Nursing practice

This care summary will look at the management of nursing practice given to one of my patients on my management placement looking at managing the transfer of care. I shall use the reflection model by Gibbs (1988) (see appendix i) to critically reflect on this situation. There are many models of reflection available which can be seen as potential frameworks to structure the reflective activity.

I have chosen this reflective cycle because I find it straightforward to use and it helps encourage a clear description of the incident, analysis of feelings, and evaluation of the experience. I have used it in previous essays so am familiar with the contents of it. Many authors use the Gibbs cycle (1988) of reflection Gustafsson and Fagerberg (2004), Slater (2003) and Campbell (2004). I have used pseudonyms throughout, to protect confidentiality in accordance with clause five of the Nursing and Midwifery Code of Professional Conduct (NMC 2002a). This essay will conclude that managing a transfer of care, was successful.

Description of event

The situation in which I shall be discussing will be transferring patients from one ward to another ward of the hospital. For this placement I am situated in the Accident and emergency department (A&E) in which there is a high turnover of patients. The reason why I decided to look at managing the transfer of patients is because it is an area of management which is commonly practised, it needs to be well planned and if not well planned can result in delay of delivery of care and can potentially put the patient at risk of inappropriate treatment. As a registered nurse under the Code of Professional Conduct we have a duty of care to ensure patients ensure safe proficient care (NMC 2002a p3).

I want to research this area in more detail to be able to provide effective care for my patients. The word management and leadership are often used interchangeably, this is based on that they use similar skills (Bowman 1997 p22 and Greenwood 1997 p22). Effective leadership is critical in any organisation and the key to effective leadership is having the staff focused and working towards achieving the desired goals (Walton 1997 p13 and Greenwood 1997 p22).

I was left to manage my own few patients of which one of my patients needed to be transferred to another ward in the hospital. This patient had come in with chest pain. Although the chest pain had subsided the patient needed to be admitted for observation. My patient’s condition was stable and an ECG had been done. As part of a government initiative the NHS plan has a target for A&E patients to be discharged, admitted or transferred within four hours of arrival (DOH 2003). Therfore this management skill of transferring patients is commonly practised.

Once the doctor had decided the patient could be transferred to a medical ward I had to inform the bed manager of this decision giving her a brief handover of what was wrong with the patient so that she could find an appropriate bed in the hospital. Communication is an important aspect of all nursing care which is done through verbal and non-verbal communication and by written documentation (Chandler 1999 p39and Currie 2002 p24). The bed manager notified me of the ward where the patient was to be transferred to. I then called the ward to make sure that they were expecting this patient. I also gave a brief verbal handover this was to make sure that they were aware of the patient they were going to be expecting and so that they could make sure that they had a side room as the patient had MRSA and oxygen available.

This would also avoid any confusion when coming up to the ward. There has been a lot of research on handovers which have looked at the contents Hesse (1983) Liukkonen (1993) and McMahon (1990), duration Matthews (1986), Sherlock (1995) Thurgood (1995) more recently into taped handovers Miller (1998) Mosher and Bontomasi (1996). This literature all conclude that handovers influences the delivery of care efficient handovers mean better patient care. Research conducted by Sexton et al (2004) argues that not all the relevant information is discussed during handover, preventing the delivery of care. However their research had limitations as it was only conducted on one ward in one hospital therefore it cannot be representative to every ward. I informed the other staff members who I was working with of this transfer and informed and supported the patient of what was happening.

I agreed a time for the transfer which helped me prioritise my care and allowed the ward time to get ready for this transfer. Prioritising is a management skill used to assess the most important nursing jobs which needs to be addressed first (Wheeler and Grice 2000 p9). Prioritizing becomes part of a nurses routine in every day practice (Waterworth 2003 p437). Using the management skill of decision making I looked at the skill mix of the staff to be able to decide how nursing skills are best used (Humphreys 1996 p28).

This can be done by using your clinical judgement of the staff and by looking at the grades of the staff available. McElroy et al (1996 p14) concurs with the using clinical judgement to ensure you make the best use of a nurse’s time. It should be recognised that skill mix research is vague. There is research on this area but it mainly looks at grade mix rather than skill mix (Spilsbury and Meyer 2001 p5). One could question skill is more than just a grade, as the grade of the person does not always reflect the experience of the person.

I had to break the tasks down. Ensuring you make sufficient use of the skill mix available to ensure that adequate staff fulfils the tasks to ensure the quality of patient care given is of the highest standard. From a management point this is a very important decision to make as it means that you can try to get the best out of your staff and that it is a way of ensuring all your tasks get complete and the management of clinical risk is not affected (Smith and Valentine 1999 p6). This was achieved by using delegation skills.

