Healthcare workers experience stress in performing their respective jobs. Oftentimes, when the situation is no longer bearable, most of these workers, quit their jobs. This section is a review of literature regarding stress being experienced by nurses as well as other health workers. This will tackle the sources of this stress as well as its effects on the workers’ job performance. There will also be literature regarding the prevention and possible solution to address the pressing concern.

Sources of Work Related Stress

The experience of stress represents a psychological state. It can result from exposure, or threat of exposure, both to the more tangible workplace hazards and to the psycho-social hazards of work. The experience of stress is one important outcome of exposure to the hazards of work and to hazardous situations. Those hazards of work which are associated with the experience of stress are often termed stressors. Applied directly to nursing, contemporary theories of stress suggest that a situation which is typically experienced as stressful is perceived to involve work demands which are threatening or which are not well matched to the knowledge, skills and ability to cope of the nurses involved, or work which does not fulfill their needs, especially where those nurses have little control over work and receive little support at work or outside of work (Cox and Griffiths 1996).

Rodham and Bell (2002) investigated the perceptions and practices of junior healthcare managers with regards to work stress. The results showed that their practices and perceptions have a culture of acceptance and expectation of stress at work. There is also a combination of lack of awareness in effectively and proactively managing this stress.

In a study conducted by Al-Omar (2003), it showed that insufficient technical facilities, absence of appreciation, long working hours, and short breaks were factors contributing to the variations in the level of work stress in hospital staff of Saudi MOH. The study also revealed that Saudi national employees show a higher level of stress at work rather than those not from Saudi. Other factors were also found to be correlated with work stress. These factors are occurrence of health problems, changing the hospital, changing the job, quitting the practice, and undesired relationship with coworkers.

In understanding the different context of stress in various cultural perceptions, Andal (2006) explored the stress levels of Filipino registered nurses working abroad. In her study, the identified nurse stressors are death and dying, conflict with physicians, inadequate preparation, problems with peers, problems with supervisors, workload, uncertainty concerning treatment, patients and their families, and discrimination. Similarly, Michie, Ridout, and Johnstone (1996) used the Nurse Stress Index (NSI), in determining the stress in nursing with patient’s satisfaction. The study showed that the pressures from coping with their patients as well as their relatives reflect three main problems: nurses’ ambivalence about dealing with death and dying; the growing problem of violence in nursing; and problems with nurse-patient relationships. It was also found out that the different conflict at home and at work are important sources of stress in the nursing profession.

A similar study conducted by McVicar (2003) identified the main sources of stress of nurses for many years. Among these are workload, leadership/management style, professional conflict and emotional cost of caring. The other causes perceived are the lack of reward and shift working. It is recommended that stress intervention measures should focus on stress prevention for individuals as well as tackling organizational issues.

Gelsema, Maes and Akerboom (2005) discussed the determinants of stress in the nursing profession. In 51 studies they have compiled from 1990-2005, it included psychological, behavioral and attitudinal stress indicators. These indicators have variety of outcomes such as job satisfaction, health complaints, absenteeism, and turnover. Challenging work, supervisor support, control and coping have been found out to alter the effects of a stressful work environment.

With regards to nurse working in psychiatric units, a review showed that a variety of factors are influencing the stress factors and job satisfaction of nurses. Particularly important to these are clinical leadership and quality inter-professional collaboration. It was found out that the job satisfaction of nurses is influenced by psychological stress and the quality of the clinical leadership (Konstantinos and Ouzouni 2008).

In a study conducted by AbuAlRub (2004) regarding the effect of stress on the job performance of nurses, as well as the relevance of support system, it was found out that social support system is important at the workplace as it enhances the level of job performance and decreases the level job stress being reported. The results also demonstrate that nurses that are reported with moderate level of job stress perform their jobs better rather than those with high or low level of stress.

Taylor, White and Muncer (1999) conducted an examination of the causes of stress of the nurses assigned in the National Health Service in England. Results were consistent with other studies. However, there were two ver significant causes for this particular case. The first one is the inadequate staffing levels which lead to the poor attitude and abilities among the staff. The second one is the relation of the patient’s suffering which affects the healthworkers’ stress level.

Jaracz, Gorna and Konieczna (2005) evaluated professional burnout among hospital nurses and its correlation on the perceive stress and styles in coping. The study concluded that the level of stress influences the professional burnout among nurses. There is diversity in the level of burnout depending on the specialization at work, which is not accompanied by a similar diversity in the subjectively perceived stress. The correlation between burnout and a coping style is rather weak, but statistically significant.

