Developing_Practice

DP1 The purpose of this assignment is to use a model of reflection to show how I have achieved my Learning needs in one of the Dimensions, as set by the KSF. I have chosen to reflect on Health, Safety and Security. I aim to show how I have integrated the learning needs identified in my action plan into my practice, and use a range of literature to give evidence based reasons for the way I have demonstrated my learning. I will reflect on how I might adapt my practice in the future, or in different circumstances, supporting my reasons with literature. I also intend to link my learning to the module learning outcomes. I am going to use Gibbs (1988) Model of reflection. When a patient is admitted on to the ward, we need to complete a risk assessment and a day case or major surgery admission form, depending on the type of operation they are having. All paperwork is filled in with the patient and any information given by the patient will be accurately documented on the correct paperwork. The risk assessment we use is a booklet assessing Manual Handling requirements, Infection control risks, Falls risk, Pressure Ulcer Risks and also Nutrition risks. The Royal College of Nursing (RCN, 2010) states that “Risk assessments should take place continuously. They must be reviewed as changes occur such as new equipment, changes to systems of work or different approaches to patient care.” The Manual Handling Operations Regulations (1992) require risk assessments to be carried out if the employer cannot avoid the need for a manual handling action which involves a risk of injury. When completing our Manual handling risk assessments, we score the answers by numbers, for example if the category is mobility, they would score 0 for independent and 4 for completely bed bound. RCN (2003) argues against using numerical scoring on a risk assessment saying “Part of the problem with a formula is that it is inflexible and only takes accounts of specific risk factors. But an experienced assessor can use judgement to look at the picture as a whole, taking a wide range of factors into account. For this reason numerical assessments are not recommended. Wicks (2006) presents an argument against using assessments at all asking “is clinical judgement better'” Sharp et al (2000) found in a survey of 444 nurses in current clinical practice that 79% did not use a tool but relied on clinical judgement alone to assess patients’ risk. Thompson (2005) suggests that “many clinicians view predictor scores to be inadequate, inaccurate and difficult to understand.” Although some nurses may be able to use their clinical judgement effectively, other nurses, for example those that are newly qualified, may not spot a manual handling risk as easily as that of a nurse or nursing assistant who have been assessing patients for a number of years. For this reason I think that the risk assessments and clinical judgement should both be used hand in hand. The risk assessments may highlight a less obvious risk to the newly qualified nurse, whereas clinical judgement may prevail an elderly patient being placed close to the toilets and wash basins as they have scored high risk due to their age, whereas In fact they are very mobile and able to move freely on their own and would like to be away from all the noise and activity that goes on near bathrooms. Working on a surgical ward, infection control is very important. When admitting a patient who has a possible infection control risk we have to follow trust protocols and isolate the patient in a side room, this is to prevent any infection from spreading through the ward. The Health and Social Care Act (2008) advises trusts “that infected patients should be isolated, 'ideally' in single rooms, although a hospital coping with an outbreak without enough rooms should create 'a closed environment' for affected patients.” We practice the “5 step hand wash technique” as supported by the DOH (2010), wet, soap, wash, rinse and dry using a liquid soap detergent. Research shows that many other authors including Ayliffe et al (2000), support this hand washing technique to keep infections at bay. “Importance of regular hand hygiene must be emphasized as one of the most crucial interventions in the prevention of cross infection in health care facilities”. (Damani, 2003). There are various methods of grading the severity of a pressure ulcer following different risk assessment scales. The most common being Waterlow (1987), Braden (1985) and Norton (1962). RCN (2000) states “there is no ‘best’ pressure ulcer risk assessment tool. Experts have been unable to unequivocally endorse one specific tool for all clinical areas, due to a lack of robust research.” At work we follow Bradens scale because it takes in to account more in depth risks of pressure ulcers, for example skin condition and incontinence. “The Braden Scale for Predicting Pressure Sore Risk was developed to help nurses determine patients' risk of developing pressure ulcers. The scale, which takes less than a minute to complete, has been used with patients of all ages and in all settings and has been found to be more accurate than other scales (including the Norton and the Waterlow scales) or clinical judgment.” Stotts and Gunningberg (2007) (Waters 2003) emphasises that “The Braden Scale is a widely used pressure ulcer risk assessment tool”. (Anthony, 1996 cited in Waters, 2003) discusses “the limitations of thresholds or cut of points. If the cut off point is too high, the majority of population will not be diagnosed. But if the cut off point is too low, then many people will be diagnosed who do not have the condition.” Despite these limitations Comfort (unknown) emphasises that “The past several years have seen an accumulation of evidence that pressure ulcer incidence in hospitals can be reduced markedly—in a number of cases nearly to zero—using risk assessment based on the Braden Scale”. Research into all three pressure prevention scales found that the waterlow score has been found to be more in favour with ward nurses in terms of how valid the content is because it contains more of the indications associated with the risk of getting a pressure ulcer. Although some areas, such as, the assessment of neurological patients, have been criticised for being vulgar and vague. (Wardman 