Clinical Remit

Clinical put offTeaching and Nursing Practice 1 A tuition require Assessment1. Clinical Remit.As a nurse pretending in defendly a clinical specialty it is indoors the remit of my job to get along the porete c atomic number 18 service and maintain high standards of look at. It is also the right of the pore grapple department to meet the training and trainingal ineluctably of shelter based nursing round to learn high feature alimony which is evidence based and kept up particular dated.Prior to coming into brand my article of faith vex had been limited to mentorship of students and informal cover based seminars. My save formal teaching experience had been as a student when appear lectures and courses.My teaching remit includes patients, relatives, wish salutaryrs, colleagues and students. It put forcellblocks me with the opport unit of measurementy to pass on my clinical skills, association and experience to junior ply. This non only allows them to de velop their own invest merely influence the surgical unit and their patients.There is allocated placement prison term to the porete team for students and we also teach students who feature placements inwardly the colorectal and general surgery unit.Teaching is often done in an informal, ward based environment where learners are able to observe and study with patients. Patients are carefully chosen and their consent obtained before the introduction of the learner. These patients are pass consequently it is beta that the patient is comfortable with every change or addition of an innovative(prenominal) person to teaching school terms. Patients and their pore nurses develop a special bond and it is important that this alliance remains strong. It is by means of this st head for the hills relationship that the patient gains the skills and acquaintance rented to equip them for life with a stoma.The stoma care nurse is a facilitator, he/she commits patients to optimise musical note of life and adjust to their new circumstances.My principle clinical use is in the teaching and support of patients who are ab disclose to lease or incur undergone surgery to create a stoma. Fulham (2008) ack instanterledged that nurses play an important voice in rooting patients adjust both physically and psychologically to a new stoma.Research (OConnor, 2003 Metcalf, 1999 White, 1998) has shown that early teaching of practical skills and coping strategies help new stoma patients brook a more favourable come forwardcome. primal education helps prepare them for surgery and allows patients to adapt more positively to the stoma (Burch, 2005).I have chosen to focus on one particular proposition aspect of teaching within stoma care, namely the changing of a one piece stoma pocket. The reason for my choice is that this is a vestigial part of the stoma care process. It is the focus of legion(predicate) patients anxieties and is key to galore( partnominal) patien ts feeling of well universe it is one area where they feel they still have nearly control. Bekkers et al (1996) saw self-efficiency as crucial to adjusting to a stoma and as a result saw fewer psychological problems post- operatively. Commonly, the presumption is that teaching stoma attention is someone elses responsibility (Turnbull, 2002).The principles of a pop step forward change are frank to follow to achieve success, yet it is in general carried verboten poorly at ward level. This could be due to a number of reasons. Pouch changing is a practical skill not widely behaved at university it is often passed on through experiential encyclopedism and reflective practice bit on placement. This intends that the flowing university class does not adequately equip students with the skills needed to support these vulnerable patients (Simmons et al, 2007).It is a specialised skill that has to be practiced to become proficient. almost nurses draw close changing a stoma pap er bag merely as a task to be carried out rather than an integral part of mortalized patient centred care (Mitchell, 1995) or a teaching fortune. Lacking association or impudence in stoma care my lead to a reluctance to become involved with patients with a stoma. Norris and Spelic (2002) reported that many nurses do not feel competent enough to support patients adapting to altered carcass sign. pore care is not an integral part of all wellness care areas therefore many nurses want the probability to practice learned skills which consequently(prenominal) become redundant.Hollinworth et al (2004) highlighted the importance of enabling all practitioners who regularly care for patients with a stoma the opportunity to develop professionally. It is with this in head teacher I have chosen to carry out a encyclopedism need estimate on a small collection of nurses who work within the surgical directorate who regularly care for patients who have a stoma. The group consists o f 3 nurses 2 trained staff and 1 untrained. The rationale organism that it is often untrained staff who carry out patient care due to time constraints and workload pressure on their trained colleagues. I thought it would be interesting to compare these groups to establish strengths and weaknesses