Introduction
In this reflective critical analysis (RCA), I would like to explore my Collaborative Success Plan (CSP) in detail. My nursing instructor and I were responsible for the development of the CSP. This kind of work is important for me because it helps to identify the areas of difficulty and addresses the problems to move forward in the clinical setting. As stated in the Collaborative BScN Program Practicum Handbook (2016), the CSP clarifies students’ responsibilities and directs the required learning effort. In this work, I would like to analyze the areas which the instructor defined as my difficulties. The problematic areas are as follows: the importance to demonstrate consistent and independent integration of knowledge, a thorough data collection and critical thinking from week to week independently, an independent and timely completion of MSAs, the necessity to present independent and accurate documentation of findings, safe and competent care provision of two patients, a clear administration of medications, a consistent demonstration of good judgment and insight into practice and scope, and the improvement of adherence to patient confidentiality.
Description of Experience
This experience is meaningful because it allows identifying my personal and professional gaps, as well as the changes which may prevent the occurrence of negative incidents. I would like to look at the experience in detail to move forward in my nursing judgments, knowledge, and skills. Therefore, I will state the incident, analyze the importance of each case, and discuss my future approach and reflection. Throughout the paper, I will clarify how I make a good judgment and insight into practice and scope and how I integrate knowledge through data collection and critical thinking independently. I will also discuss the importance of consistent and independent integration of knowledge that is based on data collection and critical thinking from week to week independently. The process of how to demonstrate good judgment and insight into practice and scope for each topic will be described. The development of this plan for success provides me with an opportunity to comprehend that I must play an active role in my practice and demonstrate my understanding of the strategies and the readiness to take any possible steps to achieve professional and personal goals.
Analysis of Experience
Independent and Timely Completion of MSAs
The first incident occurred during Week 9. I was unable to complete my Mental Status Assessment (MSA) in a timely manner with two patients and document the results independently and accurately. A patient with hospital privileges left the unit without doing the MSA.
In this part of the work, it is necessary to discuss the importance of independent and timely completion of MSAs. On the chosen mental health unit, there are the patients with suicidal or self-harm thoughts or with the intentions to harm other people. Voluntary patients may have hospital privileges which allow them leaving the floor unsupervised. It is crucial for me to be aware of such privileges to manage my time wisely and complete my MSA. By completing an MSA, I was able to gather enough data to make the judgment and clarify if the patient should go out or not. During the assessment, I had to ask my patients if they had any suicidal ideation, self-harm thoughts, or the intentions to harm someone else. If the patient said “no”, it was clear that it was safe for the patient to use the privileges. If the patients said “yes”, it could happen that the introduction of such privileges could harm them or others.
I understand that it is very important to complete the MSA on time because it could greatly impact patients, their safety, and the safety of other people around. After reflecting on this approach, I come to the conclusion that I have to make changes in my time management with two patients and administer medication at the same time. Since it was the first week of work with two patients, I was not able to manage my time properly. I was better prepared for the work during the weeks from 10 to 12. I made a worksheet with the identification of the time and scheduled to see both patients compete their MSA. I also checked the patients concerning their privileges to leave the unit or not.
There was also another benefit to complete the MSA early. On Week 10, I had the patient discharged early in the morning around 10:30. It was good that I used my judgment and completed the MSA because my colleague did not complete the patient’s assessment, and my assessments were crucial for the patient and the medical staff. I indicated that the patient did not have any suicidal ideations, self-harm intentions, and desire to harm others.
Doing the MSA before discharge is highly important too. Patients have the ability to go home and make their own decisions. Nurses, doctors, and other medical workers should make sure that these patients leave the unit without any suicidal thoughts or the intentions to do harm to themselves self or other people around. The MSA is an important kind of work that has to be performed in regards to every patient. However, it is necessary to remember that it is only a part of the comprehensive diagnostic assessment, and much additional work has to be done to make final conclusions and achieve the required results (Townsend, 2014). Besides, it is important for a nurse to use different types of assessments and rely on nursing frameworks and standards to describe patients’ situations and apply knowledge for better performance (College of Nurses of Ontario, 2009).