1991,Dealey 1994). Supporting this evidence, (Anthony et al 1998) states that neither the Braden nor Norton scale, both of which are designed for hospital patients, cater for patients using a wheelchair in the community. However Bridel states that the Braden tool is the most reliable and that the ‘validity of the tool is generally good and compares favourably in comparison with Norton and Waterlow scores’. (Bridel, 1993). I believe that none of the pressure ulcer prevention scales exceed the others, they are all beneficial if used in the correct clinical environment and after the correct training. From researching the different scales I have concluded that although pressure prevention scales are a good tool, clinical judgement should also be important. A study performed by Gould et al. (2004) against pressure ulcer risk assessments and nurses clinical judgement reported that a nurses clinical judgement was close to that of an expert opinion and were superior to the risks identified by the risk assessments. (Nixon and McGough, 2001 cited in Waters 2003) point out that “it is important to remember that the tool should not be used exclusively to identify a risk but is a part of a complete holistic approach.” The National Patient Safety Agency (2007) informs us that “accidental falls in inpatients account for 30-40% of reported safety incidents”. “A fall is the most reported safety incident in inpatients and occurs in all adult clinical areas.” (Oliver and Healy 2009). Oliver and Healey (2009) suggest that “tools that claim to predict patients risk of falling as ‘high’ or ‘low’ do not work well and may provide false reassurance that ‘something is being done’.” Oliver and Healey (2009) suggest that although tools may raise awareness of certain problems and get the staff focused, health professionals need to be more aware of the tools strengths and weaknesses instead of relying on them completely. Falls assessments ask questions such as are they aged over 65' Do they have a history of falling or fainting' Are they under the influence of alcohol or illegal substances' And do they take any strong sedative medication' If they answer yes to being over 65 and to one of the others they automatically become at a high risk of falling. However I feel again it comes down to clinical judgement as well as the risk assessment, if they were over age 65, completely independent when mobilising and their history of fainting was when they were pregnant 30 years ago, I would not deem them a high risk. However if they were aged over 65, fainted intermittently due to a cardiac issue and sometimes took strong sedatives to sleep, I would need to weigh up whether the intermittent fainting and occasional sedative deemed them a ‘high risk’ or whether they just needed a closer eye kept on them. Oliver et al (2004) emphasise that tools should add value to health professionals in their judgements in predicting risks. (Bond 1997 in Perry, 2007) state that “nutritional screening is a first-line process of identifying patients who are already malnourished or at risk of becoming so. Nutritional assessment is a detailed investigation to identify and quantify specific nutritional problems”. When doing nutrition assessments we do the patients weight and height to generate their Body Mass Index (BMI), before asking them if they have lost any weight recently. This enables us to monitor a patients diet and involve other members of the multi disciplinary team if needed, such as the dieticians. “nutritional screening is usually undertaken by nurses, doctors; assessment by dieticians” Perry (2007). If a patients BMI falls below the desired range of 18.5-25 (NHS, 2010) then we can implement a nutrition care plan and monitor what the patient is eating and drinking throughout the day. Risk assessments are an important part of a patients care; it enables their care to be personalised and monitored so they have the best level of care possible for them. However, risk assessments are only beneficial if any risk identified is acted upon. “A risk assessment is useless unless it leads to action on reducing risks” (RCN, 2003). Upon researching further into module, Health, Safety and Security, and even further into Risk Assessments, I have learnt how important it is to keep on top of all the risk assessments, they are an important part into a patients care. I have realised I need to alter my practice and act upon any risks identified when completing risk assessments, at present I have been wary that as an un-registered nurse my views would not be acted upon as readily as that of a registered nurse, however I have come to realise that if I do not mention anything at all then even less would be done to ensure the patient receives the highest level of care possible. “A risk assessment is meaningless without action. Completing risk assessment tools can become an end in itself, rather than a means to an end.” (Oliver, D, Healy, F 2009). Word Count: 1884 References Anthony et al (1998) “An evaluation of current risk assessment scales for decubitus ulcer in general inpatients and wheelchair users”. Clinical Rehabilitation. Volume 12, Pages 136–142. Anthony (1996) in Waters, N (2003) “Predicting a Pressure Ulcer Risk” Nursing Times. [Online] Volume 19. Issue 13. Page 63. Available at http://www.nursingtimes.net [Accessed 25 October 2011] Ayliffe, G, et al, 2000. Control of Hospital Infection: A Practical Handbook. 4th ed. London: Arnold Publishers. Bond. (1997) in Perry, L (2007). “Nutritional Screening and Assessment” Nursing Times. Volume 105. Issue 7. Pages 18-21. [Online] available at http://www.nursingtimes.net/nursing-practice-clinical-research/nutritional-screening-and-assessment/199381.article. [Accessed 26 October 2011] Braden, (1985). Prevention Plus. 2011. Prevention Plus. [ONLINE] Available at: http://www.bradenscale.com. [Accessed 29 October 2011]. Bridel J (1993) “The epidemiology of pressure sores”. Nursing Standard Comfort, E. (Unknown). “Reducing Pressure Ulcer Incidents through Braden Scale Risk Assessment and Support surface Use”. Advances in Skin and Wound Care. Volume 21, No 7, Page 334. [Online] Available at http://www.woundcarejournal.com [Accessed 25 October 2011] Damani, N, 2003. Manual of Infection Control Procedures. 2nd ed. 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