Zeytinoglu et al (2007) showed that nurse’s feel stressed and moderately satisfied with their jobs. Other factors aside from work intensification affect the stress of nurses. First, focusing on stress as an individual worker outcome, our results show that nurses who prefer to be employed in a different job status, such as working part-time but wanting to work full-time, are also the ones reporting stress. Nurses who continue to be employed in their jobs because of the importance of their income for their family’s economic well-being also report symptoms of stress. Heavy workload and perceived lack of organizational support are additional factors contributing to nurses’ increased stress. These factors constitute 27% of a nurses’ stress in Ontario, Canada.

The relation of problem-solving confidence, perceived tolerance, and situation-specific coping efforts to occupational burnout was examined among nurses in physical rehabilitation units. Consistent with predictions, confidence in one’s ability to handle problems and perceived tolerance were significantly predictive of lower burnout scores, regardless of time spent on the job. Of the coping variables, emotion-focused coping was significantly associated with higher burnout scores (Elliott et al 1996).

Respondents from Certified Registered Nurse Anesthetists (CRNA) showed that a broader scope of practice experience an increase in the job stress in relation to overload of responsibilities, however, they use coping resources effectively (Alves, 2005).

Critical care nurses experienced high levels of stress .The areas that produced the most stress varied depending on work in the ED or the ICU. Most of the stressors from the ED were the result of patient care, particularly from chronic and/or unstable patients. Most ICU stressors were the result of management of the unit, particularly inadequate staffing .The most frequently used coping skills by both the ED and ICU were the use of humor and talking about stressors with others. Nurses in the ED and ICU experienced comparable amounts of feelings of burnout according to the findings. The ED reported a wide range of emotional exhaustion, while ICU reported medium levels of emotional exhaustion. The ED reported med-high levels of depersonalization, while the ICU reported low-med levels of depersonalization. The majority of ED and ICU nurses expressed medium levels of personal accomplishment. These findings were congruent with much of the research available on stress and burnout in critical care nurses (Mims and Stanford 2004).

Stress levels, psychological distress and life events are all associated within time and across time. At baseline, life events and stress contributed significantly to psychological distress. The pattern of psychological distress differed between the nursing students and the newly qualified nurses with a high level in the nurses after qualifying and starting their career. Stress, individual traits, adverse life events and psychological distress are all interrelated. Future lines of enquiry should focus on the transition between being a nursing student and becoming a nurse (Watson, et al 2008).

Effects of Stress in the Workplace

Mojoyinola (2008) investigated the effects of work related stress in the workplace specifically in Ibadan Metropolis, Nigeria. The study established that job stress has significant effect on physical and mental health of the nurses. It also established that there was a significant difference in personal and work behaviour of highly stressed nurses and less stressed nurses. Based on these findings, it was recommended that the government (Federal or State) and Hospital Management Boards should improve the welfare of the nurses. It was also recommended that their morale should be boosted by involving them in policy or decision-making concerning their welfare or care of their patients. Their salary should be reviewed and that they should be promoted as at when due.

The effect of work stress in menstrual patterns of nurses in American and Italian nurses were studied Hatch, Talamanca and Salerno (1999). In their study, it showed that American nurses, especially those assigned to high stress units, had an increased risk for long and monophasic cycles. The similar pattern was also observed from the Italian nurses. In addition, the rotating shift work pattern prevalent in the Italian group was possibly associated with higher rates of short cycles and inadequate luteal phases when compared with those of nurses working fixed shifts either day or night.

Peterson (2009) investigated the relationship of job stress, job satisfaction and the workers’ intention in leaving. The results showed that the main effects of job demands, social support and self-efficacy provided partial support for the JDC-S model when examining job stress, job satisfaction and intention to leave the job. Only self-efficacy was significantly related to intention to leave the profession. There was no evidence of moderating effects of social support or self-efficacy. An understanding of factors in the work environment that influence new nurses may assist in supporting them during the transition. By exploring the effects of demands, control, social support and self-efficacy on new graduates‟ job stress, job satisfaction and intention to leave. Similarly, Williams (2003) investigated the same subject matter. The study showed correlation between the jobs related stress of nurses and their intention to leave.

Methods to Reduce and Address the Stress Concern

According to Conner and Ulrich (1999), Human Resources face the most important challenge of today which is managing organizational change. There is no industry perhaps that needs rapid change other than healthcare industry (Lowery 1997).

In a study by Lewandowski (2003), she noted that organizational factors affect workers’ frustrations and to some extent, burnt outs. To address these concerns, she recommended empowerment strategies for management of the workforce. Supervisors can engage with a dialogue with their staff to suggest improvements that can help in decreasing frustrations in the workplace. These discussions could include but not limit to both work conditions and ways in how to improve services. Strategies that serve client empowerment could have the benefit of providing the workers with a rewarding work environment. Working towards the organizational change with the clients, according to Lewandowski, is a more potent antidote to the sense of isolation and powerlessness experienced by workers.

