Efficient delivery of care is the essence of nursing. Being a successful nurse revolves around the capability to deliver care which contributes to the wellbeing of the patients (Barker, 2005).
In exploring the efficient delivery of care to patients suffering from mental illness, this paper consists of two parts. Part One outlines the practical and theoretical aspects of my chosen Service Improvement Initiative, and Part Two focuses on my personal development plan. The Service Improvement Initiative outlines a plan that strives to create a healing environment through the use of mental and physical activities, from sports to board games as a means of providing nursing care to patients. Apart from the medical aspect of this initiative, I will also analyze the theoretical aspects of health care to determine the professional role of nurses in providing care and support that aims to contribute to the wellbeing of patients. Additionally, I intend to discuss the importance of harnessing leadership qualities, management and communication skills of nurses in order to provide high-quality patient care.
Mental Health and Physical and Mind ActivitiesIn the course of my observations in a psychological ward for adolescents aged 10-17 years, I noticed that there are very little, if any, physical activities such as sports (table tennis, basketball, snooker, etc.). However, over the years, an overwhelming wealth of evidence from nursing practice and research has clearly demonstrated the benefits of such activities (Hainsworth, 2006). Researchers have established that physical activity promotes physical health and brings about physiological benefits (Department of Health, 2004b). For example, Benloucif (2004) found that daylight exercises significantly improve neurophysiological performance and sleep quality especially when they emphasize extensive duration rather than intensity.
However, not only does physical activity lead to physiological benefits, but it can also generate psychological benefits such as empowerment of patients and reduction of boredom, which in turn improve clinical outcomes (Ainsworth, 2006). Another major benefit of physical activities in hospitals and wards is the creation of a social environment in which patients thrive (Frost, 2010). For example, physical activities allow service users to socialize and engage in light conversations without showing aggression towards each other (Briles, 2005). Over time, patients will learn the importance of effective communication with other people, the purpose of staying at the hospital/ward, as well as the advantages of participating in decision-making and different activities (Wilkes-Whitehall, 2004). This is particularly important for patients who are vulnerable and are in need of re-establishing their social skills in a controlled environment, such as adolescents suffering from mental illness. In fact, research has demonstrated that a warm and supportive social environment is an important factor in the etiology of mental illness, but also in the therapeutic healing process (Cohen, 2004).
Physical activity, such as exercise and sports, has also been found to generally improve mental health conditions, such as anxiety, depression and general wellbeing (Schmitz, 2004). According to Strohle (2009), sports and exercise can moderately reduce anxiety and depression in mentally ill persons. Martinsen (2008) has also demonstrated that some activities (e.g. resistance, aerobic) can prevent the risk of depression. Goodwin (2003) reported the low scores of depression among adolescents as a result of engaging in exercise. Drawing on a large sample of 8,098 adolescents and adults from the ages of 15-54, Goodwin (2003) found that individuals who regularly kept themselves physically active were less depressed. Other researchers (Penedo & Dahn, 2005) have further supported the claim that exercise may be associated with therapeutic benefit among individuals with major depressive disorder.
Moreover, the majority of cross-sectional studies have showed that an improved cognitive performance is related to physical fitness (Callaghan, 2004). There are implications of these findings. For example, patients who frequently engage in physical activities may become much more open to considering alternative therapies and treatments.
Aside from their physiological benefits, those who participated in this exercise-therapy also showed a generally more resilient and healthier psychological state. In fact, it is well-documented that physical activities and exercise are vital in strengthening self-image and self-esteem in all age groups, especially among children and middle-aged adults (Folkins & Sime, 1981). Research has demonstrated that people who participate in physical activity have an improved self-image (Elavsky et al., 2005). As self-image is an important factor in helping patients to be less vulnerable during social re-integration, clinical outcomes are improved. Additionally, Kirkcaldy, Shephard, and Siefen (2002) presented evidence that participating in physical exercises alleviates social withdrawal, low self-esteem, and depression which are the negative symptoms of schizophrenia.
Taking the above-mentioned case studies as well as other relevant literature together, it is clear that there is considerable evidence showing that physical activity through exercise and sports is effective in improving the mental and physical conditions of mentally ill service users. These physical activities promote better life quality via boosting self-esteem, reducing anxiety, improving mood, sleep and resilience to stress (Ekeland et al, 2009).
