Within this assignment I will critically reflect on my clinical knowledge to date and consider my future development needs with a focus on my final management placement and future career as a registered nurse, and using the Gibbs model (appendix 1) as a framework will reflect upon my own learning experiences and achievements to date and write an annotated reflection highlighting my development needs from which I will formulate a Personal Development Plan. This undertaking demonstrates my commitment to the need for continuing professional development in order to enhance my knowledge, skills values and attitude needed for effective nursing practice (NMC Proficiency 4.1) and will address deficits in my knowledge and skills and identify any shortcomings within my own or others practice and help me cope with practice related issues experienced within my previous placements. I have chosen Gibbs reflective model as a basis for reflection as I feel it is easily understood and encourages a clear description of the situation, analysis of feelings, evaluation of the experience, conclusion and reflection upon the experience to consider a solution if the situation arose again (Brooker & Nicol 2003). Gibbs model is useful for less experienced staff or students as it directs you and offers an easy framework to use, which supports the introduction of reflection and the transition from student to practitioner (Pearce, 2003). It has been advocated that reflective practices are a method of bridging the gap between nursing theory and practice, and as a tool to develop knowledge embedded in practice (Chong 2009). Furthermore in reflecting on the way we deliver care we can identify weaknesses, build on strengths and develop best practice (Johns 1996). However, there are those who are sceptical of the practice and the idea of reflection in nursing is ambiguous and confused and not based on discipline related evidence based research (Gustafsson et al 2007). Some studies however, have shown a positive response from practitioners who have attributed reflective practice to changes in their practice (Paget 2000). In consideration of these views my approach to reflection as a means of recognizing strengths and weaknesses in my learning and practice to enable me to make positive changes to my future practice will be unbiased. Therefore my reflective account will include an open and honest description of what I have gained from the experience

In conclusion, my main aim is to enhance my professional development by reflecting upon past education and clinical experience using the Nursing and Midwifery proficiencies as a benchmark. Furthermore by utilizing the reflective model I will not only identify my strengths and weaknesses but also recognize potential opportunities or threats which will enable me to prepare for my future development and alert me to any threats allowing me to overcome any difficulties I may encounter. Teekman (2000), states that throughout the literature it is well emphasized that reflective practice is an effective tool to reduce or eliminate the perceived theory-practice gap. I will therefore endeavour to utilize this exercise to transform my theoretical learning into evidence based practice. By doing this I can substantiate my claim to having knowledge of evidence based care to ensure safe practice (NMC Proficiency 2.5).

Reflective Self-Assessment

Gibbs (1988) model begins with asking the question ‘What happened?’ and asks ‘What were you feeling’. This allows me to give an account of the events that occurred, and in order to add significance to the narrative I will relay my feelings about the event directly after explanation about the incident.

During the course of my placement whilst working in an acute psychiatric in-patient ward I was delegated some responsibility for particular patients by senior members of staff. In addition I was often allowed to facilitate both group and one-to-one sessions supervised by a trained member of staff. However, due to other demands within the ward environment staff were often unable to run the groups and one-to-one sessions with the patients could often be time limited.

However, on one particular day I was approached by a patient for whose care I was given responsibility He appeared very agitated and complained that over the previous few days he had become frustrated by the lack of attention he was been receiving from nursing care staff the lack of information he was being given in respect of his care. He also complained that he had been informed that he would have regular access to therapeutic groups and this was not happening. This patient had show a keenness to participate fully in his care to facilitate a quick recovery and discharge from the ward

I was aware that staff had been busy but felt uneasy at his distress and afraid to tell him that staff had been too busy therefore unable to run the groups. In addition I did not feel confident enough to explain his treatment plan. I was quite annoyed though that he had not been consulted or involved in this previously, therefore I consulted with his named nurse voicing my concerns and asked if she could alleviate his concerns. (NMC Proficiency 2.6) was achieved by my articulating my own emotional and psychological responses to situations with colleagues in a professional manner. By also being aware of my own limitations at the time I achieved (NMC proficiency 1.1) by expressing my concerns for this particular patient. The nurse took him into a quiet room and in my presence explained the situation to him apologising for the apparent lack of attention he had received. She assured him that the therapeutic group would be commencing later that day and allowed him to vent his feelings and concerns about his care and anxieties about his illness. She reviewed his plan of care with him taking account of his wishes and desired outcomes. On listening to how she handled the session, I felt quite inadequate afterwards thinking I should have been able to deal with the situation as I was competent at formulating care plans.

