This assignment is a critical analysis and reflection of my continuing personal and professional development (CPPD) needs in practice. This account will identify practical needs that I must improve with supportive evidence based research, and evaluate the impact of this need for my personal development as a future qualified nurse. My learning need was with assertiveness in communication when working with a staff nurse during admission. To meet the need and demonstrate the ability to engage in advancing my care, Gibbs (1988) framework model of reflection will be used. To maintain confidentiality as emphasised by the Nursing and Midwifery Council (NMC 2008), a pseudonym Tommy will be used to protect the patient’s anonymity. In addition, I will be using the post-registration education and practice (PREP) guidelines (NMC 2011) to maintain up to date knowledge and skills as well as empowering a lifelong learning in my nursing career. (NMC 2012)
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My skills in communication have improved in all contact and this has been acknowledged in every practice. However, I thought of this learning need, when I recognised my weakness was with assertiveness in communication when working with a staff nurse, faced with a difficult patient during admission. I took part in this learning activity in November, 2014 during my placement in hospital. I identified this need during the second week of placement, as I was able to perform patient admissions under the supervision of my mentor. The need to improve this skill was established from my mentor’s feedback and I agreed that it must be developed in order to help avoiding errors in future practice, improving my decision-making skills and professional satisfaction. I have spent a good amount of time to research and critically analyse this learning need However I felt this could be an ongoing process of improvement as Webb (2011) identified, supported by the Department of Health’s (2013) ongoing process of improvement in the NHS to be more efficient and less bureaucratic. I again felt this was important for me to work on because it had an impact on the patient and me as a future qualified nurse (Fowler, 2008).
Tommy is a 50 year old who suffers from right leg cellulitis and lives alone with his cat. I felt my first meeting with Tommy was challenging as I found it difficult to present myself as a self-assured, assertive and empathetic student nurse due to the impression that the situation was out of my comfort zone. I observed from the beginning of the visit that this gentleman was unable to cope; however I felt that I could not make a direct statement without coming across as patronising or a dominant student nurse. On the positive side, I chose to improve this learning need so that I would learn to be prepared with the knowledge and set of skills I must have in managing complex patient care in future placements (Fowler, 2008).
Having encountered patients who have refused requests from other student nurses and staff nurses alike by expressing their dislikes, disagreements and sometimes even anger when offered treatment, I have observed that patients sense how the student nurses present themselves and could base their decision on the student nurses’ abilities to communicate assertively (Fowler, 2008). This also made me think about my self-awareness and empathetic skills. As I listened to Tommy’s emotional concerns, he opened up about being terrified of not having anyone in his house to feed his cat while he was in hospital because he had no close relatives. I responded calmly and confidently, using clear language that my intention was to obtain his permission to allow health professionals offer long term support to him (Fischhoff et al, 2011).
As student nurses, our main role involves patient interaction and several studies have indicated that student nurses lack assertive skills evidenced by Bekkum and Hilton (2013) McCabe and Timmins (2005) qualitative study in two schools (n=30). It highlighted that most student nurses were assertive but chose not to display this skill to maintain positive interpersonal relations and avoid conflict. However, quantitative study (n=72) by Almost (2006) deemed it important to measure nursing students’ level of assertiveness prior to, and near completion of their pre-registration programme and to offer help throughout their programme to develop their assertiveness. Almost also considered the conflicts mainly developed from the multi-professional roles that student nurses have and that the basic nursing functions of caring and controlling can result in tension.
Many researchers have challenged these such as Iglesias and Vallejo (2012) qualitative study identified that work have established that conflict resolution techniques can be achieved through compromise and collaboration which the nurses can use for their specific work environments. However all the previously mentioned approaches suffered from serious limitations as Tommy’s safety could have been compromised when nurses failed to speak up or be heard, identified by Page’s (2004) qualitative study. I found Almost (2013) very appropriate when giving personal care because this technique would have enhanced my learning need earlier in my nursing programme to improve patient care. Bekkum & Hilton, (2013) qualitative study support and acknowledgement on these account findings imply that, education programs ought to be taken into account. The perceptions of the participant’s risks involved in not being assertive and the focal point must be on changing these perceptions rather than attempting to change student nurses’ values or focusing solely on specific assertive behaviours to improve student emotional intelligence. Based on the findings, I realised that my practice was out of date therefore would cost the National Health Service (NHS) and impact negatively on patients’ care.
As identified by Smith’s (2012) phenomenological study, 75 per cent (n=20) of student nurses felt unable to verbally express their concerns when working with qualified nurses. Yet Jones’ (2013) qualitative study identified that 60 per cent (n=30) of student nurses felt confident by the end of their training. However, there is little consensus in the research available although I feel my experience reflects Smith’s (2013) findings. My inability to be assertive during patient admission was because I was working with an experienced qualified nurse and hiding behind my mentor limited my development in skill. This impacted on my clinical ability when I failed to be an assertive student nurse. It also shows in these research studies I was not using up to date practice.
