Putting the proficiencies into practice
The Standards of proficiency for registered nurses state the knowledge, skills, and behaviours that every nurse must have by the end of their programme. The standards are set out in seven sections called 'platforms'.
In addition, there are two annexes in these standards that state the communication and relationship skills nurses must have (Annexe A), and the nursing procedures (Annexe B) they must be able to do when they join our register.
What Isabella did:
Isabella and Jasmine initially met Olivia and it was agreed that they would meet weekly, to set some specific goals for Olivia.
Under direct and indirect supervision Isabella met with Olivia on a weekly basis, in the hospital setting to start with and then in the community. This provided the opportunity to look at the practical applications of the Mental Health Act (1983 amended 2007). In Olivia’s case this included Section 3, and Section 117 for aftercare.
Isabella wanted to keep Olivia safe and found it emotionally challenging to explore the complexities around positive risk taking and risk averse practice. Supporting Olivia to always feel safe was a key goal. Isabella and Olivia explored different ways to manage emotional states, for example, rethinking or reframing of a challenging situation to reduce anger or anxiety, hiding visible signs of sadness or fear, or focusing on reasons to feel happy or calm (emotional coping skills).
Jasmine gave feedback to Isabella about the good rapport and the therapeutic relationship she had developed with Olivia throughout her practice learning experience. Olivia and Isabella were a similar age and they shared common interests and Olivia would often ask Isabella about her studies and her course. Clear professional therapeutic boundaries were maintained throughout. What Isabella learned was recorded in her Practice Assessment Document (PAD).
What this demonstrated:
1.2 understand and apply relevant legal, regulatory and governance requirements, policies, and ethical frameworks, including any mandatory reporting duties, to all areas of practice, differentiating where appropriate between the devolved legislatures of the United Kingdom
1.10 demonstrate resilience and emotional intelligence and be capable of explaining the rationale that influences their judgments and decisions in routine, complex and challenging situations
1.11 communicate effectively using a range of skills and strategies with colleagues and people at all stages of life and with a range of mental, physical, cognitive and behavioural health challenges
1.12 demonstrate the skills and abilities required to support people at all stages of life who are emotionally or physically vulnerable
1.13 demonstrate the skills and abilities required to develop, manage and maintain appropriate relationships with people, their families, carers and colleagues
What Isabella did:
During weekly sessions Isabella and Olivia discussed self-harming behaviours and in particular the ways that she restricted her food and drink. Olivia described feeling powerless most of the time, moving from place to place, and that the only sense of control she experienced was when she stopped eating and drinking.
She also talked about ‘feeling tired, cold and bored’ a lot of the time. Isabella actively listened to Olivia and was able to explore with her the importance of maintaining a healthy balanced diet for her short and long term mental and physical wellbeing. Isabella used some ‘behavioural activation techniques’ (see reflective account for further detail) to enable Olivia to try some activities in the day, and to eat some food to have the energy to do what she wants.
What this demonstrated:
2.1 understand and apply the aims and principles of health promotion, protection and improvement and the prevention of ill health when engaging with people.
2.4 Identify and use all appropriate opportunities, making reasonable adjustments when required, to discuss the impact of smoking, substance and alcohol use, sexual behaviours, diet and exercise on mental, physical and behavioural health and well-being, in the context of people’s individual circumstances.
2.8 explain and demonstrate the use of up-to-date approaches to behaviour change to enable people to use their strengths and expertise and make informed choices when managing their own health and making lifestyle adjustments.
2.10 provide information in accessible ways to help people understand and make decisions about their health, life choices, illness and care.
What Isabella did:
As part of Olivia and Isabella’s meeting for the first time with indirect supervision, Isabella presented her completed five Ps assessment. This was used as a basis to further assess Olivia’s needs and jointly develop a care plan.
Isabella had reflected on Olivia's needs, and when they met Isabella asked her how she had been feeling over the last two weeks. This helped to get an accurate representation of her current situation and any risks.
Using a strength-based approach they explored what Olivia would like to achieve over the course of their six weeks together.
Olivia identified the following:
• I want to get out of here (hospital)
• I need a good night’s sleep.
• To have enough energy to attend the art class at the hospital.
• I want somewhere permanent and nice to live where I feel safe.
• To return to college.
Olivia and Isabella then worked in partnership to develop a person-centred care plan. They worked on identifying the steps that Olivia could take to achieve these goals (for example, emotional coping skills were used). This included her daily activities and routines, food and fluid intake, and her sleep hygiene.
After this meeting Isabella met one of her supervisors, Daniel, and discussed the care plan. They reflected on keeping Olivia in hospital and the increased risks this posed. They also discussed the positive risk-taking approach and any concerns she has about Olivia’s safety. Isabella shared with Daniel the agreed plan to contact Olivia’s social worker to explore future accommodation. Daniel gave Isabella constructive feedback on this assessment and plan of care and commended her proactive and professional approach.
