Reflection on Communication in Intensive Care Setting

LPD 3 SUMMATIVE ESSAY

My identified learning need is enhancing my ability to communicate articulately and assertively with the multidisciplinary team (MDT) members, as I portrayed lack of assertiveness and competences in communicating with other healthcare professionals on my previous clinical practice experience. Hence, it is essential to improve this identified aspect of my practice as it compromises patient safety and limits my professionalism. Thus, I will critically reflect upon the identified learning need and how it impacts on my patient’s care, my personal and professional development as a nurse. Furthermore, I will critically reflect and analyse on how the learning need identified was met in my final year placement. In order to structure my reflection, I have decided to use Gibb’s (1988) reflective model which consists of description, feelings, evaluation, analysis, conclusion and action plan (Gibb’s 1988). I will apply relevant parts of this model when required.

Also, in accordance to the Nursing and Midwifery Council (2008) Code of professional conduct, confidentiality shall be maintained in the essay and all names and trust identifiers will be anonymous to protect identity. Additionally, In reference to the Post- registration education and practice (PREP) guidelines (2011), I have spent 52 hours using different databases to research for relevant articles and government policies to enable me to write the essay. The conclusion of the essay will discuss my reflection skills and acknowledgement of my level of assertiveness and competence, showing my personal and professional development.

As a student nurse, I go to clinical areas to gain experience and acquire key nursing skills that will enhance my nursing practice. For the final stage of my second year placement in the year 2013, I was allocated to an intensive care setting where treatment and monitoring was given to critically ill patients. I mainly assisted and worked with my clinical practice mentor. I had been caring for an intubated patient during my shift under strict supervision from my mentor. Although I had been caring for the patient for the duration of my shift, I was unprepared to pass on the necessary patient details to the relevant healthcare professionals. The incident occurred when my mentor insisted I followed her to the MDT meeting where a group of professionals collaborated together to make decisions regarding that specific patient’s treatments and improvements (Richards & Edwards, 2012). I thought I was just accompanying her to observe the inter-professional collaboration that was taking place. Unfortunately, my mentor asked me to handover the patient I had been caring for to the MDT.

As a result, I instantly became nervous and shaky, to the point that I struggled to articulate my first sentence coherently and I was unable to communicate assertively with the MDT members. Although I correctly delivered the basic patient’s information, I instantly panicked and gave confusing information regarding the patient’s reasons for admission and care plan. Unfortunately, it was clear to both my mentor and the other members of staff that I was flustered and needed assistance. My mentor then took over and continued with the patient’s information. As a result, I felt I was intimidated by the hierarchy, I felt nervous, embarrassed and upset by my own inability to communicate effectively with the MDT. I thought that I could not be a professional nurse if I let my nerves get in the way of my nursing care. Also, I felt frustrated when my mentor put me on the spot and I could not communicate effectively. Afterwards I also felt that she had not given me adequate time to settle my nerves and compose myself before the MDT meeting. On searching the literature, I realised that feeling nervous is a natural reaction for student nurses when interacting with other clinicians and even experienced nurses were once nervous students (Cardillo, 2010). This made me feel less embarrassed and gave me the impression that everybody has experienced these feelings at one stage or another. However, other literature does not support this belief. In fact, several recent studies show that the experience of nervousness could be due to the student being frightened and not committed in carrying out tasks (Youngberg, 2014). In my case, I did not feel it was through lack of commitment. Confidence comes with experience; however, being prepared and organised is the key to my gradually becoming more confident. Hence, to avoid this repeating itself, I will start preparing myself mentally assuming I have to handover patients’ care to other clinicians.

As I reflected on the incident, I realised I lack assertiveness in communicating with the MDT and I did not have enough confident to set an appropriate inter-professional working as it is the key to patients improvements (Royal College of Nursing (RCN), 2010). Also, reflecting back, I realised that I was really worried about the communication difficulties I encountered in the MDT meeting. Many researchers advocate the importance of maintaining an effective communication among the MDT as it is a fundamental nursing skill which plays a major role in the development for student nurses (Moss, 2008). I realised that I needed to improve on this learning need as my inability to communicate assertively and effectively with the MDT impacted on my nursing care to the patient because not going in-depth and not providing the accurate patient information limited my nursing care to the patient.

The concept of poor communication among the MDT is highlighted in a phenomenological study by Leonard, Graham and Bonacum (2011), where the authors explored communication failures as the leading causes of inadvertent patients harm. The article was of particular interest to me as it emphasised on sustaining improvement for student nurses in communicating among the MDT because it compromises patient’s safety, and the need for improvement. It is also relevant as it sufficiently discusses the issues surrounding my identified learning need and the need for improvement. In the article, the authors proposed that effective communication among the MDT is essential for delivering high quality care and safe of care to patients. Also, the points the authors raised is a very significant issue to consider, because the in 2014, RCN verified that communication issue have been identified as contributing to a large number of patient safety incidents in the United Kingdom. Thus, they require all nurses and trained student nurses to effectively hand the care of patients over to another clinicians, with an accurate communication and co-ordination to improve patients’ quality of care.

