During your cancer/palliative care placement, you may have learned, developed and demonstrated many of the clinical skills which meet the NMC standards of competence for pre-registration education (NMC 2010). The following activities highlight some of these core skills and encourage you to reflect upon your current practice abilities. The activities focus on patients with other medical conditions/heath problems to help you transfer your knowledge and skills into other clinical situations and fields of practice.

Each of you will respond to each activity in your own way and at a different level, depending on the stage of your course and your individual abilities, development and progress. You should discuss these activities with your mentor or personal tutor, using your practice document to help you identify your achievements, demonstrate your competency and highlight any learning needs and opportunities. Your mentor may find these exercises helpful to guide you and support your learning.

Activity

Essential skills clusters

What do you consider are the important issues when caring for a patient with a cancer diagnosis. Make a list of the core nursing skills needed to care for a patient with cancer and identify which part of the cancer pathway each skill might relate to.

Now consider which of the skills in your list might be important for care of a patient without a cancer diagnosis. What are the differences in your lists?

Refer to the NMC essential skills clusters (ESCs) (NMC 2010) in Box 25.1. Consider the ESCs you may have achieved while on your cancer/palliative care placement. How might you adapt these skills in other healthcare settings and with patients who do not have a cancer diagnosis? There may not be many differences.

NMC Domain 1: 1.1; 1.8

NMC Domain 4: 4.3; 4.4; 4.5

Box 25.2 Documentation checklist

Review your practice documentation to reflect on all of the clinical skills you have achieved and those that still need to be assessed. Discuss these with your mentor to develop an action plan, ensuring that you are prepared for your next placement. If this is your final placement, your sign off mentor will be reviewing your achievements and assessing your overall performance.

The following activities explore some of the fundamental aspects that you need to consider when caring for patients to ensure you are providing up-to-date, relevant and comprehensive patient-centred care, while safeguarding vulnerable individuals.

Whatever stage you are at in your nursing education and irrespective of the healthcare setting, you are accountable for your actions and omissions and must work within the professional boundaries set out by the NMC (2008). As an accountable practitioner, you are accountable to the professional governing body (the NMC), your employer, the law and yourself. Think about how your responses to the questions above link to the key aspects or pillars of accountability which include:

Accountability

You are preparing to discharge a widowed man you have looked after for 2 weeks on a surgical gastrointestinal ward. He has had a colostomy performed for benign bowel disease. The colostomy may be reversed in the future, but this decision will not be made by the medical team for several months. You might wish to consider reading a surgical book explaining the nature of the surgery he has had and the possible outcomes (such as Chapter 17 in Pudner 2010).

You are having a conversation with him about his discharge and he raises a few issues. Consider how you might respond to each of his questions and how your responses relate to your professional practice:

He asks you to explain his new flange and colostomy bag the stoma nurse has provided. This is a system you are not familiar with.

He asks that you leave out some of the information about his admission on the discharge letter since he does not want his daughter to know about his disease.

He asks that the community nurse who was looking after him before admission is not asked to go back to him since they did not see ‘eye to eye’.

He asks you to reassure him that he will soon be back to ‘normal’.

He is worried about being lonely when he gets home and asks if you will visit him.

NMC Domain 1: 1.1; 1.7; 1.8

NMC Domain 2: 2.5; 2.8

NMC Domain 3: 3.8

NMC Domain 4: 4.4

Refresh your understanding of the underpinning background of accountable practice by reading Chapter 1 in Caulfield (2005). You should refer back to Chapter 5 to revisit the ethical principles. Develop your responses further using this additional reading to help you justify your decisions.

Box 25.3 Professional practice checklist

Identify key healthcare professionals (within the healthcare setting and university) who you can discuss issues of your own accountable practice with.

Ensure that you have read up on and are aware of the current evidence regarding the nature of patient(s) conditions and care needs for those patients you are responsible for (alongside your mentor).

Reread the NMC code of conduct and refresh your understanding of your own personal and professional boundaries

You should discuss duty of care with your mentor and how this can be compromised and maintained.

If you have the opportunity, you may wish to visit a local coroners’s court. Think about the role of the nurse in a particular case.

Ask your mentor how and what they are accountable for, with respect to their accountability to their employer.

Activity

Assessment

You are working on a surgical ward and preparing to assess the care needs of a man being admitted for planned (elective) surgery. While this might be your first experience of a surgical environment, you may have transferrable skills from your cancer placement. You have already picked up knowledge and skills about caring for a person with a cancer diagnosis and you can apply these experiences to the assessment process in this new environment.

