Clinical Risk Management Health And Social Care Essay

The aim of this essay to provide the reader with insight to the term ‘clinical risk management’ and how this is implemented within NHS trusts focusing particularly on the role of Pharmacists in doing this.
Defining ‘clinical risk management’ and discussing its importance
Discussing ways in which trusts implement clinical risk management
Defining what is a medication error and identifying the role of the pharmacist to reduce these
Discussing systems or processes in place in my base hospital to reduce medication errors
1.0 Importance of clinical risk management
Clinical governance was first mentioned in British Health policy in 1997 as a term used to describe the accountability processes for clinical quality of care. It evolved as a system to address and respond to a series of high profile media cases highlighting poor quality patient care as revealed in the Nottingham IT vincristine disaster, Bristol Heart surgery, Shimpan and Alder Hey organ retention.

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During I997 in England, the Department of Health published the white paper the ‘New NHS; modern, dependable’ which introduced Clinical governance as a method of accounting for clinical quality in health care but really came to prominence in 1998 when Scally and Donaldson appraised ‘Clinical governance and the drive for quality improvement in the NHS’  in the British Medical Journal. The paper highlighted four components of quality as initially identified by the World Health Organisation:
Professional performance (technical quality)
Resource use (efficiency)
Risk management (risk of injury or illness associated with the service provided)
Patient satisfaction with the service provided.
Majority of NHS care is of a very high standard and in comparison to the high volume of care provided on a daily basis in hospital and community, incidence of serious failures are uncommon.1 However when they do occur, they have devastating consequences for individual patients and families.1 Greater patient expectations, knowledge and media exposure of high profile cases have resulted in the NHS being scrutinized focusing on its policies of operation, facilities and operating culture.
It is estimated that an average of 850,000 adverse events may occur in the NHS hospital sector each year resulting in a £2billion direct cost in additional hospital days alone.1 Poor clinical performance results in patient harm and loss of patient’s confidence in the NHS services as well as an increase in litigation costs.4 In 2009/10, 6,652 claims of clinical negligence and 4,074 claims of non-clinical negligence against NHS bodies were received by the NHS Litigation Authority, up from 6,088 claims of clinical negligence and 3,743 claims of non-clinical negligence in 2008/09.4 £787 million was paid in connection with clinical negligence claims during 2009/10, up from £769 million in 2008/09.4
Errors are discussed as either ‘human’ or ‘systematic’ in the Department of Health document ‘An organisation with a memory’. As an NHS organisation the focus is systematic, a more holistic approach when dealing with errors. This approach recognises the importance of resilience within organisations and that errors result as a number of interacting factors and failures within the system.1
NHS Quality Improvement Scotland (NHS QIS) clinical governance and risk management standards define risk management as the:
Systematic identification and treatment of risk
Continuous process of reducing risk to organisations and individuals alike
Culture, processes and structures that are directed towards realising potential opportunities whilst managing adverse events
In the past, clinical risk management was poorly managed in the NHS. There were no individuals designated to manage risk management, incident reporting in primary care was largely ignored, there was no standard approach to incident investigation, and existing systems did not facilitate learning across the NHS.1 In the 1990s there was a concerted drive to develop risk management and risk management within NHS organisations.1 Following on from this there has been an increased awareness of the cause of medication errors in NHS trusts and how these can be prevented.1 In 2000, the government made a commitment to reduce the rate of serious errors by 40%. The advances in technology and knowledge in recent decades has resulted in a more complex healthcare system.2 This complexity carries risks and evidence indicates that things do and will go wrong in the NHS sometimes resulting in patient harm.2
The NHS quality improvement strategy1 encompasses;
Clear national quality standards; NICE, NSF
Dependable local delivery; systems of clinical governance in NHS organisations
Strong monitoring mechanisms; a new statutory commission for health improvement, an NHS performance assessment framework, and a national survey of NHS patient and user experience.
It is hoped adaptation of these approaches in individual NHS organisations should have a positive impact on the development to detect, prevent and learn from system failures at a local level.1 The introduction of clinical governance provides NHS organisations with a powerful imperative to focus on tackling adverse health care events1. The time is right for a fundamental re-thinking of the way that the NHS approaches the challenges of learning from an adverse health care event.1
2.0 Implementing Risk Management within NHS trusts
The Department of Health publication ‘An organisation with a memory’ facilitated the patient safety movement in the NHS.2 It proposed solutions to risk management incidences through a culture of openness, reporting and safety consciousness within NHS organisations.2 Four Key areas highlighted from this report were:2
Unified mechanisms for reporting and analysis when things go wrong;
A more open culture in which incidents or service failures can be reported and discussed;
Systems and monitoring processes to ensure that where lessons are identified the necessary changes are put into practice;
A much wider appreciation of the value of the systems approach in preventing, analyzing and learning from patient safety incidents.
In response to an organisation with a memory, the Government report Building a safer NHS for patients focuses on how to implement these recommendations2. It outlined a blueprint for a national Incident reporting system and discussed the role of the National Patient Safety Agency (NPSA).2 The NPSA was set up by the Department of Health in 2001 with the aim of preventing harm from high risk medicines. The NPSA produced the National Incident reporting and Learning system (NRLS) to set priorities, develop and disseminate actionable learning following reports of patient safety incidents.
Following this guidance all NHS trusts should have a risk management strategy in place. This includes systems for the identification of all risks which may compromise delivery of patient care. To aid with this trusts are obliged to deliver patient services in compliance with statutory regulations according to national and local requirements highlighting the level and quality of services required. The implementation of risk management policies within NHS trusts will be overseen by Clinical Governance managers and Risk managers4. Trust Risk management strategies will need to be regularly reviewed and audited; individual trusts will have Risk Managers within each department to oversee this4. The Trust Board will ensure that risk management, quality and safety receive priority and the necessary resources within budgets.
Pharmacy departments will have a medicines management team comprising of a risk management pharmacist to implement risk management at a local level. The Risk management pharmacist will ensure staff are aware of risk management issues both locally and nationally and will update staff on actions to be taken to minimise risk thereby promoting compliance with external risk management standards. The risk management pharmacist will also need to ensure local risk management policies are kept up to date.
In order to deliver the risk management agenda, individual trusts must meet the requirements of the NHS Litigation Authority Risk Management standards and the Care Quality Commission standard’s (CQC) from the Health and Social Act 2008. From April 2010, NHS providers will need to register with the CQC and provide proof of adherence to standards set by the CQC5.
2.1 National Patient safety agency and National Reporting Learning System
In 2001, following the publication of the Department of Health document and ‘Organisation with a Memory’1 the National Patient safety agency (NPSA) was set up. The introduction of the NPSA has for the first time provided a systematic focus on medication safety6. The aim of the NPSA is to lead and contribute to improved, safe patient care by informing, supporting and influencing organisations and people working in the health sector with one core purpose – ‘to improve patient safety by reducing the risk of harm through error’7. The NPSA’s initiative was to identify patterns and trends in avoidable adverse events so that the NHS could implement changes to prevent these incidents from reoccurring.
The NPSA will 2, 8:
Collect and analyze information an adverse events in the NHS
Assimilate other safety-related information from a variety of existing reporting systems
Learn lessons and ensure that they are fed back into practice
Where risks are identified, produce solutions to prevent harm, specify national goal and establish mechanisms to track progress
The NPSA then went onto produce the National Incident Reporting and Learning system (NRLS) which aims to identify and reduce the risks to patients receiving NHS care and leads on national initiatives to improve patient safety. There are NHSLA risk management standards for each type of NHS health care organisation. The standards will address clinical and non-clinical health and safety risks.4 Individual trusts will be examined regularly and measured against standards to ensure a risk management strategy has been devised, it is in place throughout the trust, it is workable.4 This will minimise litigation costs resulting in more funds available to trusts to improve patient care; providing an incentive for better clinical and non-clinical risk management.
The NRLS collects confidential data on medication errors from all NHS trusts in England and Wales and improves patient safety by enabling the NHS to learn from patient safety incidents8. This builds on incident reporting systems that were previously used on an adhoc basis in individual trusts. The NRLS reporting system has been designed to be compatible with local risk management systems that are used in majority of NHS organisations.2 NRLS reports are analyzed by clinicians and safety experts8 and key themes and trends contributing to patient safety incidents are identified.2 Steps are then taken to minimize these risks through the development and prioritisation of national solutions.
‘Trusts reporting incidents regularly suggest a stronger organisational culture of safety’.8 Encouraging staff to report clinical incidents affecting patient safety can help implement risk management strategies within NHS trusts. The more incident reports submitted the more data available to rapidly identify and act upon patient safety incidents. The NRLS suggests trusts should be submitting incident reports monthly.8 In pharmacy these will mostly involve incidents relating to medication errors.
The development and promotion of the NHS ‘fair blame’ culture encouraged error reporting reassuring staff the root causes of errors will be looked into. However, lack of awareness and fear of disciplinary action remain as some of the main barriers to incident reporting.8 To overcome this staff need to be adequately trained on when and how to report clinical incidents. At my base hospital, incident-reporting training is included in the trust induction and at a local pharmacy level as an in-house induction.
Each trust incident is graded in accordance to standardised NPSA scoring systems; 1 being minor with no harm to patient ranging to catastrophic level 5 i.e. patient death. Following the completion of an online incident form, the risk lead for that particular area will receive a copy of the report. These reports will be analysed and appropriately graded and any serious incidents will then be reported to the Trust Board via the risk management committee.
A report by the NPSA stated the most commonly reported medicine related incidents to be:8
Wrong dose, strength and frequency of medicines
Wrong medicine
Delayed and omitted doses
Medicine related incidents will be reported to the Risk Management pharmacist who will provide feedback to the pharmacy team. All category 4 and 5 incidents have a full root-cause analysis performed and are submitted to the NRLS. These reports are then analysed by the NPSA, and if necessary rapid response alerts are produced.1, 8 Rapid response alerts act as a crucial means to focus the efforts of trust clinical risk managers into proven high risk areas.8 Delayed and omitted doses of medication led to the production of a recent rapid response alert. This alert was delivered to trusts by the NPSA via the NHS’s Central Alerting system.8 On receipt of this alert, trusts were expected to respond and act upon requests contained within it within the specified deadline provided. Each alert contains instructions for regular audits in order to review the action taken.
3.0 Medication Errors
Most medication are not without adverse effects and most side effects and adverse events are predictable, thus exposure to these adverse events can be minimised or avoided through careful prescribing and usage. Nevertheless some adverse effects are unpredictable and therefore unavoidable.6 However medication errors occurring as a result of mistakes or lapses when medications are prescribed dispensed or used are avoidable. These can be related to practice, procedures, products or systems. 6
Medication errors as defined by the NPSA are
‘any preventable event(s) that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer. Such events may be related to professional practice, health care products, procedures and systems, including prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.’ 10
