Helping student nurses to develop caring skills continues to challenge nurse educators and those working alongside students in practice, particularly in these times when the health service in the UK is under intense public scrutiny (Phillips et al, 2015; Wood, 2016).
For student nurses working in the community, striking a balance between learning the art and science of nursing can also be testing, and this paper exemplifies how a reflective model (Rolfe et al, 2011) can be a useful strategy to help students explore the art of compassionate care. The reflective framework proposed by Rolfe et al (2011) was used by the student in this exercise. It stems from earlier, more generic, reflective models, including those developed by Borton (1970) and Kolb (1984). Rolfe et al (2011) advised that there are just three fundamental questions that the learner must ask of themselves, and it is this simplicity that makes this approach easy for students to apply to their practice. Rolfe et al (2011) strengthened their framework by describing a series of cue questions for reflection (Table 1). These questions focus the student on their own involvement in an incident, thus fostering a sense of reflectivity and provoking thought about what to do should this or a similar situation arise in the future.
| What? | So what? | Now what? |
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Example cue questions:
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Example cue questions:
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Example cue questions:
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Johns (2017) suggested that reflective practice is integral to nursing curricula and advocated reflecting through writing rather than speaking. He defined reflective practice as a ‘mirror to see images or impressions of self in the context of a particular situation in a realistic way’ (Johns, 2017:2). An example of a written reflection submitted by a second-year student nurse (Donna Doran) as part of her practice assessment is the main focus of this paper. It exemplifies a powerful way of contributing to personal learning and practice knowledge and highlights the value of reflective practice.
Student reflection
I have chosen to reflect upon this specific incident because it highlights challenging elements of both the art and science of nursing (Jasmine, 2009), which will be discussed, including the humanisation of care. I will critically analyse my own nursing practice and decision-making skills, while drawing on areas of relevance, such as health education, evidence-based practice and compassionate care. The purpose of this activity was to achieve reflective learning and development of my self and professional role through exploring an experience by bringing it into focus and looking at it from various angles. Jasper et al (2013) suggested that this results in action, which positively informs professional practice by improving knowledge, skills and attitudes. In order to uphold my duty of confidentiality to the patient (Nursing and Midwifery Council (NMC), 2015), a pseudonym has been used throughout this text.
What?
Rolfe et al's (2011) reflective framework begins with discussing ‘what?’, which aims to explore the event that has taken place, and, therefore, this reflection begins with an explanation of what happened during one of my shifts working with a community team. A client named Susan regularly attended the local leg club, as she had leg ulcers, which were fully healed at the time of our interaction. Susan would regularly attend without compression stockings, which she had been advised to wear daily; she said this was because she could not put them on, as she experienced a lack of mobility and regularly used a wheelchair. As it was documented that Susan had been saying this for a number of weeks, I decided to spend some time exploring her situation further. First, I asked if Susan had anybody who could help her to put her stockings on, and she explained that her husband tried to apply the stockings each morning while she lay on her bed. Susan explained and described the method her husband used and said that this was a very painful procedure, which appeared to be placing pressure on her skin. She went on to say that this caused tension between herself and her husband on a daily basis, and because of this, they had stopped trying to use the stockings. I asked Susan if her husband had ever been shown how to apply the compression stocking, pointing out that they can be difficult to put on and that a demonstration might be helpful to them both. I asked if Susan would be happy to bring her husband to the leg club the next week so I could explain and demonstrate a better way of applying the hosiery. Susan seemed very pleased with this, and the following week, I was able to follow this up and show her husband an alternative method to apply his wife's stockings, which was safer and more comfortable. I also re-measured Susan's legs to ensure her stockings were not too tight; there did not appear to be a problem with sizing.
So what?
In order to discuss the ‘so what?’ section of Rolfe et al's (2011) framework, I will begin by exploring the role of the nurse in delivering compassionate care and the maintenance of dignity. Palos (2014) discussed how attributes such as compassion and good communication skills are seen as the art of nursing, in contrast to the science, which is usually empirically proven and evidence based. Palos (2014) suggested that, within contemporary healthcare, it can be difficult for nurses to find the time to practise developing the art of nursing, and this is why I believe it is important for student nurses to reflect on how they communicate with and care for patients. When discussing the practical application of dignity and compassion, NHS England (2014) highlighted that these are not merely ‘buzzwords’; they are values that should be embedded into daily practice to achieve excellence in care for patients and their relatives and carers.
