Student Nurse

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    Research, Clinical Governance and Reflection

    According to the Royal College of Nursing, (RCN) (2003) nursing is about using clinical judgement through the provision of care to help people reach their best quality of life. This essay will explore aspects that foster clinical judgement and the provision of care. The relationship between evidence-based practice and clinical effectiveness will be discussed, along with how clinical governance can influence the quality of healthcare for patients. Finally this essay will consider the contribution of reflection to nursing practice, including a personal reflection using the Gibbs cycle.

    Evidence-based practice has been described as a systematic process for 'finding, appraising and using research findings as the basis for clinical decisions' (Long and Harrison, 1996 cited in McSherry et al, 2002, p7). It occurs when decisions about the care of a patient are made with respect to all the information available (Chambers and Boath, 2001). It is important for nurses to understand and implement evidence-based practice as they are now expected to justify their decisions on professional expertise such as research (McSherry et al, 2002). Nurses can no longer base their care on ritual and tradition but are encouraged to use valid evidence that enables them to be accountable for what they do (McSherry et al, 2002). Nurses will be able to improve the quality of patient care, as integrating professional judgement with the best evidence available produces effective personalised nursing interventions (Simmons, 2002). Essentially the care provided is holistic, as instead of nurses applying a tested method they will have to consider the actions they take for each patient. Simmons (2002) supports this view and states that for research to be of benefit it needs to be individualised to the patient.

    The process of implementing evidence-based practice begins with the formation of a good question (Boath and Chambers, 2001). In practice a simple question that could arise could be 'what is the best type of dressing to apply to a sloughy infected wound?' The next part of the process would entail a search of the literature to find the optimum evidence (Chambers and Boath, 2001). This would be followed by an evaluation of the most relevant and appropriate literature (Chambers and Boath, 2001). In this instance the literature accessed would likely be research into wound dressings and the nurse would evaluate the evidence for its usefulness and validity before selecting (Sackett et al, 2004). The nurse would then apply the evidence to practice, (Chambers and Boath, 2001) by selecting a dressing based on research of its effectiveness.

    The easiest way to find research is to access journals stored on electronic databases, CD-ROM or the internet (Craig and Smyth, 2002). It is also important to check the Cochrane library for systematic reviews on the subject (Craig and Smyth, 2002). Additionally the Internet can be useful, although the danger being lack of quality control and a vast amount of information to search through (Craig and Smyth, 2002). In regards to the best evidence to use a hierarchy has formed with systematic reviews considered the most useful and case reports the least (Greenhalgh, 2003).

    It has been said that 'Clinical effectiveness is the cornerstone of evidence-based practice' (Reagan, 1998 p245). This suggests that clinical effectiveness is the result of evidence-based practice. Clinical effectiveness has been described by the NHS executive (NHSE) as 'the extent to which clinical interventions when deployed in the field for a particular patient… do what they are intended to do' (1996, p6). Being clinically effective involves making sure changes in practice are benefiting patients (NHSE, 1996). It is also about ensuring the care provided is based on knowledge that it will make a difference to the patient in terms of effectiveness and efficiency (Cox and Reyes-Hughes, 2001). It can be suggested that effective practice only occurs when practitioners have used the right evidence to achieve the desired patient outcomes (McKenna et al, 1999). For instance nursing models such as the activities of living can help nurses provide clinically effective care by being an evidence-based tool that helps them determine the intervention best suited to the patients needs (Aggleton and Chalmers, 2000).

    It is therefore appropriate to suggest that evidence-based practice cannot be performed independently of clinical effectiveness. According to McSherry et al (2002) the two are interdependent of each other with evidence being used to improve practice and therefore enhancing the effectiveness of care. The relationship between evidence-based practice and clinical effectiveness can be further emphasised by Dawson (2001) who believes that practitioners cannot make their services more clinically effective unless they are basing it on the best evidence. It is thus apparent that an important relationship exists between evidence-based practice and clinical effectiveness, being that by implementing the evidence-based process into practice the effectiveness of services can be improved.

    Encompassing the concept of evidence-based practice and clinical effectiveness is the clinical governance framework introduced by the White paper 'A First Class Service' (Department of Health (DH), 1998). Clinical governance can be viewed as a means by which 'NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care' (NHSE, 1999, p3). It is also the aim of clinical governance to promote an environment in which evidence-based practice and clinical effectiveness can flourish (NHSE, 1999). Clinical governance has been introduced due to the publics concerns over inadequacies and poor standards of care in the NHS (Wright and Hill, 2003). Therefore it is hoped, that the introduction of clinical governance will improve the quality of care and reduce variations in services provided (NHSE, 1999).