Numerous studies have been conducted to investigate the incidence and outcomes of medication-related harm. A 2008 study conducted in an emergency department in Scotland found 2.7% of admissions were related to adverse drug reactions. 11 In 56.7% of cases the adverse drug reaction was the documented reason for admission but only 13.3% were considered to be unavoidable.11 Another study carried out by Charles Vincent reviewed more than 1000 records and found that 10.8% of patients experienced an adverse event and that half of these were preventable.12 It was found that a third of these adverse events led to either serious consequences or death.12 Medication errors also occur in other health care systems, and is estimated harmful errors occur in 1.8% of hospital admissions in the United States, leading to about 7,000 deaths each year.6 Similarly, an Australian study showed that 0.8% of inpatients suffered a harmful medication error.6
3.1 Why do medication errors occur?
To be able to reduce the risk of medication errors, the cause of medication errors need to be understood.6 Previously medication errors were thought to be the sole responsibility of the individuals considered to be the cause of the error. However, now a more holistic approach is taken and it is acknowledged errors occur when both human and system factors interact in a chain of events – often complex- resulting in an undesirable outcome.6 Not only the individual at fault but latent conditions within an organisation and triggering factors in clinical practice should also be considered as important causes of error as well.6 As Lucian Leape, the Physician and Professor at Harvan school of Public Health said:
‘Human beings make mistakes because the systems, tasks and processes they work in are poorly designed.’ 6
Human factors result from the individual and may occur due to lack of training and education and lapses in concentration. System errors result from the running of the organisation and the lack of policies and procedures in place to reduce clinical risk. Recent experience shows in certain situations those safeguards have not been adequate and have failed to prevent serious error and harm to the patient.6
Active failures and latent conditions cause holes in the defence system to open up.6
The active failures occur as a result of unsafe practices of the people working with a system, examples include the prescriber failing to double check a prescription, or the pharmacist failing to identify an incorrect dose on a prescription.6 Latent conditions occur due to the structure of the organisation and its resources, management and processes in place.6 These either alone or in combination with an active failure, can lead to error. Examples include the lack of a computerised prescribing system with inbuilt systems to highlight an erroneous prescription or the lack of an effective communication system between primary and secondary care.6
3.2 The role of the pharmacist in managing medication errors
Pharmacists as experts in medicines have an invaluable role in reducing medication errors. As a profession and specialists in the careful use of medicines we are best placed to minimise the risks associated with medication usage.12
The government ‘safety of doses’ report recommended seven action points to improve medication safety. These are:13
Increase reporting and learning from medication incident.
Implementation and audit of NPSA medication alerts guidance.
Improve staff training and competence.
Minimising dose errors.
Ensure medicines not omitted.
Ensure correct medicine correctly labeled gets to the patient.
Document patient allergy status.
The three areas of focus in medication error reduction for Pharmacists to detect and prevent are:12
Risk in the medicine itself.
Risk in the manufacture, storage, and distribution of medicines.
Risk in use of medicines.
Pharmacy departments as a whole are similar to high quality manufacturing units and test each stage in the production, storage and distribution of medicines.12 Pharmacists are involved in almost all stages of the medication cycle from clinically checking of the prescription to the accuracy checking and final release of the medication dispensed. Within the pharmacy culture there is the expectation for errors to occur and consequently systems have been developed and put in place to minimise these.12 Examples of pharmacy services to reduce medication related errors in hospitals are:12
Checking of prescriptions and supplying of drugs.
Ward drug charts.
Use of our knowledge and pharmacokinetics to assess toxic and sub-therapeutic doses.
Quality control and assurance measures.
3.2.1 Ward based Pharmacy services
Pharmacy services at ward level were first proposed as a health policy in 1970 and have proven to detect and prevent prescribing errors.12 The role of the pharmacist is ever evolving and pharmacists are becoming recognised as an integral part of the multi-disciplinary team. The pharmacists role has moved on from the traditional ‘supply role’ to a more ‘clinical role’ allowing pharmacists to use their specialist knowledge surrounding medication use to reduce medication errors at ward level. Pharmacists are a lot more active at ward level and as such are now the first port of call for advice on medication by patients and other health care professionals. The pharmacist’s role also extends to medicines management and formulary development, medicines information and involvement in various dispensing stages. Throughout these different roles the pharmacist’s remain active in promoting safer practice and reduction of medication errors.
3.2.2 Medicines Reconciliation
Medicines reconciliation is a process designed to ensure that all medication a patient is currently taking is correctly documented on admission and at each transfer of care. It encompasses:
The National Institute for Health and Clinical Excellence (NICE) in collaboration with the NPSA issued guidance to ensure appropriate processes are in place to assure any medication patients are taking prior to admission is properly documented on admission to hospital.8 The NPSA reported the number of incidents of medication errors involving admission and discharge as 7070 with 2 fatalities and 30 that caused severe harm (figures from November 2003 and March 2007).8 An accurate medication history is necessary to aid safe prescribing.
To improve medicines reconciliation at hospital admission NICE/NPSA has recommended that:8
pharmacists are involved in medicines reconciliation as soon as possible after admission
the responsibilities of pharmacists and other staff in the medicines reconciliation process are clearly defined; these responsibilities may differ between clinical areas
strategies are incorporated to obtain information about medications for people with communication difficulties.
At my base hospital, medicines reconciliation involves doctors, nurses, pharmacists and pharmacy technicians. Systems and policies are in place to deliver medicines reconciliation in different areas of care and to ensure all staff involved in the medicines reconciliation process are accredited and adequately trained.
3.2.3 Education and Training
At my base hospital information regarding clinical risk management is widely accessible to all staff through a variety of sources; alongside co-operate clinical mandatory training sessions and in-house local training sessions, a wide variety of information is available on the local trust intranet. These include a governance newsletter entitled ‘Lessons Learned’ detailing adverse events which have occurred and steps taken to prevent reoccurrence of such events, risk management manuals available on-line and the NPSA patient safety literature. At a local pharmacy level, the monthly medicines management bulletin includes medication safety updates and is distributed to all pharmacy staff.
As well as these measures education and training to other health care professionals and patients on medication is paramount. Pharmacists are the professionals best placed to do this. The Central Manchester Foundation Trust took part in a prescribing error audit known as the EQUIP study. This showed pharmacists as experts in medicines held invaluable knowledge and through organised education programmes can help reduce medication errors.14 The main cause of prescribing errors amongst newly qualified medical staff was simply due to lack of knowledge regarding medicines.14 Results demonstrated the need for pharmacists at ward based level and the prevention of potentially serious medication errors through their presence on the ward.14 Pharmacists on wards gave medical staff immediate access to advice regarding dosing, interactions and therapeutic monitoring of drugs.14 Pharmacists are also more likely to complete incident reports involving medicines and should encourage other staff to do the same. Ensuring staff are aware the only way to improve the systems in place is to learn what we are doing wrong.
Pharmacists are also involved in developing and delivering teaching sessions for various groups of staff. Examples included at my base hospital are VTE prophylaxis, IV drug calculations and monitoring for unfractionated heparin. All Pharmacists are encouraged to deliver and attend teaching sessions early on in their career. As well as educating medical staff, pharmacists counselling of patients in outpatients and at discharge will also aid reduction in medication errors.
As well as delivering information and teaching packages, pharmacists need to ensure information provided is sufficient, easily accessible and up to date. Medicine information pharmacists will review how best to provide information for safe prescribing and drug administration.6 The formulation and dissemination of medicine policies and clinical guidelines by pharmacists contributes to risk management. Pharmacists also advice clinicians on risk issues arising from quality assurance reports e.g. NPSA, national and local clinical audit.4
3.3 Reduction in medication errors
Medication errors occur due to a number of failures. Pharmacists clinically reviewing a prescription can detect and prevent prescribing errors, but prescribing is only one aspect of the medication cycle.7 Failures in the processes of reviewing, dispensing, administering and monitoring of medicines also occur.7 To overcome these adequate systems and checks to prevent medication errors need to be in place. Examples of such systems include:13
Effective communication
Education of all health care professionals
Integrated electronic care records
Systems and policies in place for ordering, dispensing, administering and transporting in medicines
Providing 24 hours medicines information services and support to medical staff
Increase specialists staff, more training for junior staff from an undergraduate level and improved discharge procedures
Development of information technology services and standardised electronic incident reporting systems
3.3.1 Information Technology
The developments of technological systems have helped in the running of medicine based services and include automated dispensing systems and electronic prescribing. Similar packagings of medications by the same manufacture lead to frequent dispensing errors. The implementation of an automated dispensing robot in my trust has significantly reduced error rates through the incorrect selection of medication. It also minimises administration errors through the production of standard warning labels such as Methotrexate weekly dosing warnings, and reminders to attach ‘penicillin containing’ stickers to relevant antibiotics. However, the system is not fool proof and as such errors still occur mainly due to over reliance causing staff to become deskilled. Near miss audits to identify potential errors are conducted regularly within my trust to highlight areas of concern and systems put in place to prevent these errors reoccurring.
Implementation of electronic prescribing systems (medisec) for discharge and electronic dose calculator on our neonatal unit has also proven to reduce medication errors. Medication errors due to illegible handwriting no longer occur minimising risk of dispensing errors. The availability of drug name, dose, formulation and dosing schedule have also reduced the risk of medication errors.7
3.3.2 Medication safety at discharge
Poor communication between different health care professionals can lead to medication errors at discharge. Medicines reconciliation on admission has proven to be useful in linking patient’s care at primary care and secondary care. However, more focus needs to be placed on ensuring community pharmacists and GPs are aware of changes to medication at the point of discharge. Improved communication will prevent GPs from prescribing drugs that are no longer indicated, contra-indicated or even duplicate drugs.7 The implementation of the electronic discharge system medisec and the automated electronic copy of the discharge summary detailing information regarding medication changes has proven to be a useful tool in improving communication to GPs, and maintaining the link between primary care and secondary care. In addition to this, patients receiving a copy of their discharge summary and being counseled on their medication at the point of discharge will contribute to reducing medication errors.
4.0 Conclusion
The need to manage risks is particularly important in the NHS because of:
Finite resource – the NHS has a limited amount of money and staff to provide a service
Complexity – the service we provide is extremely complex because of both the size and nature of the task
Expectation – we strive to meet the expectations of an increasingly aware public
Clinical Risk Management is an integral part of clinical governance and thus everyone’s business. Managers in all areas are responsible for ensuring that risks in the area are identified, monitored and controlled in line with the Trust’s Risk Management Strategy. This will contribute to improved delivery of services by providing a structured approach to decision-making. . All staff working in the NHS have a responsibility to be aware of and implement risk management within their individual job roles. The development of technology, systems and processes and education of all staff will be the key to implement clinical risk management at local and national levels in individual trusts.
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Clinical case scenario assignment