However, further research is still needed to identify the effective exercise regimes and feasible delivery modalities for patients with varying illnesses. It is advised that activities that are any way strenuous or too rigorous would not be suitable for mentally-ill patients with cardiovascular conditions. Also, in order to prevent any form of musculoskeletal injuries, the duration and intensity of exercises should be increased gradually. It is therefore clear that a full assessment of patients must be carefully done by the appropriate medical practitioner before such activities are implemented (Richardson, 2005).
Prior to outlining the Service Improvement Initiative, I will first outline the theoretical aspects that need to be considered when implementing a new initiative, and how these can be applied in practical terms.
Theoretical AspectsIn order to implement a service improvement initiative and effectively manage the changes that ensue, a clear understanding of theoretical aspects must take place. In this paper, the theoretical aspects will be drawn from John Kotter’s model and Pender’s Theory of Health Promotion (1996). In the former model, Kotter’s eight distinct phases will be organized into three broad phases: 1) creating a climate for change; 2) engaging and enabling the whole organization; and 3) implementing and sustaining change (Campbell, 2008). In the latter model, an action can directly motivate the behaviour of others through an extensive and rigorous plan of commitment from which the expected benefits will result (Pender, 1996). This author will examine theoretical aspects such as change management; accountability and responsibility, leadership and management skills, and professional/inter-professional collaboration.
The first phase will focus on the importance of urgency, the building of guiding teams and getting the vision right. In fact, it is particularly important that a multi-disciplinary team has a sense of urgency in achieving the programme’s aims. The team must possess four main skills as highlighted by Campbell (2008): up-to-date knowledge about the necessary changes, an ability to justify and add credibility to the changes, awareness of any relevant knowledge on the changes and a sense of leadership in carrying out the changes. Moreover, the vision of the team must be summarised into a short-statement that encapsulates the goals of the initiative. Thus, in the case of the service improvement initiative, it is pivotal that the team of nurses and other staff has exposure to the benefits of physical and mental activities. This can be achieved through a day of seminars given by external scholars and practitioners, as well as take-away booklets and handouts that emphasise the need for integrating physical activity into healthcare.
The second phase involves communicating the proposed changes that will enable action to take place. On the communication of the proposed changes, it is vital that all individuals involved in the initiative are completely knowledgeable about the changes that are being proposed. There must be a constant dialogue among the people involved to ensure that all parties are kept in the loop (Campbell, 2008). In fact, a clear communication strategy is also important for raising sufficient funds for a server improvement initiative. In order to garner both emotional and financial support, it is imperative that the short-term and long-term benefits of a service improvement initiative are communicated. For example, in the case of the service-user initiative for improving physical activity, the importance of improving the patient experience and the overall clinical outcome needs to be emphasised.
Finally, the third phase highlights the importance of keeping a momentum when implementing change By creating a drive and motivation amongst employees, it becomes necessary to ensure that change does not become institutionalized but is a forward-looking process (Campbell, 2008). According to Kotter, “culture change comes last.” In other words, when change has been successfully implemented for a certain period of time, that is when attitudes and opinions change. In light of this, one would expect that it would take a certain amount of time for the service user initiative to become rooted in the culture of the health-care community.
Other important theoretical aspects that also need to be discussed include accountability and responsibility. It is important that each member of the multidisciplinary team, in particular the nursing staff, are vigilant in maintaining both accountability and responsibility. In this case, responsibility is equivalent to the duty of care in law. This applies to all nursing tasks, from simple things such as bathing a patient to complex ones such as surgery. There is a certain degree of risk in any nursing task. When practitioners accept responsibility to perform a task, they must ensure that they accomplish it with competence and at least to the accepted standard (Scrivener, 2011).
Accountability is commonly defined as “an inherent confidence as a professional that allows a nurse to take pride in being transparent about the way he or she has carried out their practice” (Caulfield, 2005, p.24). This reflects the positive aspect of accountability and puts focus on the development and demonstration of competence in practice (Scrivener, 2011). The Nursing and Midwifery Council (NMC, 2008) states that all nurses are accountable for their own actions in practice. As the last few years have seen a rise in litigation for nurses (Diamond, 1995), accountability can be a source of anxiety for nurses. It is therefore imperative that nurses follow strict protocols and guidelines, verifying when unsure and being constantly alert to new situations and information.