Throughout the scenario described, my attempt to deliver care compassionately and with dignity was underpinned by a humanising values framework (Galvin and Todres, 2013), which I had learned about at university. Galvin and Todres (2013) advocated that nurses should, as part of their everyday practice, place the patient and their relatives at the heart of care and try to make them feel respected and valued as human beings. I could see that both Susan and her husband needed to be more informed and thus empowered to cope with their situation. It was clear to me that the tension with her husband was more of a concern to Susan than the lack of hosiery, and she did not want to trouble him further by asking for help. By adopting a humanised approach, I felt as though I was truly helping Susan and her husband, and the intervention we planned together focused on them as a couple and not just her legs and the risk of the leg ulcers recurring. This approach was endorsed by Nicholson et al (2010), who explained that focusing on the social dimension throughout decision-making confers to the service user a sense of importance as a person, rather than the nurse simply completing a task. My actions were further supported by Perez-Bret et al (2016), who in their systematic literature review, recognised that compassion is a complex concept and defined it as:
‘The sensitivity shown in order to understand another person's suffering, combined with a willingness to help and promote the wellbeing of that person, in order to find a solution to their situation.’
Building on this quote, it seemed important to me to be led by compassion throughout the decision-making process so as to resolve Susan and her husband's situation. Throughout the consultation, I discussed ideas with Susan and asked for her consent to educate her husband at a subsequent leg club. By requesting consent, a practitioner offers dignity and respect for the patient's choice, making the experience patient-centred as well as adhering to national policies, such as Essence of care (Department of Health and Social Care (DHSC), 2010b). Upon further reflection, I believe that, while delivering care to Susan with compassion and dignity, I had to overlook the immediate issue (i.e. the lack of stockings), which had previously been investigated, and search a little deeper, to identify what was troubling Susan and assist with this. I continued to read around the subject of compassion and focused my interest on the series of Compassion in Practice reports (DHSC, 2012; NHS England, 2014; 2016), which highlighted the need for nurses to ensure best practice and advocated that compassion become embedded in care. This reflection has equipped me with a stronger sense of self-awareness and enabled me to focus on how I deliver compassionate care, which I now understand in a new light and can, therefore, take forward in my future nursing practice.
So far, my reflection has focused on the ‘art’ of nursing, but ensuring the appropriate application of Susan's compression hosiery leans more towards knowledge and skill based on theory, or the ‘science’ of nursing. Thus, I decided to involve Susan's husband in a demonstration of hosiery application, which I believed would be the most effective form of education. Through the process of reflection and reading around the subject, I now know that a leading factor in lack of concordance with compression hosiery is application difficulties and discomfort (Johnson, 2002; Tandler, 2016). Tandler (2016) mentioned poor education techniques as a cause for this, suggesting that written or verbal instructions may not be enough to educate patients on how to apply their stockings. As a result of this reflection, I now realise this is particularly true in the case of older people in community settings. I was conscious that the method I had been using to apply the stockings was not necessarily evidence-based practice; I had, in fact, been copying others. Therefore, I decided to investigate further and identified a different technique, which according to Johnson (2002) as well as more recent manufacturer guidelines, appeared easier and, most importantly, was evidence based.
Supporting practice with a strong evidence base can challenge student nurses (Ryan, 2016); yet, its importance should not be underestimated if students are to learn how to deliver best practice while studying at university and on practice placements (Hill et al, 2009; Emanuel et al, 2011). Through this reflection, I understand the risks of following custom and practice and relying on role models rather than developing my own knowledge by reading pertinent literature. At the time, I was not aware of national guidelines informing nurses on the management of patients wearing compression stockings, such as those produced by the National Institute for Health and Care Excellence (NICE) (2012). This guidance supports a person-centred approach by advising that the health practitioner involve the patient in the choice of colour of their stockings, for example, and, more importantly in relation to Susan and her husband, provides education of how to apply them. By reading the NICE (2012) guidance as part of this reflection, I have advanced my own knowledge around compression hosiery, and this has reinforced my understanding of the importance of evidence-based practice. I learned that strengthening Susan's understanding of why she needed to wear compression stockings, discussing various application aids and listening to her all reflected person-centred care. This highlights the value of students learning through reflection and extending their knowledge of evidence-based practice, which ultimately enhances humanised care.
Now what?