Choose one of the nursing assessment tools you have been introduced to in your current placement or from this book (for example, the activities of living section on page 131, family assessment in Appendix two or pain assessment on page 137). Spend some time considering how the tool you have chosen might be used for a patient who has been admitted to an acute surgical environment for routine surgery and make some notes under each part of the assessment. To guide you with this activity, you might choose to look at some of the examples of surgical interventions given in the surgical placement pocket book in this series.

NMC Domain 3: 3.1; 3.3

NMC Domain 4: 4.1

Box 25.4 Principles of assessment checklist

1. Aims to gather information

2. Allows an opportunity to give information to the patient and family

3. Assists the patient to tell their own story

4. Ascertains patient understanding of what is planned for their care

5. Affirms patients’ holistic identity and needs

Now refer back to your completed assessment tool for the surgical patient and check that you have covered these five principles.

For further information on the principles of assessment, refer to Chapter 1 in Holland et al (2008) which consolidates the principles of assessment as it is applies to the activities of living model.

Communication is a core skill that is central to effective high-quality health care. As well as communicating with patients and their carers, it is essential that we communicate with other healthcare professionals to ensure information is shared appropriately and in a timely fashion. It is important that we think about who we are communicating with; what the purpose of the communication is; what the person needs to know; what the best method of communication is; and when the best time to communicate is.

As well as preserving confidentiality in terms of professional accountability, patients have the legal right to confidentiality under the Data Protection Act 1998, the Human Rights Act 1998 and the common law duty of confidence (Freedom of Information Act 2000). They have the right to ask for a copy of their health records and any other personal information that healthcare organisations hold about them. Find out what the process is in your healthcare organisation in order for patients to access their medical records.

Activity

Communication

You are a final year student and preparing to hand over a critically ill woman to the nurses arriving on the next shift. The patient has been diagnosed with sepsis (see page 99) and is deteriorating. You have been caring for this patient for the past 4 days and have got to know her family quite well. Her husband has dementia.

Make notes on the important elements of what you need to communicate at this handover to the next shift under the following headings:

Evaluation of current condition.

Ongoing medical interventions.

Role of multiprofessional team members.

Evaluation of care delivered during the last shift.

Ongoing observations and nursing care requirements (don’t forget to consider her care needs from a holistic perspective. Refresh your memory on page 45).

Relatives’ understanding of the situation (go to page 32 to refresh your memory on supporting patients and relatives who may be given bad news).

You can refer back to page 99 where you were introduced to the principles of caring for a patient with sepsis. Use this as a checklist to review how you have planned your communication.

Read Jootun and McGhee G (2011) (see References) for guidance on communicating with a person who has a diagnosis of dementia. This will help to focus on the needs of the husband.

At every handover, there is the potential that vital information may not be communicated correctly and this can have a detrimental impact on the experiences and outcomes for the patient, relatives and care team. Therefore, you need to structure the way you communicate and be systematic in your approach to providing this information.

NMC Domain 1: 1.4; 1.5; 1.6

NMC Domain 2: 2.1; 2.2; 2.7; 2.8

NMC Domain 4: 4.3; 4.6

Activity

Confidentiality

A man has been admitted to your ward without any family members with him. You have been asked to admit him and have completed a full assessment of his medical history, current health problems, care requirements and personal details using the hospital’s admission documentation.

Consider your professional responsibility regarding the issue of confidentiality in the following situations:

The doctor asks you what medications the patient is taking.

You receive a phone call from a relative who wants to know how the patient is.

The ward waitress recognises the patient as a neighbour and asks you what is wrong with him.

The patient records office phones and ask you to confirm the patient’s address.

Make some notes on how you would respond to each situation. What are the reasons for your answers? What are these based upon?

Almost all healthcare situations place patients in a vulnerable position and healthcare professionals have access to extremely personal and intimate patient information. As healthcare professionals, we have a legal and professional responsibility to safeguard verbal and written information. In addition, confidentiality is crucial to develop trusting relationships with patients.

NMC Domain 1: 1.1; 1.5; 1.6

NMC Domain 2: 2.1; 2.8

Now go back to your answers for the previous activity – Is there anything you would like to change? How might you act in future situations?