    The concept of quality in health care can mean different things for carers, patients and organisations (Clayton, 2003). Patients feel that quality is reflected in the care they receive in regards to their quality of life, whereas for staff quality is measured by the care they deliver (Clayton, 2003). Quality in healthcare has been described in 'The New NHS' white paper as 'doing the right things, at the right time, for the right people, and doing them right - first time' (DH, 1997, p3). According to Swage (2003) clinical governance guarantees quality through processes such as risk management, clinical effectiveness and professional development. The systematic approach of quality assurance also ensures quality by providing the healthcare team with tools that facilitate continuous improvement and gage performance levels (Campbell, 2004).

    If quality is at the heart of clinical governance then it can be said that Clinical governance can improve the health of patients. For example clinical governance ensures that health professionals are competent to deliver care safely with the right training and skills (RCN, 1998). This importantly protects patients from risks and mistakes allowing them to have confidence and faith in their care providers. Clinical governance also ensures that practitioners are accountable for the quality of patient care they provide (RCN, 1998) meaning that they are more likely to question their practice and seek to make it of more benefit to the patient's health. Clinical Governance especially influences the quality of patients health by promoting them as being at the heart of care delivery by involving them in decisions about their care and providing them equity of access to services (RCN, 1998). Clinical Governance will also ensure that patients receive more information and have clear methods of communication for voicing complaints (RCN, 1998). An example from practice is when a nurse directed a patient to the Patient Advice and Liaison Service in order for them to make a complaint about the care they received. The nurse facilitated clinical governance by providing a clear method for the patient to voice their concerns and feel they were treated fairly. It is the motive of clinical governance to develop practice that is accountable, organised and patient-focused (Wright and Hill, 2003) thus reducing risks and improving quality.

    Clinical governance can potentially contribute many gains to the healthcare patients receive; yet there are still restraints that may prevent it reaching its full potential. For instance time, costs, resources and demands placed on busy professionals may all effect the successful implementation of clinical governance (McSherry and Pearce, 2002) It is also important that a culture is in place that welcomes and supports Clinical governance to enable it to flourish (DH, 1998). In order to monitor standards of clinical governance the government have established the National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement (CHI) (DH, 1998). The role of NICE is to set standards for quality within the service whilst CHI is responsible for monitoring the standards set (Kenworthy et al, 2002). Both contribute to the quality of healthcare by ensuring that the most effective practices are in place and that malfunctions are avoided (Kenworthy et al, 2002).

    As the clinical governance framework incorporates a standard for continuing professional development (DH, 1998) it is now relevant to consider the contribution that reflection makes to practice. Reflective practice has been described as the means by which practitioners can systematically and thoughtfully make sense of their practice (Taylor, 1998). It entails reviewing an incident in practice by describing, analysing and evaluating the event so as to inform the learning process (Gerrish, 2003). Portfolio building, diaries and the use of narrative are all useful tools for aiding reflection in practice (McKenzie, 2002). Reflection can be further developed by the use of cycles such as Gibbs (1988) experimental learning model. The experimental learning model explores reflection through a series of stages that include a description of the event, feelings, evaluation, analysis, conclusions and personal action plan (Gibbs, 1988). Gibbs intends that by reflecting using this cycle, thinking will be linked to doing and therefore new ideas will emerge for dealing with future situations (1988).

    Schon (1991) identifies two types of reflection; reflection-in-action and reflection-on-action. Reflection-in-action involves reflecting on practice whilst in the midst of it. Schon argues that this type of reflection enables practitioners to cope with troublesome situations as they emerge (1991). Someone who is able to reflect-in-action is able to combine thinking and doing, (Schon, 1991) for nursing this means practice is enhanced as it is carried out. Johns (1998) emphasises this view as he believes that reflection-in-action is a way of constantly monitoring the self in the situation. Reflection-on-action on the other hand involves retrospectively looking back at practice in order to uncover and analyse the knowledge used (Fitzgerald and Chapman, 2000).