In the article of Abbasi and Hollman (2000), they examined the cause of turnover in the workplace. Among the causes that they noted are the hiring processes, managerial style, lack of employee recognition, lack of competitive compensation system, and toxic workplace environment. With these mentioned causes, they noted recommendations to address the same. First, the employers should provide strong leadership in an environment with a runway pace, change is constant and uncertainty is never ending. Managers should be required of ingenuity and strategic wisdom to a greater degree in managing the workforce. They must always keep in mind that the employees are the major contributors in the efficient achievement of an organization’s goals. Hiring and training the right people is very important, as well as adapting managerial styles that are appropriate for today’s workers. Employee recognition should also be practiced as well as compensating superior performances and creating a non-toxic and productive working environment.

Mimura and Griffiths (2006) reviewed the current approach in the stress intervention of nurses. These are stress management programs that are being conducted in the nursing profession. The review showed that the programs show more effectiveness basing on the provision of personal support than environmental management for the reduction of stress.

Davis, et al (2005) studied the effect of aromatherapy massage with music on the stress and anxiety levels of emergency nurses. The findings indicate that aromatherapy massage and music significantly reduced anxiety levels. Regular on-site aromatherapy massage with music has the potential to increase the job satisfaction of the staff and decrease the number of sick leave.

Mackenzie, Poulin, and Carlson (2005) investigated the effectiveness of brief mindfulness-based stress reduction intervention. The results showed that together with a natural fit between mindfulness philosophies and nursing practice theory, suggest that mindfulness training is a promising method for helping those in the nursing profession manages stress, even when provided in a brief format.

Judkins and Ingram proposed a long-term solution for decreasing stress among nurse managers. Use of an education module can be effective by increasing knowledge of stress and hardiness, and increasing hardiness levels. Through increased hardiness among managers and staff, organizations can expect higher levels of commitment, more involvement of staff in workplace issues, and greater receptivity to changes in work environment.

In a study conducted by Zarowin (2001), he examined the ways on how to keep the best employees for the coming century and to re-model the corporate benefits to be able to meet the need of the new workforce. The first way according to Zarowin, is the crafting of new package dividends. These packages are benefits more enriched with programs tailored-fit to an individual’s needs. While the study did not specifically measure the pay back it was reported that year after year absenteeism and turnover rates were lowered. Another note that was emphasized is family-support packages especially with female workers with dependents. Based on the study, this kind of programs often creates an affirmative response from workers in continuing their tenure in the healthcare organization where they belong. The third note emphasized by Zarowin is the adapting non-traditional work schedules such as flexitime schedules, part-time contracts, job sharing and others. Finally, he emphasized that employers need to focus on the importance of communication in the workplace.

Arandelovic and Ilic (2006) studied possible prevention of stress in the workplace. It is generally agreed that improving the ability to cope with stress is a valuable strategy in the process of combating stress. Once the existence of stress has been recognized and the stressors identified, action to deal with stress should be taken. Intervention of the external socioeconomic environment, intervention on technology and work organization, intervention in working place and task structure, intervention to improve individual responses and behaviour, specific intervention for health protection and promotion.

Strategies for Retention of Nurses

The most obvious result of nurses’ stress is just to quit their jobs. This worst case scenario can be prevented. A healthcare organization that has good employees’ retention policies, is able to reduce the employees intention to quit, and subsequent turnover, thereby saving organizations the considerable financial cost and effort involved in the recruitment, use of vicars, induction and training of replacement staff.

Several organizations have distinct ways in retaining employees. The Healthcare Industry can pattern these strategies. Denton (1992) wrote an article about how Federal Express keeps the loyalty of their employers. Based on the article, one of the company’s key is the advancements after hiring. Career advancement of employees is enforced, as well as incentive programs that help their people to become motivated. Acknowledgment of employees’ efforts is also practiced which is essential, according to the officers of Federal Express, in keeping the employees satisfied with their work. The company is also open in the suggestions of their employees and in fact gives awards to the best suggestions. Another key for the employee retention is the open communication between employers and employees. They use various kinds of techniques such as message boards and feedback forms. According to Denton (1992), Federal Express’ ways in retaining employees are worth emphasizing; however, these are not the only ones. Their strategies may not be appropriate for all organizations, but one main point is universal. If organizations want to keep their employees, it must think of comprehensive ways on how to keep the employees fit and involved in the workplace so that they will not quit.

According to Risher and Stopper (2002), successful organizations understand the dimensions of commitment in retaining its workforce. These organizations promote a sense of inclusion and camaraderie in all workers; membership and pride that include the use of language and rituals; security and fairness; fulfilment and growth; and economic interdependence.