Think about possible or actual situations you may have encountered where information may have, or has, been disclosed. Remember, disclosure of information is only lawful and ethical if the individual has given consent to the information being passed on. Such consent must be freely and fully given. Revisit Chapter 8 which discusses consent.

To assist you to complete the confidentiality activity, it is invaluable to visit the NMC Website and reread the code of conduct (NMC 2008):

http://www.nmc-uk.org/Nurses-and-midwives/The-code/The-code-in-full/ (accessed May 2011).

Also, read the NMC advice on confidentiality (NMC 2009):

http://www.nmc-uk.org/Nurses-and-midwives/Advice-by-topic/A/Advice/Confidentiality/ (accessed May 2011).

In addition to these general guides, the NMC provides specific guidance for student nurses (NMC 2011) which will also aid your development:

http://www.nmc-uk.org/Documents/Guidance/Guidance-on-professional-conduct-for-nursing-and-midwifery-students.pdf (accessed May 2011).

Think about how this guidance helps student nurses make decisions regarding confidentiality. See Box 25.5 for some examples from the guidance that might help you complete this exercise.

Box 25.5 Examples from the NMC (2011) guidance on professional conduct for nursing and midwifery students

As a student nurse you should:

– respect a person’s right to confidentiality

– not disclose information to anyone who is not entitled to it

– seek advice from your mentor or tutor before disclosing information if you be-lieve someone may be at risk of harm

– follow the guidelines or policy on confidentiality as set out by your university and clinical placement provider

– be aware of and follow the NMC guidelines on confidentiality

Look up the Mental Capacity Act (2005) to explore possible situations where consent cannot be given:

http://www.legislation.gov.uk/ukpga/2005/9/contents (accessed May 2011).

Find out what should happen in situations where capacity is compromised in the healthcare setting.

Activity

Decision making

A 15-year-old teenager with cystic fibrosis is admitted from his school to the medical assessment unit following an exacerbation of his respiratory condition. He is accompanied by his parents, who are keen for him to be transferred immediately to the respiratory ward for observation and treatment as an inpatient. However, he requests that he is treated quickly and allowed to go home and be seen by his cystic fibrosis specialist nurse as an outpatient.

In this exercise, you are encouraged to think about the ethical, legal and professional issues when considering his request. Make notes under each of the three headings to help you to explore the decision making:

1. Ethical: consider how you will balance doing good and doing no harm for all involved. To refresh your memory on ethical reasoning, turn to page 48.

2. Legal: what does the law say about a 15-year-old making a decision? What does the law say about the rights of parents of teenage children? More information is available at the NHS choices Website: http://www.nhs.uk/chq/Pages/900.aspx?CategoryID=62&SubCategoryID=66 (accessed May 2011).

3. Professional: what is your responsibility on decision making? Look at the NMC Website about professional responsibility in decision making: http://www.nmc-uk.org/Nurses-and-midwives/The-code/The-code-in-full/ (accessed May 2011).

NMC Domain 1: 1.1; 1.2; 1.3

NMC Domain 2: 2.1; 2.2; 2.3; 2.5

NMC Domain 3: 3.1; 3.8; 3.; 3.10

Now you have explored each perspective, consider who might be involved in this decision and what your role might be in the decision-making process. Go back to Chapter 7 and make a list of all the professionals you think will be important in this decision-making process. Make a list of additional team members who you may need to add to the list.

Help with decision making for children in transition can be found at the Association of Children’s Palliative Care (Together for short lives) available at:http://www.act.org.uk/ (accessed May 2011).

Teenagers are often cared for in adult clinical areas and, if assessed as competent, can take an active part in the decision-making process regarding their own care.

Using the information you have gathered, now consider how you will evaluate the care given in addition to this patient’s current condition. To do this, go to page 153, where you were introduced to the EEMMA assessment tool, and make notes under each section. To refresh your memory on anatomy and physiology of the lungs, refer back to your lecture notes or recommended physiology textbooks. Remember, relating anatomy and physiology to the evaluation process is an important aspect of ongoing patient care.

Reflect on how using a structured assessment tool can help you to evaluate the care given. Make some notes about this activity and be prepared to discuss the links of assessing a patient and ongoing evaluation with your mentor.

