Introduction
This journal utilises Borton’s 1970 reflective cycle which the Royal College of Nursing Institute (RCNi) (2016) deems an appropriate tool for developing practitioners, with which I will analyse the two core apprenticeship standard areas: case management, and supervision and teaching, and how these have developed in my time of study. This journal also seeks to assess the challenges and difficulties I have faced since beginning the apprenticeship and how I can overcome these and develop myself moving forward.
Case Management
What?
Case management is an area of work that I have significantly improved upon throughout the apprenticeship. I recognise that better management of case and work load not only correlates to better patient outcomes but also improves my own wellbeing (Van den Oetelaar, et al., 2016) where I have found that prioritising, organising tasks and a more developed knowledge base to be fundamental to this. Development in this area is important as it applies the principle of person-centred care – a critical factor in providing for the needs of the patient, rather than the service (Royal College of Nursing institute, 2016). This is certainly a factor I was less aware of eighteen months ago but which now means that I can take appropriate action to cater to the needs of each individual and be empathetic towards their circumstances.
So what?
I believe that improving my case management and working in safely in a busy environment is due to better prioritisation of tasks and a greater understanding of my role and the role of others, attitudes that the RCN (2016) considers essential in reaping the benefits of better care for patients and greater staff experience. The apprenticeship has highlighted the importance of teamwork, through group module work and peer review, and how these are essential to my practice, particularly in a busy and demanding environment.
At work, I am able to divide my time appropriately, to assist patients, to chaperone clinics and to complete administrative tasks as part of my duties. Effective communication is integral to this, I recognise that I can also be honest with colleagues if I am not able to complete tasks and can ask for help, or conversely, assist others with their work and I recognise that in line with the NMC Code (2018) I am able to support those who may require help with their own caseload.
To ensure that I take action relative to the needs of the individual, I am aware of the need to ask each patient what their expectations are of the care they are receiving, a principle NICE (2012) recommendation to support each individual and their beliefs and preferences and this principle also reflects a need for patient autonomy. This could be something simple like arranging the clinic environment to the preference of the patient rather than maintaining a generic layout, or more generally, discussing whether the care I provide is working for them and if they would like to continue before acting further. In my clinic setting this could result in an onward referral to more qualified staff such as a physiotherapist or for a consultant review where previously I may not have taken this action in such a timely manner and this reflects the RCN (2018) nursing standard to work-cooperatively for effective care. This also highlights a greater awareness of the broader requirement to practice within my limitations and to collaborate with colleagues to provide personalised care (Department of Health, 2013).
The best example of this is through my provision of care to patients through external neuromodulation, an electrical stimulus treatment I provide to sufferers of chronic pain. Competence, as well as being a one of the 6Cs of care, permits me to say ‘I know that I am providing the best care, because… ‘, and have the supporting skills to treat patients accordingly. Specifically, this could refer to how best to use the equipment, the questions to ask a patient to elicit answers that support their treatment (i.e. stimulus position, stimulus pressure, etc.) or more simply asking a patient how they are feeling and showing understanding of their response and acting with discretion where necessary – this includes making sure that conversations with patients are private and that identifiable information is only used for its intended purpose in accordance with recently updated NHS Confidentiality Policy (2018) and the 2018 Data Protection Act. With consideration of these actions, I feel I am able to demonstrate a conscientious and empathetic approach to care.
I feel confident that I can identify and implement programmes of care to treat patients correctly where, pre-apprenticeship, my skills were confined to the outpatient environment in which I work. Notably, I have adapted to care for acute patients using methods of assessment such as ABCDE, pain assessment, and how to competently assess for signs of deterioration as per NICE (2007; updated 2019; NMC, 2014) guidelines, through the use of NEWS2. A Nursing Times (2011) practice review highlighted instances where recognition of patient deterioration was missed or delayed, in many instances by unqualified HCAs resulting in harm or in some instances death in acutely ill patients. In this setting I have focused on recognising the parameters for NEWS2 scoring to be able to quickly identify signs that can be escalated to senior staff, showing that I can take timely action relative to a patient’s care needs and therefore, demonstrate committed care. Understanding and being able to confidently utilise the VitalPac system in an acute environment means that I can confidently take action relative to the needs of a patient in situations which have the potential to result in harm to patient welfare and condition. In addition to learning new skills I have also developed upon pre-existing skills such as basic life support and feel confident that I can act appropriately in an emergency situation.
Now what?
My responsibilities and workload as a health worker will increase as I progress through this qualification and beyond. In light of this, maintaining the values and behaviours expected and remembering that patients should always be at the heart of our work is a fundamental requirement of my practice that I feel can be easy to overlook in an often busy and stressful environment. This highlights a committed and caring approach as aspects of compassionate care of the 6Cs (RCNi, 2015) and values expected of the apprenticeship standard.
Supervision and Teaching
What?