and where make betterments mountain be made that is patient centred, secern and of the highest standard. education TheoriesConducting a larn need mind is critical to the educational process. This can lead to change in practice and forms the cornerstone of continuing professional development (Grant Stanton, cited in Grant, 2002). inference based practice has become the focus of NHS policy over youthful years with emphasis on cost metier. This ensures patients receive the most streamlined care based on evidence from the most up to date look (Upton, 1999). Turnbull (2002) highlighted that ostomy teaching starts at the patients bedside often by non specialised staff therefore it is important that staff have the necessary friendship and skills to be able to support these patients. It is also important that patients receive the best realizable care and advice no matter who is giving it.Prashnig (2006) discussed the receptions of teachers to the varying nurture need of students when the teachers are aware of their teaching styles. I use a junto of styles. My approach is ab initio pedagogy as particular skills and entropy is being taught as the learner is often a new stoma patient. It then develops into an andragogical approach as the teacher learner relationship changes to guide and empower the learner towards independence through discussion and problem-solving rather than just information (Jarvis, 1985 as cited in Smith 1996 1999). This can be illustrated through many of the learning theories used in education today. Banduras (1977) social learning opening shows learning comes form observing and copying behaviour before adopting it and adopting his role model when teaching practical skills and giving advice. Skinners (1954) conditioning guess of positive reinforcement can be applied to stoma pouch changing. reenforcement in the form of repeated practice helps to form a usual pattern and the necessary skills to perform the task. The nursing process model of assess, pattern, employ and evaluate can also be applied to this theory. Kolbs experiential learning cycle (1984) has influenced nurse education for decades (Quinn, 2000). The learner moves around the cycle through the quaternity adaptive abilities of concrete experience reflective reflection inductance and application from action to placard through the learning process. Ausubels (1978) assimilation theory enables the student to build on their existing association. I teach in small, easily managed sections. Revising what was learned previously and ensuring it is understood before continuing with the next stage.Rational for carrying out a learning demand sagacity .Identifying a learning need is the starting time step in prep any education programme (Dyson et al, 2009). This ensures that the programme is appropriate for all, regardless of companionship and experience and forms the basis of the objectives and content (DeSilets, 2007). In this case the sound judgement will be carried out on a small group of healthcare professionals but the principle can be used on a bigger scale.A learning ineluctably assessment forms a baseline it identifies what is already known and what is needed to fill in wisecracks in knowledge or experience. The need to carry out a learning necessitate assessment in this clinical area was determine through casual observation of interactions between ward staff and new stoma patients. The poor intake of stoma patient education was highlighted by a disap destineing escape of documentation within patient records and limited assessment of the stomas function, the local grate condition and the patients independent progress. This has an impact on the patients psychological adjustment and last their satisfaction regarding quality of care. Nursing is based on holistic, individualised needs if a fundamental part of a new stoma patients social welfare is not being steered it can increase length of hospital stay, delaying independent stoma management introductory to discharge with evident associated fiscal implications. Employers too have expectations of their staff.The NMC codes (2008) states knowledge and skills should be kept updated and healthcare professionals should attend education which maintains and develops competence. A learning needs assessment enables the setting of goals do good not only the learner (through improving practice) but also proceeds the patients and ultimately the organisation.There are but drawbacks with carrying out a learning needs assessment. Learners often concentrate on positive aspects of their practice and do not highlight areas that need refining or adv ertise work. Teachers may focus on the negative aspects and may not make water the learner credit for what they do well.Identify an area of learningA round off of ward notes and patient questioning identified a poor apply up of patient teaching in stoma care. When questioned staff answers ranged from time constraints, lack of confidence when dealing with stomas and feeling that it was the responsibility of someone else to take charge. Some staff when questioned thought responsibility lay with the specialist stoma nurses. CNSs were carrying out the majority