The impact of oral conditions on an individuals’ quality of life can be profound, more so when they are increased risk patients such as the elderly or those with Down syndrome. These individuals experience the same dental problems as the general population; however, poor oral health may add an additional burden, whereas good oral health has benefits in that it can improve general health, social acceptability, self-esteem and quality of life (Fiske, Griffiths, Jamieson, & Manger, 2000).

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When formulating an oral health care plan for higher risk patients, it is valuable to have a general knowledge of how to treat such cases. This assessment will explore two clinical case scenarios and the process through which each treatment plan is developed. Furthermore, the importance of providing a patient with quality care, rather than merely treatment, will be explored.
Appointment 1:
Complete Initial Assessment
Take medical history
According to Duggal, Hosy, and Welbury (2005, p.42), taking a comprehensive case history is an “essential prelude to clinical examination, diagnosis, and treatment planning”, and also plays a role in establishing a relationship with the patient.
In this case the patient is a thirteen year old female with Down syndrome, a genetic disorder that ranges in severity with unique characteristics that can influence dental care (Pilcher, 1998). It is associated with physical and medical conditions such as cardiac defects, compromised immune system, and upper respiratory infections (MacDonald & Avery, 2000).
Dental consideration
The history reveals that the patient received surgery for a cardiac abnormality at birth, and does not require antibiotic cover for dental treatment. The National Heart Foundation of New Zealand (2009) state that antibacterial cover is given as a prophylactic measure to prevent endocarditis; a serious and potentially fatal infection that affects the endocardium when bacteria is transported through the blood stream from the mouth because of dental work. Although prophylaxis is not necessary, consultation with the patient’s physician is crucial to determine any underlying medical conditions that concern her dental treatment.
According to Pilcher (1998) the eruption of teeth in persons with Down syndrome is usually delayed, may occur in an unusual order and there is an extremely high rate of missing teeth in both the primary and permanent dentitions. Therefore, it is important to maintain the primary dentition for as long as possible. Additionally, The National Institute of Dental and Craniofacial Research (NIDCR) (2010) state that patients with Down syndrome can experience rapid destructive periodontal disease thought to be a result of their lowered host immune response. Other related factors include abnormal tooth morphology with an increased likelihood of smaller or conical roots, bruxism, malocclusion, and poor oral hygiene (Boyd, Quick, & Murray, 2004).
Therefore, good homecare is vital to manage periodontal disease and carious lesions. The mental capability of people with Down syndrome can vary widely (NIDCR, 2010), which is why as a health professional it is important to perceive how much information the patient is able to comprehend. Education should be given to the family and caregiver to ensure optimal homecare is provided.
Plaque index
Taking a plaque score is a quick and useful way for a dental provider to assess oral hygiene by estimating the tooth surface covered with debris and/or calculus (Wilkins, 2009). The patient has plaque deposits along the gingival margins of many tooth surfaces and calculus deposits on the lingual surfaces of the lower anterior teeth indicating poor oral hygiene.
Periodontal probing
It is described that the patient has red and inflamed gingival tissues with the worst area associated with the upper anterior teeth. This is likely to be a result of mouth breathing which is common in patients with Down syndrome due to a small nasal airway and incompetent lips (Pilcher, 1998). Periodontal charting will determine whether the condition is gingivitis which is reversible or periodontitis. If there are periodontal pocket depths greater than 3mm, bone loss and root surface involvement, a more extensive treatment will be required (Wilkins, 2009).
Record examination and dental charting
– Upper permanent lateral incisors appear to be absent
– Upper deciduous canines show no mobility & permanent canines not visible
– Mesial marginal ridge of 75 broken down as a result of dental caries and is symptomless
– Fistula buccal to 74
– Permanent incisors and first molars show signs of mild to moderate hypoplasia
Bitewing radiographs should be taken to check for bone levels, calculus, overhangs of restorations, and carious lesions in the posterior teeth. An orthopantomogram (OPG) will determine the presence and position of permanent teeth and assess growth and development as well as other pathology (Cameron & Widmer, 2003). Additionally, a periapical radiograph will be necessary for pre-operative assessment of tooth 74 and 75 to determine the origin of the fistula.
– Abscessed tooth (74 or 75 depending on radiographs)
– 75 has dental caries with pulpal involvement
– Periodontal disease (depending on pocket depth)
Differential diagnosis: – Severe plaque-induced gingivitis or
– Chronic periodontitis
– Mild to moderate molar incisor hypomineralisation hypoplasia
Oral health education and instruction
The patient has poor plaque control and therefore should be taught brushing and flossing techniques using the tell/show/do method so the dental provider can see how well the patient and parent or caregiver understand what is being instructed. She should be advised to brush at least twice a day and floss daily, as well as brush the tongue and gingiva.
The use of an electric toothbrush and floss holders should be recommended as those with Down syndrome often have limited manual dexterity (Sacks & Buckley, 2003). Additionally, a high concentration of fluoride such as Neutrofluor 5000 Plus toothpaste is recommended for daily use by patients with high risk of dental caries which Wilkins states will promote remineralisation and help strengthen the teeth (2009).
Dietary advice
Diet should be discussed with a focus on finding if the patient has a lot of sugar in her diet and educating her on the effects of cariogenic foods, perhaps using Stephan’s curve to explain depending on her level of understanding. The patient should be encouraged to eat cheese, unsweetened yogurt, milk and other dairy products as they contain calcium, phosphorous and magnesium which helps protect dental health (The Dairy Council Digest, 2000). Moreover, sugary and acidic drinks should be minimised as they can cause enamel erosion. It is vital the parent or caregiver receive this information as they may have a significant influence over her diet and pamphlets taken home to serve as a reference or reminder.
Formulate a treatment plan
Cameron and Widmer (2003, p. 6) state that treatment should be performed in the following order: (1) Emergency care and relief of pain, (2) preventive care, (3) surgical treatment, (4) restorative treatment, (5) orthodontic treatment, (6) extensive restorative or further surgical management, and (7) recall and review.
Once this has been completed it should be discussed with both the patient and her parents or caregiver and informed consent must be given.
Appointment 2:
The amalgam restoration in the 74 is described as appearing sound but there is a fistula present buccal to the tooth. A fistula is a channel allowing excess exudate to drain from an abscess (Ibsen & Phelan, 2004). Although this can be painless, it is considered an emergency and should be dealt with before any dental treatment.
It is likely that the fistula is related to the 75 which is broken down due to dental caries. When the marginal ridge of a primary molar is broken down due to dental caries, the pulp is consistently exposed (Cameron & Widmer, 2003). Although the 75 is described as symptomless, this may be because the drained exudate is relieving pressure from inside the tooth meaning it is less likely to be painful. If the PA radiograph confirms that the carious lesion on tooth 75 has pulpal involvement, it will be treated with either pulpectomy or extraction.
Pulpectomy: If tooth 35 is not present, the 75 should be preserved and a referral to a dentist to perform root canal therapy will be given. It is advised that a stainless steel crown be placed as according to Cameron and Widmer (2003) this is the strongest possible final restoration following pulpectomy and will be necessary to preserve the 75 for as long as possible.
Extraction: If 35 is present, the 75 should be extracted. However if 35 is not ready to erupt, a space maintainer is recommended to preserve the gap after extraction of 75 to prevent the adjacent teeth drifting into its space. This will enable the 35 to erupt in the proper position and prevent malocclusion in the future and will require a referral to an orthodontist.
The amalgam restoration on tooth 74 appears sound and depending on radiograph results, if there is no abscess on tooth 74 and 34 is present, no treatment is needed on this tooth. If there is abscess on 74, the same treatment for abscessed 75 is indicated.
Appointment 3:
Reassess oral hygiene: Reinforce good behaviour and make necessary recommendations for continual improvement.
Scale and polish: The aim of this is to remove as much bacteria from the oral cavity as possible and have a healthy mouth to perform restorative work in. According to Stefanac and Nesbit (2001), when planning treatment, it is sensible to put the least invasive treatments first when possible so that the patient can familiarise themselves with the dental setting and feel comfortable. (Pilcher, 1998) states that having a patient with Down syndrome that is relaxed and at ease can assists with cooperation in the chair and useful for future appointments.
Hypoplasia: The permanent incisors and first molars are described as having mild to moderate hypoplasia. Enamel hypoplasia is a deficiency in quantity of enamel that results in a defect of contour in the surface (Cameron & Widmer, 2003). This defect can cause tooth sensitivity, may be unsightly and more susceptible to dental caries. A compromised immune system is a characteristic of most individuals with Down syndrome which contributes to a higher rate of infections (Pilcher, 1998) and it is possible that the hypoplasia is related to the patient’s condition. Because of the teeth involved, this is likely to be Molar Incisor Hypomineralisation (MIH) which is defined as a hypomineralisation of systemic origin of one to four permanent first molars frequently associated with affected incisors (Weerheijm, 2003).
It is important that MIH be treated as soon as identified to minimise the heightened risk of dental caries and prevent the patient from experiencing tooth sensitivity. Treatment options depend on the severity of the hypoplasia and the symptoms associated with it (University of Iowa, n.d.). It should be noted that the worst area of inflamed gingival tissue is associated with the upper anterior teeth which could be a result of the patient avoiding these as they are sensitive or painful to brush. It may be useful to ask the patient about this so that education can be given on the importance of brushing all areas and the problem can be addressed.
In this case scenario, the most effective treatment would be the application of a fluoride varnish to the hypoplastic areas followed by resin-based sealants. Alternatively, if ideal moisture control cannot be achieved, glass ionomer sealant can be used. According to Subramaniam, Konde, and Mandanna (2008), the retention of resin sealant is seen to be superior of that of the glass ionomer which should be treated as temporary only. Cameron and Widmer (2003) explain that localised defects may be restored with composite resin and pitting defects may require stain removal with either rotary instruments or some sort of bleaching system. Furthermore, if there is sensitivity, the use of tooth mousse products should be advised to assist with remineralisation and desensitisation of the teeth (Walsh, 2007).
Appointment 4:
Remove IRM: Although the temporary restoration on tooth 65 is sound, it should be replaced with a permanent filling as Mount and Hume state that zinc oxide eugenol hydrolyses in time and should not be used for over six months (1998). Additionally, composite should not be used because the release of eugenol will inhibit the polymerisation of the composite resin (Mount & Hume, 1998). Therefore, an amalgam restoration should be placed on tooth 65 if the radiograph shows tooth 25 is present. If the permanent successor is not present, the temporary restoration should be replaced with a permanent restoration like a stainless steel crown and may require pulpotomy depending on how far the carious lesion has progressed in the tooth.
A three month recall should be arranged as the patient is high risk for caries and periodontal disease. It is essential that optimal oral hygiene is maintained and well monitored by the dental practitioner.
The human needs of each older adult must be assessed individually and not based on preconceived stereotypes as the healthcare needs of elderly persons can vary from health to severe illness (Darby & Walsh, 2010). According to Fiske et al. (2000) there is a general trend for a reduction in edentulism and an increase in the retention of natural teeth. This attitude leads to more people wanting to understand how to best maintain good oral hygiene and it is the role of the dental provider to assist these individuals with appropriate educational instructions.
In this clinical case scenario the patient is an 81 year old man who comes to the clinic for dental hygiene care.
Appointment 1:
Complete Initial Assessment
Take medical history
The patient shows early signs of Parkinson’s disease; a progressive neurodegenerative disorder of neurons that produce dopamine (Little, Falace, Miller, & Rhodus, 2008). Loss of these neurons results in characteristic motor disturbances including a resting tremor, muscular rigidity, bradykinesia and postural instability. It is common for those with Parkinson’s disease to also experience xerostomia as a result of polypharmacy and is significant as this increases the risk of periodontal disease and coronal and root surface caries (Wilkins, 2009).
It is described that the patient has mild congestive heart failure which The American Heart Association (2011) state is the inability of the heart to supply sufficient blood flow to meet the needs of the body and can be a result of myocardial infarction and other forms of ischemic heart disease, hypertension, valvular heart disease, and cardiomyopathy. As the heart failure is mild, he will not require antibiotic prophylaxis for dental treatment however it is wise to confirm this with his physician.
The patient is taking nitroglycerin tablets under the tongue to relieve chest pain several times a week. It is taken sublingually for immediate relief of chest pain by reducing the oxygen need of the heart and may cause dizziness, light-headedness and fainting and may cause xerostomia (Medline Plus, 2011).
The patient has stiffness in the fingers of his dominant right hand due to arthritis; an inflammatory or degenerative process which involves the joints (Arthritis Foundation, 2011). Patients with arthritis may experience pain, swelling, limitation of motion and deformity of the joints and may find it difficult to keep an open mouth for long dental procedures.
Oral hygiene assessment
The patient has poor oral hygiene. It is likely that due to his arthritis which affects the fingers in his right hand, he is not adequately brushing quadrants 2 and 3. It should be noted that there are signs of abrasion lesions on the buccal surfaces of quadrants 1 and 4. Abrasion is the mechanical wearing away of tooth substance by forces other than mastication (Wilkins, 2009, p.272) and this is likely to be a result of the patient vigorously brushing horizontally. Furthermore, he has heavy plaque deposits on the lower lingual and all interproximal which indicate interproximal plaque removal methods must be instructed.
Periodontal probing
All periodontal pockets measure 1-3 mm except for 26 mesial with a probing depth of 4mm indicating generally good periodontal health.
Record exam and dental charting
– 27 moderately filled teeth present with tooth 25 lost due to a fractured root
– Gingival recession is present with 1-2 mm areas of root surfaces exposed on most teeth. A couple of theses surfaces present with light brown marks that are soft to touch
– Tooth 26 shows sign of periodontal bone loss palatally as well as tipping and drifting forward into the space left by 25
– Heavy plaque deposits on the buccal surfaces of quadrant 2 and quadrant 3 as well as lower lingual and all interproximal surfaces
– Very light plaque deposits on the buccal surfaces of quadrant 1 and quadrant 4
– Some surfaces with light plaque show signs of abrasion
To complete the initial assessment, bitewing radiographs and an OPG should be taken. This can give the dental provider information on alveolar bone levels, plaque retention factors, interproximal and secondary caries, furcation defects, subgingival calculus and additional pathology (Tugnail, Clerehugh, & Hirschmann, 1999). A periapical radiograph of tooth 26 is taken to examine bone loss and to check for subgingival calculus and root surface caries.
Risk assessment
The patient is at high risk of developing dental caries and moderate risk for periodontal disease due to his medical history. His lack of manual dexterity associated with Parkinson’s disease and arthritis, makes adequate plaque removal difficult to achieve. Moreover, due to medications, he is more likely to have xerostomia which will increase his risk of periodontal disease and dental caries, especially root surface caries (Wilkins, 1999).
– Moderate plaque-induced gingivitis
– Localised moderate chronic periodontitis on tooth 26 due to tilting
– Generalised gingival recession
– Toothbrush abrasion
– Areas of root surface caries
Oral health education and oral hygiene instruction
Perhaps the most important treatment a dental provider can give is that of oral health education, information, promotion and counselling. This enables the patient to maintain good oral hygiene themselves and prevent further disease processes. In this clinical case scenario it is vital to advise the patient on homecare which will address his risks of dental caries and periodontal disease.
According to Darby & Walsh (2010) caries control and prevention activities must address three interrelated factors: (1) removal of bacterial plaque and biofilm, (2) reduction of refined carbohydrates and snacking in the diet, and (3) use of topical fluoride.
The patient’s oral hygiene activities are compromised due to the arthritis in his right hand and in the future will be further affected by his developing Parkinson’s disease. His poor oral hygiene should be addressed firstly by recommending the use of adaptive devices. Using a powered toothbrush and modifications of handle size, width, and grip, will provide assistance for the patient with thorough plaque removal. It should also be suggested that the patient use floss holders to ensure the effective removal of interproximal plaque or alternatively, interproximal brushes can be recommended if the patient is able to use them effectively.
Poor dietary practices involving the over consumption of soft, retentive refined carbohydrates and frequent snacking patterns are common among older adults (Darby & Walsh, 2010). The dental provider has an obligation to educate the patient on optimum food choices and nutritional patterns to promote oral health. It could also be beneficial to speak with any caregivers regarding the patient’s diet and make suggestions to prevent further carious lesions. Replacing sweet snacks with cheese and crackers or substituting sugar-free hard candy for mints are examples of two specific dietary interventions that may be more easily and realistically implemented for older adults.
Furthermore, the frequent use of topical fluoride products for home use should be encouraged. A high fluoride toothpaste (5,000 ppm) will help to strengthen enamel and aid in the prevention of dental caries and will cause little change in the routine of the patient.
For management of xerostomia, the patient is advised to take frequent sips of water and avoid the consumption of alcoholic drinks which will further dry out the oral mucosa. Sugar-free chewing gums will help stimulate the saliva but if the patient experiences difficulty in chewing because of arthritis, this may not be advisable. Additionally, tooth mousse should be recommended to provide lubrication and assist in preventing root surface caries (Walsh, 2007).
If the patient is unable to provide adequate home care, alternative solutions should be provided, such as the introduction of the Collis curve toothbrush, assisted brushing, or chlorhexidine rinses (Little et al., 2008) These aids facilitate self-care and hence self-determination for the patient. The patient may suffer from mild dementia and due to his age may have difficulty remembering everything discussed at the initial appointment therefore all instruction should be written down and passed to him or a caregiver.
Formulate a treatment plan
Appointments should be kept short and scheduled in the morning or early afternoon when patient is less tired or whenever suits his needs best. Once a care plan has been completed it should be discussed with the patient and informed consent must be given.
Appointment 2:
– Re-assess oral hygiene
– Quadrant scaling is recommended in case a full debridement cannot be completed in one appointment
– Reinforce good oral hygiene
Appointment 3:
– Re-assess oral hygiene
– Complete scaling and full mouth polish
– Reinforce good oral hygiene
A referral letter to the patient’s dentist is to be written and given to him regarding the restorative work required on the root caries present in his mouth. The importance of treatment should be explained to the patient and if necessary his caregivers should also be advised of the work required. As a preventive method, fluoride varnish should be applied to the other receded areas to help remineralise the enamel and reduce any sensitivity the patient may be experiencing (Wilkins, 2009).
Upon completion of treatment for this patient, a three month recall should be arranged as his medical history indicates he may require regular maintenance in the future. This is also a good chance to evaluate the outcome and effectiveness of the previous treatment.
According to Stefanac and Nesbit (2001) an oral health care plan is about balancing the ideal with the practical, and emphasis should be placed on the patient and their needs which ought to drive the treatment planning process. There has been a shift in treatment given by dental providers, where the focus is now on not only restoring the problem in the clinic, but educating the patient on how they can best achieve optimal oral health themselves.
This assessment has investigated two different clinical case scenarios and discussed oral health care plans for each. In addition, it has examined the importance of treating each patient as an individual with specific needs and the significance of providing them with methods or self-care.

Reflection on a Clinical Experience on Staffing Challenge

As a requirement of my nursing course, am writing an essay on an incident that happened during my clinical experience. This was in a Tier 4 public hospital which serves a whole county within the republic in a densely populated area that has a population of 10 million people as per the latest censes of 2009. It also serves the neighboring counties. It has all the prescribed services of a tier 4 hospital apart from an Intensive Care Unit (ICU), and a Renal Unit of which those requiring this service are referred to the country’s National Hospital and are escorted by the nurses on duty.

