Clinical Remit

Clinical RemitTeaching and treat form 1 A tuition inescapably sound judgment1. Clinical Remit.As a control working inside a clinical specialty it is at heart the remit of my job to promote the stomatetete administer service and moderate high standards of care. It is in bid manner the business of the stoma care department to meet the training and disciplineal necessarily of ward found nursing module to secure high quality care which is evidence based and kept updated.Prior to coming into post my teaching experience had been limited to mentorship of students and incourseal ward based seminars. My solely formal teaching experience had been as a student when attending lectures and courses.My teaching remit embroils diligents, relatives, carers, colleagues and students. It provides me with the chance to pass on my clinical skills, friendship and experience to junior provide. This non only conquers them to develop their own intrust but influence the working(a ) unit and their patients.There is allocated placement time to the stoma team for students and we alike teach students who suck up placements within the colorectal and general surgery unit.Teaching is lots done in an informal, ward based purlieu where learners are able to observe and study with patients. Patients are care bountifuly chosen and their consent obtained before the introduction of the learner. These patients are assailable therefore it is important that the patient is comfortable with any change or addition of an other person to teaching sessions. Patients and their stoma nurses develop a special bond and it is important that this family relationship remains strong. It is through this unique relationship that the patient fetchs the skills and familiarity fatalityed to equip them for life with a stoma.The stoma care nurse is a facilitator, he/she empowers patients to optimise quality of life and adjust to their new circumstances.My principle clinical employment is in the teaching and support of patients who are about to receive or have undergone surgery to create a stoma. Fulham (2008) ac acquaintanced that nurses play an important role in helping patients adjust both physically and psychologically to a new stoma. explore (OConnor, 2003 Metcalf, 1999 White, 1998) has shown that early teaching of practical skills and coping strategies help new stoma patients have a more favourable outcome. Early teaching helps prepare them for surgery and allows patients to adapt more peremptoryly to the stoma (Burch, 2005).I have chosen to concentre on one particular aspect of teaching within stoma care, namely the changing of a one piece stoma pouch. The reason for my choice is that this is a fundamental part of the stoma care mould. It is the focus of many patients anxieties and is key to many patients feeling of well beingness it is one area where they feel they still have some control. Bekkers et al (1996) saw self-efficiency as crucial to adjus ting to a stoma and as a result saw fewer psychological problems post- operatively. Commonly, the assumption is that teaching stoma management is someone elses responsibility (Turnbull, 2002).The principles of a pouch change are simple to follow to achieve success, yet it is generally carried out poorly at ward level. This could be referable to a number of reasons. Pouch changing is a practical skill not widely coiffured at university it is often passed on through existential fellowship and reflective example while on placement. This indicates that the current university curriculum 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. some(prenominal) nurses approach changing a stoma pouch merely as a task to be carried out rather than an integral part of individualised patient centred care (Mitchell, 1995) or a teaching opportunity. Lacking experience or confidence 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 plenty to support patients adapting to shifted body image. Stoma care is not an integral part of all healthcare areas therefore many nurses lack the opportunity to practice learned skills which then 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 headway I have chosen to carry out a encyclopaedism needs judging on a small group of nurses who work within the surgical directorate who regularly care for patients who have a stoma. The group consists of 3 nurses 2 trained staff and 1 untrained. The rationale being 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 improvements can be make that is patient centred, individualised and of the highest standard.Learning TheoriesConducting a learning needs mind is critical to the educational process. This can lead to change in practice and forms the cornerstone of continuing professional development ( relent Stanton, cited in Grant, 2002). Evidence based practice has become the focus of NHS policy over recent years with emphasis on cost effectiveness. This ensures patients receive the just about efficient care based on evidence from the most up to date research (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 knowledge and skills to be able to support these patients. It is also important that patients receive the best possible care and advice no matter who is natural endowment it.Prashnig (2006) discussed the responses of teachers to the varying learning needs of students when the teachers are aware of their teaching styles. I use a combination of styles. My approach is initially pedagogy as particular skills and information 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 indicate and empower the learner towards license through discussion and problem-solving rather than just instruction (Jarvis, 1985 as cited in Smith 1996 1999). This can be illustrated through many of the learning theories employ in education today. Banduras (1977) social learning theory 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 theory of positive reinforcement can be applied to stoma pouch changing. Reinforcement in the f orm of repeated practice helps to form a habitual pattern and the necessary skills to perform the task. The nursing process model of assess, plan, implement 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 four adaptive abilities of concrete experience reflective utterance initiation and application from action to observation through the learning process. Ausubels (1978) assimilation theory enables the student to build on their existing knowledge. I teach in small, soft managed sections. Revising what was learned previously and ensuring it is understood before continuing with the next stage.Rational for carrying out a learning needs discernment.Identifying a learning need is the first step in be after any education programme (Dyson et al, 2009). This ensures that the programme is appropriate for all, regardless of knowledge and experi ence and forms the basis of the objectives and content (DeSilets, 2007). In this case the assessment will be carried out on a small group of healthcare professionals but the principle can be utilize on a big scale.A learning needs assessment forms a baseline it identifies what is already known and what is needed to fill in gaps in knowledge or