Although Sharif and Masoumi (2010) qualitative research states most second year nursing students often experience anxiety and nervousness when interacting with other clinicians compared to final year students, which there is a bit of agreement on, I strongly believe my experience reflects more on Leonard, Graham and Bonacum’s (2011) findings as I was unable to communicate assertively with the MDT during the meeting, which limited by nursing development. It impacted on my clinical ability when I failed to provide the accurate patient information to the MDT. This resulted in creating confusion to the other healthcare professionals as what I stated about the patient did not match with the information the MDT had on their patient handover sheet. Resulting in one of the healthcare professionals asking if am providing them with the accurate patient details which led to a break down in the inter-professional collaboration (Vincent, 2011). This did not just impacted on my nursing care to the patient but also impacted on my personal and professional development. As stated by the Dougherty and Lister (2011), a good nurse is the one who knows what he or she is doing as there is an expectation that nurses and trained nurses must show assertiveness and competencies in carrying out duties. There is a reflection to this approach to my personal and professional development recognising that being assertive and competence does not just mean how you carryout tasks, but understanding the rationale behind it and the impacts it may have on patients (Masters, 2014).

This demonstrates how relevant and essential it is to communicate assertively with the MDT as reflecting back on my learning need, not being able to collaborate inter-professionally with the MDT limited my professional development and hindered my patient not receiving a high standard care from me. Although Leonard, Graham and Bonacum’s (2011) findings adequately outline and provide insights into the importance of being assertive among the MDT, the results of their study do not show the significant increase in the enhancement of patients’ care due to the small amount of sample size the authors used. The data was collected from a medium size hospital where performance of the reporting system might be different from other hospitals. This was seen as a weakness, but I felt the article was helpful as it is relevant to my learning need and reminds me of how poor communication impacts negatively on patients safety (Burnard & Gill, 2013).

Also, in a qualitative study by Krautscheid (2012) the author explored the need for improving communication among other clinicians for student nurses, preparing them for practice. In the article, the author identified that most student nurses have a great deal in communicating effectively to other healthcare professionals, which should not be so as it compromises patients care. There is an agreement on this research even though a study by Burton (2013) identified that not all student nurses’ presents lack of assertiveness in their training but I feel my clinical experience reflects more on Krautscheid (2012) findings as my inability to communicate assertively with the MDT limited my nursing development because it impacted on my clinical ability when I failed to show a competence workforce to the other clinicians in the MDT meeting, which also limited my nursing care to the patient as I did not deliver a high standard of care to the patients’ development. For instance, if high-quality care is been delivered to patients by the ones looking after them, it increases the opportunity for patients to benefit from therapeutic nursing (Freshwater, 2007) as evidence demonstrates that this does contributes to the highest degree of patient care (Scott, 2008). Therefore, by not communicating assertively with the MDT limited my personal and professional development as the issues surrounding it was not being confidence, prepared , proactive and not portraying an accurate level of competencies hindered my patient not receiving an excellent standard of care from me.

As a result, not providing the accurate information about the patient to the MDT compromised the patient’s care. Youngberg (2014) affirms that effective clinical practice involves instances where critical information must be communicated accurately with a team and as a nurse, exploring ineffective communication in a teamwork does not only puts patients safety at risk but also demonstrates not being competence. As such, this highlights the needs to be more assertive and competence in communicating with the MDT as student nurses also plays a vital role in the multidisciplinary team approach to patient care (Miller, 2009), and effective involvement enhances patient outcome (Hughes & Quinn, 2007). Although Krautscheid (2008) research shows lack of detailed information on how to effectively deal with miscommunication, its qualitative design allows insight into the need of improving communication among healthcare providers. I found the results of the thematic analysis linked to my own clinical experience including the feeling of being nervous. The author provided a relevant and a valid article as a large sample size of 285 student nurses was used and had significant results which were inherently repeatable. The article was helpful in reminding me how important effective communication implements the aspects of patient safety. Hence, it is significant to enhance on my identified learning need.

On reflection it was clear that my lack of assertiveness in my ability, when put on a spot by my mentor contributed to my feelings of inadequacy. Through reflection and what my mentor did enabled me to clarify that my weakness was not skill or knowledge level. But my inability to communicate articulately and assertively with the MDT during the meeting was due to being intimidated by the hierarchy. This led to a lack of assertiveness, and confidence in my skill level and clinical knowledge, which also enabled me to know the need to change my practice. Furthermore, after the incident, I received feedbacks from my mentor who stated I should be more proactive in the future, show a competence workforce and develop a tool that will enable me hand in the care of a patient accurately in the future. As explained by West (2012), teamwork is vital if care is carried out efficiently in clinical areas as effective communication creates a positive contribution to patients’ outcome.