of teaching and support in the minimum amount of time, with teensy support from other members of the multi-disciplinary team. This identified an area of learning and an opportunity to address some of the issues through an education programme. This would re-empower ward staff and give them the skills and confidence to work with new stoma patients. This will also have a positive impact on time management. An initial increase i n time spent teaching and supporting patients to manage their stoma would be rewarded when the patient was independent and more confident in their own ability. faculty are encouraged to observe, work and participate in teaching patients along with the Stoma cover CNS on the ward where she is available to answer any queries and offer assistance.Discussion with ward staff has shown that although stoma care is carried out regularly in a general surgery unit there are staff members who a greater interest and by and by are more confident when providing stoma care.Nursing staff from the colorectal ward were informally approached and asked if they would participate in a stoma care education programme. Three members of staff expressed an interest and agreed to participate. It was distinguishable that this would form a pilot study group. Like other forms of research a pilot study should be carried out to ensure cogency and reliability (Burns and Grove, 2005). The group consisted of 2 qual ified and 1 unqualified nurse. This was to seek to determine the varying strengths and weaknesses of the grades of staff (Hesketh and Laidlaw, 2002).In accordance with the Nursing and obstetrics Council Code Standards of conduct, performance and ethics for nurses and midwives (2008), to maintain client confidentiality, all name have been changed and no reference has been made to vocation.Kate- Qualified for 3 years. Worked initially as a bank nurse but recently conjugate the staff of the general surgical ward full time. She has been in post for 6 months.Amy- Qualified for 5 years. Worked in a medical ward for 1 year but has worked in the general surgical ward for 4 years. Janet- Worked as a health care assistant for 14 years, all within the general surgical ward. She had aspirations to train as a nurse but never pursued this after having a family and now feels she has missed the opportunity. She is a part-time member of staff.It was decided that the teaching session should inclu de other aspects of stoma care for which patients often need plain support e.g. skin assessment and simple remedies, measuring a stoma and template cutting.Some common but relatively simple problems such(prenominal) as sore skin can be improved or resolved by prompt and correct treatment (Burch and Sica, 2008). With this in mind it was decided that the education should contain a practical session to edict and practice pouch changing, using stoma measuring tools, cutting out templates and dealing with simple problems.Methods of assessing the learning needs.To assess learning needs it is first necessary to choose a method for gathering information. As learning needs are individual based on knowledge, understanding, attitudes and self-assessment (McKimm, 2009 Norman et al, 2004 Grant, 2002). It was hoped the results would bust the individual learning needs of each participant.Vaughan (1992) discussed that a learners competency can be assessed through direct observation. It identifie s the learners performance level and capability.Bee and Bee (2003) also discussed the grade of observation as a tool to determine strengths and weaknesses in learners practice. Quinn (2000) however identified that observation can be subjective, so to prevent percipient bias a checklist or rating scale should be used. adjacent the example of Bee and Bee (2003) Observation can be subdivided into get observation, Work samples and Simulations.Direct Observation Enables assessment in real time. It quickly identifies good practice and areas requiring work. This was carried out by the Stoma Care CNS. It was decided that as she was a familiar face in the wards the nursing staff would be relaxed in her presence and would not alter their practice when on show and results would be accurate. It was seen as an efficient use of time/resources by ward staff and the CNS as she was available to advise and help patients and staff.Work Samples- Assessing current work practice can be difficult to a ssess accurately, peculiarly as ward staff and the CNS have individual commitments and priorities. Assessing competed work does not give the assessor a true reflection. If the CNS is inaccessible to offer advice on potential issues then a vulnerable patient can be put at unacceptable risk of stoma or skin complications. Therefore this method was excluded on moral and ethical issues.Simulation- Allows the observation of the learners when dealing with different views e.g. the availability of a simulator mannequin for practice. standardised pieces replicate differing shapes and sizes of stomas which assess basic pouch changing skills but would not allow assessment of any complication or teaching of the patient. It does however, not encourage the learner to consider the