Langan (2002) states that to address the issue of retention, employers are opting to adapt the new employee incentive system. Employers find that in combining traditional salary and additional benefits package and other highly desirable benefits of employment, they are able to attract and retain employees. In some employment settings, employees are offered with such conveniences.

As Wiggins (1998), wrote in his article, “On Keeping Good Employees”, he enumerated pointers for the subject matter: discover the things that the employee don’t like and get rid of these as many as possible; give emotional rewards generously for good works; compensate them properly; clam on the silver handcuffs; be as flexible as possible; remove the abusive people fast; promote only the best employees; try to talk them out of quitting.

Permission for use of Leslie’s (ficticious name) case notes was granted verbally from the director of Nursing following a letter of application for same (appendix 1).

Due to restrictions on word count ,a full and more comprehensive case history of Leslie’s journey during the last three months of his life will be included as an appendix (appendix 2).

Definition of pain:’ An unpleasant sensory and emotional experience associated with actual potential tissue damage or described in terms of such damage’.(2) Suffering may be caused by not only physical pain but also the phychological ,social or spiritual distress associated with illness.(6)

The case study that I have chosen for this assignment is a 60year old man who was admitted to our unit for palliative care. Leslie suffered not only physical pain but his psychological and social pain were also of great concern. Through the reflection of the assessment , evaluation and treatment of his holistic pain it is hoped to demonstrate the importance of these concepts and how they are intertwined. For the purpose of the assignment to enhance clarity each aspect of his total pain will be discussed separately with reference to the tremendous overlap which exists between physical psychological social and spiritual pain (5)

Leslie, a 60 year old man widowed but living with his partner Bridget for the past 13 years was admitted to the ward from home following a sudden deterioration, he was in a semi comatosed state and unresponsive..He was first diagnosed in 2004 with colonic carcinoma which was surgically removed. He had reoccurrence with liver metastases 18 months later, which was also treated surgically and made a good recovery. In 2007 he was diagnosed with metastases of the lung, bone and brain and was treated with radium, dexamethasone and zometia .He had commenced Palliative third line treatment of oral Capecitabine one month before admission.

He was accompanied by his partner Bridget who was his main carer .Leslie had one daughter to whom he was also very close. Leslies admission assessment was taken from the GP’s referral letter ,homecare team correspondence and information from his partner who was obviously distressed due to his sudden deterioration. Leslies daughter Claire visited later and requested that she be also listed as next of kin.

Physical pain

Leslie was commenced on a Graseby syringe driver by the homecare team prior to his admission of morphine sulphate 10mgs and buscopan 40mgs. He had been suffering abdominal pain which Bridget stated was described by Leslie as a pressure type pain right across his lower abdomen which caused him discomfort but was well controlled on morphine 10mgs bd. This noceciptive visceral type chronic pain of moderate severity was attributed to his disease progression and generally responds well to opioids and anti-inflammatory drugs.(10) Leslie’s dexamethasone was increased from 4mgs to 6mgs daily as its effectiveness as a multipurpose adjuvant analgesic in advanced cancer is well recognised by its modification of the disease process resulting in reduced pain(6,7) The World Health Organisational ladder was instrumential in standardizing and giving clear and simple guidance in the administration of analgesia,at regular intervals and in a stepwise fashion(25)

. Over the next two weeks Leslie’s condition improved , he regained consciousness and began to take oral fluids. His pain was assessed as it is essential to relieve pain and suffering that accurate and continuous pain assessment is adhered to(8) The Bieri Faces Pain Scale (FPS) tool (appendix 3) which is useful for verbal and non- verbal assessment was used as per hospital guidelines. This pain scale was developed to measure pain intensity in children and its usefulness in the palliative care patient is questionable.(8)It is a unidimensional tool that only assesses pain intensity using a visual analogue scale(VAS) of seven faces and a numerical rating scale (NRS)of 0 -10.(ref)and so is very restrictive and lacking in information. An expert working group of the European Asociation for palliative care (EAPC)reviewed the status of pain measurement tools(PMT) in palliative care research and recommended the Bieri Faces scale for children.(9). However in adult patients such as Leslie with no cognitive impairment ,the Brief Pain Inventory(BPI) ‘Short Form PMT was advised (9)(appendix 4), The BPI is multidimensional and addresses pain etiology, history, intensity, quality, location and effects on activities.(8)It uses the NRS to assess the effects of pain on a range of daily activities and this is recommended over the VAS or the VRS due to evidence of better compliance.(9)The location, cause and duration of the pain relief is also included. (8) The Edmond Symptom assessment tool (ESST)is also recommended for use in palliative care settings and has been identified as being a simple and effective tool for regular assessment in symptom distress (19) It assesses symptoms such as energy , nausea, depression , anxiety, drowsiness, appetite, constipation ,dysponea and overall feeling of well being which results in an overall symptom distress score. However despite a large number of pain assessment tools available( ref)there are none that deal specifically with all the dimensions necessary for palliative care patients and an international standard is needed for palliative care pain assessment.(11)

