The focus of this essay will be to select one clinical skill in which I am developing competence in and reflect upon how to achieve the necessary level of competence for this stage of the programme. For the purpose of this essay I have chosen to focus on subcutaneous injections technique as my clinical skill.
The nursing and midwifery council’s (NMC) Standards for Medicines management states that administration of medicine “is not solely a mechanistic task to be performed in strict compliance with the written prescription other medical practitioner. It requires thought and the exercise of professional judgement”. In order to perform safe practice it is essential to possess sound knowledge of the anatomy, patient assessment and nursing interventions and methods used are evidence based. (NMC 2007).
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My rationale for selecting subcutaneous injections (SC) was whilst on my first placement based on a surgical ward this was a widely used skill, which was performed on many occasions. This technique was mostly used for the administration of an anticoagulant (tinzaparin sodium) also know as heparin, given to patients in order to prevent harmful blood clots forming in veins following an operation. Heparin works by changing the way blood clots, allowing blood to flow smoothly through the vessels. (REF)
Whilst giving an injection was once the role of the doctor, since the invention of penicillin in 1940s it became the activity of the nurse (Workman 1999). Administering injections is an important part of drug administration and a regular, common place activity for the nurse which unfortunately can easily become a complacent task; the technique should be mastered with a sound knowledge base.
Injections are used to distribute medication through a needle or syringe. SC injections are administered for various reasons; these include slow distribution into the body, good absorption due to intramuscular tissue containing small blood vessels and unable to take orally because medication would become inactive by stomach acid. Workman (1999) suggests taking four considerations when administering injections; the site of administration, technique used, equipment used and the route to be used.
The choice of the site of injection is based on sound clinical judgement, best evidence and patient assessment (Potter 2010). Site selection is normally upper arm, abdomen or thigh. (Lister & Dougherty 2008) suggests upper arm as a most favourable choice as they contain fewer large blood vessels and less painful sensations, however in practice the abdomen is a more common site for heparin as the skin contains a thicker subcutaneous tissue (Hunter 2008).It has been expressed that rotation of sites can decrease the likely hood of irritation and ensure improved absorption (Dougherty and Lister 2009). Traditionally the technique used when administering subcutaneous injections has been using a 45degree angle into a raised skin fold, however since the introduction of shorter needles and pre filled syringes this has been challenged and it is now recommended that the injections are given at a 90 degree angle into a raised skin fold to ensure medication is given into the SC layer. (REF)
The manner to which a medicine is administered determines the extent to which a patient gains clinical benefit. Nurses are responsible for the correct administration of prescribed drugs to patients in their care at all times. Standards for medicine management (NMC 2008a) Adopting a skilled injection technique may make the patients experience less painful and prevent unnecessary complications, whereas poor understanding of the technique could result in the injection being administrated intramuscular which could affect the rate of absorption and cause potential harm to the patient (Hunter 2008).
SC injections involve depositing medications into the loose connective tissue underlying the dermis, this tissue is not a richly supplied with blood vessels as muscles are thus allowing the medication to be absorbed slowly. Prior to administering a SC injection the following precautions must be followed: a patient’s pre-existing condition must be assessed to prevent contraindications, patients prescription chart checked to check correct route, correct dosage of medication, expiry date, hands washed with soap and water to prevent infection, positive patient identification then record the administration on the appropriate chart to avoid any duplication of patients treatment (Dougherty and Lister 2009)
The Royal Marsden Hospital Manual suggests that before administering injections the skin should be cleansed with an alcohol wipe for 30 seconds and allowed to dry in order to prevent any contamination, However it has been questioned that the alcohol in the wipe was causing irritation to the skin or prolonged use may cause skin hardening (Hunter 2008). The local trust do not recommend the use of any skin preparation prior to administering SC injections, however aseptic technique to be maintained and as with all patient contact gloves must be worn (Pratt et al 2007)
Disposal of the used injection is extremely important to prevent needle stick injuries, a needle should never be re-sheathed; the most frequent route of exposure to blood-borne diseases for health care workers is from needle stick injuries (Potter 2010).