psychological needs of the patient advertize and see that changing a stoma pouch and disposal of the pouch is more than merely completing a task (McKenzie et al, 2006 Rust, 2007).Heskth and Laidlaw (2002) discuss other tools when assessing learning needs. These includePractice Testing- Routine review of notes and graphs. This can give an indication of good practice and areas requiring improvement.Informal Testing- Will establish the knowledge and current practice of the group by carrying out a simple test prior to the teaching session. This would enable the teacher to gear the education to the specific needs of the learner group. Reflective Practice- Discussing a memorable situation or experience whether it was memorable for good or bad reasons. This allows the individual to recognize their own strengths and weaknesses and identify learning needs. This can be carried out on a one-to-one basis or within a group as in individual or group supervision. It gives an opportunity to share feelings, attitudes and knowledge with their peers and is itself a valuable learning experience.The use of questionnaires and structure interviews are commonly used measuring tools used in needs assessment (Maillo ux, 1998 Hopkins, 2002 Bee and Bee, 2002)Using different types of questions within the questionnaire will gain the information required.Classification questions check how representative the sample is. It enables respondents to be put into or classified in a group e.g. gender, race or age.Coded/ unified questions measure knowledge and attitudes. Open questions allow respondents to expand on their answers it gives the opportunity to express their views.Semantic- differential questions also ask for opinion using a numerical scale.Lickert-type questions ask the respondent to express their opinion against a qualify rating scale.Grant (2002) warns that reliance on formal needs assessments when planning education can restrict the learning process instead of encourage it.To ensure learning needs are appropriately measured a questionnaire using a combination of question types was used (Appendix 1). beat was delegate for simulated practice using the mannequin and direct supervision of 10 p ouch changes by the Stoma Care CNS. This would be the starting point for teaching stoma care.Learning needs assessmentTo assess the learning needs of the chosen group the questionnaire was given out two weeks prior to the teaching session. It was hoped that an education programme would address some anxieties and encourage some deeper understanding of stoma care so the questionnaire include all aspects of stoma care including skin assessment and simple treatment, measuring a stoma and preparing patients for discharge. This required the participants to have a basic knowledge of stomas and the principles of changing a stoma pouch.The questionnaire was made up of a combination of coded/structured open and Lickert- type questions. This will gain information on the learners knowledge on the subject and an indication of knowledge on particular aspects which they may have limited or no experience. The Lickert-type question was used to identify knowledge and opinion on a specific skill used when condole with for patients with a new stoma.One week later a present moment needs assessment was carried out. This took the form of ward based direct supervision. Time within the teaching session was also allocated for simulated practice using the mannequin. This included template measuring and cutting and treating minor complications using stoma care accessories. Questions were encouraged and following the simulation the group reflected on what they had learned. out-of-pocket to close links with the nursing process model (Rolf, 1998 Masters, 2009) this needs assessment was based on Kolbs experiential learning theory (1984). Kolbs Learning StylesKolb (1999)The needs assessment is reflected within the learning cycle.The questionnaire and simulated practice reflected the learners knowledge and identified their learning needs Concrete experience.Group reflection and simulation rehearse Reflective observation.Identifying topics for inclusion in the education Abstract conceptu alisation.The learners application of new knowledge to practice when performing and teaching stoma care- Active experimentation.Williams (1998) advises a combination of three methods of assessing learning needs. A triangulation approach addresses the limitations and assumptions of each (Robson, 1993).A Lickert-type assessment tool was certain as the third method of assessing learning needs when observing the learners during their supervised practice and using the mannequin (Appendix 2).These methods provide valuable qualitative and quantitative date, as it provides both concrete knowledge and opinion from the learners (Moule and Goodman, 2009 Polit and Beck, 2008).Analysis of the Results of the Learning Needs AssessmentTo analyse the questionnaire and ward observation each participants results are examined in turn and a individualised learning need will form a conclusion.The questionnaire was divided into four parts1. The Stoma (5/5=25%)2. Pouch management (4/4=10%)3. Skin assessm ent and