experience. The need to carry out a learning needs assessment in this clinical area was identified through occasional observation of interactions between ward staff and new stoma patients. The poor uptake of stoma patient education was highlighted by a disappointing lack of documentation within patient records and limited assessment of the stomas function, the local skin condition and the patients independent progress. This has an impact on the patients psychological adjustment and ultimately their propitiation regarding quality of care. Nursing is based on holistic, individualised needs if a fundamental part of a new stoma patients wellb eing is not being addressed it can increase length of hospital stay, delaying independent stoma management prior to discharge with evident associated financial 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 benefit not only the learner (through astir(p) practice) but also benefit the patients and ultimately the organisation.There are barely 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 further work. Teachers may focus on the negative aspects and may not tip over the learner credit for what they do well.Identify an area of learningA review of ward notes and patient wondering identified a poor uptake of patient teaching in st oma 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 little 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 in 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.Staff are encouraged to observe, work and participate in teaching patients along with the Stoma Care 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 subsequently 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 decided that this would form a navigate study group. Like other forms of research a pilot study should be carried out to ensure validity and reliability (Burns and Grove, 2005). The group consisted of 2 qualified and 1 unqualified nurse. This was to attempt to determine the varying strengths and weaknesses of the grades of staff (Hesketh and Laidlaw, 2002).In accordance with the Nursing and Midwifery Council Code Standards of conduct, performance and ethics for n urses and midwives (2008), to maintain client confidentiality, all names have been changed and no reference has been made to vocation.Kate- Qualified for 3 years. Worked initially as a bank nurse but recently joined 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 follower 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 include other aspects of stoma care for which patients often need extra support e.g. skin assessment and simple remedies, measuring a stoma and template cutting.Some common but relatively simple problems such as sore skin can be improved or resolved by incite and corr ect treatment (Burch and Sica, 2008). With this in mind it was decided that the education should contain a practical session to revise 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 forum information. As learning needs are individual based on knowledge, concord, attitudes and self-assessment (McKimm, 2009 Norman et al, 2004 Grant, 2002). It was hoped the results would reveal the individual learning needs of each participant.Vaughan (1992) discussed that a learners expertness can be assessed through direct observation. It identifies the learners performance level and capability.Bee and Bee (2003) also discussed the value 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 observer bias a checkli st or rating scale should be used.Following the fount of Bee and Bee (2003) Observation can be sub dissever into Direct 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 apprize and help patients and staff.Work Samples- Assessing current work practice can be difficult to assess accurately, particularly 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 unavailable to offer advice on potential issues then a vulnerable patient can be put at unaccept able risk of stoma or skin complications. Therefore this method was excluded on moral and honest issues.Simulation- Allows the observation of the learners when dealing with different situations e.g. the availability of a simulator mannequin for practice. Interchangeable 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 further 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 charts. 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 o ut 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 care. 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 (Mailloux, 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/Structured 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 specified rating scale.Grant (2002) warns that reliance on formal needs assessments when planning education can restrict the learning process instead of encouraging it.To ensure learning needs are suitably measured a questionnaire using a combination of question types was used (Appendix 1). Time was assigned for simulated practice using the mannequin and direct supervision of 10 pouch 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 ad dress 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 caring for patients with a new stoma.One week after a second 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 cut ting and treating minor complications using stoma care accessories. Questions were encouraged and following the simulation the group reflected on what they had learned. cod to close plug ins 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 exercise Reflective observation.Identifying topics for cellular inclusion in the education Abstract conceptualisation.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 developed 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). psychoanalysis of the Results of the Learning Needs AssessmentTo analyse the questionnaire and ward observation each participants results are examined in turn and a personalised 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 assessment and treatment (6/6=40%)4. readying 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 suppositional 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 drain 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 single wrong answer reflects only that there is still room to learn. Experience is important but as technology and approaches change it is important to keep up with current trends and 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 like 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 hands-on 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 compares 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 l earner and makes comparisons among the group. The chart reflects that Amys knowledge on stomas and management is crack 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 continuing 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, t herefore 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 four 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 throughout wards to ascertain knowledge and skills of all nurses within the surgical areaReferences1. Ausubel, D. (1978)2. Bandura, A. (1977) Social Learning Theory. 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