Activity

Evaluating care

You are looking after a woman admitted with chronic bronchitis who is experiencing an acute exacerbation of her condition. A chest infection is suspected and she is commencing on oxygen therapy and intravenous fluids and is due to start intravenous antibiotics. Towards the end of the shift, you notice she is becoming increasingly drowsy and has a reduced urine output. Using your assessment skills, consider the important factors in evaluating her changing health status. To help you with this exercise, consider:

– the observations you would need to do to assess the effectiveness of the oxygen therapy and intravenous fluids. Include what can be measured (e.g. pulse, respiration rate) as well as direct patient observation (e.g. position in bed/number of pillows)

– the impact of her changing condition on each of the activities of living

– where this information is recorded and how it is communicated to the care team

– members of the care team who will need to know about your ongoing evaluations

NMC Domain 1: 1.5

NMC Domain 2: 2.7

NMC Domain 3: 3.1; 3.2; 3.3

NMC Domain 4: 4.2

As well as ensuring that healthcare professionals are competent to undertake a clinical procedure or intervention, it is essential that the rationale for undertaking the task is considered and that the procedure is based on current, reliable and valid research. Therefore, you need to make sure that procedures you undertake are based on research and are not just a result of ‘this is the way we have always done it’. When you encounter a procedure you are unfamiliar with, you should take time to read up on the background and the current guidance, to ensure you are approaching the procedure based on the most up-to-date evidence.

However, research is not always available or there may be conflicting research results which present clear recommendations for practice. The knowledge and the expert opinion of an experienced healthcare professional may also constitute ‘evidence-based practice’, although this is subjective and often difficult to quantify. Usually a combination of evidence is used to dictate how a procedure is undertaken, based on local and national policy guidelines as well as research.

Activity

Evidence-based practice

You are caring for a patient who has had a stroke. They have lost the ability to swallow and are at risk of aspiration (fluid/food entering the lungs). Therefore, the patient has had a percutaneous endoscopic gastrostomy (PEG) tube cited so they can receive nutrition safely. You may be asked to assist in setting up the patient’s enteral feed. If you are unfamiliar with this device and procedure, your mentor might demonstrate the practical procedure and inform you that this is up to date and is based on research evidence. You would observe the procedure, making a note of the main aspects of care in your notebook.

Access the hospital trust database of clinical procedures and read the enteral feeding procedure guidelines.

Refer back to your essential skills clusters in your clinical skills booklet. Read and familiarise yourself with the enteral feeding skills cluster.

Access the university electronic database to verify any information your mentor has provided by searching for relevant articles and books on the anatomy and physiology of PEG tubes and the care required to manage a patient receiving enteral feeding.

NMC Domain 1 : 1.1; 1.8; 1.9

NMC Domain 3: 3.4

NMC Domain 4: 4.1; 4.2; 4.4; 4.5; 4.6

Review the research evidence you have identified via the university database. How reliable and valid is this research? Does the research support the hospital trust procedure guidelines? Refer back to any lecture notes you have been given or have written yourself during a practical session on the topic. Does this research and theory support the information your mentor provided for you?

Activity

Leadership

Using the same scenario as in the previous activity which focuses on evidence-based practice, think about how you will integrate this newly acquired theory and evidence into your clinical practice and how will you share your knowledge with your mentor, practice colleagues and fellow students. The NMC (2008) stipulates that, as healthcare professionals, we must share our knowledge and experience to improve patient care. This can be done in many ways, both formally and informally.

NMC Domain 1: 1.1; 1.3; 1.4; 1.5; 1.6

NMC Domain 2: 2.1; 2.2; 2.3;

NMC Domain 4: 4.1; 4.3; 4.4; 4.6; 4.7

Make a plan of how you intend to integrate your new knowledge into your clinical practice. This may be done by writing a piece of evidence to add to your portfolio. You could write a reflection, using a reflective model such as the Driscoll (2007) model introduced in Appendix one which allows you to follow a structured reflective process to integrate the evidence base and will help you consolidate your learning. When and where possible, you should include any references to support your discussion.

Discuss your portfolio evidence/reflection with your mentor and highlight any new knowledge and any research which either supports or challenges any procedures you have been shown. You need to take care to do this in a respectful, sensitive, non-threatening manner in order to clarify your mentor’s rationale for undertaking the procedure in the way they have. You need to seek further information to find out why they may have contravened the research you have found. Caution is required as your mentor may be using their expert knowledge and experience to adapt the procedure within a specific context. Listening is a key element of assertiveness; it demonstrates respect for the other person’s opinion. Other non-verbal skills will also be needed so think about how your body language can reduce an aggressive approach to a discussion.

