and wound management. Journal of Community Nursing. Vol.19, No.3, pp26-28
• Benbow, M. (2006) Holistic assessment of pain and chronic wounds.Journal of Community Nursing. Vol.20, No.5, pp24-26
• Calianno, C. (2003) How to choose the right treatment and dressings for the wound. Nursing Management [on-line]. Vol.34, pp6-14. Available athttp://gateway.uk/com/gw1/ovidweb.cgi [Accessed 17/07/07]
• Casey, G. (2001) Wound Dressing. Paediatric Nursing. Vol.13, No.4, pp39-42
• Collier, M. (2004) Effective prevention requires accurate risk assessment.Journal of Wound Care/ Therapy Weekly. pp3-7
• Crawford, P., Brown, B., Bonham, P. (2006) Communication in Clinical Settings. Cheltenham: Nelson Thornes
• Cutting, K. (2006) Silicone and skin adhesives. Journal of Community Nursing. Vol.20, No.11, pp36-37
• Cutting, K. (1999) The cases and prevention of maceration of the skin.Journal of Wound Care. Vol.8, No.4, pp200-210
• Cutting, K., White, R. (2002) Avoidance and management of peri-wound maceration of the skin. Professional Nurse [on-line] Vol.18, No.2, pp33-36. Available at http://gateway.uk/com/gw1/ovidweb.cgi [accessed 29/07/07]
• Dealey, C. (1999) The care of wounds. A Guide for Nurses. (2nd Edition).Oxford: Blackwell Science
• Doughtery, L., Lister, S. (2004) The Royal Marsden Hospital of Clinical Nursing Procedures (6th Edition). Oxford: Blackwell Publishers
• Dykes, P., Heggie, R., Hill, S. (2001) Effects of adhesive dressings on the stratum corneum of the skin. Journal of Wound Care. Vol. 10, No. 2
• Entwistle, V., Watt, I. (2007) Exploring Patient Participation in Decision Making. Department of Health [on-line]. Available athttp://www.dh.gov.uk/en/Policyandguidance/thestudies/DH_4127209[Accessed 3/08/07]
• Evans, J., Stephen-Haynes, J. (2007) identification of superficial pressure ulcers. Journal of Wound Care. Vol.16, No.2, pp54-56
• Fletcher, J. (2002) Exudate theory, and the clinical management of exudating wounds. Professional Nurse. Vol.17, No.8, pp475-478
• Fowler, J., Fenton, G., Riley, J. (2007) Solution focused techniques in clinical supervision. Nursing Times. Vol.103, No.22, pp30-31
• Gannon, R. (2007) Wound Cleansing: Sterile Water or Saline? Nursing Times. Vol. 103, No. 9, pp44-46
• Gibbs, G. (1988) Learning by doing: a guide to teaching and learning.Oxford: KC Unit Oxford Poly. Cited in Bulman, C., Schuts, S. (2004)reflective practice in nursing (3rd Edition). Oxford:
• Blackwell Publishing
• Griffiths, R., Fernandez, R., Ussia, C. (2001) Is tap water a safe alternative to normal saline for wound irrigation in the community. Journal of Wound Care. Vol.10, No.10, pp407-411
• Guy, H. (2007) Pressure Ulcer Risk Assessment and Grading. Nursing Times. Vol. 103, No.15, pp38-40
• Hampton, S., Collins, F. (2004) Tissue Viability. London: Whurr Publishers
• Hampton, S. (2005) Death by Pressure Ulcer; being held to account when ulcers develop. Journal of Community Nursing. Vol.19, No.7, pp26-29
• Hampton, S. (2004) Dressing selection and associated pain. Journal of Community Nursing. Vol.18, No.1, pp14-18
• Herman, M., Bolton, L. (1996) the Influence of Dressings on the Cost of Wound Treatment. Dermatology Nursing [on-line]. Vol.8, No.2, pp-93-100. Available at http://gateway.uk/com/gw1/ovidweb.cgi [Accessed 17/07/07]