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I reported to work one Saturday, a day after reporting in this institution for very first time on rotation as per the nursing council requirement as partial fulfillment for the nursing degree course, in a medical ward that had seventy two inpatients the previous day. To receive us was the night duty staff who confirmed that there were only two of us to man the ward, a resident nurse and I.
As the report was being read, I noted that two patients were waiting for blood transfusion and still others needed to be assisted with activities of daily living, and at the same time it was reported from the outpatient department (OPD), that we prepare beds to receive patients from them.
After the report, those on night duty left and the resident nurse allocated the duties. She assigned me to administer medication, while she takes care of all the other duties.
I asked her how this was possible of which she replied calmly and confidently that on this day, we were “overstaffed” as most times during the weekend only one nursing staff reports and that everything was going to be just fine. She was happy to have me around!
I managed to quickly mentally adjust to this new and unfamiliar setting and hoped for the best.
We started off by assisting those that required assistance in activities of daily living and tidying up the ward and then I immediately started off with the drug round alone. Almost half of the patients were on injectable medication meaning that I had to take time to restitute and calculate the doses as prescribed, taking care of infection prevention.
The administration of drugs took too long noting that those that had a prescription of eight hourly administration of drugs as per this particular institution should get their doses between 9am and 10am but by the time I was through, it was almost 12.30pm meaning that those that got drugs after 11am were two hours late yet it was the best I could do given the circumstances as the resident nurse was busy with new admissions and attending to those that had been discharged as relatives complained of being kept too long before being attended too.
As the report was being read, I was wondering how the two of us were meant to handle all the patients efficiently and effectively in relation to patient care outcome, not mentioning that we were also meant to admit those who would present during the day. Were we going to be timely in administering drugs? How would we handle an emergency arising in the midst of all the procedures awaiting us? How could the nurse manager leave and be settled wherever she was with such a situation in the ward?
As a nurse, am aware that quality of care is more important than quantity yet these two should go hand in hand for positive productivity to be felt. Here I felt that the nurse manager had not forecasted on the staffing requirement for the unit which ought to be as indicated by the following, states,
Nursing staffing methodology should be an orderly, systematic process, based upon sound rationale, applied to determine the number and kind of nursing personnel required to provide nursing care of a predetermined standard to a group of patients in a particular setting. The end result is a prediction of the kind and number of staff required to give care to patients (Adelotte & Rousell, 2009).
When learning as a student it was made clear that two nurses should be assigned administration of drugs as a team so as to counter check on the same and as per the Kenya Nursing Council Procedure Manual 2010. Also with the blood transfusion pending procedure, two nurses were required.
I felt very inadequate and unprepared to face the day partly because I had not fully familiarized with these new environment and to me, this was a very big institution to be have had such a noticeable shortage of nursing staff. This is in reference to this institutions mission that reads
‘ To Promote And Provide Quality Curative, Preventive And Rehabilitative Health Services for All Kenyans’ making me feel that the organization in this unit did not put into consideration quality of service but rather left it to fete. According to Rousell (2009), ‘organizations exist to bring people and material to accomplish the work of the organization which should also allow for personal adjustment’, which to me did not seem to be observed as this was my second day in the said hospital.
I feared that I would not deliver quality services and that the patients would find fault in me as I felt I would keep on enquiring from the resident nurse on areas that I was not certain.
What was positive about this situation is that I worked with what I had, here meaning limited consultation. The resident nurse was very supportive with excellent interpersonal communication skills as she treated me with respect and as her equal, and provided me with a brief orientation on how to go about it, giving me confidence to take up the task with ease. I took it positively and interacted with patients very comfortably and at the end of it all I enjoyed my achievement and felt secure to undergo the same task should it so arise.
Good communication skills are essential in mentoring new staff as well as goes a long way in removing barriers and obstacles to effective teamwork (Gullatte, 2011). This was what motivated me to carry on with the assigned activity without complaining.
The nurse delegated this task to me which is an efficient time management tool and made me comfortable by reassuring me that she would be accountable and responsible to everything that I did and that she would be present in the ward in case of anything. I learnt that self-confidence coupled with a pleasant confident manager is in itself very motivating and felt I would use this skill in future.
The patients were very relaxed and some going out of their way to assist me lift those that needed a little help as they took their medication. It made me realize how passionate patients can be once they stay and get to know one another and that they feel helpful once they are allowed to assist.
What was negative is that it took too long to accomplish one assignment and that almost three quarters of the patients got their treatment late and did not raise a voice, maybe because they do not know of the right to timely services or are too intimidated to do so. This to me was an ethical issue that needed to be addressed as the full benefit of medication was compromised as a direct result of understaffing. One of the ethical issues in nursing is distributive justice meaning giving a person that which is deserved (Sullivan & Decker, 2007). They did not deserve to get medication late.
Goal setting for both long and short term are stated in terms of what the patient and the nurse will accomplish providing direction and vision for actions and time frames (WHO, 2010).
This to me had not been factored in as the duties were being prepared which left room for risks arising that would cost the patients a lot in terms of long recovery time plus maybe subject them to long hospital stay.
This hospital is a teaching institution whereby nursing and other health service providing students come for practice and internship during the weekdays and I could not understand why all the students in all the basic schools are allowed weekend offs. To the best of my understanding, this was the best time to introduce students to the unique working times of health care workers as health issues are not regulated by the time of the day but rather by the demand of the services.
I am looking at an opportunity of balancing students throughout the week in contrast to allowing them to overcrowd specific days as had been the case the previous day and overworking the resident nurse over the weekend. I feel that this would have eased the burden had students been allocated weekends as part of their training.
I strongly agree that,
Addressing the nursing shortage requires a response to the total number of nurses but also the level of nurse’s education due to the fast growing demand and complex patient care, technologies, and a widening scope of knowledge and expertise (McHugh, 2010).
At the end of the day I was left with mixed feelings on one hand that I had provided services to the best of my ability given the prevailing constraints, and on the other, that the patients didn’t get the kind of quality care meant to be rendered due to staffing shortage.
I feel that since decision making is a key function in management, this institution, should as a temporary measure incorporate students in rendering services during the weekends under supervision as happens during weekdays starting off with simple tasks and scaling up responsibilities as they gain confidence.
I feel that the nurse managers and the administration ought to call in the policy makers in this county with a well-defined document ,in it the international standards of staffing as per the World Health Organization (WHO) recommendations in the Workload Indicators Staffing Needs (WISN),
It is a method of human resource management tool that provides
health managers with a systematic way to make staffing decisions
In order to manage human resource well and is based on health
workers workload with activity (time) standards applied for each
workload component (WHO,2010).
The manager should at this sitting have found out the external standards of nursing as developed by non-nurses here meaning the county government in question as I believe they also do have expected practice by the same. This is in confirmation by Burkhardt & Nathaniel,( 2008) who have demonstrated that ‘External standards of nursing standards are guides for nursing developed by the government or institutions describing expectations of agencies or groups that utilize services for nurses’. This could go a long way in advocating for hiring of more nurses and is a better platform to effecting productive changes in the running of health services than the industrial actions that nurses undertake due to frustrations other than strikes.
According to Rousell (2009), ‘There is strong evidence that adequate number of nursing staff available to care for and coordinate care among the disciplines has an impact on patient outcomes.
I want to acknowledge here that from accounts from fellow colleagues, nursing shortage is felt in most institutions but this particular experience was almost horrifying.
The action plan for me and the entire team is to acquire the WHO, WISN manual and use this tool to make a workable staffing outline and call in the county health committee and present our findings in comparison with the actual on the ground and help make recommendations so that as the policy makers budget for the next financial year, they be advised by this document which will have been prepared by the stakeholders in addition to re- distributing student nurses throughout the week.
Burkhardt, M.A, & Nathaniel, A.K. (2008).Ethics and Issues in Contemporary Nursing. (3rd ed.).United Kingdom: Delmar.
Gullatte, M, M. (2011), Nursing Management Principles and Practice (2nd ed), ONS: Atlanta
McHugh, D. (2010), Hospital Staffing and Public Health Emergency Preparedness; Implications for Policy; DOI; 10 111/J 1525-1446.2010.00877X Retrieved from 2998349
Tomey, A, M (2009), Nursing Management and Leadership (8th ed): Mosby, Indiana.
WHO, (2010). Workload Indicators of Staffing Needs (WISN), ISBN: ISBN 978 92 4 1500197.

Use of Enzymes for Clinical Diagnosis

Clinical enzymology is branch off medical science deals with the usage of enzymes for diagnosis prognosis of various diseases. In general, each enzyme of clinical significance is found in many tissues of the body, and in healthy individuals, these enzyme exhibit very low levels in serum. In certain disease states or with cell injury, these intracellular enzymes are released into the blood and are indicative of the presence of a pathological condition. Quantification of enzyme levels in serum is useful in determining the presence of disease. Based on the individual’s physical symptoms, several enzymes may be chosen for analysis to determine if a pattern develops that aids in identifying the tissue source of the enzyme elevation in the serum(2). The understanding of enzyme kinetics allows for laboratory measurement of plasma levels. Damaged or dying cells within organ can release enzymes into the circulation, these plasma enzyme levels can be used to develop a differential diagnosis of a patient with respect to specific organ disease and dysfunction(1).

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Like others analyte use for clinical chemistry analysis, specific pre-analytical influences have to be taken into consideration. Analysis of enzyme measurement would involve the process from the start to the end that comprises the pre-analytical factors, analytical and post analytical factors. Pre- analytical issues in the enzyme measurement include the types of specimens, the specific anticoagulants and preservative in the tubes and the specimen collection procedure. Table 2.0 describe the type of enzymes, the specimen of choice and the pre-analytical factors that can affect the enzyme measurement.
Slight hemolysis can be accepted as there is no CK ain rbc, however severe or moderate hemolysis can cause enzymes and intermediates (adenylate kinase,ATP,glucose – 6-phosphatea) liberated from the erytrocytes and may affect the lag phase and the side reactions occurring in the assay system(3)
Lactate Dehydrogenase
Serum or heparanised plasma
Plasma containing anticoagulant especially oxalate, should not be used. Haemolysed specimen 150 times LDH in rbc than serum(3)
Alkaline Phosphatare
Serum or haparinized plasma
ALP-, free hemolysis. Complexing anticoagulants such as citrate,oxalate, and edta must be avoided.
Storage and doing test later than 4 hours can cause loss of activity
EDTA concentration in the sample-reagent mixture, causing chelation of metallic cations, and this can affect the activity of the alkaline phosphatase
Gamma Glutamyl Transferase
Serum free from hemolysis preferred.
EDTA -plasma ( up to 1 mg/mL blood) can be used
Heparin produces turbidity in the reaction mixture; citrate, oxalate and fluoride depress activity by 10 – 15 %
The rate of disappearance of substrate or the rate of appearance of product had been utilized for enzyme measurement. Usually, measuring small increase in product it is much easier than to measure small decrease in a large amount of substrate. In some enzyme measurements, neither the product not the substrate of a chemical reaction can be measured conveniently. In such cases the enzymatic reaction can be ‘coupled’ to another reaction that uses the product of the enzyme catalyzed reaction to produce an indicator substance (1).
The rate of change in concentration of substrate or product is the principle of ‘kinetic’ method for most of the enzyme measurement. The accuracy of Kinetic makes it easier to detect changes in reaction conditions and samples requiring dilution. In a kinetic reaction, the rate of reaction can be expressed as ΔP/ΔT, the change in amount of per unit time. The amount of enzyme in a sample is measured by the rate of reaction catalyzed by the enzyme. This rate is directly proportioned to the amount of enzyme and is expressed in enzyme unit, IU/L (4).
Substrate depletion phase is a period during an enzyme assay when the concentration of substrate is falling and the assay is not following zero-order kinetics(5). The amount of substrate must be present in sufficient quantity, so that the reaction rate is limited only by the amount of enzymes. In order to get optimal method of enzyme measurement, the substrate concentration is one of the important parameters. It is essential for the concentration of the substrate(s) is saturating during the measured period of the reaction(6). At saturating substrate concentrations, the reaction velocity is pseudo zero order with respect to the substrate and the velocity is proportional only to the enzyme concentration. Figure 1.0; describe the importance of substrate depletion in enzyme measurement.

Enzyme activity
Substrate depletion
Substrate depletion
Lag phase

Figure 1.0 – Enzyme activity can be calculated from a plot of absorbance versus time when monitoring an enzyme-catalysed reaction. When reagents and serum are mixed, there may initially be a period of a time when mixing and any preliminary reactions occur; this is termed the lag period. Following this phase, the reaction will proceed at zero-order kinetics (V max); at this point, the rate of appearance of product (as measured from the slope of the line, ΔA/ΔT) is directly proportional to the enzyme activity present. As the reaction proceeds and substrate is depleted, the rate of reaction will fall below V max and the plot is no longer linear. At this point, the reaction is no longer zero order with respect to substrate concentration; rate of reaction is now dependent on both amount of substrate (which is declining) and amount of enzyme present, making it difficult to calculate amount of enzyme present. (Adapted from Henry’s Clinical Diagnostic and Management by Laboratory Methods)
An organic component of enzymes is called coenzyme. Coenzymes participate in many of the enzyme analyses performed in the clinical laboratory. As the coenzyme make up a part of the active site, the role of this coenzyme in enzymatic transamination is crucial as an example the use of pyridoxal phosphate for expression of enzyme activity for aspartate aminotransferase and alanine aminotransferase measurement(7). Table 3.0 describe the enzyme, the coenzyme and the clinical relevance of the enzyme measurement for laboratory diagnosis.
In conclusion, the type of assay method, sample preparation, age and storage conditions are the variables that have to be taken into consideration in the determination of enzyme activity. Other important variables in determining enzyme activity include temperature, pH, concentration of substrate, concentration of cofactors of the assay, use of other enzyme reactions as indicators, and whether the forward or backward reaction is used to measure the enzyme. All of these variables can lead to significant differences in enzyme activity between methods (1).
Clinical relevance
Creatinine kinase (CK)
Nicotinamide adenine dinucleotide
Elevations of total CK in serum are associated with cardiac disorders, such as AMI, and skeletal muscle disorder, such as muscular dystrophy. Occasionally,elevations are due to central nervous system, including seizures and cerebral vascular accidents.
CK-MB values greater than 6 % of total CK are suggestive of AMI. When AMI is suspected, troponin is assayed in conjunction with CK-MB, and sometimes myoglobin is assayed. Following AMI, Ck-MB levels rise within 4-6 hrs,peak at 12-24 hours, and return to normal within 2-3 days(2).
Aspartate aminotransferase
pyridoxal phosphate
AST is used to evaluate hepatocellular disorders (up to 100 times upper reference limit in infectious mononucleosis, and up to 4 times upper reference limit in cirrhosis), skeletal muscle disorders ( up to 8 times upper reference limit) and acute pancreatitis(8).
In AMI, AST rises within 6-8 hours, peaks at 18-24 hours, and return to normal within 4-5 days. AST is not used to diagnose AMI, but awareness of the AST pattern may be useful when ruling out other disorders, including concurrent liver damage(2).
Lactate dehydrogenase (LD)
Elevated in cardiac disorders (AMI), hepatic diseases (viral hepatitis,cirrhosis,infectious mononucleosis),skeletal muscle diseases, haemolytic and haematological disorders (acute lymphoblastic leukemia)
In AMI, LD levels rise within 8-12 hours, peak at 24-48 hours, and return to normal in 7 – 10 days. Although LD and LD isoenzymes are not used to diagnose AMI, knowledge of their pattern may be useful when assessing concurrent liver damage(2).