Breakthrough Pain

On regaining consciousness Leslie had no complaints of pain when assessed at rest but complained of pain on movement.This was identified as breakthrough pain as it This he scored as 5-7 on the faces pain scale and he described it as a sharp type pain radiating to his right shoulder lasting 10 to 15 mins when mobilising from the bed to the chair. On assessment it was felt that this radiating pain was due to his infrahepatic disease causing diaphragmatic irritation due to compression of visceral structures. This incidental volitional type breakthrough pain made Leslies mobility difficult and was causing him anxiety due to its severity and causing increasing loss of independence. Oramorph 10mgs was administered initially when Leslie complained of pain after mobility and was effective but onset of action did not occur for 20-30mins with full analgesic effect only after 60 mins (24).Because Leslies pain was predictable and therefore best managed prophylactically(23) ,he was commenced on pecfent 100mcg prior to transferring from the bed to the chair as pecfent provides pain relief within 5mins from administration with clinical meaningful pain relief from 10mins lasting up to 60mins.(22) The dosage was increased to 200mcg(2 nasal sprays) as a repeat dose cannot be given for 4 hours(22) and this increase allowed Leslie to mobilise with the use of a zimmer frame and with the assistance of the physio .His pain was well controlled with scores of 0-2 on the visual analogue faces pain scale .Assessment of the temporal pattern of Leslies breakthrough pain was not possible on the Bieri Faces Pain scale and the inclusion of this aspect of pain on current pain assessment tools is extremely limited.(31) However the Alberta Breakthrough Pain Assessment Tool for Cancer patients has been developed in Canada for research purposes and it is hoped that this tool will become more widely used internationally. (31)

.Social Pain

While recognising the patients right to privacy it is necessary as stated by Pederson in order to address issues of concern that every effort is made to help the patient overcome the fear, embarrassment or simple inability to recongnise what needs to be said.(1) With gentle guideing on questions and the use of therapeutic communication, Leslie spoke about his feelings of anxiety due to loss of physical independence and financial security ,but it was evident that the poor relationship between his daughter and partner was causing him grave anxiety , his feelings of loneliness at’ leaving them’ and’ how long more did he have? ‘.concerned about the relationship between his partner and daughter which had become apparent to staff from the lack of communication between them.

His wife had died from cancer when his daughter Jennifer was only 10 years old and she was now 22yrs and had a very close bond with her father .She never accepted his partner Biddy and they had not spoken for years. This disharmony was the reason Leslie never married Biddy . On gently prompting Leslie about his legal affairs ,he revealed that he had not made a will , On posing the question to Leslie towards his knowledge of his condition, while he recongnised that ‘ things didn’t look good ‘ he expressed a strong wish for an appointment to see his oncologist .He had grave concerns about loosing his autonmy and independence

Psychological Pain

Leslies social pain was causing him alot of psychological distress . Helping Leslie express his fears and anxieties was recognised by the staff as paramount in helping him address issues of concern. ‘.His awareness and concern that he had not made a will due his fear of’ not doing right by everyone’ was causing him increasing stress and anxiety and had him preoccupied and withdrawn. This type of suffering which is driven by psychological distress , threatens the integrity of the person and can have a huge effect on how physical pain is perceived and dealth with.(21) These psychosocial factors also have a direct effect on sleep(14) and fatigue(15) in advanced cancer patients and Leslie was experiencing both these symptoms. Leslies suffered from sleep disturbance and early waking and an overwhelming feeling of mental and physical fatigue .Palliative care assessment forms should be designed to elicit information on symptoms such as sleep and fatigue to ensure early intervention. While many tools such as The Edmonton Symptom Assessment System do include these symptoms, their assessment is confined to a single question and are therefore inadequate.(14.15) Fatigue and anxiety have a negative impact on quality of life (QoL) and assessment of severity should be systematic and mandatory (16) Maintaining a good QoL is central to the ethos of palliative care and therefore management of these symptoms should be paramount in the palliative care setting(17)

(Qol ass. Tools and desktop article on ESST)

Leslies awareness of his deteriorating condition and the uncertainty of the future was also causing him psychological distress and this aspect of distress generally escalates as patients experience subsequent diagnosis of cancer reoccurance.(18)and can cause great anxiety and depression(20)A family meeting was initiated and Leslie spoke openly about his fears and anxieties. There were three positive pactical decissions agreed 1. that an appointment would be made for Leslie to see his oncologist to discuss his prognosis and 2. arrangements would be made for Leslie to make a will. 3that following family discussions a decission would be made as to wheather Bridgt or Claire would be the main family contact for Leslies care and that all information would be communicated to the other family members through that person.