treatment (6/6=40%)4. formulation for home (5/5=25%)Analysis of Kates resultsKate showed a good basic knowledge of what a stoma and the importance of assessment and treatment of the parastomal skin.These results would indicate that the theoretical component of the education programme will re-enforce Kates good knowledge base. The results do however show that Kate does need to improve her knowledge with management of the stoma, namely the draining and timing of pouch changing and in the teaching and support of patients as the aim for self care of the stoma.Analysis of Amys resultsAmys results have shown that she has a sound knowledge of stomas there management skin assessment and treatment of common simple problems.This would reflect the experience Amy has within the colorectal specialty. Her bingle wrong answer reflects only that there is still agency to learn. Experience is important but as technology and approaches change it is important to keep up with current trends a nd techniques.Analysis of Janets resultsJanets results were also impressive, particularly as she has had no formalised nurse training. She showed a good basic knowledge of the stoma, although was unable to identify specifics. She did know the picture was an ileostomy but not that it was a loop-ileostomy.Janets assessment skills also reflect good practice. She can identify changes in the stoma and has the knowledge and skills to adjust treatment to minimise minor setbacks the likes of sore skin.She showed a patient centred approach to teaching and supporting patients towards stoma self care this may reflect that as a healthcare assistant Janet has greater patient contact and therefore has more active experience.Analysis of direct observationThe information obtained from the Lickert-type observation study carried out during direct observation by the teacher was transferred onto a bar chart. This was compiled while the learners were practicing stoma care skills on the mannequin.It com pares the learners practical skills and highlights areas of good practice and where further practice is required.The Lickert-type scale used documents each learners current level of competence. The range 1-5 was used, 1 (very poor) 5 (very good).The bar chart illustrates the strengths and weaknesses of each learner and makes comparisons among the group. The chart reflects that Amys knowledge on stomas and management is better than her practical management skills. Kate requires further practice with both theory and practice. Janet has shown consistency with theory and practice, scoring well in both.It is hoped that Kate, as the least experienced nurse will improve in time as her knowledge and skills increase as reflected by Benner (2001).Reflection the learning needs assessment.Learning needs assessment is a specific form of educational research (Williams, 1998) and conducting a learning needs assessment requires careful planning. It forms a vital element of teaching within continui ng professional development (McKimm, 2009). It is important to address a need rather than a preference for learning that benefits the organisation and enhances the practice of health professionals. Grant (2002) reported only limited evidence of educational effectiveness as a result of needs assessment alone, therefore it should be used in context within a wider learning plan which must be relevant to practice.Learning needs assessments focus on identified need and often fails to address needs not looked for, therefore it requires flexibility (Hicks and Taylor, 2002 as cited in Dyson et al, 2009).It re-enforces that the needs of individuals are different.No single needs assessment is effective. Using a variety of assessment methods provides a comprehensive picture of an individuals performance (Hesketh and Laidlaw, 2002).SWOT analysis is an auditing tool developed by a research team from the Stanford Research Institute in the 1960s, led by Albert Humphrey. It is built on the use of f our dimensions Strengths, Weaknesses, Opportunities and Threats which enables pro-active thought.Strengths and weaknesses are internal factors Opportunities and threats are external. Strengths* LNA produced information required to address a gap in knowledge and practice.* Observation of small sample identified individualised needs.Weaknesses* Only small sample used, Is this representative?* Is practice under observation reflecting everyday practice?* Time consuming.* Limiting due to design and response subjectivity.Opportunities* Address the knowledge gap through education.* Identify individuals with skills to act a link nurses.Threats* Response to survey may be poor.* Time and financial barriers to effective education.Needs assessments should be an ongoing process which facilitates learning to ensure practice and knowledge are kept up to date (Hicks and Hennesy as cited in Dyson et al, 2009).It would be useful to carry out the needs assessment on a larger scale, perhaps initially t hroughout wards to notice knowledge and skills of all nurses within the surgical areaReferences1. Ausubel, D. (1978)2. Bandura, A. (1977) Social Learning Theory. 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