    Reflection makes an important contribution to practice as it enables nurses to constantly question the care they give, thus ensuring safety and effectiveness (Kenworthy et al, 2002). It can also be used as a means of identifying areas in practice that are lacking (Johns, 2000). Reflection contributes to practice in the sense that to practise it takes commitment, which in turn means that practitioners care about their work and are willing to accept responsibility for it (Johns, 2000). Reflection contributes to practice by enabling practitioners to know themselves and how they respond in situations (Johns, 2000). This leads to an assimilation of personal knowledge (Johns, 2000) therefore enhancing practice in the long-term experience of the practitioner. Self-awareness is important for all aspects of nursing as it involves being conscious of beliefs, values, strengths and weaknesses (Atkins, 2000). It can be seen as the basis for reflection as it is a way of honestly observing the self in a situation (Atkins, 2000). According to Taylor (2000) reflection also involves using critical reason to inform practice as practising it involves carefully and analytically reaching conclusions.

    According to Johns to 'be a reflective practitioner is to be a holistic practitioner' (1998, p23). Nurses who are holistic in their practice take into account a person as an individual, considering their emotional, spiritual, physical, intellectual and sociocultural needs (Kenworthy et al, 2002). It is important not only to consider the physical health of a person but the spiritual too, that being a belief in a unifying force (Kenworthy et al, 2002). A disease is a disorder with specific cause and symptoms (Oxford, 2003) and therefore far easier to treat then the spiritual health of a person. Holistic practice is thus challenging to the practitioner requiring them to look deeper then the diagnosis.

    The holistic perspective of reflection may not be easy to assert in a healthcare system organised largely from a medical model viewpoint (Johns, 2000). The medical model separates the body from the person, reducing them to a diagnosis (Johns, 2000). Johns challenges this view by arguing that you cannot separate disease from the person (1998). The medical model supports the Cartesian theory of personhood that persons are separate minds and bodies, whereas reflection supports Merleau-Pontys theory that persons are minds and bodies intertwined (Edwards, 2001). In this sense reflection makes an important contribution to nursing by enabling nurses to see their patients as a whole.

    Reflection also makes a contribution to practice in the ethical sense by encouraging nurses to analyse their morals, value, beliefs and motivations (Ferrell, 1998). It encourages nurses to do the right thing in their practice (Ferrell, 1998). By identifying the true meaning of their actions, nurses are able to enhance or discard them to better them (Douglas, 2002). Reflection especially supports the beneficence and nonmaleficence principles of biomedical ethics by ensuring that care is beneficial to patients in respect that it is safe and effective (Beauchamp and Childress, 2001).

    A reflective account from practice will now be portrayed using the Gibbs cycle.

    In my first week on my first placement I found myself observing and assisting in the removal of K-wires from a gentleman's hand. The man was young, foreign and had nobody accompanying him. He was frightened of the procedure and asked me of details of how much it would hurt and how long it would take. I could not tell him as I had not seen the procedure before but I comforted him throughout.

    I felt helpless in the situation as I could not tell the patient anything to allay his fears. I felt I was not prepared for the discomfort he would be in and I was relieved when it was over.

    I was happy to be a support for the man when he had no one else to comfort him but felt that I was at a loss due to my lack of knowledge.

    I now realise that I should have asked the nurse I was assisting more about the procedure before I went in to help. I could have helped the situation by asking the trained nurse to give the patient more information.

    This experience has taught me to be aware of procedures before I assist, as otherwise I cannot be of use to a patient who has questions. It has shown me that I often rush into situations and I feel uneasy when there are deficits in my knowledge.

    Action Plan:
    In future I will seek knowledge about interventions before I assist and I will seek to allay patient's fears wherever possible.

    For the reflector this reflection was a valuable contribution to their practice as it highlighted issues that were not apparent beforehand, enabling them to be learnt from.

    In conclusion this essay has shown the importance that evidence-based healthcare, clinical effectiveness, clinical governance and reflection all make to practice. It can be seen that a definite relationship exists between evidence-based practice and clinical effectiveness in that you cannot practice one without the other. Clinical governance means valued improvements in quality of health care to patients, ensuring that their needs are met and they are treated as individuals. Reflection contributes to practice by enabling nurses to continually question their care and seek better ways of working for the safety and benefit of the patient. It can be seen that evidence-based practice, clinical effectiveness, clinical governance and reflection are not isolated from each other as they all seek to improve the effectiveness and quality of healthcare for patients and clients.

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