Analysis of the Use of Clinical Audits in Healthcare

The quality of health care system is important to patients and the Government. High level of quality patient care is the ultimate aim in current health care practices. Service providers wish to deliver quality health care. Patients are the appropriate authority to determine whether the experience of health care is good. Effectiveness of care pertains to treatment and support and helps us to judge whether staffs are, doing the right thing in a right way to achieve best clinical outcomes (Patel, 2010).Audit of services is therefore very important to ensure that the clinical practices are adhered to set professional standards and criteria. On the other hand health services are focusing on new information and knowledge for advanced clinical practice. Research is focused on this area in order to develop new practices and standards in health care system. Researches make changes to health care system by advancement of knowledge and practice.
The aim of this paper is to identify the difference between audit and research and analyzing the benefits and limitations of audit.
An overview of clinical audit.
‘Audit’ derived from a Latin word, which means an official inspection of an organization’s official accounts, by an independent body (Esposito & Canton, 2014). Clinical audit is measuring the quality of patient care provided against a set well defines standards (Yorston &Wormald, 2010). It gives staff a systemic way of looking into their practice and making improvements (Bennadi et al, 2014). Pioneer of clinical audit is Florence Nightingale whose work was searching reasons for high mortality in hospitals in 1850’s. As per her assessment she reinforced cleanliness resulted in a drastic reduction in mortality rate. (Bennadi et al, 2010).
Clinical audit Vs research
Clinical audit and clinical research are entirely two different domains (Yorston & Wormald, 2010). Clinical audit and research involves some common components. Hence, there is a great deal of controversy (Bennadi et al, 2014) in both terms. Audit compares the current clinical practice against well-defined standard/criteria, while research aims to define the characteristics of good practice on an unknown land (Esposito & Canton, 2014). Audit focused on evaluating the existing practice; rather than discovering new information. Research is proven to be a larger scale study that aims at establishing new practices or procedures to carry out a particular task in a different method. The focus of research is further development of existing practice. However, audit is monitoring a task to determine whether a particular task has undertaken as per set standards or criteria. Audits check the quality of the task or procedure (Bennadi et al, 2014). Audit is generally undertaken on a local basis; however it is not limited to. (Hughes, 2005).
Research aims to obtain new knowledge and to fill in any knowledge gaps.
Research focuses on defining questions, making inclusion and exclusion criteria’s for people or problems to address and any developing clinical interventions or outcomes. Research methods for data collection and analysis that is applied are suitable to the topics for research (Strauss and Sackett, 1998, Hughes, 2005).
Audit focuses on evaluating and analyzing the existing ones, not developing new practices (Difference between audit and research, 2014). But, research is aimed at developing new procedures to carry out in a more effective ways of carrying out. The focus on research is invention of new and further development of the old. The aim of an audit is to determine whether the standards and procedures are being followed and whether a task is completed properly. The aim of research is to add onto a body of research and to increase the amount of knowledge and learning available on a specific subject matter (Difference between audit and research, 2014). Also, unlike audits that measure tasks and procedures against a set out standard, research aims to test the hypothesis that is established by the researcher when beginning their experiments (Twycross &Shorten 2014).

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Research considered as a broader field in the field of health. Research requires lot of education and training. Researchers undergo research education and training as a part of their university programme of study to gain the foundation to conduct a research (Hughes, 2005). In contrast, audit emphasized on areas, which needs improvement. Audit can undertake by anyone who is interested in a particular field and few receive education and training (Nettleton and Ireland, 2000).
As per Hughes’s review, researchers involved in audit may benefit from approaches and techniques used to implement findings that could potentially serve to fill the research-practice gap. Equally, those involved in audit will benefit from sampling techniques in research that can help to improve generalisability.
Some similarities are identified between audit and research despite their differences. Audit and research starts with a question, require data to answer questions, and systematic approach (Twycross &Shorten 2014), also both needs an investigator (Abbasi &Heath, 2005).
Difference between clinical audit and research is showed in the below table, which was adapted from Bennadi et al, 2014 and Twycross &Shorten 2014.

Clinical audit



Audit uses comparison of current clinical practice

Research uses experimental methods such as randomised control trials.


Uses simple descriptive statistics to describe current practice standards.

Uses a range of statistics to make inferences.


Audit relates to a particular area of attention.

Research can be generalized to other populations.


Audit measures how well current practices are carried out against clinical policies and procedures.

Research provided evidences for clinical policies and procedures.


It is practice based.

Research is theory based practice.


Ongoing process of quality assurance.

One- off study.


No involvement of placebo treatment.

May involve placebo treatment.


No changes involved in treatments of patients.

Changes in treatment process.


Ethical approval is not required.

Requires ethical approval.

Benefits of clinical audit
Audit conducted against set standards (Patel, 2010, Hughes, 2005) in a cyclic (Tsaloglidou, 2009, Hughes, 2005) process to ensure tasks carried out correctly. At the end of audit cycle auditors are able to address the areas of improvement and give feedback to the personnel who are involved in that particular task. Reaudit should carry out after an agreed period of implementing changes (Bennadi et al, 2014). Regular auditing alerts the health care professional the shortfall (Patel, 2010) in health care delivery system. Also helps us to find out whether staffs are practicing as per standards set by the organization to achieve therapeutic (Patel, 2010) patient care, identifies the factors causing failure to make improvements (Yorston &Wormald, 2010). Therefore, organization can take actions to improve the area. “Every time an audit cycle is completed there should be further improvement in patient care” (Yorston and Wormald, 2010).

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Audit and feedback often used in health care setting to improve health care professional performance. Discrepancies in health care practices against set standards are highlighted in clinical audit that helps to identify the practices needed to improve for quality care (Esposito &Canton, 2014). Tsaloglidou explains that the key for quality assurance and consistent delivery of high quality health services is the appropriate organization of the health center environment.
The benefits of audit are apparent for health care professionals as it reduces frustration, reduces organizational and clinical error, improves communications between professionals and secures effective medical defense through risk avoidance (Tsaloglidou, 2009). An audit is not only a tool for monitoring change in clinical practice, but also an educational tool (Tsaloglidou, 2009). As the improvement of health care is a cost-effective procedure, audit is revealed to be a very useful tool in management
Limitations of clinical audit
Educational and training issue has a huge impact on carrying out an effective audit. Audit should not consider as a light work. It does require knowledge, experience and skills to perform effectively because auditing required to choose appropriate question, analytical method and to be undertaken in a sensitive (Hughes, 2010) way. In general, audit tends to be an activity that be undertaken by anyone without proper training and analytical skills with an aim to improve clinical practice. Nevertheless, it is very important for the staff member who will take on to implement the audit cycle to have proper training, supervision and protected time (Mercel et al, 2006).
Bowie et al identified that lack of protected time to conduct a clinical audit is a major disadvantage for health care professional. They have to do it within their own allocated clinical time. Therefore, it can potentially affect direct patient care when allocating clinical time for auditing. It is not possible to justify leaving wards understaffed and underfunded to undertake audit unless instant results are attained (Esposito &Canton, 2014, Ellis et al, 2000, Hughes 2005). Subsequently it causes additional workload on key staff members when undertaking an audit (Collis, 2006, Johnston et al, 2000).
Lack of support from management to make audit related improvements and changes with the view of providing quality patient care. Inadequate organizational monitoring of auditing activities and progress is a barrier to make changes in patient care. It can lead to frustration and distress on auditors (Bowie et al, 2012, Hughes, 2005).
Indirect situational factors influence the success of auditing such as lack of time and resources, lack of supervision, lack of support from management, conflict within multidisciplinary team, negative attitudes associated with audit process ((Travaglia & Debono, 2009, Hughes, 2005).
A systematic review of Cochrane study of 140 studies tested the effectiveness of clinical audit outcome against other methods of study such as meetings and distribution of printed materials. Results were variable. Audit outcome ranges from negative outcome to very positive effect. When the audit was effective, results range from small to moderate. Moreover, the study concluded that effectiveness of audit is likely greater, when baseline adherence to recommended practice is low. Therefore, there is no clear scientific evidence to support the real effectiveness of clinical audit (Esposito & Canton, 2014, Ivers et al, 2014).
In general, clinical audit considered as an effective and cost effective method for continuous quality improvement even though there are numerous limitations. Therefore, it is important to pay more attention to clinicians having trouble in auditing and to determine what recommendations are made to make the audit more effective. In order to overcome the difficulties of audit, auditors need to be clear about the areas of clinical practice audited. In addition, it is very important to know the difference between audit and research to avoid inappropriate data collection while conducting an audit. Clearly, audit and research serve two distinctive purposes.

Abbasi, K., &Heath, A. (2005). Ethics review of research and audit, BMJ, 330(7489), 431-432. doi: 10.1136/bmj.330.7489.431

Bennadi, D., Konekeri, V., Kshetrimayum, N., Sibyl, S., & Reddy, V. (2014). Clinical audit – a literature review, Journal of international dental and medical research, 7 (2), 49-55.Retrieved from

Difference between audit and research (2014), Audit vs research, retrieved from

Esposito, P., & Canton, A.D. (2014). Clinical audit, a valuable tool to improve quality of care: General methodology and applications in nephrology, World journal of nephrology, 3(4), 249-255. doi: 10.5527/wjn.v3.i4.249.

Hughes, R. (2005). Is audit research? The relationships between clinical audit and social research, International Journal of Health Care Quality Assurance, 18(4), 289-299. doi: 10.1108/09526860510602550.

Mercel, S.W., Sevar, K., & Sadutshan, T.D. (2006). Using clinical audit to improve the quality of obstetric care at the Tibetan Delek Hospital in North India: a logitudinal study. Quality health care, 3(4), 1-4. doi:: 10.1186/1742-4755-3-4

Nettleton, J. & Ireland, A. (2000). Junior doctors’ views on clinical audit. Has anything changed?, International Journal of Health Care Quality Assurance,13(6), 245-53. Retrieved from improvement.

Patel, S. ( 2010).Iidentifying best practice principles of audit in health care, Nursing standard, 24 (32), 40-48. Retrieved from

Travaglia, J., & Debono,D. ( 2009) Clinical audit: a comprehensive review of the literature, Centre for Clinical Governance Research, University of New South Wales, Sydney Australia . Retrieved from

Tsaloglidou, A. (2009). Does audit improve the quality of care, International journal of caring sciences, 2(2), 65- 72. Retrieved from

Twycross, A., & Shorten, A. (2014). Service evaluation, audit and research: what is the difference?, Evid Based Nursing , 17(3), 65-67. doi:10.1136/eb-2014-101871

Yorston, D., & Wormald, R. (2010). Clinical auditing to improve patient outcomes, Community eye health journal, 23(74), 48-49. Retrieved from

Clinical Supervision in Practice and District Nursing

The following research reports a systematic literature review of studies which have assessed the development, implementation and outcomes of clinical supervision within practice and district nursing.
Background – The demands which are being placed on nurses within the modern health care environment continue to increase. It is important that effective measures are identified which provide appropriate education, support and quality control for nurses to ensure that they can meet these demands. One such approach is referred to as clinical supervision. Through this, a nurse can be supervised by a more superior colleague who can oversee their actions and make interventions when necessary.
Aims – This literature review will critically review research which has assessed the development, implementation and outcomes of clinical supervision in practice and district nursing. This will enable an assessment of the effectiveness and efficacy of clinical supervision within this group of health care workers.
Methodology – A systematic literature review was conducted. Relevant articles were identified via computer based searches, manual searches and internet-based searches.
Results – It was found that clinical supervision was developed based on a set of standards but that more work is required to improve the dissemination of these standards, role definitions and to standardise the process of supervisor selection and training. A need was also identified for supervisors to me made more available for both nurses and the supervisors themselves. Finally, the perceived benefits of clinical supervision in terms of support, socialisation into ward culture, providing clinical experience and improving the nurses’ job satisfaction were discussed. Further research is recommended to developed standardised and validated assessment tools to enable empirical analyses of the effect of clinical supervision on nurse performance and the quality of care provided to patients.
Conclusions – Clinical supervision is seen to be an effective way of providing support for practice and district nurses. However, more work is needed to ensure that it is more feasible and that it is not viewed as a form of control or assessment by the nurses.
Keywords – Clinical Supervision Practice District Nursing Evaluation
What do we already know about the topic?

Clinical Supervision focuses on providing nurses with education, support and management (quality control)
Health care workers perceive that clinical supervision aids support, skill development, team building, provides a monitor and helps colleagues to share information
Little research has critically analysed the effectiveness and efficacy of clinical supervision for practice and district nursing

What does this study add to the knowledge in this topic?

Clinical supervision standards have been developed but they need to be more effectively disseminated, standardised and the roles need to be better defined
This review highlights the need for there to be an increase in the availability of supervisors for both nurses and the supervisors themselves
Standardised assessment tools need to be developed and validated to enable an assessment of the effect of clinical supervision on nurse performance and quality of care

The world of nursing has gone through a period of significant change over the last ten years. In the acute nursing environment, nurses are using increasingly more complex health care interventions and have to incorporate the use of advances in both medical technology and disease management. Within primary care, nurses are required to face the burden of chronic disease and to facilitate patients beginning to self manage their own health. Such changes have been made as a result of Governmental policy and strategic approaches (Wanless 2002, Wanless 2004).