Independent and Accurate Documentation of Findings
Documentation is another important aspect in this kind of work. On Week 9, it was identified that I needed to specify what the patient said. That activity was important because it allowed other readers use my documentation and rely on the already gathered information to save time and underline the most crucial points in patient’s history. Documentation may be introduced in different forms: electronic, audio, or visual (College of Nurses of Ontario, 2017b). This component of nursing practice is integral because it helps to monitor patient’s progress and support communication with other involved health care providers and medical workers. Besides, it reflects the portion of care already provided (College of Nurses of Ontario, 2017b). It cannot be neglected because of its main impact that is the contribution to the development of high quality and timely delivery of care and therapies (Perry, Potter, & Ostendorf, 2015).
During my practice, I had to face with a number of different tasks. The result of such necessities was my inability to keep all documents filled properly. Therefore, it happened that I was not able to complete the FAIR note in time. I had to address my co-assigned and asked to check if I was correct. Unfortunately, my inability to deliver the required portion of information led to the necessity to repeat several screens. That one mistake (or even a shortage) provided me with an important lesson: each step and activity made in relation to the patient have to be documented. It is impossible that someone could read my mind or guess the steps I choose. Therefore, I have to share my experience and help other medical workers and doctors to assist our patients. If I make a mistake or neglect one simple step in care delivery, I may harm the patient. I cannot afford the same thing happen to me again. Therefore, nursing documentation is crucial to prove my commitment to practice, identify the goals of my work, and promote the development of effective relationships between medical workers and patients (College of Nurses of Ontario, 2017b). In future, I want to remember my mistakes with documentation and plan my working time properly to provide all information in a clear way.
Safe and Competent Care Provision of Two Patients Independently
During Week 10, I was assigned to two patients, both having hospital privileges. My task was to reflect on what happened during Week 9 and complete their MSAs prior to them leaving the unit. I completed the assessments with both patients. The results showed that they defined the idea of having suicidal thoughts and did not want to harm to themselves or others. Such assessment and communication with patients promoted the insurance that patients were safe for themselves and for the public. By doing this, I completed my MSA findings accurately and performed safe and competent care provision of 2 patients independently. Another example happened on Week 12 when I had two patients: one was with hospital privileges, and another was on a form. I chose to do the MSA on the patient with hospital privileges as that patient could leave the unit soon, and it was important for me to know if the patient’s departure was safe.
In both cases, I had to stay competent and remember about my responsibilities and accountability. As a professional nurse, I had to demonstrate my professional presence and the possibility to communicate with patients to gather enough information and communicate with medical workers to make sure that the required portion of information was introduced in the unit (College of Nurses of Ontario, 2014). In case I neglected the necessity to ask questions or clarify the situation, I could put the patient or other people around under threat. Nursing practice is the necessity to integrate cognitive and technical skills, values, and even intuition to make sure that acquisition of knowledge is sufficient (Oermann & Gaberson, 2014). It is not enough for a nurse to be aware of the rules and standards. It is necessary to observe the situation and make the decisions to protect patients, assist medical workers and health care providers, and investigate different aspects of nursing practices for any possible improvement.
Consistent Demonstration of Good Judgment and Insight into Practice and Scope
I had to attend ECT and observe five patients on Wednesday. It was the morning of March 8, just the beginning of the shift. This case contains the description of an observational experience only. There are two incidences I would like to reflect on.
First, in my RCA#2, using the permission of the physician, I asked the patients if they noticed a change in their moods. I did not indicate the role of the physician in this process. However, I was able to compare the results achieved by myself with the results observed during the conversation that occurred later between the patients and the physician. The interactions differed considerably. I did not clarify that point in my RCA #2, but I would like to do it now.
Second, in my past work, I also mentioned that “for the future, if allowed, instead of watching on the sideline, I would like to participate in giving oxygen to the patient during the ECT or place the pads on the patient’s chest prior to the ECT.” When I wrote “for the future”, I referred to it as if I were a graduate student, but not a student nurse. My instructor explained to me that that part of the RCA was to reflect on myself as a student nurse. It was the main mistake in that part of the work. I misunderstood the goals and made a mistake while writing the RCA.
After discussing my RCA with my instructor, I realized that I was in need of new details with the help of which it was possible to indicate that the physician was with me the entire time. Moreover, it was a portion of an observational experience only. Asking those questions was out of my scope of practice. If I have to repeat the same experience again as a nursing student, I will make sure not to ask such questions, but focus on observing patient-physician communication. After reflecting on that case, I felt like I was unable to articulate what I wanted to say. I want to use the assistance of a writing service representative and ask someone to proofread my paper so that this person could look through the paper and articulated the way it could be improved, and different misinterpretations could be avoided.