Areas of learning that I have developed through this apprenticeship have been in the areas of supervision and teaching, two components of the apprenticeship standard. The RCN (2015) considers that the most effective health care services ensure that staff are properly trained with up-to-date skills and knowledge base, while the HCA Code of Conduct (Department of Health, 2013) recognises that healthcare can be improved through my development of others. I feel that I have improved in these areas for two reasons – firstly, through better overall communication with my colleagues and service users, and secondly, through greater confidence and competence in my role and actions.
So what?
The first module of the apprenticeship was important for me to be able to develop in this regard. This required a half hour group presentation to be given to assessors where I led in the structure and layout of the assignment. This was very successful; with the assessor stating that we ‘worked well together’ with the presentation exhibiting ‘flow’, awarding us an overall mark of 96%. I feel that this would not have been achieved without effective collaboration between me and the rest of the group. In a broader context I can apply this experience to multi-disciplinary team working within my own place of work – something that the World Health Organization (2010) considers a vital aspect in improving health outcomes. Throughout this process, the allocation of work to others featured heavily, where there is no doubt that I developed the confidence to ask others to complete areas of the presentation and provide my opinion on work that I thought was good and other areas that I thought could be improved for which I could recommend subsequent action. Whilst studying for this apprenticeship I have allocated work and supervised new staff to the department in which I work, ensuring that they follow correct procedure in relation to documentation and manage the care of patients through best practice. I have learned that successfully allocating work to others relies upon determining the skills and understanding of those I am giving work to, and ensuring that they are comfortable in managing and completing that work safely (Skills for Health, 2009). Through this course, I also accept and factor in the importance of accountability and taking responsibility (RCN, 2019) when allocating tasks to others and the likely impact my actions may have on patients through delegation.
I feel that behaviours expected by the apprenticeship standard were exhibited, notably in regards to respecting the beliefs and preferences of others and being adaptable. Elements of the NMC Code (2018) such as effective communication and respecting the opinions of others was also essential to the success of this work where I felt I could be constructive and maintain rapport with group members, even when there were disagreements. I feel that I may not have had the confidence or courage to do this previously and would perhaps have made concessions on work and actions that I did not agree with. This is important in the broader context of my work as being able to speak up is fundamentally important to patient safety and appropriate culture in a working environment (Freedom to Speak Up, 2015). I feel that I have carried the skills I developed through this work into my workplace and into other areas of the apprenticeship.
Developing and teaching others are examples of areas that I was apprehensive of pre-apprenticeship because of my confidence talking in front of peers and students. Despite this, developing others has been something that I have very much enjoyed and relish developing in future. For me, improving my practice in relation to the values of competence and commitment through study, reflection and repeat practice has allowed me to become more confident in delivering what I know to others – Price-Dowd (2017) considers this sharing of knowledge and support of colleagues vital in educating the next generation of healthcare workers.
My role requires me to treat patients using external neuromodulation to treat chronic pain and I have become competent in the application of this treatment through experience, where I have focused on feedback from service users gathered during practice placements, and through the use of evidence-based care (Price-Dowd, 2017). I therefore selected this treatment method as the subject of my module five teaching session. I feel that my ability to teach has significantly improved since the start of this course where I consider this to be due to greater knowledge of the subject material and an element of reflection between the first and fifth modules where I have been able to learn from experience, discuss with my mentor, and improve upon previous work. An important aspect in the successful delivery of this session was the use of a model of learning – in this case I found Peyton’s 4-Step’s Approach to teaching to be helpful in providing a template for the session, assisting staff and students in adapting knowledge of theory to practice – the aim of any mentor or teacher as stated by the Royal College of Nursing (RCN) (2017).
Following this session, I understand the importance of the role of a mentor and teaching in healthcare and how it leads to safe and effective practice in a wider context and feel that I am better able to engage students in the learning process and adapt my teaching style to suit the student. For example, my staff training session used a presentation as its main focus while demonstration was also used. On reflection and student evaluation, it is clear that demonstrating correct use of the equipment and then asking students to follow was the most engaging aspect of my session and allowed me to provide constructive feedback on their actions and how to improve, a reflection on the values considered of an effective mentor according to the RCN (2017).
Now what?
I feel that the most important area for me in continuing my development of supervision and teaching is regular professional development and reflection as to how I can improve which I feel is easily overlooked, often because of a busy work schedule. Without this, a fundamental issue would be, ‘how can I support best practice, develop and teach others if my own practice is inadequate or flawed?’ Not only is up-to-date knowledge a requirement of nursing staff in The Code (2018) but committed care as a nursing and apprenticeship value (Skills for Health, 2015) can also only be achieved if I continue to learn and practice correctly. I also recognise that my skills and development as a practitioner are largely due to the time that others have invested into supporting and developing me and I wish to pass on the skills that I have learned, and continue to learn, to others.
References
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