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Such changes have resulted in there being a range of extra demands being placed upon the nurse, both during and after their training. The Royal College of Nursing (2004a and 2004b) acknowledged the change which is occurring and stated that nurses’ continuous education needs to be assessed and adapted to meet the changing role of the nurse. Changing have particularly taken place within the education of student nurses through the implementation of Project 2000 (UK Central Council for Nursing, Midwifery and Health Visiting 1986)Nurses are now required to undertake tasks which were traditionally performed by doctors. Through these changes the need for effective CLINICAL supervision within nursing has become ever more salient. As a result of the potential effects which a supervisor nurse relationship can have on the nurse’s learning, their experience of training, their subsequent performance on the training course, their future effectiveness as a nurse and ultimately on the quality of the care which is provided by the nurses, it is an important topic to consider within the fields OF BOTH PRACTICE AND DISTRICT nursing.
Much has been written about the practitioner as facilitator, supervisor, assessor and role model, and the overlay of role functions (Windsor 1987, Hughes 1990, Donovan 1990, Bailey 1992). Despite this, there is still a lack of consensus within the literature in terms of a clear definition of what is meant by the term ‘supervisor’ (Hagerty 1986, Phillips et al 1996a, Phillips et al 1996b). It has been argued that the task of defining the term supervisor is made more complicated by the fact that other terms are used, such as assessor, facilitator and mentor, to describe the same role (Phillips et al 1996a, Phillips et al 1996b). As a result of the wide range of aspects of the role which is played by a supervisor, it can be stated that a definition of supervisor can only be a general description as anything more specific would run the risk of excluding important elements of the position (Davies et al 1994). For the purposes of the following review, the definition of supervision which was provided by Zwolski (1982) will be adopted:
‘Supervision is a relationship which is aimed at guiding the novice towards an established place within the profession’ (Zwolski 1982)
In the nursing profession the aims of the supervisor will be to form a relationship with their nurses which enables them to be successful during their training and throughout their subsequent career. Jarvis (1995) emphasised that it is important to focus on the supervisor’s role as a function and as a relationship with the nurse rather than being about them as a teacher or practitioner. Through this role the supervisor can help to narrow the gap between theory and practice (Pelosi-Beaulieu 1988, Armitage and Burnard 1991). Butterworth and Faugier (1994) theorise that the role of clinical supervisor has three key elements, namely Education, Support and Management (through quality control).
However one conceptualises clinical supervision within practice and district nursing, the benefits of the process have been demonstrated through previous research. It has been found that nurses require their supervisor to provide a good role model and to provide a source of support, particularly in the earlier years of a nurse’s career (Gray and Smith 2000). Research has indicated that nurses tend to leave the profession because they cannot cope with the demands of training or the job itself (Fulbrook et al 2000) or because of more personal factors (MORI 2003). It may be that clinical supervision has a broader role to play here in reducing the probability that a nurse will leave the profession. Based on questionnaire research, Thomas and Reid (1995) identified five important benefits of clinical supervision. They were support, skill development, team building, monitoring clinical performance and the sharing of information. The following review will consider research which has focussed on the clinical supervision within practice and district nursing.
A systematic review aims to integrate existing information from a comprehensive range of sources, utilising a scientific replicable approach, which gives a balanced view, hence minimising bias (Hart 1998). In other words, a scientific approach will help to ensure that research evidence is either included or excluded based upon well defined and standardised criteria. This should ensure that the possible effects of researcher bias should be kept to a minimum. Brealey and Glenny (1999) also states that systematic reviews provide a means of integrating valid information from the research literature to provide a basis for rational decision making concerning the provision of healthcare.
The methodology employed within the research will involve obtaining data from three key sources: Computerised searches, Manual searches, and the Internet. Each of these data sources will now be considered in more detail.
Multiple databases, both online and CD–Rom will be accessed to retrieve literature because they cite the majority of relevant texts. (Loy 2000) The computerised bibliographic databases are:-

British Nursing Info BNI
Science Direct(All Sciences Electronic Journals)

However because articles may not be correctly indexed within the computerised databases, other strategies will be applied in order to achieve a comprehensive search (Sindhu & Dickson 1997).
A manual search will be performed to ensure that all relevant literature is accessed. The manual searches will include:-

Books relevant to the topic from university libraries and web sites
Inverse searching- by locating index terms of relevant journal articles and texts
Systematically searching reference lists and bibliographies of relevant journal articles and texts

The internet will provide a global perspective of the research topic and a searchable database of Internet files collected by a computer.
Sites accessed will include:-

National Institute of Clinical Excellence
English National Board of Nursing, Midwifery and Health Visiting

The selection of search terms is an important task. The search needs to be sensitive in that it should identify as many of the key articles as possible. It should also be specific in reducing the number of irrelevant articles which it produces. The search words were derived based on the research question, as recommended by Loy (2000). They were:

Clinical Supervision
Practice Nursing
District Nursing

In order that a manageable quantity of pertinent literature is included in this study, it is essential that inclusion and exclusion criteria are applied. These are outlined below:
The articles which are highlighted within the proposed searches will be assessed in terms of whether or not they meet the following criteria. Each article will need to be viewed as appropriate with regards to all of these constraints if they are to be included in the final analysis. From the pool of data which is obtained, the most appropriate articles which meet these inclusion criteria will be selected for use within the review.

A literature review encompassing all methodologies will be applied (International studies will be included
Available in English
Relate to Clinical Supervision
Relate to Practice or District Nursing

The articles highlighted by the searches will also be assessed in terms of whether or not they fulfil the following exclusion criteria. If a potentially relevant article meets one or more of these criteria then they will be immediately excluded from the data set and will not be included within the analysis stage of the methodology.

Articles relating to supervision in industries other than health care will not be included
Literature in a foreign language will be excluded because of the cost and difficulties in obtaining translation.
Research reported prior to 1985 will not be included within this review.

Any research involving NHS patients/service users, carers, NHS data, organs or tissues, NHS staff, or premises requires the approval of a NHS research ethics committee (Department of Health 2001). A literature review involves commenting on the work of others, work that is primarily published or in the public domain. This research methodology does not require access to confidential case records, staff, patients or clients so permission from an ethics committee is not required to carry out the review. The researcher will also act professionally when identifying, reviewing and reporting relevant studies.
The most relevant research which was identified by the methodology employed within this research will now be critically analysed. In order to structure the discussion more effectively, the analysis will address the three stages which should comprise the evaluation of a training intervention (Kirkpatrick 1979). Thus the discussion will consider the development, implementation and outcomes of clinical supervision in practice and district nursing.
Whenever one is considering a health care intervention, it is important to first address the foundations upon which it was developed. In the case of clinical supervision, one must consider the relevant policies and theoretical frameworks. A set of standards which govern the preparation and role of supervisors were produced by the UK Central Council for Nursing, Midwifery and Health Visiting (2004). The English National Board have outlined the five key aspects of the supervisors role: Assisting, Befriending, Guiding, Advising and Counselling (Anforth 1992). Research has been conducted with the aim of evaluating the supervision process from a theoretical perspective as well as those of the nurses and supervisors themselves. This research will now be outlined.
Researchers have conducted reviews of clinical supervision of nurses and have highlighted some potential limitations. Andrews and Wallis (1999) reported that a range of different frameworks for conceptualising the supervisor role were prevalent and that more specific guidelines needed to be developed. They also found that supervisors often attended short and local courses whose effectiveness had not been evaluated. Furthermore, Wilson-Barnett et al (1995) stated that the continued use of terms such as mentor, assessor and facilitator, as well as supervisor, led to confusion of the specific nature of the role. Therefore, it appears that although standards have been developed regarding clinical supervision in nursing, further work may be required to ensure that they are more effectively disseminated.
The process of clinical supervision needs to also be evaluated from the nurses’ perspective. Watson (1999) conducted semi-structured interviews with 35 nurses to investigate their perceptions of the clinical supervision which they had received. Two key findings were reported. Firstly, the respondents reported that they felt that the supervision process was not sufficiently defined by the English National Board. They also felt that the supervision process was not adequately clarified by their internal organisation. Standards were seen to be appropriate but they were not effectively applied to the practical situation. This research did employ a small sample and the extent to which the findings can be generalised to the UK as a whole may be questioned Having said this, these findings do demonstrate that nurses clinical supervision is based on appropriate standards but that the roles of supervision and the person being supervised need to be more specifically defined.
The third and final area of evaluation concerns the supervisors themselves. Cahill (1996) reviewed the relevant research in this area and reported that there are a range of different supervisor selection and training procedures. This ensures that there is sufficient scope for different supervisors to be selected based on different criteria and for them to then go on and receive different levels of training. This lack of standardisation has the potential to mean that the quality of supervision provided throughout the UK may significantly differ. Further research in this field has been reported.
For instance, Neary (1997 and 2000) interviewed 155 clinical supervisors. It was found that there was some confusion over the nature which the supervisor/nurse relationship should take. The supervisors were not clear on what their specific role was and the extent to which they should help their nurses. This causes problems in terms of competency assessment as the supervisors were not clear on what was expected of them and the nurses whom they were supervising. Therefore, issues regarding standardisation and role definition are prevalent within supervisor perceptions of this topic. This section has demonstrated that work is required to improve the dissemination of standards, role definitions and the standardisation of supervisor selection and training.
A relevant research study which has been conducted in this area involved nurses and their supervisors completing activity diaries for a week (Lloyd-Jones et al 2001). The data provided via the activity diaries were then analysed in order to determine the extent to which the nurses were adequately supervised and what happened when their supervisors were not present. It was reported within this research that the nurses did spend a significant amount of time away from their supervisor. It was identified that in the absence of a supervisor, the student nurse was often supervised, either directly or indirectly, by another qualified member of staff. Although this may be a good short term solution, it is unlikely to be standardised across organisations and to only occur when there is an appropriate member of staff available. More strategic approaches to clinical supervision may be required such that practice and district nurses have appropriate support when it is required.
The importance of supervisor availability has been highlighted within international research. For example, Saarikoski (2002) collected data from 558 student nurses who were based in both Finland and the UK. They completed the Clinical Learning Experience and Supervision Instrument. The Finish students were found to be significantly more positive regarding their clinical experience and their supervision relative to the UK students. This difference was found to be significantly associated with the fact that Finish students spent a significantly longer amount of time with their supervisor. This methodology benefits from using a relatively large sample. Other research has focussed on the extent to which the supervisors themselves are adequately supervised.
Aston et al (2001) conducted research which was commissioned by the English National Board. They collected information via documentation, one-to-one interviews and focus groups using samples of 76 lecturers and 46 practitioners. The research focused on the participants’ perceptions of the extent to which the supervisors of student nurses are adequately supervised, monitored and audited. It was found that supervisors believed that they were not sufficiently prepared, supported or monitored. They had a wide range of different experiences and they believed that there was a need for a more organised approach which would enable more consistent support and supervision to be available. It is important that the supervisors themselves are supervised so that they have someone to guide and advise them in their role and to provide them with the support that they need to effectively supervise their student nurses. The methodology used in this study benefits from having a relatively large sample and because it obtained data from a number of different sources. This facilitated an overall view of the topic to be gained by enabling a more comprehensive approach. This section has demonstrated that further work is required in the implementation of clinical supervision to ensure that both practice and district nurses, as well as their supervisors, are appropriately supervised.
A key area of any evaluation will focus on the relevant outcomes. However, in terms of clinical supervision, this is not a straight forward task as there is a lack of clear and standardised assessment tools. Calman et al (2002) conducted 12 focus groups and 72 one-to-one interviews with nurses and supervisors to gain an understanding of their perceptions. It was reported that assessment tools were not seen to provide a fair reflection of a person’s ability and that the approaches taken varied significantly between organisations. As a result of this the research which has empirically assessed the effects of clinical supervision on both the quality of patient care and the nurses’ skill acquisition is limited.
Having said this, questionnaire research involving 19 nurses has highlighted some of the perceived positive outcomes of clinical supervision (Earnshaw 1995). The respondents indicated that the supervision provided vital support, aided their socialisation in terms of ward culture and facilitated their gaining of clinical experience which helped to improve their skills. Thus, through both direct and indirect methods, clinical supervision can have positive outcomes in terms of the nurses themselves. However, one cautionary note should be made here in that further research by Cahill (1996) has revealed that some nurses view clinical supervision as a form of control and assessment rather than a source of help to them.
Therefore, more standardised and validated assessment tools are required before confident conclusions can be made regarding the actual effects of clinical supervision on nurses’ skills and the quality of the care which they provide to their patients. There are some perceived outcomes of both a positive and negative nature which are associated with clinical supervision. Further work here would help to maximise and realise the perceived benefits and to minimise the effects of any possible negative aspects.
Other relevant research has focused on the outcomes of clinical supervision in terms of the nurses job satisfaction. Gray and Smith (2000) interviewed 10 nurses at five different points in their careers. A positive correlation was found between the quality of the supervisor/nurse relationship and the nurses’ satisfaction with their learning experience within their role. Therefore, if a positive relationship can be facilitated between a nurse and their supervision then this should, in theory, help to improve the chance that the nurse will be satisfied within their role. Research has also investigated the longer term aspects of the relationship between clinical supervision of the nurses’ satisfaction with their career. One such study was recently conducted by Pearcey and Elliott (2004) and involved interviews with 14 student nurses. Four key aspects were associated with whether or not the student nurses would be likely to go on and seek a career as a nurse in the future. These factors included ward culture, the reaction to negative incidents, the student nurses perceptions of the qualified nurses/supervisors and how these people were seen to treat the trainee nurses. Thus the supervisors can help to improve the learning experience in each of these areas.
This section has shown that improvements need to be made in establishing a standardised assessment to enable more accurate evaluations of the effectiveness of clinical supervision to take place. Nurse perceptions of clinical supervision do reveal that there are both positive and negative outcomes. One interesting finding merits consideration here. Andrew and Chilton (2000) interviewed supervisors and nurses regarding the benefits of a teaching qualification on the outcome of clinical supervision. The supervisors reported that they felt that it made them more effective in the supervisory role and that they provided better support as a result of the qualification. However, the nurses’ ratings of supervisors with and without a teaching qualifications revealed no significant differences. Thus more work is required in developing the training of supervisors to ensure that it has a positive effect.
This review has considered research which has evaluated clinical supervision within practice and district nursing. The discussion focussed on the development, implementation and the outcomes of clinical supervision. In terms of the developmental factors, a need for an improvement in the dissemination of standards was identified along with the establishment of clearer role definitions. A drive towards a more standardised approach to supervisor selection and training is also advocated. As for the implementation of clinical supervision, the need for both nurses and supervisors to be supervised was identified. Research has demonstrated that supervisor availability is associated with the nurse’s performance and hence it is important that supervisors are available as much as possible.
The final section of the discussion considered the outcomes of clinical supervision. The lack of standardised and validated assessment tools ensure that it is difficult to quantify the effects of clinical supervision on the nurses’ performances and ultimately on the quality of patient care. However, the perceived benefits of clinical supervision, such as support, socialisation, enabling clinical experience and enhancing job satisfaction, were identified. It may also have longer term benefits in terms of reducing the probability that a nurse will leave the profession. It is through working towards the realisation of the perceived benefits that clinical supervision can be made as effective as possible. Through this, more effective training programmes for clinical supervisors can be developed and the potentially negative view of clinical supervision as being about control and assessment can be replaced with a more positive image of aiding continuous improvement in nurse satisfaction and performance along with the quality of care which is given to patients.
7.0 References
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Armitage P and Burnard P. Supervisors or preceptors? Narrowing the theory/practice gap. Nurse Education Today, 1991, 11 (3), pp 225-229
Aston L, Mallik M, Day C and Fraser D. An exploration into the teacher/lecturers in practice: Findings from a case study in adult nursing. Nurse Education Today, 2000, 20 (3), pp 178-188
Bailey D. Facilitator not teacher: a role change for tutors in open learning nursing education. Journal of Advanced Nursing, 1992, 17, 983-991
Brealey S. and Glenny A, A Framework for radiographers planning to undertake a systematic review. Radiography, 5 131-146, 1999
Butterworth T and Faugier J Clinical supervision in Nursing, Midwifery and Health Visiting. A briefing paper. Nursing Times. 1994, Vol.90 No.48 pp.38-42
Cahill HA. A qualitative analysis of student nurses’ experiences of supervision. Journal of Advanced Nursing, 1996, 24 (4), pp 791-799
Calman L, Watson R, Norman I, Redfern S and Murrells T. Assessing practice of student nurses: Methods, preparation of assessors and student views. Journal of Advanced Nursing, 2002, 38 (5), pp 516-523
Davies WB, Neary M, Philips R. Final Report. The Practitioner-Teacher. A Study in the Introduction of Supervisors in the Pre-Registration Nurse Education Programme in Wales. Cardiff, UWCC, School of Education, 1994.
Department of Health. National service framework for older people: Modern standards and service models. London, UK: Author 2001.
Donovan J. The concept and role of supervisor. Nurse Education Today, 1990, 10 (4), pp 294-298
Earnshaw GJ. Supervision: The students’ views. Nurse Education Today, 1995, 15 (4), pp 274-279
Fulbrook, P., Rolfe, G., Albarran, J. and Boxall, F. ‘Fit for Practice: Project 2000 Student Nurses’ Views on how well the Curriculum prepares them for Clinical Practice’ Nurse Education Today 2000, 20 (5): pp 350-357
Gray MA and Smith LN. The qualities of an effective supervisor from the student nurses’ perspective: Findings from a longitudinal qualitative study. Journal of Advanced Nursing, 2000, 32 (6), pp 1542-1549
Hagerty B. A second look at supervisors. Nursing Outlook. 1986, 34, 16-20.
Hart C. Doing a literature reviewLondon: Sage Publications 1998
Hughes P. Evaluating the impact of continual professional education (ENB 941). Nurse Education Today, 1990, 10 (6), pp 328-336
Kirkpatrick DL. Techniques for evaluating training programmes. Training and Development Journal, 1979, 33 (6), pp 78-92
Jarvis P. Towards a philosophical understanding of supervising. Nurse Education Today, 1995, 15 (6), pp 414-419
Lloyd-Jones M, Walters and Akehurst R. The implications of contact with the supervisor for pre-registration nursing and midwifery students. Journal of Advanced Nursing, 2001, 35 (2), pp 151-160
Loy. J. New on the Net MIDIRS Midwifery Digest, 2000
MORI. Student Nurses: The Pressure of Work. 2003
Neary M. Supporting students’ learning and professional development through the process of continuous assessment and supervision. Nurse Education Today, 2000, 20 (6), pp 463-474
Neary M. Defining the role of supervisors, assessors and supervisors: Part 1 and 2. Nursing Standard, 1997, 11 (43), pp 34-38
Pearcey PA and Elliott BE. Student impressions of clinical nursing. Nurse Education Today, 2004, 24 (5), pp 382-387
Pelosi-Beaulieu L Preceptorship and supervision: bridging the gap between nursing education and nursing practice. NSNA/Imprint, 1988, 111-115.
Phillips RM, Davies WB, Neary M. The practitioner-teacher: a study in the introduction of supervisors in the pre-registration nurse education programme in Wales part 1. Journal of Advanced Nursing. 1996a, 23 (5), pp 1037-1044
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RCN. The Future Nurse: The RCN Vision Explained 