Safe Administration of Medications
On Week 9, there was an incident that helped me to comprehend what kind of work should be done to promote a safe administration of medications. I completed my first check successful. I went to pour my drugs during the second check. In fact, I was reminded to do the second check before I made a decision to pour the medication. Anyway, the medication was for a female patient of childbearing age. She received a medication with the risk for some teratogenic effects. I did not ask the patient if there was the possibility of pregnancy prior to administration. Still, the instructor asked the patient about different possibilities during a post-administration period.
Therefore, it was a mistake of mine that I was not unable to ask the required questions and clarify the situation. Since Week 10, I reviewed the CNO standards according to which any nurse has to follow three main principles which are authority, competence, and safety (College of Nurses of Ontario, 2015). I learned that a nurse has to ask several questions before giving medications to patients. As a rule, patients do not know what they have to take but rely on the experience of their physicians and nurses. Therefore, nurses have to check all procedures thoroughly. Besides, Lehne et al. (2015) indicated the standards and questions with the help of which the choice of medication can be safe and appropriate. I safely provide medications with the articulation of all elements of the process independently each time. To ensure safety before administering the medication, it is necessary to go through the eight rights and pose a number of questions.
There is a “right patient”. As a nurse, I have to be sure that a patient is a correct person before administering the medication. This is how I avoid any complications and the possibility to give the medication to a wrong patient. It is necessary to check the name on order, observe the patient’s wrist badge, and also ask to identify himself/herself by a full name.
The next is a “right medication”. To ensure the administration of the right medication, I checked both, medication label and the order for the drug.
There is also a “right dose”. To confirm I was giving the right dose, I checked the order. It is necessary to use a current drug reference and confirm the appropriateness of the dose using a therapeutic range.
It is necessary to consider a “right route”. A nurse should give the medication by the right route. I checked the order to see if the route is specified and confirmed, if the route is appropriate for the medication, and if the patient is able to take the medication by the ordered route. My patient’s route was by PO, meaning by mouth.
A nurse should follow a “right frequency”. According to this standard, I checked the frequency of the ordered medication and compared the results with the standards mentioned in the hospital frameworks.
There is also a “right time”. It is necessary for a nurse to give medications at the right time. I had patients who had meds due for 7:30AM, 9AM & 12:00AM. It was important to know when to give these medications and never miss the deadline. The physician may want the patient to take the medications before eating, during eating, or after eating. A nurse has to clarify this point.
Then, there is a point known as a “right reason”. It is used to find out the rationale for each step taken and medication offered. I had to clarify the rationale for the ordered medication before administering it not to make a mistake and be responsible for the outcomes.
Finally, there is a “right documentation”. Nurses have to document after giving the medication. As a rule, I signed my initials to show that I gave the medication, to indicate the time, and to describe the changes if any.
After the CSP, I made sure to follow a number of steps to prove a successful administration of each medication.
The first step includes checking. I checked if it was the correct patient, if a nurse verified the MAR, if the patients had allergies. Besides, I had to sign at the front and follow the date it was printed to make sure I used the most updated MAR. I checked the MAR on the med card. The next step was to consider the above-mentioned rights and check if all of them were followed. The third step was similar to the previous step with the only difference that included the time of checks. Each patient had to be observed several times to indicate if any changed could influence their health conditions. The fourth step included taking the medications. That step was followed by the third check regarding all eight rights. The next obligation was the necessity to write down the patient ID number, get a cup of water, and approach my patient. It was necessary to ask their full name and check their badge to check the match of their ID number. The final step of a working process was to come back to the MAR and sign off the papers that proved that I gave certain medications to a certain patient.
The pre-administration assessment, dosage and administration, evaluation and promotion of the therapeutic effects, minimization of adverse effects and interactions, PRN decision-making process, and management of toxicity are the most crucial components that have to be addressed before medications are administrated directly to a patient. Since the CSP feedback, I made sure to consider all those factors before administering medications to my patients. The med-select dispensing system was used for medication administration. Then, it was necessary to review the medication administration. During medication administration, I was able to articulate eight rights. However, I did not have a chance to require any reminders from my instructor about the checks. Therefore, all steps should be taken independently. As soon as first two checks were completed, the third check should occur to prove the necessity to pour the drug.