It may be appropriate to write a separate reflective piece to explore how you find such a discussion with your mentor. Think about what skills you used to approach the topic in order to explore your mentor’s opinion and provide feedback on your discovery of this evidence.

Assertiveness is a core attribute that all healthcare professionals need to develop and is essential for effective communication and team working. Remember, feedback is a two-way process – just as your mentor will be providing you with feedback on your progress and achievements, you can feedback new information and theory that may contribute to improved patient care.

It may be a good opportunity to contact your personal tutor to explore the clinical procedure as well as ascertaining how reliable the evidence you have acquired is before you approach your mentor.

Find out if your university offers assertiveness training to help you explore assertiveness and communication skills for handling situations on placement to increase personal effectiveness.

When you have examined the evidence base and had a discussion with your mentor and/or personal tutor, you should take the opportunity to share your new knowledge with your fellow students on placement. This can be done to a greater or lesser extent depending on your confidence and progression through your course.

Activity

Giving significant news

In many clinical environments, this is referred to as ‘significant news’ and may not just be a life-limiting diagnosis for a wide range of reasons. You are observing a doctor informing an elderly woman that she cannot be discharged home. Instead, referral has been made for a social care assessment so she can be transferred to a local care home. This is a decision that has already been discussed with her sons. Consider why this might be ‘bad news’ for this patient and list the things that might distress her. Consider this distress from a holistic perspective and make notes under the following headings:

To do this activity, give some thought to the losses she may already have experienced and to future losses. Now consider how this news might be given sensitively.

Return to the East Midlands Cancer Network guidelines for breaking bad (significant) news introduced on page 32, available at:

http://www.eastmidlandscancernetwork.nhs.uk/_HealthProfessionals-ServiceImprovement-SupportiveandPalliativeCare-BreakingBadNews.aspx (accessed May 2011)

Make notes under each of the 11 headings. This will help you to prepare to give the news to this patient. Here is a reminder of some essential elements of breaking bad (significant) news:

Preparation.

Find out what is already known.

Offer explanations.

Encourage expression of feelings.

Summarise the conversation.

Plan of action.

Communicate with others.

Reflect back to page 208 where Michelle receives bad/significant news of her changing condition and make a list of all the things that can represent ‘bad news’.

For further reading on loss and transition, refer to the article by Trowel (2008) (see References). If you are unsure about completing this activity, reading this article first will give you some ideas about losses in society that are not associated with dying.

NMC Domain 1: 1.1; 1.2; 1.3; 1.4; 1.5; 1.6

NMC Domain 2: 2.1; 2.2; 2.3; 2.4; 2.5

NMC Domain 4: 4.7

Activity

Holistic care

You are working on a busy ward for care of the older person. A man who has been an inpatient for several weeks appears to be withdrawn and reluctant to chat with other patients or look forward to his afternoon visitors. When you ask him how he is feeling, he reluctantly tells you he is a ‘bit down in spirit’. Consider what he might mean by this phrase. Make notes on what might be impacting on how he is feeling. Identify what information might be needed to assess his holistic needs.

Now refer to page 45 where we looked at the concept of holistic care. Consider how you might respond to what this patient has said to you. What factors do you need to take into account? What assessment tools can you use to help assess his anxiety/distress? Return to the distress thermometer introduced on page 35 and make some notes about what might be impacting on this patient. What nursing interventions might help? Write down some sentences that you might use to initially respond to his comment. Now consider multiprofessional colleagues who might be able to support the needs of this man.

NMC Domain 1: 1.2; 1.3; 1.4; 1.5

NMC Domain 2: 2.1; 2.2; 2.3; 2.4; 2.5

NMC Domain 3: 3.3; 3.4; 3.7

For further reading to link holistic care to the ADLs, refer to Appendix 4 in Holland et al (2008) (see References).

For further reading about the concept of meeting spiritual needs in nursing, refer McSherry et al (2004) (see References).

Activity

Infection control

Working in cancer services, you will be exposed to some very specific infection control risks. Each clinical setting will have infection control policies that will assist you to maintain a safe environment for yourself and for others.

You are nursing a woman who requires a wound dressing to be changed. You are aware that the lady is known to have methicillin-resistant Staphylococcus aureus (MRSA). You are unsure of what precautions you should take.

Find the infection control policies and procedures of your current/next placement and look up MRSA. Find out who the link person is with responsibility for supporting ward staff with infection control queries.