Following the session I decided to approach my mentor to ask to discuss the situation and we agreed that I would take the time to read through the Integrated Care Pathway of each patient under my care and become familiar with their use by suggested I attend and participate in multi-disciplinary meetings. By recognising this I was adhering to the code of professional conduct (NMC) 2008, to consult with a colleague when appropriate and work within the limits of my competence. Moreover, I achieved (NMC Proficiency 4.1) by demonstrating a commitment to the need for continuing professional development and personal supervision activities.

In addition a multi-disciplinary meeting was arranged for the patient and his father and my mentor allowed me to co-ordinate this and provide feedback on his progress in order that I gain experience in multidisciplinary working. Prior to the meeting I scrutinized his ICP to familiarise myself with his situation and plan of care to enable me to identify his needs and achieved (NMC Proficiency 2.2) by providing relevant and current health information to the patient during the meeting. Rees et al, (2004) informs us that ICP’s are tools which map out the pathway of clinical events and activities for all professionals involved in a specific patient group. The ICP helped clarify my roles and responsibilities as well as improve team working and communication. This enabled me to become more informed and also provide the patient with information on his plan of care which would be carried out throughout his journey from admission to discharge

In attendance at the meeting were the Consultant Psychiatrist, Named Nurse, Pharmacist, Community Psychiatric Nurse, Occupational Therapist and myself. I provided feedback on the patient’s progress to the Consultant Psychiatrist and other team members, and highlighted the patient’s concerns about his treatment demonstrating (NMC proficiency 3.2) by working collaboratively with multi-disciplinary team members to enable the delivery of effective patient care, prior to the patient and his father attending. This provided the Consultant Psychiatrist with an overview of the patient’s mental health and progress to date. The patient and his father were then invited to attend the meeting the patient was given the opportunity to tell the Consultant Psychiatrist how he was feeling and discuss any issues he may have. He was also given the opportunity to talk about his prescribed medication and ask questions which were answered both by the doctor and pharmacist. The pharmacist also gave some advice about his present dose of prescribed medication making suggestions to the doctor about possible changes due to a complaint by the patient that he was experiencing stiffness in his legs. Despite being aware that I had the necessary information about the patients care, on occasion during feedback to the team I looked to my mentor to reassure me that the information I was imparting was accurate. The patient was allowed to discuss his involvement in therapeutic groups he had attended and their benefits. The patient’s father was also given the opportunity to ask any questions and voice any concerns he may have. Discussion between me, the consultant and patient provided clearer picture of the situation I and felt more at ease having further clarified the process of his care would be while on the ward. I felt more confident and satisfied that the patient was now more at ease and satisfied with his present care and was able to meet (NMC proficiency 2.4) by updating the patients plan of care following the meeting.

The next stage Evaluation Gibbs model ‘making sense of the situation’ and asks ‘What was good or bad’. I was pleased to see a positive outcome which was due to inclusion of the patient in his plan of care and collaboration within the multidisciplinary team meeting which alleviate the patient’s concerns. I was not happy at my own lack of confidence to initially deal with the client’s concerns and the fact that the patient had to complain before being fully involved in his care. Having this awareness of my own emotions and of weaknesses in my practice and consulting with the patient’s named nurse assures me that I am managing myself, my practice and that recognizing my own abilities and limitations (NMC Proficiency 1.1) and resolving this by taking action to improve in this area of practice.