The final part of Rolfe et al's (2011) reflective framework is ‘now what?’, focusing on how new learning can be carried forward in future practice. The greatest impact of this reflection has undoubtedly been to highlight the importance of adopting a humanised and compassionate approach and how I can use this in my role as a nurse to help people resolve issues and improve their quality of life. Before my community placement, I felt that delivering compassionate care was something I was good at, but I was not consciously aware how I was doing this or thinking about the impact I was having on my patients. Exploring the evidence that underpins compassion has taught me that nurses need to demonstrate their understanding of a patient's situation through listening, observing and respectful questioning. I have learned that it is important to see the patient (and their family members) as people first, rather than focusing on their problems. It has become important to me to work with them to find a way to resolve their issues so that their quality of life can be enhanced. Exploring the humanising values framework (Galvin and Todres, 2013) has made me think about what it means to be human as I care for my patients and, as suggested by Scammell and Tait (2014), it has given me a support system to deliver the best care that I possibly can.
On further reflection to seek and know more about the ‘science of nursing’, I wonder if more could have been done to support this couple. Susan had complex health needs. She is an older woman who is supported by her husband to live in their own home in the community. This is not an unfamiliar picture, and the aim should be to enable this couple to remain in their own homes (DHSC, 2010a) and prevent hospitalisation. In 2016, the electronic frailty index (eFI) was introduced in primary care (Clegg et al, 2016). Its aim is to identify patients who are frail, where they are on the frailty continuum and who would benefit from targeted interventions to improve their outcomes. Frailty is a clinical syndrome, which is a combination of the natural effects of ageing and the impact of multiple long-term conditions leading to a loss of function and reserves (Clegg et al, 2013). Frailty takes 5–10 years to develop, and there is often a slow trajectory of functional deterioration (Rogers et al, 2017). However, frail older people often present in crisis, and clinicians may manage the crisis but not recognise and address the underlying frailty (Inouye et al, 2007). If recognised early, there are effective interventions that can prevent exacerbation and improve independence and quality of life (Rodriguez-Manas and Rodriguez-Manas, 2014; Clegg et al, 2016; Elliott et al, 2017). The intervention with the most compelling evidence is comprehensive geriatric assessment (CGA) (Beswick et al, 2008; British Geriatric Society, 2014). In considering Susan's needs, we did not assess where she was on the frailty continuum or consider if she would benefit from a CGA. Perhaps, as the use of the eFI becomes more embedded in primary care, the needs of patients like Susan will be considered from a more holistic perspective, and targeted interventions will be put in place before a crisis occurs.
Emanuel et al (2011) suggested that reflection is a strategy students can use to gain a deeper understanding of the practical implementation of evidence-based practice. Although I understood the meaning of evidence-based practice before my encounter with Susan and her husband, the process of reflecting has undoubtedly illuminated what compassionate care really means and encouraged me to find out more about trends in healthcare, such as frailty. My personal learning through reflection has been powerful and has the potential to influence my future nursing practice.
In the future, I hope to identify my own personal barriers to adopting evidence-based practice as a means to safe and skillful nursing. Majid et al (2011) suggested that a copious amount of new theory is produced at any given time, and therefore, hoping to keep abreast of everything is unrealistic. Instead, I intend to identify what is most relevant to my area of nursing and the knowledge and skills I need to sustain and develop my practice. By linking theory to practice and focusing on patient safety and humanised care, I can see how theory will enhance both my nursing practice and decision-making skills. I aim to continue to use reflection to develop my skills in balancing the art with the science of nursing, as I believe this will be an effective way to overcome the challenges encountered by many nurses.
Value of reflecting on practice
This students reflection highlights the value of completing an academic assignment that facilitates students' reflective skills in relation to their developing knowledge for practice. It is evident that the process of reflecting on a scenario from practice prompts student nurses to consider alternative ways of thinking and can result in impactful learning. Using a reflective model, such as the one designed by Rolfe et al (2011), provides a framework of ordered sequences that empowers students to think critically about their practice and the role they play within it. The final stage of the framework stimulates questions around the student's future practice and how they can take their new learning forward. Perhaps, most importantly, this scenario demonstrates how reflection can prompt changes to a student's approach to their practice, which positively impacts on the quality of care that patients and their loved ones receive.
Had the student nurse chosen not to reflect on this incident and the role she played in delivering compassionate care, she would have missed a valuable learning opportunity. The questions she asked of herself in following Rolfe et al's (2011) framework prompted her to explore both the art and science of nursing and the need to consider wider issues such as frailty.
Conclusion
Working in a community setting offers opportunities for student nurses to care for people who may be old and frail and attend to what might appear on the surface to be minor issues but, in reality, make all the difference to a person's quality of life. This paper shows how reflection can be a powerful way of helping students explore their practice and the surrounding underpinning evidence, with the result that learning and care quality are enhanced.