After Week 9, I administered antipsychotic drugs and realized that those medications could be harmful to a fetus (in case a patient was pregnant). Therefore, I had to check if the patients were not pregnant prior to medication administration. I had three patients: a 66-year-old female who was not pregnant, a male who could not be pregnant, and another female. The third patient had to pass the lab value to prove that she was not pregnant. Besides, during her MSA, she was asked if there was a chance of being pregnant. She denied the possibility. If the patient was pregnant, I would have let my instructor know prior to administering the medication. On Week 12, I asked one of my patients if she was pregnant since she was on an anti-psychotic medication. Another patient took an anti-psychotic medication, and I checked her lab results to see if she was pregnant. The results were “negative.” I also asked my patient if she was pregnant before she took the medication. Such activities promoted a safe administration of medications that had to occur under the supervision of a clinical instructor or with the help of the med-select dispensing system. In general, I provided safe and competent care for two patients independently with medication administration.
The representatives of College of Nurses of Ontario (2015) identify several crucial factors that could improve medication practices and promote public protection. One of them is authority. Regarding this factor, I gave the medications which were ordered to the patients by a professional physician. I accepted the order because it was clear, complete, and appropriate for the patient. Now, I know that if the order is unclear or incomplete, I should not administer the medication. As a student nurse, I will notify a co-assigned nurse or as a graduated nurse or clarify the medication and the order with the doctor. Another important principle is competence (College of Nurses of Ontario, 2015). I believe that I had a good portion of knowledge, several important skills, and judgment to perform medication practice safely.
I completed three successful checks and followed eight rights before administering for drug. I understood the reason for the taking each medication. Looking at my PPR, it was possible to see the reason why each patient had to take a certain medication. Finally, safety has to be taken into consideration (College of Nurses of Ontario, 2015). As a student nurse, I need to offer safe care. I have to educate patients and inform them about their medications. For example, my patient was extremely anxious after a phone conversation with her lawyer. When I went to obverse my patient, her anxiety was a serious sign. I asked her to rate her anxiety level. She rated it very high 9/10. I told her she could not have PRN medication. Still, Lorazepam which was ordered by the physician was that she could take. She was educated that such medication could help her reduce the level of anxiety. She agreed to take it, and a co-assigned nurse was informed about the change. The co-assigned nurse agreed and administered the Lorazepam in the medical card.
For the future, I realize that medications are a crucial part of any treatment regime, and any nurse has to know how to administer medications in a safe and proper way (Koutoukidis, Stainton, & Hughson, 2016). At the same time, the administration process is not the only task that should matter. A nurse has to improve knowledge on medications and know when to use different options or how to make a right choice in regards to the alternatives offered.
Adherence to Patient Confidentiality
The incident that occurred Week 9, on Tuesday, had to be used as the example to rely on. I had to shred my patient reports which I printed off with the help of Meditech. As a student nurse, it is very important to adhere to patient confidentiality. Therefore, the main lesson that had to be taken was connected with the necessity to reflect upon the importance of patient confidentiality and the situations when the importance of shredding patient reports was forgotten.
Patient’s documents are confidential (College of Nurses of Ontario, 2017a). If a nurse forgets to shred patient’s information, it can be revealed and compromised. Other people may have access to this information. Therefore, my task was to do everything possible to safeguard it. If I took it out and lost the report by accident, it could breach patient’s confidentiality. As a student nurse, I have to take steps to safeguard all data and protect patients’ personal health information. According to the Personal Health Information Protection Act (2016), “personal health information must be disposed of in a secure manner, such that the records cannot be reconstructed… paper records should be crosscut shredded and electronic files or hardware must be deleted or destroyed” (p. 20). I understand the importance of shredding patient’s personal information and continue to check its location before leaving the unit. I followed my CSP to demonstrate competence and adherence to patient confidentiality.
On Week 9, on Tuesday, I forgot to shred my patient’s documentation, and my instructor reminded me. Before that case, I followed all instructions and checked the safety of each piece of patient’s information. On Tuesday, I had a challenging day. As I moved forward from Week 10, I shredded all the worksheets and patient documents prior to leaving the unit and followed my CSP. I used the worksheet and prepared myself to check off all patient reports. Now, it is the way of how my continuous behavior looks like: shredding papers in the unit before leaving.