White’s (2009) phenomenological study identified that 75 per cent (n=28) nursing students in clinical placements suffer from self-doubt, have anxiety about their clinical performance and do not possess the characteristics of strong self-confidence. A qualitative study conducted for student nurses by Jones, Mccoy and Pitt (2013) have indicated that majority of student and staff relationships highlight that a sense of belonging was central for student nurses for a good clinical experience. A students’ sense of belonging and feeling a part of the team were essential before students could learn. This is reflected in Lathlean and Levett-Jones’ (2009) quantitative study (n=200) of student findings on third year student nurses who participated in the study as they had been on a number of clinical placements. This explanation, however, seemed to overlook the fact that many students feel compelled to work hard in order to fit in the nursing team rather than become motivated to learn. This has made me realise that although being in a good nursing team, I would still prioritise looking after my patients by paying more attention to the patient needs and expectations. A qualitative study conducted by Lyndon (2006) mentioned that student nurses’ ability to make a clinical decision could be influenced by patient situation, availability of resources and interpersonal relationships. Student nurses, however, on a variety of situations, can experience moral distress as Ganske, Iseminger, Lachman and Murray (2012) have identified in their phenomenological study. These two articles revealed that the ability to communicate with patients should not cause moral distress as student nurses would neither be aggressive nor patronising, nonetheless the interaction would achieve the patient’s best interest.
This is reinforced by Grumbach and Bodenheimer, (2004) qualitative study which identified (n=18) of student nurse, who noted that greater disability may be as a result of anxiety in some cases and loss of self-confidence. However, Begley (2010) phenomenological study (n=20) identified and argues, little has been investigated to explain the reasons why assertive behaviour occurs in one situation and not in another. Results suggest that, student nurses’ standard measures of assertiveness and of anxiety are irrespective of their scores p=00.1 chances. One should consider the consequences of student practitioners being assertive, while making a decision regarding how to behave I felt this was helpful in reminding me how important self- confident skills can aid improved patient care. Although, their underlying theories of subjectivity are very different, there are some important affinities between the researches that correlate which I believe would help me care better in future placement.
In addition, Begley’s (2010) qualitative study established that patients were to be considered as partners in their health care delivery. Trust does not come easily for people and I have since learnt from past experiences that patients need to be included and actively involved in the planning and evaluation of their care. By learning to ask open questions helped promote and encouraged patient expression and enabled patients to enhance trust in a relationship as I have shown my interest and investment in the patient’s care and treatment. This study has an impact in addressing my need and offered help on how to be assertive when dealing with difficult patients.
As highlighted by White (2014) qualitative study, majority of student nurse depend on their mentors to be assertive and sometimes adopt it as coping strategies. Even though, this is a small number of student nurses, (n=30) to base a judgement on, it provides statistically relevant data and allows an insight into practical experiences. I also felt this research was significant for me to work on my assertiveness, because it had an effect towards the patient and me as a future qualified nurse. I solely depended on my mentors for assertiveness as a coping strategy.
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Conversely, these poor coping strategies I adopted were highlighted in a qualitative study by Fischhoff et al, (2011) where common coping strategies utilised by student nurses being assertive in clinical settings are explored. Although this is a small sample size (n=18) which does not provide statistically relevant data, it is qualitative design allows an insight into the student nurses experience of assertiveness coping strategies (Parahoo, 2006). I found these results of the thematic critical analysis linked to my own clinical experience, including the poor coping assertiveness strategy I adopted. This was due to underestimating my capacity from the onset of being self-assured and self-confident without being aggressive (REF). I found that these researches gave me insight into how unethical and limiting avoidance practices are when dealing with patients, which was seen in a small number of participants in this study (n=3) (Morris & Turnball, 2006). I felt this was helpful in reminding me how important assertiveness skills can improve patient care (Morris & Turnbull, 2006).
Besides, Fischhoff et al, (2011), descriptive study postulates assertiveness in student nurses who become attached to their mentors remain as consistent helpers for weeks in their placement during the period from the first till the third year, and it is suggested that this is due to the students underestimating their capacity from the onset of being self-assured. Although this is a small sample size (n=207) which does provide statistically significant relevant data, 60 percent (n=127) were more positive compared to 40 percent (n=83). Its quantitative design allows an insight into the student nurses’ experience of assertiveness skills (Begley, 2010).
Nonetheless, Phillips and Simmonds (2012) phenomenological study supported this descriptive study and further on said this is a key concern for some student nurses within practice setting. The concept of assertiveness and understanding concept as student nurses will enable them to consider that the patient’s aggressiveness might be about other issues rather than their care. In a phenomenological study of (n=50) nursing students in London, Monsu (2014) identified that greater disability may be as a result of anxiety and loss of self-confidence dealing with a difficult patient. Findings of these researches do not seek to be generalised but were reliable to me due to the appropriateness of the methodology and the thematic analysis being correctly applied. This will aid me in caring for my patients in future practice.