Delegation is the process from which responsibility for performing a task is transferred to another person who accepts responsibility for the task. But although you have asked someone else to do the task overall the person delegating the task is still actually accountable (Sullivan and Decker 2005 p144 and NMC 2002 p7). Delegation is an important management process and allows organizations to function resourcefully and successfully with and through others (Ellis and Hartley 2004 p530). Delegation involves assessing the situation, planning your actions, implementing your plan and then evaluating the results. Delegating a task involves good communication skills (Bower 2000 p191).

Delegating work to others has been found to be problematic for some nurses (Hansten and Washburn 1996 p24). I made sure that when delegating the tasks for making sure Betty was ready to be transferred of packing up Betty’s bags, ensuring a property form was to be filled out and that a full set of observations including repeat ECG needed to be done. I made sure that understood to inform me when these tasks had been complete and to inform me immediately if her observations had fallen between normal limits i.e. if her oxygen saturations fell below 92%. I asked them if they had any questions before they began their work. There are four main types of leaderships styles as described by Ellis and Hartley (2004 p495) and Decker and Sullivan (2005 p46) Autocratic, democratic, Laissez-faire and multicratic (see appendix i for explanation of these).


I feel I approached this management issue with a democratic approach. As I asked who wanted to do which task and ensured that there was a two way communication which is typical of a democratic leader. Although this particular type of leadership could encounter problems, as you may be faced with the dilemma of an untrained member of the team wanting to volunteer for a task in which they have not been trained to do. Luckily this did not happen but if I was approached with this problem I would make a suggestion that they maybe consider another task which they are trained to do. However, the NMC (2002 p3) emphasis that a nurse should acknowledge their limitations knowledge and competence so as to decline any duties or responsibilities unless able to perform them in a safe and skilled manner this is in light of patient safety.

Research by Greenwood (1997 p23) and Lockwood-Rayermann (2003 p248) has found that leaders should adopt the style in which they find most comfortable to be an effective leader. It felt strange asking some one more senior than myself to do a task, however despite this I feel I approached delegating the tasks well as delegation is often avoided in junior staff due to this task to be addressed by more senior staff (Hansten and Washburn 1996 p25). I made sure that Betty had analgesia prescribed and any fluids written up prior to the transfer.

The next process in transferring a patient was to inform the relatives of where the patient was moving to. I tried to telephone the patients relatives but got the answer phone. I went back to check that the number was the correct one with the patient. I re-tried the phone number but as it was an answer machine I did not leave a message as there was still a chance that this may not be the correct person’s phone number.

The patient was not happy about being moved to another ward but I explained the situation and explained that this would be where they would stay until they get better. Having reflected on this situation it is hard for patients to understand the pressures that nurse are under and that patients are not aware of the four hour targets. But unfortunately bed movements are necessary to be able to keep to the target. Also I feel that handing over to the staff on the new ward to inform the relatives about where that patient was now going to be was better than leaving a message on the answer phone as this could have just cause more concern for the relatives.

Now that the patient had had her observations all done I had to just assess the risk management in transferring this patient to another ward. Her mews score was at an acceptable level and Blood pressure was stable. I asked the patient if she wanted any pain relief before the transfer took place. I then bleeped a porter to help with the bed move. Gloves and apron where to be worn due to her MRSA status so I informed the porter of this.

Then assessing the clinical need of the patient I decided to transfer the patient and had my mentor attend with me for back up, although I did the complete management of transfer for this patient. I made this decision by again looking at skill mix and prioritising the care it was necessary for a trained member of staff to stay on the ward which only left a healthcare assistant to do the transfer and due to the health needs of my patient I felt it necessary for someone with ore experience and someone who had been given more training could fulfil this task.

As soon as we got to the new ward I settled the patient into her new ward in the side room and made sure that she was comfortable and how to summands a nurses if she needed one. I then gave a full handover to a staff nurses up on the ward and just documented in the notes that the patient had been transferred to a new ward and that I tried to contact the relatives but handed this information over. This is to make sure that the nursing records are up to date to cover if any complaints and show that I was accountable for the transfer of this patient.

On returning to the ward I had to call central team which is the local cleaners to perform an MRSA clean on the room to ensure that this was ready for the next patient. Later on during this shift I had to discharge two patients home. For this I had to make sure that they had there TTO’s (medication to take out) find ref to take home and that they had there keys to get in and a district nurses letter due to the fact that they needed to have a dressing changed later during the week.

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