In conclusion, stage five of the Gibbs (1988) model, I feel the more experience I gain in the ward environment and more I learn about ICP’s I can improve patients quality of care and collaborating with other members of the multidisciplinary team I will gain knowledge and confidence to enable me to take that step from being a student to becoming a confident registered nurse and deal complex situations such as described above.

In the final stage of Gibbs reflective model the question is asked ‘If the situation arose what would I do?’ I will continue to utilize reflective practice to improve on my knowledge and skills and develop my Personal Development Plan to highlight gaps in my knowledge. I will use my personal development plan within my final placement to address my weakness and build on my strengths whilst seeking opportunities for further development taking account of any threats.

Personal Development Plan

I have chosen two areas which I feel are relevant to my future development needs namely Quality Assurance and Multidisciplinary/Agency team working. I will now take each area of developmental need and produce a personal development plan for each.

What is it?

NES (2007) explains that a personal development plan is another name for a plan of action which allows you to set personal goals and identify the best way to achieve them. I feel having a plan of action plan will keep me focussed on my learning objectives and allow me to keep track of my development as I progress in my career as a mental health nurse. In doing this I will continue to meet (NMC proficiency 4.2) by being a good role model, sharing my knowledge and experience with my colleagues to enhance their professional development.

How is it important?

One the recent requirements by the NHS is that all staff working in the NHS should have a professional development plan to ensure that staff continue their professional development and update their knowledge and skills (Kenworthy e al, 2001). In adhering to this I will be accomplishing (NMC proficiency 4.2). Department of Health (2004) state that it should prepare the individual to meet the requirements of their post, including the future interests of both the organization and the individual maintaining a balance between them to enable progression. This will be important when I am a registered nurse and there will be commitment to meet the requirements of my role.

What are my objectives?

Although both long and short term goals will be reviewed as your life moves forward, they guide you in making day-to-day more effectively (Ellis & Hartlet, 2004). Furthermore, it is important to keep goals flexible and be willing to consider alternative goals and a variety of pathways to one goal.

Short-Term Goals

By setting my short-term goals in two development areas I will enhance my knowledge of both Integrated Care Pathways and Multidisciplinary/Agency working and be more proactive in taking responsibility for specific leadership roles within the multidisciplinary team, as well as initiating individual Integrated Care Pathways. Consequently, in taking a leadership role, I will have accomplished (NMC proficiency 3.3) by delegating duties within the level of my responsibilities and taking responsibility for managing patient Integrated Care Pathways.

More specifically I will identify my short-term objectives within the 2 areas:

Integrated Care Pathways -By the end of my management placement I will have a better understanding of Integrated Care Pathways. I will have completed an ICP document for a specific patient, which will enable me to guide the patient through the nursing process from assessment to discharge competently and confidently. Lastly, I will have learned the concept of variances used to measure the quality of patient care.

Multidisciplinary/Agency working – within my management placement, I will have acquired good knowledge of multidisciplinary/Agency working and be able to competently participate in multi-disciplinary meetings. I will be competent in facilitating multidisciplinary team meetings and have the ability to effectively communicate with members of the multi-disciplinary team. Finally I will have knowledge of any barriers to multi-disciplinary working.

Medium and Long-term Goals

I will meet both Medium Term and Long Term Goals by procuring employment within a nursing profession (preferably with the National Health Service), and once accomplished my aims will be to develop my practice from a novice practitioner and become an accomplished expert knowledgeable practitioner fulfilling the requirements of my job profile within the Knowledge and Skills Framework. By participating in continuous professional development, achieved by setting objectives within my Personal Development Plan I will have met all (NMC proficiencies) as I will have attained my NMC registration.

How am I going to meet my objectives and why?

Objectives are short-term, direct and rapidly testable (Kerry, 2002). In practice, objectives must be specific and often state the new ability that the learner is seeking to acquire for instance, new knowledge, a practical skill or an attitude. My short-term objectives are to address my weaknesses within both my development areas and this can be achieved by setting these as a priority and focussing on these within my next practice placement. In order for me to meet my objectives within my personal development plan I will arrange regular review with my mentor to gain feedback from supervision and to review my learning contract to see how I am progressing.