What this demonstrated:
3.4 understand and apply a person-centred approach to nursing care, demonstrating shared assessment, planning, decision making and goal setting when working with people, their families, communities and populations of all ages
3.5 demonstrate the ability to accurately process all information gathered during the assessment process to identify needs for individualised nursing care and develop person-centred evidence-based plans for nursing interventions with agreed goals
3.9 recognise and assess people at risk of harm and the situations that may put them at risk, ensuring prompt action is taken to safeguard those who are vulnerable
3.13 demonstrate an understanding of co-morbidities and the demands of meeting people’s complex nursing and social care needs when prioritising care plans
3.16 demonstrate knowledge of when and how to refer people safely to other professionals or services for clinical intervention or support.
What Isabella did:
As part of their meetings, Olivia completed ‘routine outcome measures’ and ‘service user feedback forms.’ Isabella explained that this is important because it offers an opportunity to evaluate their sessions and reflect on her progress. For example, while filling out the outcome measure, Olivia said she felt able to give honest feedback about the work she and Isabella were doing. They completed the outcome measure on a weekly basis and were able to update the care plan accordingly.
Isabella also had a weekly meeting with her practise assessor, Jasmine, to discuss Isabella’s progress with Olivia’s care. For instance, Olivia described her preference for drawing rather than writing her feelings down, so this was agreed for the next session. As a result, Olivia engaged more openly in her sessions, discussing the pictures and she felt as though she was understood.
After the session with Jasmine, Isabella reflected upon and tried to make sense of Olivia’s emotional pain, which she had been able to express through her drawings. Please see further discussion in the reflective account.
What this demonstrated:
4.1 demonstrate and apply an understanding of what is important to people and how to use this knowledge to ensure their needs for safety, dignity, privacy, comfort and sleep can be met, acting as a role model for others in providing evidence based person-centred care
4.2 work in partnership with people to encourage shared decision making in order to support individuals, their families and carers to manage their own care when appropriate
4.8 demonstrate the knowledge and skills required to identify and initiate appropriate interventions to support people with commonly encountered symptoms including anxiety, confusion, discomfort and pain
4.18 demonstrate the ability to co-ordinate and undertake the processes and procedures involved in routine planning and management of safe discharge home or transfer of people between care settings.
What Isabella did:
Because of her age Olivia is transitioning from CAMHS to adult services. She is currently in hospital under Section 3 of the Mental Health Act (1983 amended 2007) and is entitled to Section 117 after care. Isabella investigated the Mental Health Act (including section 3 and 117), the Care Programme Approach (CPA) processes, the Community Mental Health Framework for Adults (and older adults) and the role of the Care Coordinator. Under the supervision of Daniel, Isabella set up a 117 meeting and invited the relevant MDT members. She was able to demonstrate a better understanding of mental health law, including processes and decision making; some of the local policies and apply them to Olivia’s care and management.
What this demonstrated:
5.1 understand the principles of effective leadership, management, group and organisational dynamics and culture and apply these to team working and decision-making
5.4 demonstrate an understanding of the roles, responsibilities and scope of practice of all members of the nursing and interdisciplinary team and how to make best use of the contributions of others involved in providing care
5.11 effectively and responsibly use a range of digital technologies to access, input, share and apply information and data within teams and between agencies
What Isabella did:
Reflecting on the 5Ps assessment that Isabella and Olivia had carried out, she and Jasmine were able to discuss the risks associated with being in hospital as well as living in the community.
What this demonstrated:
6.1 understand and apply the principles of health and safety legislation and regulations and maintain safe work and care environments
6.3 comply with local and national frameworks, legislation and regulations for assessing, managing and reporting risks, ensuring the appropriate action is taken
6.5 demonstrate the ability to accurately undertake risk assessments in a range of care settings, using a range of contemporary assessment and improvement tools
6.10 apply an understanding of the differences between risk aversion and risk management and how to avoid compromising quality of care and health outcomes.
What Isabella did:
Oliva has made it clear that she doesn’t want to be in hospital and would like to have somewhere nice to live more independently, and have more freedom. To meet these needs Isabella set up a 117 meeting to arrange aftercare following discharge from hospital. To do this Isabella contacted all members of the wider MDT, working in partnership throughout.
Given that the 117 meeting is a legal requirement under the Mental Health Act (1983 amended 2007) Isabella was able to demonstrate understanding and application of health legislation and policy. After doing some further reading Isabella was able to discuss with Jasmine that the Mental Health Act relates to the laws in England and Wales and are not the same in Scotland and Northern Ireland.
What this demonstrated:
7.1 understand and apply the principles of partnership, collaboration and interagency working across all relevant sectors
7.2 understand health legislation and current health and social care policies, and the mechanisms involved in influencing policy development and change, differentiating where appropriate between the devolved legislatures of the United Kingdom
7.8 understand the principles and processes involved in supporting people and families with a range of care needs to maintain optimal independence and avoid unnecessary interventions and disruptions to their lives
7.10 understand the principles and processes involved in planning and facilitating the safe discharge and transition of people between caseloads, settings and services
7.11 demonstrate the ability to identify and manage risks and take proactive measures to improve the quality of care and services when needed.
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