• Hess, C. (2005) Wound Care (5th Edition). Philadelphia: Lippincott, Williams and Wilkins
• Jones, M., SanMigule, L. (2006) Are wound dressings a clinical and cost effective alternative to the use of gauze. Journal of Wound Care. Vol.15, No.2, pp65-69
• Kaya, A., Turani, N., Akyuz, N. (2005) The effectiveness of hydrogel dressing compared with standard management of pressure ulcers. Journal of Wound Care. Vol.14, No.1, pp42-44
• Kingsley, A. (2002) Wound Healing and potential Therapeutic Options.Professional Nurse. Vol. 17, No.9, p539
• Land, L. (1995) A review of pressure damage prevention strategies. Journal of Advanced Nursing [on-line] Vol. 22, No.2, pp329-337. Available athttp://gateway.uk/com/gw1/ovidweb.cgi [Accessed 17/07/07]
• Moore, Z. (2004) Pressure Ulcer Prevention: nurses’ knowledge, attitudes and behaviour. Journal of Wound Care. Vol.13, No8, pp330-334
• Neander, K., Hesse, F. (2003) The protective effect of a new preparation on wound edges. Journal of Wound Care. Vol.12, No.3, pp369-371
• Nursing and Midwifery Council. (2004) Code of professional conduct. Standards for conduct, Performance and Ethics. London: NMC
• Page, M. (1995) Tailoring nursing models to clients’ needs using the Roper, Logan and Tierney model after discharge. Professional Nurse. Vol.10, No.5, pp284-288
• Payne, M. (2000) Teamwork in Multi Professional Care. Hampshire: Palgrave
• Rainey, J. (2002) Wound Care. A Handbook for Community Nurses.London: Whurr Publishers
• Roper, N., Logan, W., Tierney, A. (2000) The Roper, Logan, Tierney Model of Nursing. Edinburgh: Churchill Livingstone
• Russell, L. (2004) Patient repositioning revisited. Journal of Wound Care.Vol.13, No.8, pp328-329
• Selim, P., Bashford, C., Grossman, K. (2001) Evidenced based practice: water cleansing of leg ulcers in the community. Journal of Clinical Nursing [on-line] Vol. 10, No.3, pp372-379. Available athttp://gateway.uk/com/gw1/ovidweb.cgi [Accessed 17/07/07]
• Smith, L., Booth, N., Douglas, D., Robertson, W., walker, A., Durie, M., Fraser, A., Hillan, E., Swaffield, C. (1995) A critique of “at risk” pressure sore assessment tools. Journal of Clinical
• Nursing [on-line]. Vol.4, No.3, pp153-159
• Available at http://gateway2.uk.ovid.com/ovidweb.cgi [Accessed 10/08/04]
• Southern Derbyshire Health Community Wound Management Guidelines. (2005) Derbyshire Dales and South Derbyshire. NHS: Primary Care Trust
• Thomas, S. (1997) assessment and Management of Wound Exudate.Journal of Wound Care. Vol.6, No.7, pp327-330
• White, R., Cutting, K. (2003) Intervention to avoid maceration of the skin and wound bed. British Journal of Nursing. Vol.12, No.20, pp1186-1192
• Williams, C., Young, T. (1998) Myth and Reality in wound Care. Salisbury: Mark Allen Publishing Ltd
• Wright, K. (2005) Ensure Patients’ Wounds are Best Dressed. Nursing Management. Vol.36, No.11, pp49-50
• Zoellner, P., Kapp, H., Smola, H. (2007) Clinical Performance of a hydrogel dressing in chronic wounds: a prospective observational study. Journal of Wound Care. Vol.12, No.3, pp369-371

Appendices

1. Client pen portrait.
2. Plan of care
3. Wound evaluation
4. Activities of Daily Living
5. Waterlow Pressure Score