Integrated Care Pathways

Through self-directed study and utilising all resources within the ward I hope to enhance my knowledge on integrated care pathways and how it is implemented within the ward setting to improve quality of care for patients. Scottish Executive (2003) highlights that under the new mental health act any treatment given to patients should include meaningful involvement by the patient and carers. Furthermore by being involved in all aspects of the nursing process from assessment to discharge I aim to be more involved in the patient’s journey through the integrated care pathway and empower the patient to participate throughout their journey on the ward. A well as this, by having responsibility for my own case load I will be able to improve my confidence and be more assertive in making clinical judgements and my decision making skills. I will continue to ensure that my practice is evidence based by continually updated my theoretical knowledge by self-study utilizing relevant academic literature.

Multi-disciplinary/Agency Working

My aim is to improve my collaborative working skills by interacting with other members of the team and identifying what skills each member brings to the team to meet the patients needs. Beer, et al (2008) states that multi-disciplinary teams can be effective if there is good communication between themselves and other teams and shared goals. I aim to participate in multi-disciplinary team meetings and give feedback on my patients’ progress to enable me improve my communication skills, and also participate in joint working with all members of the team on the ward on a daily basis to enable me to become more assertive and a productive team member. It will be important to ensure that the patient is also involved in decisions that affect them. In addition to joint consultation between the multidisciplinary team I am aware of the importance in involvement of the patient in their care for example, by involving them in the process of single shared assessment and care planning. Claire & Cox (2003) highlight the importance of those providing services to explore the experiences, preferences and opinions of service users when assessing their health and social care needs. Finally, Regular consultation with my mentor will assist me in identifying my strengths and area’s which he/she may feel I need to develop in with regards to collaborative working.

My Future Development Needs

Area of development for Integrated Care Pathways

The purpose of Integrated Care Pathways has been defined in various ways within the literature. Quality Improvement Scotland (2007) highlights the quality assurance aspect indicating that ICP standards will support service improvements in relation to the process of care and outcomes for individuals. It also specifies the patient’s anticipated clinical care pathway and co-ordinates necessary tasks in management of patient care (Chew et al 2007). No matter how it is defined, the outcome for the patient is to improve their quality care through managing the process of care appropriately.

The purpose of Integrated Care Pathways has been defined in different ways within the literature. Caring for patients is an essential part of the nurse’s work, and the quality of the care can be dependent on how far the nurse has come, in his/her professional development (Gustafsson, 2004). My experience of Integrated Care Pathways during my training has been limited; therefore I require improving my knowledge and skills in undertaking and documenting a comprehensive, systematic and accurate nursing assessment of physical, psychological, social and spiritual needs of patients. This will entail further enhancing my knowledge within the requirements of (NMC proficiency 2.3) as part of my development needs. ICP’s have not been implemented within any of my placements in the community or long term ward settings. However, an Integrated Pathway for admission and discharge has been employed within an acute ward setting where I was placed. This has been implemented to standardize practice across every psychiatric admission ward within Lanarkshire (Kent & Chalmers 2006), and to facilitate better co-ordination of discharge planning and facilitate continuity of treatment in the community (NHS Lanarkshire 2007). Quality Improvement Scotland (2007) highlights the quality assurance aspect indicating that ICP standards will support service improvements in relation to the process or care and outcomes for individuals.