Prior to making his will, Leslie became very anxious ,his breakthrough pain relief was less effective and following further assessment and consultation was increased to pecfent 400 mcgs prior to mobilisation. His appetite decreased and his sleep pattern disimproved. This requirement for extra analgesia it was felt was due to his deteriorating condition but as expressed by Skevington as one of the most consistant findings when considering how psychological factors contribute to the aetiology of cancer pain is that emotional distress has a huge impact on how the patient experiences pain and how effective the response to treatment will be.(29)Enabling the resident to express his fears and concerns and providing information and help to allay those fears can ease anxieties and associated physical and psychological symptoms.(30)

Spiritual Pain

‘Conceptualizations of spirituality often include the following as aspects of spirituality: the need for purpose and meaning, forgiveness, love and relatedness, hope, creativity,and religious faith and its expression’ (28)p581

Spiritual needs are well recognised and documented in the ‘total care’ context of palliative care principals and its importance in end of life care (26)Assessing spiritulality is essential in providing spiritual care and can be the most important aspect of patient need when death is imminent.(28) However while there are many models for spiritual assessment there are no validated assessment tool (32) .The European Organisation for Research and Treatment of Cancer Qol group began in 2001 to develop a spiritual assessment tool, but the individual concept of what spirituality means and the difficulty in defining spirituality makes the formulation of a standerdized assessment tool difficult.(27)Parhaps spirituality shoud be more ……ref red book

Leslie described himself as religious, a member of the Church of Ireland but partook in all religious cermonies on the ward regardless of denomination. Through the act of active listening and assessing non verbal indicators it was apparent that spirituality to Leslie was synonymous with his values and relationships as much as his religious affiliation. He loved conversation , had a wide circle of friends and his tolerance and endurance of his illness portrayed an acceptance and selfless attitude towards life and death .He was visited by his rector on a weekly basis and obviously had a strong relationship which was based on the mutual love of motorbikes and dogs. This rapport was invaluable when Leslie was faced with difficult decisions about his family relationships and later when death was imminent.

Conclusion

Despite the major emphasis of physical pain in palliative care there is a greater awareness of the effects of As stated in the World Health Organisation definition of palliative care early detection and impeccable assessment and treatment of psychological, spiritual and social pain are included with that of physical pain.(12)

Leslie felt a great sense of peace having resolved his financial issues and in doing so had witnessed closure to his fears and anxieties through a more open relationship with Claire and Bridget. The act of making a will ,leaving a legacy ,witnessing the reconciliation of relationships between Biddy and Claire and the oppertunity to say goodbye to loved ones had a huge impact on the quality of life and death that he experienced while in our care.

Education and the resources necessary to incorporate practical psychological pain management strategies such as cognitive therapies and psychological pain management methods into the present health system is a major challenge(13)These therapies can be incorporated as adjuvant therapies in the WHO analgesic ladder.(13) While there is greater awareness of the significance of .with the first psycooncologist unit in st james hosp (20) …since the first writings of cicely saunders on total pain it is a well documented but poorly resourced concept.

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(20)Collier S. Dr Sonya Collier.Irish Independent.2011 Feb 21; p. 10

*(21)Portenoy RK. Mathur G. Cancer Pain chapter 8 in Yeung SCJ. Escalante CP. Gagel RF. Medical Care of Cancer Patients :Peoples Medical Publishing House, Shelton ,Connecticut. 2009 p. 60

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Reflective account of on-going nursing training programme

This essay is a reflective account on the progress I have made during the on-going nursing training programme I have embarked upon. The areas I intend to cover include the usefulness of assessment feedback for facilitating growth and for understanding the areas that need to be improved in my learning, the extent of the development of key transferable skills, an overview of meetings with my personal development tutor and issues related to my personal learning. Finally, areas for future development will be identified with a view on how to address them, all of which will go towards improving my personal and indeed professional development.

Individuals may spend a lot of time thinking over experiences they have had and things they have to do. However, within nursing it is believed that in order to progress, these thoughts should be turned into guided reflection enabling one to improve them in the future. The essential purpose of reflective practice is to enable the practitioner to access, understand and learn through, his or her lived experiences and, as a consequence, to take ‘congruent action towards developing increasing effectiveness within the context of what is understood as desirable practice’ (Johns 2000, p3).