Implications of Stanley Milgram’s 1963 Study on Obedience on the Clinical Environment

Describe the key points and the potential implication of Stanley Milgram’s 1963 study on obedience for patients’ behaviours within a clinical environment and radiographers’ professional conduct in the context of a hierarchical working environment.

Milgram’s question which initiated the thought for this experiment started by the dispositional attribution of the Germans. He questioned how the German Nazi soldiers could permit the termination of the Jews and the harsh treatment (, 2019).  Milgram could not comprehend how the Nazi soldiers could act inhumanly without any conscience. The biggest question for Milgram was under what conditions would a person obey authority who commanded actions that went against their conscience (, 2019). This essay will explore Milgram’s study and his variations; relating to clinical environment and hierarchical working order. The variations which will be researched are the telephone orders, uniform variation , physical contact variation and run down office block.

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The aim of Stanley Milgram’s, Behavioural Study of Obedience was to investigate the level shown by members when told by authority to administer electric shocks to another person. The investigation examined the nature of human behaviours and its relationship to  hierarchical working order and conventions. The experiment helped investigate the relationships between group behaviour and blind obedience to authority. Obedience can be defined as compliance with an order, request, or law or submission to another’s authority (Lexico Dictionaries, English, 2019). The experiment was carried out as a controlled observation in a laboratory. It took place at Yale university; a prestigious place of education. The participants in the experiment were 40 males aged between 20-50 year old and a range of occupations and educational backgrounds. This increased Milgram’s generalisability with a varied range of occupations taking part. However, a downfall from this study is that there is a low generalisability in terms location as it was ethnocentric. Another disadvantage was, low population validity of this study was androcentric as the participants were only males (Yogi, 2019). Milgram advertised the experiment in a newspaper and asked for American male volunteers. Subjects were told that the was about the effects of punishment and memory (Medium, 2019). The participants were paid $4.50 as a convenience and was theirs’s to keep no matter the outcome. The type of sampling used were self-selecting and volunteer sampling.

During the procedure the participant was introduced to a strict looking experimenter; the authority figure wearing a white lab coat. One of the participates was a ‘teacher’ and one was the learner. They drew rigged lots to determine roles so that the naïve participant will always be the teacher and the confederate was always the learner. The learner was given shocks when they gave the wrong answers to questions the teacher asked. However, there were no actual shocks given to the learner. The only shock through the whole set-up procedure was a slight shock given to the teacher to show the authenticity of the experiment. The learner and the teacher were in separate rooms. The shocks increased every 15 volts up to 450 volts. Throughout, the authority figure gave prompts such as; “please continue”, “the experiment requires that you continue”, “it is absolutely essential that you continue” (Stanley, 2019). The results of this study were that 100% of participants obeyed the experimenter and delivered shocks up to 350 volts and 65% of participants delivered shocks up to maximum which was 450 volts. Additionally, 26 out 40 participants continued to the maximum voltage. (Stanley Milgram, 2019)

Uniform was one of the variation’s in Milgram’s study. Researcher left the room and was replaced by another person. This person was another confederate and without an official uniform and instead, was in ordinary clothes. During the experiment the confederate was suggesting to increase the voltage every time the learner made a mistake. The percentage of participants who administered the full 450 volts when being instructed by an ordinary man, dropped from 65% to 20% (Sage Journals, 2019). This percentage decrease demonstrated the significant influence of the uniform and the legitimacy is has. Individuals who are in positions of authority have a specific clothing that is symbolic of their authority (Khan, 2019). It indicates who is entitled to expect at their obedience.  was another study which showed that the power of uniform makes people obey orders. This can be related to clinical environment as there are hospital staff and different healthcare professions who are entitled to wear uniform (Timmons and East, 2019). For example, doctors, nurses and radiographers can be projected as people who have power over patients to an extent as it signals their biomedical authority as it signifies a profession’s identity. In terms of radiography hierarchy in a workplace, it is a code of conduct for radiographers wear appropriate uniform to demonstrate trustworthiness and integrity. (, 2019)

The second variation which will be explored is the absence of authority. During this absent experiment condition, the researcher gives the participant who was administering the.  The researcher then leaves the teacher in the room. Due the fact the teacher and learner were in separate rooms, this lead to a significant decrease in obedience. The level of obedience decreased to 20.5% (Mcleod, 2019). Different levels of obedience can be devised by patients when they are within a hospital environment compared to when they are not e.g. at home. Patients tend to listen to healthcare professions when within the clinical environment as they know they will have members of staff monitoring their treatment or actions taken are essentially benefiting the patient. An example would be that a nurse or physiotherapist may encourage a patient to take their pills on time or do certain exercises and patients would comply as they know how important it is for them but most importantly, they do not want to ruin the relationship they have with the healthcare professions (, 2015). Patients tend to think that if they are obedient they will be treated well rather than someone who is not obedient. REFEENCE. This is the same where the subject in Milgram’s study continued to administer the volts because the authority told him to continue was afraid of what could happen with him if he stopped. REF Secondly, since the subject was being paid to do that, even though he did not find it enjoying or knowing he was hurting someone, he was going to earn money. Relating to the patient and healthcare profession

 This can be linked to Milgram’s study because when patients are away from a clinical institution, some tend to not comply with the treatments instructed when they go home.

Getting paid – ruin relationship

Telephone orders was another variation in Milgram’s study. The researcher was giving orders to the participant administering the shocks over the phone. This means they weren’t in the same room as them and this lead to decreased obedience.   It is easier to resist the orders from an authority figure if they are not close by. When the experimenter instructed and prompted the teacher by telephone from another room, obedience fell to 20.5%. Hofling et al.’s (1966) Study of Obedience (, 2019), was an hospital study to see if nurses would obey a doctor even if it meant breaching hospital regulations and risking the life of patients. Nurses received a phone call from a unidentified doctor asking them to administer a drug to a patient. The dose of drug the nurses were asked to give were significantly high and would have been an overdose. The nurses then carried out to do so knowingly break hospital rules in a situation where a doctor tells them to, even if it could endanger a patient’s life. Although this study contradicts Milgram’s findings since it shows nurses did comply when the order was given over the telephone, it also supports Milgram’s study in how people obey authority figures since doctors are more senior than nurses. Another variable in a clinical environment is that radiographers have an authority over doctors and a responsibility for the patient by making sure any type of imaging is justified under IRMER protocol (, 2019). This is especially shown in theatre where the radiographers are responsible for everyone to wear lead and for the protective shielding to be up.  Doctors may request x-rays which do answer clinical questions and instead increase radiation for patient that is unneeded.

Run down office was another variation in this experiment. The study did not happen in a prestigious university like Yale in the original experiment. This decreased obedience to 19 (45.5%) (Psychology Wizard, 2019). Patients more likely to follow health professionals orders when in hospital as they are authority. Hospitals have strict protocols in place and regulations that must be followed by patients. Therefore they are likely to do what nurses, doctors and radiographers as they are seen as high authority figures and health professionals in the patient’s perspective. This is a vital part of their patient pathways and care. Another variable would be a setting of a room or bed in which the patient will have to spend time in during their treatment. A clean and tidy environment provides the right setting for good patient care. Patients would expect anything they come into contact with to be clean, especially with the bed they will be spending their time in (Cleantex, 2019). It’s also critical to have clean linens and towels to help stop the spread of diseases and infections (AM, 2019).

In conclusion, Milgram’s study on obedience reveals the extent to which society’s behaviour is influenced by other people. Due to the situation the teacher obeyed the instructions which were given to them even though they did not want to administer shocks. This shows that people are likely to obey people who have a position of authority even if it may go against their personal belief. However since there are set protocols and guidelines set in place in a clinical environment it is an advantage. This ensures employers understand what is expected of them and what will happen if they violate the rules.


AM, A. (2019). Mattress cleanliness: the role of monitoring and maintenance. – PubMed – NCBI. [online] Available at: [Accessed 8 Aug. 2019].

Cleantex. (2019). Healthcare Linen | SWS GROUP. [online] Available at: [Accessed 8 Aug. 2019]. (2019). Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) | Care Quality Commission. [online] Available at: [Accessed 6 Aug. 2019]. (2015). A good patient? How notions of ‘a good patient’ affect patient-nurse relationships and ART adherence in Zimbabwe. [online] Available at: [Accessed 5 Aug. 2019]. (2019). AS Psychology Milgram. [online] Available at: [Accessed 9 Aug. 2019].

Khan, H. (2019). RhinoSpike : English Audio : symbolic clothing. [online] Available at: [Accessed 6 Aug. 2019].

Lexico Dictionaries | English. (2019). obedience | Definition of obedience in English by Lexico Dictionaries. [online] Available at: [Accessed 9 Aug. 2019].

Mcleod, S. (2019). Milgram Experiment | Simply Psychology. [online] Available at: [Accessed 8 Aug. 2019].

Medium. (2019). Milgram’s Experiment and its Implications for Human Behaviour. [online] Available at: [Accessed 6 Aug. 2019]. (2019). Basis for Milgram’s Obedience Experiment. [online] Available at: [Accessed 9 Aug. 2019]. (2019). Hofling et al.’s (1966) Study of Obedience on SimplyPysychology | (beta). [online] Available at: [Accessed 7 Aug. 2019].

PSYCHOLOGY WIZARD. (2019). Milgram AO1. [online] Available at: [Accessed 8 Aug. 2019].

SAGE Journals. (2019). Milgram’s shock experiments and the Nazi perpetrators: A contrarian perspective on the role of obedience pressures during the Holocaust – Allan Fenigstein, 2015. [online] Available at: [Accessed 6 Aug. 2019]. (2019). 4. Personal & Professional Standards | Society of Radiographers. [online] Available at: [Accessed 9 Aug. 2019].

Stanley Milgram. (2019). Overview. [online] Available at: [Accessed 6 Aug. 2019].

Stanley, M. (2019). BEHAVIORAL STUDY OF OBEDIENCE. – PubMed – NCBI. [online] Available at: [Accessed 6 Aug. 2019].

Timmons, S. and East, L. (2019). Uniforms, status and professional boundaries in hospital. [online] Wiley Online Library. Available at: Cited by: 15 [Accessed 7 Aug. 2019].

Yogi, P. (2019). Milgram (1963) – Obedience to Authority | Psych Yogi. [online] Available at: [Accessed 9 Aug. 2019].


Mental Health Assessment Case Study Using Clinical Reasoning Cycle

This paper intends to provide a reflection upon a case study of ‘Alison’, who is a 38-year-old single mother of two. It uses the clinical reasoning cycle as a framework to explicitly discuss the situation and learnings from the mental health assessment (MSE) of Alison by utilizing the clinical reasoning cycle (CRC) and referencing to the components of MSE upon watching the video. Levett-Jones (2018) describes CRC is as a process by which nurses collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and learn from the process. It can be used to assist us to learn about critical thinking and decision-making. Alison works in a local supermarket. She went to see her general partitioner due to low mood and was currently diagnose of Clinical Depression. In consideration of her current situation financially, it causes her low mood and anxiety to occur again after being divorced with her husband. Financial stress has an enormous impact especially on a single parent which contributed to being a significant stressor of Alison. On the other hand, there are some protective factors that can alleviate the situation Alison such as having loving children and supportive sister as well as good friends.