Refer back to your lecture notes on infection control procedures and policies and read Gould (2011) (see References).

Write a care plan for undertaking this dressing and discuss this with your mentor. Find out how to contact the infection control team. Think about the psychosocial impact of having MRSA on the patient and make some notes which will help you answer her and her family’s questions.

Refer back to page 99 to refresh your knowledge on reducing infection risk for a person who has an increased risk of acquiring an infection.

Visit the NHS Choices Website and read up on the common signs and symptoms of MRSA:

http://www.nhs.uk/Conditions/MRSA/Pages/Symptoms.aspx (accessed May 2011).

NMC Domain 1: 1.1; 1.2; 1.4; 1.5; 1.7; 1.8; 1.9

NMC Domain 2: 2.1; 2.2; 2.3; 2.7; 2.8

NMC Domain 3: 3.1; 3.2; 3.6; 3.8

Activity

Record keeping

Your mentor asks you to complete a discharge letter to the community nursing team referring a postoperative patient for subcutaneous anticoagulation (in order to reduce the risk of deep vein thrombosis (DVT) which may result from limited mobility postoperatively). You have only just met the patient today and are not very familiar with this individual care requirements. Write down all the ways of ensuring that important information documented is correct and up to date for the community team. What should you document in order to maintain continuity of care and patient safety once discharged? What are the issues of confidentiality when communicating with agencies outside the acute clinical setting?

Refer to the NMC record keeping guidelines to consolidate your practice and knowledge:

http://www.nmc-uk.org/Documents/Guidance/nmcGuidanceRecordKeepingGuidanceforNursesandMidwives.pdf (accessed May 2011).

Think about the legal aspects of record keeping. Find out how your documentation may be used in the event of a complaint about care given to a patient or in a case involving the coroner.

Remember, all documentation needs to be dated, the time of writing noted and signed (plus countersigned while you are a student nurse) and you must print your name clearly. It needs to be factual, recounting events that have occurred or care that needs to be given, and naming all individuals that have been involved or need to be involved. Never abbreviate and always explain jargon or technical terms.

NMC Domain 1: 1.1; 1.5; 1.6; 1.7

NMC Domain 2: 2.2; 2.3; 2.7; 2.8

NMC Domain 3: 3.6; 3.9

NMC Domain 4: 4.3; 4.6; 4.7

Activity

Risk assessment

There may be situations in all clinical environments that may place you, co-workers, patients and visitors at risk of harm. As a student and qualified nurse, you have a responsibility to be aware of the specific risks in the environment you are working in and should ensure an assessment of the environment is undertaken. In your cancer services placement, you will have learned about the risks associates with giving chemotherapy, the hazards associated with spillage of chemotherapy or contaminated body fluids and the hazards of radiation. Now consider you are working on a mental health ward and some body fluid has been spilt on the floor. How would you assess the risks? What are the underpinning principles of dealing with a spillage? How will you pass this information to your colleagues? Refer to page 73 to refresh your knowledge on the management of spillages.

Now make a list of responsibilities of the nursing team:

To deal with the spillage.

To ensure all team members know what to do if a spillage happens again in the future.

To ensure equipment needed is stored in the clinical area.

To complete required documentation.

NMC Domain 1: 1.5; 1.7

NMC Domain 2: 2.2

NMC Domain 3: 3.6

NMC Domain 4: 4.3; 4.6

Visit the National Institute of Health and Clinical Excellence Website to read about risk assessment:

http://www.nice.org.uk/aboutnice/whoweare/aboutthehda/hdapublications/risk_assessment_at_work_practical_examples_in_the_nhs.jsp (accessed May 2011).

Visit the Health and Safety Executive Website at:

http://www.hse.gov.uk/ (accessed May 2011).

Activity

Team working

Reflect on a couple of patients you have cared for during your current placement. Refer back to Chapter 7 and make a list of all the members of the multiprofessional team you have worked alongside. What were the main contributions each of the different professionals made towards patient care and management? How did their role link with your role?

Are there any healthcare professionals in the list you have not worked with or had the opportunity to find out what their specific role is in this clinical setting? If so, consider what their role might be, and if you still do not understand their roles, discuss them with your mentor, making a note for future placements. This can help you to focus on finding out more about these roles on your next placement and it may be possible to arrange insight visits so that you can work alongside these specific individuals. It is vital that you understand the roles of each professional in order to respect the boundaries of each role and appreciate the function of individual team members. Remember, you will all be working towards a common goal – high-quality, patient-centred care.