Area of development for Multi-Disciplinary Working

Multidisciplinary working is the cornerstone of caring for patients within both a community and hospital setting. I have observed multi-professional collaboration and this seemed a very effective way of providing the best treatment available for patients. Cook et al (2001) identified from several studies that team working enhanced communication channels between different professionals resulting in better co-ordination of care, more timely access to services, and the provision of a more holistic approach to care. This was my experience when I was involved in the Multi-disciplinary meeting within the acute admission ward. Decision making within the team was enhanced by involvement of the nursing, medical, pharmacist, client and carer which resulted in a more holistic approach to the patient’s care thus improving the quality of care provided. This enabled me to accomplish (NMC proficiency 2.8) by demonstrating that by effective collaboration with the multidisciplinary team I was able to adapt the patients nursing care plan to meet his individual need. However, I am aware that I have had limited experience of working autonomously within the multidisciplinary team and intend to take the opportunity as a management student with delegated responsibility to enhance my knowledge and experience of joint working. In particular I will ensure that I take a lead role in multidisciplinary review meetings as a named nurse. However, I will ensure that I have adequate supervision from my mentor and other senior nursing staff to enable me to perform the role to the level of my responsibilities.

Evaluation

Weaver (2008) states that SWOT is an effective tool for reflection of a person’s values, interests, priorities and effectiveness of their practice by means of self-evaluation. It has also been identified as an effective way of recognizing an individual’s strengths and weaknesses, and examining the opportunities and threats that a person encounters (Pearce 2007). This therefore is an effective tool to evaluate a Personal Development Plan. Makinson (2001) highlights that by preparing a personal SWOT it helps to identify and analyse the current situation, the relevant features, circumstances and resources applicable to a personal development plan

Amar (2003) suggests that the outcomes of learning and the process of learning can be evaluated by identifying learning needs using questionnaires, clinical audit, and patient satisfaction questionnaires. Rucker (2003) stresses the importance of timely feedback as a requisite for effective professional development. For both development areas namely Integrated Care Pathways and Multidisciplinary working I will utilize feedback from my mentor within the ward. However (Mumford 1998) highlights that although a mentor can enhance the acquisition of knowledge this will be dependent on their own level of knowledge. I will therefore supplement this by utilizing the knowledge base of other members of staff I encounter within my next placement area achieving (NMC proficiency 4.1 and 4.2) by sharing my knowledge and experience and identifying any deficiencies in my practice and seeking guidance on this. This would be achieved by ensuring that my NMC learning objectives were achieved and by ensuring that my mentor was aware of the Personal Developed Plan in (Appendix 3). I will also utilize verbal feedback from the patient as I would be limited in respect of using questionnaires due my student status, time limitations and possible ethical issues. However, in the long term I would hope to utilize this method as a qualified practitioner to ensure that I was achieving my objectives with regard to the quality of patient care. I will also continue to utilize self-reflection as a means of improving my practice ensuring that I continue to set continuous achievable goals using the SMART framework.

Annotation List

4.1 By the development of a personal development plan I identified weaknesses in my practice and demonstrated a commitment to the need for continuing professional development.

2.5 By linking theory to practice and reflecting on my own practice has enabled me develop my skills and evidence base to ensure I carry out safe practice with my patients.

2.6 Consulting with the patient’s named nurse about my concerns demonstrated that I identified and articulated my own emotional and psychological responses to situations with colleagues in a professional manner.

Recognising my own abilities and limitations by carrying out practice in accordance

with the code of professional conduct and consulting with a registered nurse when I

felt the patient was not receiving the best quality of care.

2.2 By scrutinizing the patient’s ICP I was able to promote his health and well being throughout the meeting.

2.4 By updating the patient’s plan of care accordingly I had established priorities of care in partnership with the patient within the framework of informed consent.

3.2 demonstrated knowledge of effective inter-professional working by participation in the multi-disciplinary meeting presenting feedback on the patient’s health status.

4.2 By sharing my knowledge and skills with my colleagues and utilising my personal development plan to contribute to a climate conducive to learning.

3.3 By taking on a leadership role within my management placement, having responsibility for my own case load, I will be able to delegate duties to others, as appropriate, ensuring they are supervised and monitored.

2.3 By utilising the ICPs within the acute setting I was placed I was able to identify the physical, psychological, social and spiritual needs of the patient, document clinical data and take appropriate action.

2.8 By participating in the multi-disciplinary meeting I demonstrated sound clinical judgement and was able to adapt nursing care to meet the patient’s individual needs.