In relation to responsibility and accountability, according to the NMC, nurses must always ensure that they take complete responsibility for their actions, and always act in according to what is agreed with their patients, their families and carers, and in line with the laws of professional health bodies (Scrivener, 2011). Given these guidelines, in my service improvement initiative, I will ensure that the appropriate responsibility is handed to managers and nurses. Whilst the manager will be ultimately accountable and oversee and be the primary point of contact regarding the actions of the nurses and other staff, there will also be others responsible such as administrative staff. It is therefore essential that there are good management and leadership practices in place so that nurses should have to achieve the proper provision of health care.
Another important theoretical aspect to consider is the importance of managing in order to achieve the goals of an organization. Thomas and Worley (2009) describe management as a process of coordinating actions and allocating resources to achieve organizational goals. Similarly, Hersey and colleagues (2001) explained that management is a way of working with and through individuals and groups to accomplish organizational goals. The researchers identified management as a special kind of leadership that concentrates on the achievement of organization goals. Koontz and Weihrich (2008) stated that management is the process of organizing and maintaining an environment in which individual working together in groups efficiently accomplishes selected goal or aims. In application to nursing profession, Sullivan and Decker (2011) define management as the abilities to plan, manage, organize and deliver care. It includes the process of discovering a good way of caring for patients. The goals of the service improvement initiative must therefore be clearly structured and outlined to ensure that both individuals and groups can work towards the initiative’s aims which are to improve the quality of patient care.
Leadership may be defined as the ability to direct and influence the task or activities of the members of a group in its efforts to achieve certain objectives (Huczynski & Buchanan 2007). These authors further define leadership as the process of influencing the activities of an organized group in its efforts towards creating an environment focused on goal achievement. Mullins (2007) stated that leadership is a relationship through which one person influences the behavior or action of other people. According to Gopee and Galloway (2009), the key elements of leadership are leader’s personal characteristics, interpersonal relationships, team working and being a role model. They also identified four styles of leadership which include autocratic, democratic, laissez-faire and bureaucratic. In the context of nursing, Sullivan and Garland (2010) list many leadership and managerial skills required from a nurse. These skills range from the initiation and implementation of change, critical thinking, problem-solving, effective communication, time-management, appropriate delegation, budgeting and allocating resources and understanding power and politics. In the service improvement initiative, it is therefore important for nurses to acquire both leadership and management skills to be able to function effectively (Marquis and Huston, 2009). In fact, Barr and Dowding (2008) explained that management and leadership skills should be integrated in order to provide high-quality care to the patients.
Finally, another critical element for a successful implementation of the service improvement initiative is a culture of “inter-professional collaboration”. The World Health Organization defines inter-professional collaboration as a process in which “multiple health workers from different professional backgrounds work together with patients, families, carers, and communities to deliver the highest quality of care.” An expert panel of Inter-professional Education Collaborative (2011) defines inter-professional competencies in health care as “integrated enactment of knowledge, skills, and values/attitudes that define working together across the professions, with other health care workers, and with patients, along with families and communities, as appropriate to improve health outcomes in specific care contexts”. In the context of the service improvement initiative, a panel of inter-professionals will be involved from the first day to actual implementation to ensure that the highest quality of care is given to patients.
The Service Improvement InitiativeTo improve the nursing services in the ward, I plan to execute a six-month program involving 10 adolescent patients from the ages of 10-17, from the psychological ward. Patients will be invited to partake in a range of physical activities, such as exercise and sports, as well as mind games. The overall aim of this initiative is to establish whether such activities have any effect on the behavior or wellbeing of patients. A secondary aim of the initiative is to explore various aspects of the delivery of care, taking into consideration the different theoretical aspects of the nursing practice.
The budget will be need to be closely decided in liaison with the manager to ensure that there is sufficient funding for purchasing the sport equipment and the personnel for facilitating and monitoring physical activities. Although the programme is to be conducted in a normal hospital setting, funding will also need to be allocated for the services of the experts and all the administrative and logistical aspects of the initiative. Whilst as a nurse, I can initiate the set of activities for patients, I will need to draw on the assistance and expertise of other medical practitioners for the intervention to be successful.