Thus, I decided to action plan on this reflective experience to develop my nursing knowledge in my final year clinical placement. I looked at various nursing journals and government policies detailing how to communicate effectively with the MDT and use the advice I gained to plan out how to do so. As shown in Watts (2011) phenomenology study, student nurse can further develop their skills in understanding and applying latest research evidence by looking into journals, clinical guidelines and policies to enable them develop their skills. NMC (2010) further supported this statement stating that, trained nurses and nurses need to keep updating their basic knowledge and skills, and be fully equipped and work effectively to deliver essential care to patients.

Therefore, to develop my confidence and communicate assertively, I adapted the Situation, Background, Assessment and Recommendation (SBAR) tool which was published by the Institute of Healthcare Improvement in the year 2004. I chose this tool because it has proven to be an effective communication tool (RCN, 2014). It was also seen to be an easy to remember method that enabled me to frame conversations and to clarify what information should be communicated between members of the team and how. This was a relevant tool to adapt as it assisted me develop teamwork and have confidence to deliver safe quality care. Also, there is a good evidence to suggest that communication improves when nurses used structured format such as SBAR (RCN, 2014). In 2010, the National Patient Safety Agency suggested that effective communication among MDT is a key factor in enhancing clinical practice and patient outcome. Therefore, the National Institute for Health and Care Excellence (NICE) (2010) supported these findings and recommended that nursing and medical staff should use the SBAR tool in structuring patients’ clinical information to other clinicians, supported by written plan as this will prevent healthcare providers from giving unclear patients’ documentation and miscommunication of patients’ details. As a result, they released these guidelines for nurses and medical staff to adhere to in order to enhance patients safety as communication failures causes inadvertent patient harm. This is a reliable guideline as it is a national policy and discusses the need to adapt the SBAR tool.

Upon using the SBAR tool, I became proactive and requested the assistance of my first final year clinical mentor to assess my communication skills and knowledge base as it is something I won’t to improve on. By doing this, I was able to reinforce my communication skills and most importantly developed my self confidence as I ensured that I was always prepared, organised and able to successfully communicate assertively with other clinicians during my third year clinical placement while completing the necessary skills unassisted to become more independent as a final year student nurse. Webb (2011) comments that one of the basics of good nursing is effective communication between clinical staffs as failure to communicate efficiently with the MDT destroys the delicate nurses’ inter-professional relationship. As a result, through reflection, practice and the use of my mentor and awareness of factors that affects my assertiveness in communicating with the MDT, and the adaptation of the SBAR tool, I was able to confidently and assertively communicate with other clinicians.

As seen in O’Daniel and Rosenstein (2011) study, to enhance the ability of nursing students, they must have a strong focus to develop skills that will enhance their own professional identity. This is significant as this approach ensures that student nurses become aware of their own competencies, and resulting confidence in their value as a team member. Reflecting on my identified learning need and adapting the SBAR tool have made me attempt to protect my patients from harm and have improved me as a nurse. In addition, I feel I have become more assertive in communicating with other clinicians as assertiveness is an important behaviour for a nurse, which is necessary for effective inter-professional communication (Cardillo, 2010).

This implies to the Chief Nursing Officer’s (2012) 6 C’s which states communication is central to successful relationships and effective team working. Thus, improving on my ability to communicate assertively with the MDT is essential and have made me a committed nurse who desires the very best for all her patients, and provide them the very best of care and not to put them at risk. This is in accordance to the NMC Code of Professional Conduct (2014) which states nurses are accountable for their practice. Thus, they must maintain professional knowledge and competence and act to identify and minimise risk to patients. I believe upon reflecting on my identified learning need and improving on it, I am now a better nurse as I have learnt how to do things differently, and deliver the most up to date evidence based care to enhance my patients care and my nursing development.

Reflecting back on my final year clinical experience, I have now identified a new learning need which needs development. In reference to the PREP (2011) guidelines and the NMC Code (2008), nurses need to be responsible and accountable for keeping their skills and knowledge up to date through continuing professional development, and must aim to improve their performance to enhance patients’ safety and care. Thus, my new identified learning need is to be able to develop more competent in recognising and addressing challenges relating to patients care. This is essential to develop as according to the NMC (2014), all nurses must be fit to practise and show professionalism by being able to identify and address ethical challenges that relates to patients and decision making about their care, and act within the law to assist with acceptable solution. Consequently, it is vital to develop on this.

This essay has critically reflected and analysed on a personal learning experience from a clinical practice. The key points that have been discussed in the essay are that of the importance of communicating assertively with the MDT and how student nurse and nurses can improve their communication skills and maintain assertiveness to enhance patients’ safety. This is because we as nurses must provide a gold standard of care for our patients. Thus, upon improving on my identified learning need, I have been able to enhance my nursing practice in order to deliver safe care to my patients.