As a mature student with experience of an access course I felt I had developed self-discipline, which is important for effective learning. Throughout this course I have gradually developed strength and confidence in all the transferable skills, such as communication, effective learning, and teamwork and information technology. These skills have been developed through both the coursework and the placement.. I felt confident about my verbal communication whereas I was concerned about my literacy skills which are impeded by my dyslexia. In my case dyslexia results in poor spelling, grammatical errors and difficulties with organising work. It should not affect my understanding of my subject, although it can take me time to absorb what I read.

The course has helped me to recognize the importance of all aspects of communication, both verbal and non-verbal, such as body language, touch, facial expression and eye contact. It has shown me how crucial non-verbal communication can be in expressing meaning. During my placement visit at the hospital I put into practice my communication skills which enabled me to interact with people from different cultures and backgrounds. For example, while I was working in the ward with a staff nurse, I observed through facial expression that a patient was in pain. I went over to ask her what the problem was. She told me she was in pain. I immediately reported it to the nurse in charge. After this, I made her comfortable and continued to communicate with the patients. From this scenario I have learnt that good communication skills are important in delivering health care services. Good therapeutic communication can help to relieve patient pain and anxiety.

I believe the best way of learning is to become an autonomous learner which in itself requires good communication skills and discipline. During this course, I have developed good time management skills, especially for meeting deadlines in submission of assignments and for combining studying with domestic demands. Initially, accessing the internet and using the electronic searching method was a bit difficult but it became clearer with the help of the IT workshop. It also helped greatly when finding articles needed for annotated bibliography assignment. Having to do presentations is another effective way of learning because it provides an opportunity to research the topic and then teach others. I prepared a research presentation and I knew little about the components that would make the type of presentation successful. I experienced some nervousness because I find it difficult to face an audience and deliver a speech but with the help of the tutor’s feedback I am beginning to work on my fears and confidence by becoming involved in group discussion.

My IT skills have improved quite considerably since the beginning of this module. I knew how to use e-mail, Microsoft word and various ways to search for information. The IT sessions have contributed greatly, so much, now have the confidence to use the internet regularly. I have also learnt how to use database and PowerPoint I will continue to build on what I have learnt and improve on it because the technology is updating frequently and it is necessary to keep up with this trend. (See appendix).

Carrying out a literature search during an assignment, taught me how to use the search engines using keywords in order to find relevant articles. Carrying out a literature review has given me an insight into what research involves the ways in which research can be carried out and the different methodology that is used. I now understand that academic articles are peer reviewed before being published in reputable journals.

Assessment feedback is an important part of learning. It gives the student an awareness of what they can do and what needs to be improved, in both written and practical work Whilst evaluating my feedback sheet on the role and function of health related organization, Module IPH1625, I felt that the mark received was above my expectations which left me feeling positive and motivated to continue the good steady progress. I found the research section of the essay quite challenging and spent many hours preparing my essay. Fortunately the organization that I had picked was of great interest to me as British heart foundation was an organization that dealt and helped people from all walks of life. The fact that this topic was of interest to me made it much easier for me to discuss and write about it with passion, and I could really express how I felt about the issues involved. Through the feedback received, I realized that I had addressed all areas of the marking criteria to an effective level. Having not previously shown my work to my module leader, to my surprise the contents of my work was above standard and very well done. My dyslexia is a worry regarding typographical errors which I may not notice. To combat this I used the computers grammatical and spelling checkers as well as showing my essays to my dyslexia tutor who helped me to proof reading. I was thrilled to see that in the feedback given, my grammar, spelling and punctuation was not seen as a problem. It is very motivating to receive this kind of feedback and the self satisfaction left me with a positive feeling which I hoped to maintain. (See appendix)

My first learning stage was the novice level which Benner (2001, p20) described as ‘beginners who had no experience or skills to practice in the situation in which they are expected to perform’. At this stage of my learning I had limited knowledge and understanding of patient condition as well as the environment in which care is delivered. This made me anxious and nervous. My culture (which forbids me from addressing an elderly person by name) inhibited my ability to communicate effectively with patients and various members of staff. This problem was due to lack of previous experience in caring for patient and lack of understanding of the situation in which am expected to perform. My knowledge regarding patient’s illness or disease process was lacking. Hence I did not know how to assess or carry out patient admissions or pain assessments. For example, when patients complained of pain I always informed my mentor instead of carrying out a pain assessment to identify factors which may be contributing to the pain.