It will also be necessary to set up a multidisciplinary team that will aid in the implementation and completion of the initiative. Team members will be psychiatrists, physical therapists, mental health practitioners, and other experts. It is particularly important to draw on the expertise of a Physical Therapist as it is essential to determine the capabilities of mentally ill individuals when it comes to engaging in physical activities. Psychiatrists also play an important role in assessing the clinical outcomes of patients within a certain time-frame.
Given previous research on the risks of physical activity for mentally ill patients (Richardson, 2005), careful considerations shall also be made to ensure that the types of physical activity will depend on the psychological condition of the patient and all physical activities will be limited to light exercise and light sports, such as table tennis.
The assessment of the clinical outcomes of the service improvement initiative for adolescent patients will take place on a weekly basis. The assessment criteria will be decided by consulting experts and mental health practitioners. The amount of exercise given in the following week will then depend on the clinical results of the patients at the end of the week. This allows a continuous assessment of patient improvement.
It is important to note that the proposed initiative may face a number of challenges. These challenges include the specific culture of a workplace in which some staff may oppose the change, funding costs, fear of increase in work load amongst nurses and a subsequent increase in staff anxiety level (Paton and McCalman, 200; Sharma, 2008).
Professional Development PlanIntroduction
In this section, I will focus on one of the aspects of my personal development which I intend to concentrate on within the first six months of registration. In my personal development plan I will explore my strengths, weaknesses, opportunities and threats (SWOT) and write an action plan that is specific, measurable, achievable, realistic and timely (SMART).
Using the reflective tools and SWOT analysis (Appendix B), I have identified my strengths, weaknesses, opportunities and threats, One of the main areas of expertise where I see the weakness and where I would like to see improvements in my knowledge and abilities in the management of medications.
Being a nurse does not only require clinical skills but also good leadership, management and communication skills that are learned from practice.
Action PlanAdministration of medicines is a key element of nursing care. Drug administration is one of the major parts of the nurse’s clinical role. Although doctors traditionally take control of prescribing medicines, a registered nurse does have primary responsibility in administering the correct dosage of medicines. Nurses are responsible regarding the preparation of medicine, verifying and checking appropriate medication, monitoring the effectiveness of treatment and in certain cases, reporting any adverse drug reactions. Given research findings that patients do not always receive the correct medication at their drug rounds, nurses must be vigilant in ensuring appropriate medicine management (Andalo, 2006).
However, there has been evidence that medicine management has not been given considerable priority by health care services, and that it is commonly excluded from pre-registration training or in practice (Snowden, 2011). The development of competency in medicine management requires an explicit academic component is present. This is particularly important given recent failures such as those highlighted in Francis Report (Wright, 2013). In this report, Robert Francis revealed the failure among nurses and healthcare assistants to feed patients and give them the basic elements of care such as dignity and respect. Initiatives to combat such behaviour in the future included holding nurses personally and criminally accountable, as well as holding hospital boards responsible should they fail to ensure that all patients are receiving high quality care (Wright, 2013). As I am a student who is in the transition period to a staff nurse, I am aware of the changing responsibilities and accountability that are inherent to being a nurse.
Personal Development PlanNagelkerk (2005) highlights the importance of setting and identifying goals that are intrinsic to your personal development, as it allows you to reflect on your practice and also highlight your strengths and weaknesses, which gives you the opportunity to initiate and implement change.
With this in mind, I plan to draw on Snowden’s “clusters on essential skills for medicine management”. This is relevant to the current service improvement initiative as it highlights the need for newly registered nurses to be completely briefed on patient history and able to responsible administer medicines (Snowden, 2011).
Moreover, I will draw on the SMART (Specific, Measurable, Achievable, Realistic and Time) bound framework to set a time scale for my action plan. I will also draw on Snowden’s clusters on essential skills for medicine management as it is a parsimonious model that allows me to evaluate educational needs and professional development.
During the first month of the programme, I will ensure that I am completely knowledgeable of the commonly administered medicines that the patients are taking, their actions and side effects. I will do this by liaising with doctors and psychiatrists, and also attending weekly ward rounds.