The clinical environment is a never ending source of potential learning experiences that become more meaningful the more you participate. (Sharples 2009) The NMC will only accept that a nurse is competent if they are a competent learner (NMC 2004)
Evidence Based Practice (EBP) is a systematic approach adopted by nurses to provide a rational decision making that facilitates achievement of best practices often achieved by obtaining the strongest available evidence whilst applying patient care (Potter 2010). EBP is implemented because it allows the highest quality of care and resulting in the best patient outcome (Melnyk and friecut-overholt 2011)
The NMC (2008) states that “patients have the rights to have a safe environment and staff has a duty to protect patients in maintaining knowledge based practice and continuing with their lifelong learning”.
I realised in order to be able to become a competent nurse in the future I would need to recognise the type of learner I am and be able to reflect upon this. If I am unaware of my strengths and weaknesses, it is more likely I will be unable to help others (Burnard 1992).
Self-awareness and analysis are key component in reflection, and reflection is an essential skill which needs to be acquired, developed and maintained; being self- aware allows us to take control of the situations we find ourselves in, thus becoming less vulnerable (Wilding 2008).
There are four different learning styles identified these are; Activists, Pragmatist, Reflector and Theorist.
Activists immerse themselves in new experiences, using their enthusiasm to flourish on new challenges. Pragmatists are thought to be practical, putting thoughts, theories and techniques into practice. Reflectors like to take a step back and observe, collecting and analysing information about events and experiences, often slow to reach a conclusion. Theorists on the other hand have a tendency to to favour the facts and are not content on things which don’t seem rational (McGill and Beaty 1995)
I discovered my learning style was the Activist, although I felt I possessed a few of the other characteristics in the other styles. I enjoy learning most by doing the task at hand and witnessing things rather than reading about them.
Bremer (1984) advocates the preferred method of learning is by observing role models, this is often displayed whilst on placement observing mentors carrying out tasks before they allow the student to attempt it for themselves.
According to Boud (1993) reflecting on personal experiences plays a major factor in developing to a higher level. Brenner (1984) agrees by suggesting nurses develop to become experts by taught knowledge, by applying the intuition and experience through work practice, however, not all nurses will become experts.
In order to develop my learning fully I recognised the need to start completing a reflective diary, recording experiences good and bad, strengths and weaknesses in order to improve my performance. Reflecting on experiences allows us to learn from them and how to improve on them to increase patient care. I am often told by nurses who have been qualified for many years that they often reflect on various situations and if they could have responded to a situation more differently and more effectively.
Frazer and Greenhalgh (2001) states that “capability is the extent to which the individual can apply, adopt and synthesize new knowledge from experiences and continue to improve performance.
The World Health Organisation (WHO 1998) identifies competence as the ability to carry out a certain professional function which is made up of a repertoire of professional practice.
Schon identifies two particular types of reflection, a reflection on action and a reflection in action. Reflection in action takes place in practice and may influence future decisions and outcomes, whilst reflection on action traditionally occurs in educational settings either clinical areas or in the classroom (Hinchliff et al, 2008). Ghaye et al (1996) believe that without reflection it is almost impossible to improve in practice.
Understanding your own individual learning style is extremely interesting and considered invaluable in developing the ability to learn and partake in learning experiences, and especially important whilst on placement (Sharples 2009).
By gaining personal insight and understanding it may help us understand others better (Burnard 1995)
An essential part of learning is to seize any learning opportunity that may be presented, a student must show willing, motivated and recognise they are responsible for your own learning. If you as a student present yourself as unmotivated, it will be unlikely that your mentor or others will be motivated to encourage your learning (Sharples 2009).
Learn through experimental learning on clinical placement and insightful learning in uni
Strategic approach to learning
(Kolb 1984)
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