However, I constantly relied on my mentor for guidance. Through advice, feedback on my performances and by observing my mentors and other members of staff, I was able to develop strategies on how to overcome communication problems on my next placement. During this placement I was able to reassure patients, carry out pain assessment, monitor and record vital signs (under clinical supervision) as well as understand their implications for patients’ care. Although I had developed confidence in clinical skills in my first placement, there was an increase in my confidence during my second. There was an increase in learning, however, my skills and knowledge within this domain were still limited. I still relied on general guidelines or instructions given to me by my mentor on how to execute some of the duties delegated to me. As a result I could not use my initiatives to prioritize or plan care appropriately or make sound judgment regarding the care which I was giving to patients. My communication skills also improved as I was able to listen and reassure patients, carry out pain assessments. In the future I hope to ensure effective communication in my daily activities, building on my strengths until I become competent in my communication skills, and able to identify potential problems and difficulties and ways to find solutions to the problem. (See appendix)

The advanced beginners’ level was the second level of my learning. As explained by Benner (2001, p22) ‘the advance beginner is one who can demonstrate marginally accepted performance; one who has coped with enough real situations to note the reoccurring meaningful situational components’. In relation to performing at this level, the status quo is that the theory sessions are in the final stages, after which we would move into placement, where yet again I would have the opportunity to relate acquired theoretical knowledge to practice.

Personally, I have found that the various placements were the biggest learning curve for me and influenced my learning immensely. I feel that I have performed well, as I have done things that I had never done before such as taking measurements of blood pressure, giving injections, and administrating the correct medication. The biggest impact on me was the learning disability placement. I felt that this is where I really put my communication skills into practice. I found learning disability extremely interesting and at the same time challenging. One of the major challenges I encountered was the aggressive behavior of the patient. I learnt the importance of being patient and to try to understand what is making them angry in order to calm them down. Sometimes medication is needed for this. (See appendix)

Meeting with my Personal development tutor (PDT) has been extremely useful; at the first meeting we met as a group which we had an open discussion on learning, teaching approaches and available learning support. My second meeting was one to one and I was able to express the problems I faced with modules in terms of understanding prospective assignments and in selecting textbooks which are user friendly to facilitate introduction to new areas of knowledge. It was also a good opportunity for me to discuss issues encountered during placement, in relation to my experiences, which included difficulties as well. I generally found these meeting to be useful because it was and still is an avenue for me to discuss and analyse both personal and professional development. (See appendix)

On reflection I can see that I was able to achieve the above nursing needs of patient due to 12 months of acquired knowledge and experiences. In progressing through the stages of skill acquisition, reflecting enabled me to gain new ideas, insights, understanding of clinical practice and I was able to change and improve my practice as I progressed. This ability is vital for personal and professional development. By reflecting I developed reflective skills such as self-awareness, ability to describe, critically analyze, synthesize and evaluate (Bulman and Schutz 2004, p10).

‘Self improvement builds on awareness’ (Moon 1999, p14). Learning is a lifelong process of discovering what is not known and recognition of learning needs is the basis for further development. NMC code of conduct and the life long learning document requires one to be able to recognize when further learning and development may be required. The NMC’s PREP (2001, p7) requires registered nurses to keep up to date with new development and to go for courses that are relevant to the practice area so as to ‘deliver care based on current evidence, best practice and, where applicable, validate research when it is available (NMC 2002, p5).

I would like to continue building on my nursing competency so as to increase my knowledge and skills. Achieving this will be through practice and self-directed learning, as well as through clinical supervision which provides support for the student; this will help me in further development of skills, knowledge and enable me to enhance my understanding in practice area. I will also further my education to degree level.

In conclusion, I have critically demonstrated how my learning has evolved from novice to advanced beginner of nursing. I have also planned to continue to maintain my personal and professional development by engaging in regular learning activities and also updating my professional portfolio. Furthermore, I will continue to acquire more knowledge to prepare me to face professional challenges, especially in the area of decision making, and the ability to spot opportunities and utilise them. I have an understanding of and confidence in my chosen profession as adult nurse. I want to see learning as part of me; learning new skills everyday is a lifelong experience. Reflective practice will not only improve the quality of care I give but also enhance my personal and professional development thus helping me to close the gap between theory and practice.

REFERENCES

Benner, P. (2001). From Novice to Expert. Excellence and Power in Clinical Nursing Practice. (commemorative edition). New Jersey: Prentice Hall.

Bulman, C. & Schutz, S. (2004). Reflective Practice in Nursing. (3rd ed.). Oxford: Blackwell Publishing.

Johns, P. (2004). Becoming a Reflective Practitioner. (2nd ed.). India: Blackwell Publishing.

Moon, J.A. (1999). Reflection in Learning and Professional Development. London:

Kogan Page.

NMC. (2001). The PREP handbook. London: NMC.

NMC. (2002). Code of Professional Conduct. London: NMC.

Appendix 1: Use of key transferable skills.

Appendix 2: Feedback sheet.

Appendix 3: Evidence of learning from practice assessment / skill development in practice.

Appendix 4: Copy of meeting with Professional Development Tutor.

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