Within the second month, I intend to increase my confidence when it comes to managing my medication round effectively using the eight rights checklist: “right medication”, “right patient”, “right dose”, “right time”, “right date”, “right route”, “right preparation” and “right documentation” (Morgan, 2000). I will also develop my knowledge of pharmacology such as the interaction of medicines with different systems of the body.
In the third and fourth months of training, I will build up my knowledge on the necessary techniques for administering medicine. I will attend a series of sessions on medicine management as well as observe trained professionals. This is in line with research that nurses must constantly build their body of knowledge and develop their professional skills (Burton & Ormrod, 2011).
The fifth and sixth months will focus on the application of the knowledge I acquired. This is where safety management, administration and monitoring of drugs come in. I will practice my skills in ordering medication, their storage and disposal of used medication. I intend to keep a reflective diary about all that I learnt from my own experience and experience of colleagues.
The support and assistance of an experienced professional is very important and vital for a newly qualified nurse to gain confidence and practice effectively (NMC, 2008). With the right support and guidance from experienced colleagues, I should be able to manage medications safely and effectively. This will greatly enhance my professional confidence.
Having clearly identified my goals and assigned a time limit to achieve them will help me to monitor my progress. I will work hard to make sure that my goals are achievable within the clinical setting.
ConclusionOver the course of this paper, it has become clear that the responsibilities of a newly registered nurse are vast. The transition from a student to a nurse is not without its challenges and requires continuous training, support and guidance. To ensure that I am progressing in my knowledge of nursing, I will constantly engage in evaluations and assessment of my learning. For example, I will verify my learning in accordance with the standards of the Nursing and Midwifery Council.
APPENDIX A
Service Improvement Activity Notification Proforma
Details of service improvement project/activity:
The main aim of the Service Improvement Initiative is to provide physical activity to mentally ill adolescents aged 10-17 years. The initiative will assess the clinical outcomes following the physical activity intervention, as well as the development of nursing skills needed for the efficient and effective delivery of care.
Reason for development:
Based on my observations in a psychological ward for adolescents aged 10-17 years, there are no opportunities to be involved in activities such as sports (darts, snooker, etc.). These activities are proven to provide multiple benefits to the service users, both in terms of physical fitness and mental health.
Time spent on the project/activity:
The program will take place over a span of six months.
Resources used:
There are a number of resources needed for this initiative. Resources include sufficient funding for paying for the services of team members and experts, as well as a range of sporting equipment, such as table tennis tables.
Who was involved:
A multidisciplinary team consisting of a group of nurses a physical therapist, psychiatrists, mental health practitioners, and other experts will be set up.
Future plans:
The initiative will be implemented in six (6) months. It is hoped that the program will become successful and beneficial for the service users and the multidisciplinary team.
APPENDIX B
Strengths·Good communication skills,
·Good team player
·Positive attitude
·Good interpersonal skills
·Motivated and enthusiastic
·Responsible
Weaknesses
·Assertiveness
·Medicine management skills
·Professional boundary issues
Opportunities
·Access to training
·Learning from other members of inter-professional team.
·Education, development and research
·Effective supervision
·Effective feedbackThreats
·Lack of time
·Staff attitude on ward
·Staff shortage
·My inexperience
APPENDIX C
Objective
1. Improve my knowledge of medication management.
Where I am now
Insufficient knowledge about medication.
Goal
To become competent in medication management.
Action plan
Read British National Formulary
Check NICE guidelines on medication
Work with colleagues on the ward.
Administering medication regularly with supervisionTime
2 weeks
1- week
1- week
continuouslyEvaluation
Self-evaluation and evaluation by experienced professionals
2. Develop good knowledge of NICE guidelines on medication and current government policies on medication.Insufficient knowledge of NICE on medication management.Competency and ability to practice independently.Read through NICE guidelines on medication (internet, Nursing publications)
Administering medication regularly with supervision.
2-month.Self- evaluation and evaluation by experienced professionals 3. Attend training on medication.
Insufficient knowledge of certain medicinesGood knowledge about drugs, their use, dosages and side effectsAttend training and seminars on medication 4-monthReflects on the experience gained, discuss with mentor 4. Develop confidence in ordering medication, organising its storage and disposal.
Inadequate knowledgeAbility to practice with confidenceActively participate in the daily running of the ward 6-monthEvaluation by mentor and reflecting on practice
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