In a questionnaire survey of (n=200) student nurses in London, Smith (2013) identified that 70 per cent (n=49) of university students preferred mentors to do all the assertiveness communication for them due to underestimating their ability. Only 20 per cent (n=4) of students responded and of those who did respond, many of them did not fully complete the questionnaire. The data suggested that 70 per cent of students who preferred a mentor to do all the assertiveness communication do not constitute very strong evidence. Yet Monsu (2013) argues that from his own experience as a student in placement, there was a strong attachment with mentors being assertive in all him / her communication which did help with the assertiveness skills needed for future practice. This cannot be generalised as Monsu (2013) is not referring to a piece of empirical research but to his own experience. Having identified the context of Monsu’s (2013) own experience argument, I found it very relevant to me and it topped my hierarchy of evidence, but does not appear to have been undertaken in a thorough manner to help my caring for patients in future due to their lack of a soundly-based qualitative theory compared to Smith (2013).
Having discussed with my mentor what happened during the admission; it felt good to have attempted the interaction with the patient and recognised some of his needs. Even though the patient seemed reluctant, I demonstrated the ability to remain calm although I did struggle with my approach when I spoke to him about offering more support. Instead, I focused to help the client respond to my questions and identify what his concerns were. I believe during that incident, I showed assertive behaviour because I maintained my duty of care to the patient. I have reflected that this would have an effect on my clinical ability if I had failed to be the patient’s advocate. With the DOH (2009) updated work on providing guidelines on consent to treatment and putting these principles of consent into practice, my actions caused me to consider my practice whether obtaining informed consent would be an issue. Tommy fully realised that he should comply with the nurse as she understood the consequences if his pains were not treated (Cole, 2012). According to Baldwin, Duffield, Fry and Merrick (2011) the interaction between the decision-making, skill development opportunities, social support and identity comes with the nursing role so as to be prepared for the upcoming nurse population to meet new challenges.
When this type of situation happens again, I believe I have the skill to show my assertiveness skills by using compromise as well as recognising the boundaries of my actions. Using clinical decision skills and asking open questions, which I can gain from meeting other patients would enable me to show that I am a self- assured, reliable and trustworthy student nurse. I need to try and achieve leadership skills that could be essential for patient satisfaction and to achieve this, I have learnt to engage in leadership activities such as handovers and undertaking tasks on behalf of my mentor. I recognised that once I fitted into the clinical environment, I needed to be more actively involved in challenging clinical situations such as detecting unpredictable patient deterioration and learning to make quick clinical decisions. Cook & Leathard (2004) suggested that good student nursing leadership and good quality nursing care will be effective if nurses go through leadership training programmes during the early stages of their career. This can help me in preparation to become more aware of how I feel, think and act in front of my patients. Reflecting and learning to be assertive can increase my confidence and self-esteem through appreciating what I have done well and maturely, accepting the improvements I must make to become a better nurse in the future.
Having said that, I was satisfied that I had the opportunity to practice nursing handover, as it is one of the vital roles of a qualified nurse and one aspect of nursing care that is required of me when I am qualified.Loseby, Hudson & Lyon (2013) wrote, handovers are information that can influence the delivery of care. In the process of this learning experience I felt well supported by my mentor giving me several opportunities to practice my handover until I felt more confident and less anxious because she created quality time for me and necessary feedback that helped my learning need as well as other aspects ofnursing. McCloughen, O’Brien & Jackson (2010) defines a mentor as someone that helps others grow by teaching them, encouraging them and being interested in their success. This is also further supported byHamric, B.A., Hanson, M.C., Tracy, F.M., & O’Grady, T.E.,(2013) who indicated that a good mentor is one who spends quality time to foster growth, committed to the development of their learning need, willing to share and feedback on any rough spot in their career development.
In conclusion, I have critically analysed and reflected on clinical learning needs, which are essential for my continuing professional development. As a student, critical analysis and reflection helped to facilitate good learning outcomes so that I can relate and apply concepts to clinically orientated situations as well as explore and evaluate evidence. Also my clinical learning need was acknowledged through mentor feedback by showing assertive skills in communication with difficult patients. This need is an on-going process of development for me. However; I recognised that attempting interactions with patients and collaborating with nursing staff will help in my development to be a more self-assured nurse. Participating and engaging in leadership activities such as handovers and task delegation would be beneficial at this stage of my learning. Through the reflection and recognition of these learning needs, I could only move forward and continue to develop my learning proficiency as a student nurse towards professional competency as a qualified nurse.
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