As I reviewed the Personal Health Information Protection Act, I also reviewed the Collaborative BScN Program Practicum Handbook (2016) and studied the principles of Safety and Confidentiality thoroughly. To make sure the patient is safe, my activities must provide safe physical and psychosocial environment. Physically, I provided safe care by doing assessments and notifying my co-assigned nurse and also providing interventions. To provide the safe care, I would look at the policies and procedures of the hospital, the CNO standards, and the professional standards. These helpful tools are used to provide nurses with an overall framework for the practice of nursing and link other standards, guidelines and competencies together which were developed by CNO.
To promote safety in the psychosocial environment, I maintained confidentiality by shredding the personal patient information papers so that my patients did not face racism, sexism, discrimination, harassment and other non-caring behavior from myself, the medical staff, or other patients on the floor. I also had to check if all information remained to be protected. Since my CSP and reflection on the incident, I remembered to shred the paper, ensure confidentiality, and protect my patient’s personal information. I followed the overriding principles of confidentiality and never discuss my patients and their problems in public. I never provided the police or media with the information about my patient. I know that if I do these things, I may be reviewed and dismissed from the program. I have access to private health information, and I need to respect and protect my patients from their information being leaked out. I should never share my password for Meditech. Also, I do not access any unauthorized information about myself, family, friends, colleagues or any other health care workers or patients.
Personal Areas for Development
The experience I was lucky to get during the last weeks helped to evaluate the role of nurses in the unit and the importance of knowledge in any kind of work. To complete the tasks given, I had to rely on the sources offered by College of Nurses of Ontario (2009; 2015; 2017) and learn the standards offered by the Personal Health Information Protection Act (2016). The impact of this practice remains to be considerable because my work helped me to comprehend that it was not enough to know some main principles and rules. A nurse had to be ready to cooperate with patients and physicians, to consider the suggestions offered by other medical workers, and to listen to the information ordinary people tried to share with.
At the same time, it was important not to fail in protecting patients’ privacy but give the required portion of information in case of emergency. Therefore, each step taken and every decision made was a significant contribution to further development and improvement. I learned that even if a nurse thinks that they know a lot on the topic, there is always the situation when additional knowledge is required, and new facts are preferable. Therefore, in order to be successful, a nurse should read and improve personal and professional skills. Such attitude to nursing practice may help to encourage other nurses and become a supportive colleague for other people.
Several months ago, I was confident in every step taken. Nowadays, I realize that nursing is a profession where self-insurance is not the key. I feel that nurses should have many responsibilities. I believe that it is necessary to use every second in order to learn more information and share a personal experience with other people. However, it is also crucial for a nurse to think about time and manage it properly. It is so easy to lose one minute or to forget to close the file and put a patient under threat.
Nurses have many responsibilities, and I was able to gain several crucial insights for the future. First, any nurse should be ready to plan the steps and manage time in order not to miss deadlines and do everything properly. Second, the relations between a nurse and a patient are specific. Though a nurse should follow the conditions and changes and report on them in a short period of time, it is necessary to remember about the information that has to stay private. Finally, nurses have to communicate with physicians and other nurses and never be afraid to ask questions. Sometimes, it is not an easy task to be a nurse. Still, students have all chances to be properly educated.
Taking into consideration these insights and the already gained experience, I would like to clarify several points. First, a nurse promotes safety and order in the unit. Therefore, it is better to stop and think if there is anything missing instead of making fast and sometimes wrong decisions. Second, a nurse is responsible for any kind of information on a patient. On the one hand, the information should be offered to the medical staff in order to develop a treatment. On the other hand, the information has to be closed to a number of people. A nurse has to feel the line and never cross it.
Conclusion
In general, this critical analysis and reflection help to understand that nursing is the profession with a number of aspects. At this moment, I was a student nurse with a number of problematic areas including a poor integration of knowledge, week data collection and critical thinking, late completion of MSAs, the inability to present an effective documentation of findings, the necessity to provide two patients with care and succeed in administrating medications, a poor demonstration of good judgment and insight into practice and scope, and the necessity to keep all patients’ information confidential. The evaluation of the standards, my knowledge, and professional expectations help me to realize that I am ready to learn and change. In the future, it is expected to investigate how to combine learning and nursing practice and how to improve communicative skills which are crucial for nurses.
References
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