Consider why team working, particularly multiprofessional team working, is needed in the healthcare environment. Think about how well the multiprofessional team worked together while you were on placement. What aided it and what hampered it?

Read Daly (2004) (see References) to consider some of the wider issues that influence the delivery of multiprofessional care.

You may have had the chance to learn alongside other students from other healthcare disciplines, such as medicine, physiotherapy, occupational therapy and social work, in the classroom or in the clinical setting. A number of universities have introduced and integrated interprofessional educational learning into the health curricula. Find out from your own university how interprofessional learning takes place locally.

Read Kelley et al (2009) (see References) and visit The University of Nottingham’s Website to find out more how interprofessional learning can enhance team working and improve understanding of role and professional boundaries:

http://www.nottingham.ac.uk/ciel/index.aspx (accessed May 2011).

On this Website, you can explore the learning outcomes for interprofessional learning and you can view the ‘values exchange’ scenarios that are used to consider different professionals’ viewpoints and values.

As well as working in a team with other healthcare professionals, you will have been working within a nursing team. Think about how the nursing team functioned on your placement. How well did they communicate, collaborate and support each another? What do you consider are the advantages of working in a team?

NMC Domain 1: 1.4; 1.5; 1.6

NMC Domain 4: 4.6; 4.7

Holistic care means a person is viewed as a whole and this includes physical, psychosocial emotional and spiritual needs. The activities of daily living (ADLs) effectively explore the holistic needs of a person, taking a systematic approach.

Future professional practice

During your final interview with your mentor for this placement, you should present your portfolio of evidence alongside your ongoing record of achievement (ORA), demonstrating your clinical competence achieved on this placement, as required by the NMC (2010). During your interview, your mentor should provide comprehensive constructive feedback on your performance as a whole and specific feedback related to the objectives and goals you agreed at the start of your placement. You may not have achieved all of the NMC competencies this time, perhaps due to lack of evidence of your abilities or as a result of a lack of opportunities to develop these skills. Your mentor should help you identify the competencies not achieved and support you to develop an action plan for future placements.

Your university will have set two progression points during your course. You need to find out when these are to ensure you have reached the required level of competence at these two points in order for you to progress from one part of the programme to the next. Normally the first progression point is at the end of year 1 and the second progression point is at the end of year 2. To pass the second progression point, you will need to demonstrate that you are increasingly working independently and taking more responsibility for you own learning and practice.

If this is your final placement, your sign off mentor will assess your overall competence. They will carefully be scrutinising your ability to deliver safe, effective care in practice and apply your theoretical knowledge. Overall, they will be assessing your competency and fitness to practise and they will confirm that you have successfully achieved all of the NMC practice requirements. Refer to Chapter 6 to revise the role of the sign off mentor.

Once you have had your ORA document signed by your mentor, you should arrange to meet with your personal tutor who will review your achievements and countersign the ORA.

Before you start your next placement, you should read your competency outcomes and essential skills clusters and make a note of what was outstanding from your previous placement and identify what your leaning outcomes will be on the next placement. This will help you to think about how you might be able to meet these learning outcomes to maximise your learning opportunities and achievements throughout the rest of your nursing training programme.

If this is your final placement, you will be nearing the completion of your course. Even though you might have achieved your competencies, you will still need to reflect on and identify your strengths and areas of professional development following your placement. Nursing is a profession that requires life-long learning to ensure that practitioners maintain up-to-date knowledge and skills and you have a professional responsibility to continually reflect on your performance and address your learning needs.

Before you start your first job, you will need to identify what your learning and development needs will be during your period of preceptorship. Preceptorship is where newly qualified registered nurses are offered support by a more experienced registered nurse (a preceptor) in the early stages following their initial registration. This will allow you to consolidate your knowledge and skills and develop confidence in your new role, but to optimise this you should be able to identify and develop your particular learning needs from the outset. This might include orientation to the ward environment, to learn and become familiar with new policies and procedures, or it may be specific, such as how to care for a patient with a particular complex medical condition.

You may, at a later date, wish to pursue formal education in the form of ‘learning beyond registration (LBR)’ or ‘continuing professional development’ (CPD). You should discuss this with your line manager and investigate the local university’s post-registered education provision.