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In mental health, there are various components and factors that influence mental illnesses. According to Stallman & Wilson (2019), biopsychosocial approach plays an important role in examining the cause of these mental illnesses to enable clinicians to evaluate the corresponding intervention to have a positive outcome. MSE is one of the assessment tools that can be used to identify the patient’s current mental state. In Alison’s case, this was undertaken by her general partitioner. Alison presented to be neat and tidy in her pink blouse. During her interview, Alison is very depressed and tearful, poorly eye-contact and sitting at a slumped posture with fidgeting her hands at times. Her speech was soft, slow and mumbling at times. Thought form was relevant and logical. But she displayed a depressed, restricted and congruent affect. No perceptual hallucination was observed with Alison. There was no delusion and paranoia observed, however, there was self-harm reported. Regarding perception and cognition, Alison was alert and orientated with a good memory. However, she had poor concentration and she also stated that she felt exhausted and not interest in having social activities with her friend. She aware of her illness and seek for mental health professional help. Therefore, her level of insight was good, and her judgment was unimpaired.

By analysing the data gathered after the MSE assessment, Alison was diagnosed with depression. American Psychiatric Association (2013) explains that depression is the presence of sadness and feeling empty that coexist with somatic and cognitive changes that considerably affect one’s capacity to function. Major depressive disorder criterion symptoms of Alison include depressed mood or anhedonia, sleep disturbances, change in appetites or weight, poor concentration, and feelings of worthlessness or guilt. In a review of the risk assessment of Alison, she has a suicidal history record in the past. Hence, it is important to clarify the risk factor of Alison to harm self and prevent her from relapsing into that situation.

The current financial status and the mental state of Alison has a significant impact on her ability to function as a single mother of two children, who are 11 years old and 9 years old. She feels that she is useless in taking care of her children. Moreover, the relationship between Alison and her boyfriend is complicated. Dave is upset with Alison that he does not want to communicate with her.

For Alison, her nursing care plan is to let her ability to cope with her life and her stress. In order to establish a treatment plan, Evans, Nizette & O’ Brien (2017) explain that the health-promoting behaviours could contribute to the good relationship by building effective communication. The health professionals should assist patients in identifying their goals and aims for the future. According to The Department of Health (2013), recovery-oriented approach is a way to support patients to recognise and embrace the possibilities for recovery and wellbeing created by the inherent strength and capacity of their mental health issues, to maximise self-determination and self-management of their own mental health and wellbeing, and assist their families to understand the challenges and opportunities arising from their family member’s experiences.

When an individual under treatment presents with symptoms of depression, with compounding financial and personal issues, as a nurse, I would consider building a therapeutic relationship and goals for my patient. For example, active listening can establish a rapport and trust to Alison to allow us to achieve some goals together. Moreover, motivational interviewing can assist Alison in constructing back her self-esteem will enable her to contribute to her distress and resolve her emotional difficulties (Evans et al., 2017). Furthermore, collaborating with multidisciplinary teams such as social worker and the mental health professional might help to meet patients’ needs more effectively (Evans et al., 2017). Multidisciplinary teams convey many benefits to both the patients and the health professionals working on the team. These include improved health outcomes and enhanced satisfaction for patients, and the more efficient use of resources and enhanced job satisfaction for team members.

In order to evaluate clinical outcomes, I might need to discuss at a later date with the individual the mutual set goals. Other means of evaluation could be the complaint on her depression and prescribed medications and the relationship between Alison with her children and her boyfriend.

Through the case study and assessment of Alison, I have learned that MSE can provide information and psychiatric history about the client’s mental state, which includes educational, cultural and social factors. It also involves establishing a therapeutic relationship and using that relationship to collect a range of information about the client and to formulate a collaborative plan of care. Moreover, I realised that depression is a serious condition that affects your physical and mental health. It might impact the performance at work and the levels of concentration; hence it could negatively affect productivity. As a student nurse, I believe that in my future practice, the mental health assessment will enhance me to understand the client’s mental status. It also assists me to deliver high quality of care to my client.

This paper embedded steps of the CRC (Levett-Jones, 2018) for the purposes of reflecting upon the scope, nature and rationale for assessment of Alison in this case study.


American Psychiatric Association (APA). (2013). Diagnostic and Statistical Manual of Mental Disorders Fifth Edition DSM-5. Washington, DC: APA

Evans, K., Nizette, D. & O’Brien, A. (2017). Psychiatric and Mental Health Nursing. (4th ed.). China: Elsevier.

Levett-Jones, T. (Ed.) (2018) Clinical Reasoning: Learning to think like a nurse. (2nd ed.) Frenchs Forest, N.S.W.: Pearson.

Stallman, H., & Wilson, C. (2019). Attending to the biopsychosocial approach in Australia’s mental health agenda. Australian & New Zealand Journal of Psychiatry,53(2), 173. doi:10.1177/0004867418783569


The History of Clinical Mental Health Counseling


Clinical mental health counseling is often confused with its closely related neighbors psychology, psychiatry and social work. This paper examines the profession’s growth throughout history into its own distinct identity.  The origins of philosophy on mental health from early Greek and Roman philosophers are traced.  The inhumane and humane treatments of those suffering from mental illnesses in the Middle Ages are highlighted.  The scope of counseling as a profession before and after World War I and World War II is discussed, and the political agendas that paved the way for a distinct identity as a clinical mental health counselor are highlighted.  

The History of Clinical Mental Health Counseling

The professional identity of clinical mental health counseling can sometimes be confused when viewed only in the present. Gerig (2014) wrote, “Clinical mental health and professional counseling is still the new kid setting up residence on the block where the other mental health professions have lived” (p. 2). The profession has commonalities with its historical neighbors, but there are unique identities that set the profession apart (Gerig, 2014). Relevant history best outlines the emergence of a professional identity for clinical mental health counseling. Leahey (1980), with regard to the discipline of psychology, noted:

The events of today are influenced by the historical past and will influence the historical future. To understand what we are doing and why we are doing it, we need to understand what psychologists did before us as well as the nature of historical change. To ignore the past is to cut off a source of self-understanding. (p. 14)

Mental health and illness theories are not new to the 20th century. Gerig (2014) wrote, “Useful sources of information are the study of myth, comparative religion, and the writings of early philosophers” (p. 2). References to madness and confusion of the mind were given in the Old Testament of the Christian Bible. According to Gerig (2014), “Early distinctions were made between behavioral conditions beyond human control and those related to poor judgment and faulty decision making” (p. 22).

Early Greek philosophy also gives insight into the views of mental illness and its treatment. Hippocrates (406-377 BCE) believed that aberrant behavior had natural causes and should be treated as a physical ailment (as cited in Viney & King, 2003). Plato (428-348 BCE) thought abnormal behaviors stemming from madness required a community response (Plato, n.d.).

The Middle Ages were branded by both humane and cruel treatments toward persons who exhibited aberrant behaviors. Behaviors not readily explained were attributed to supernatural causes. Gerig (2014) wrote, “Humans were thought to be the site where the ultimate battle between good and evil took place” (p. 23). Abusive “water tests” were used to identify whether or not a person collaborated with the devil. In contrast, the Colony of Gheel grew into a center of care for the mentally ill that was characterized by love and kindness (Gartland, 2000). During the 16th century, Europe developed a system of hospitals known as asylums. These institutions were built to provide shelter for people who were not able to take care of themselves. Residents were frequently kept in restraints and left to lie in their own waste, making the conditions deplorable (Whitbourne & Halgin, 2014). During the 1700s, advocates for more humane approaches to mental illness ushered in the moral treatment movement (Linhorst, 2006). The movement was initially opposed by those in the mental health profession. By the mid-19th century, the tireless work of advocates like Dr. Benjamin Rush (1745-1813) and Dorothea Dix (1802-1887) influenced psychologists to adopt the strategy (Parry, 2006). Making the argument stick for moral treatment has been described by Gerig (2014) as “an important step in the profession’s eventual success at securing a monopoly on the treatment of ‘lunacy’” (p. 176).

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Early philosophy demonstrates that healthy and unhealthy forms of behavior have been distinguished by societies (Gerig, 2014). Furthermore, some behaviors were thought to be under conscious control, and some forms were not. As various mental health professions emerged, the fundamental framework for treating pathology or treating to enhance the human function remained intact (Gerig, 2014). According to Fancher (1995), “Professional care for mental health has evolved from giving ‘moral treatment’ to the clearly deranged, to claiming to offer, in the name of scientific advance, access to live reasonably free from emotional distress” (p. 53).

In 1879, Wilhelm Wundt established the first psychological laboratory at the University of Leipzig in Germany. This is thought to be the origin of psychology because he was a philosopher and physiologist who viewed psychology as the study of immediate experience (Resnick, 1997). When he set out to create a science of the mind and behavior, the discipline of psychology emerged as an academic field.

The American Psychological Association (APA) was formed in 1892 by a group of philosophers, educators, and physicians (Resnick, 1997). The organization decided not to incorporate a philosophical psychology division in 1898; and psychology moved toward psychophysics, animal behavior, and human assessment and away from philosophy (Sokal, 1992).

In 1908, William Healy, a Freudian psychoanalyst, established the Juvenile Psychopathic Institute (Gerig, 2014). The Chicago-based clinic was historically significant in the discipline of psychology. First, Laughlin and Worley (1991) noted that it was the first psychiatric clinic within the community. Second, the clinic was the first recorded institution to integrate “psychological skills and training for the treatment of social problems” (Gerig, 2014, p. 26). Until this time, applied psychology had been limited to mental testing. Third, Gerig (2014) identified that “the clinic used a multidisciplinary approach to treatment” (p. 26). The psychiatrists conducted therapy sessions, the psychologists facilitated testing and assessments, and a social worker focused on dealing with any problems the patients had at home (Rogers, 1961).

Around this same time, problems of youth unemployment became a major concern for adolescents. Urbanization had occurred, and sustainable work on family farms was not as available (Whiteley, 1984). Frank Parsons, known as the father of guidance, recognized the impact of this transition, and in 1908, he developed the Boston Vocation Bureau (Gerig, 2014). The goal of the bureau was to identify the aptitudes and the interests of a young person and match them with occupational choices (Smith & Weikel, 2011).

Gerig (2014) identified Parsons as a key contributor to the development of professional counseling, writing:

First, his approach was clearly directed to relatively normal youth who were facing a developmental transition. Second, the method of vocational counseling had prevention as a foundational goal. Third, Parson’s questionnaire could be self-administered and included input from family, friends, and teachers. (p. 26)

His work encompassed numerous theoretical emphases and processes of clinical mental health counseling in its most elementary form.

 In 1908, Clifford Beers, a former mental hospital patient, wrote the book, A Mind That Found Itself. In the book, Beers exposed the horrible conditions of mental health institutions and advocated for reform. The book’s popularity shed light on the struggles of the mentally ill in the United States. He used the momentum to form The National Committee for Mental Hygiene in 1909. It became the forerunner for the National Mental Health Association (Smith & Weikel, 2011).

The Great Depression created a need for counseling methods and strategies to aid in employment. In 1932, John Brewer wrote Education as Guidance. The book helped broaden counseling’s scope beyond occupation. He suggested that teachers share in the implementation of counseling and that guidance needed to be a part of every school curriculum(Gladding, 2018).

Carl Rogers’ book, Counseling and Psychotherapy, was published in 1942. The book emphasized a nondirective approach to counseling (Gladding, 2018). Rogers (1961) summarized his essential hypothesis: “If I can provide a certain type of relationship, the other person will discover within himself the capacity to use that relationship for growth, and change and personal development will occur” (p. 33). His approach laid the foundation for professional counseling. Out of nondirective counseling grew client-centered and person-centered therapy.

During World War II, psychologists, counselors, and social workers came together to work with psychiatrists on the front lines. Few of them had doctoral degrees and many had minimal clinical experience (Gerig, 2014). In addition, the military and industry needed help with the selection and training of specialists. Soldiers were entitled to professional counseling services upon being discharged. The Veterans Administration obtained additional funding to support the training of such mental health professionals. Simultaneously, the APA’s Committee on Training in Clinical Psychology (1947) developed a training philosophy and model of clinical training. Attendees at a conference in Boulder, CO endorsed this model, which ultimately led to the requirement of a PhD for clinical psychologists. University programs quickly responded and began offering doctoral degrees in both counseling and clinical psychology (Cummings, 1990). Counseling psychologists were trained to deal with issues presented by people with mental health. Clinical psychologists were trained to treat and diagnose individuals with chronic disorders. This led to a new designation for psychologists and marked the introduction of government spending on counselor preparation, as we know it today. The Division of Counseling and Guidance of the APA changed their title to the Division of Counseling Psychology.

Flaws in the mental health system began to surface in the 1950s. Effective pharmacological treatments were developing that could be provided in outpatient options for patients. This led to a need for community-based clinics, but access to these services was very limited. The Community Mental Health Act of 1963 was important in the development of the counseling profession. After the government analyzed the problems with mental illness and effective treatments, President John F. Kennedy believed that high-quality treatment centers located in the patient’s community could lead to the phasing out of state mental hospitals and drastically improve the mental health system in the United States. The national network of community mental health centers created a demand for counselors, and the profession began to expand and increase numbers of counselors.

As the counseling profession grew, there came a need to regulate the quality of services being provided by professionals via state licensure. In 1974, a special committee was appointed by the American Personnel and Guidance Association. It focused on counselor licensure. This began the steps toward the first counselor licensure law in Virginia in 1976. In the 1980s, mental health counseling had clearly established itself as a profession with a distinct set of regulations and methods to providing services. According to Gerig (2014), distinct professionals are characterized by “role statements, codes of ethics, accreditation guidelines, competency standards, licensure, certification, and other standards of excellence” (p. 32). The counseling profession as we know it today has established all of these facets of a distinct profession and is being recognized more and more as a valuable and much needed helping profession in our society.

As of May 2016, the Department of Labor identified almost 140,000 Licensed Mental Health Counselors (LMHCs), also referred to as Licensed Professional Counselors (LPCs). With professional designation now recognized in all 50 states the clinical mental health counseling field is poised to make an even larger positive impact in communities and the nation.


Beers, C. W. (1908). A mind that found itself. Garden City, NY: Longman Green

Cummings, N. A. (1990). The credentialing of professional psychologists and its implication for the other mental health disciplines. Journal of Counseling and Development, 68, 485-490.

Fancher, R. T. (1995). Cultures of healing: Correcting the image of American mental health care. New York, NY: W. H. Freeman.

Gartland, D. M. (2000, August). Biba San Dymphna: Cultural security and mental health in Guam. Paper presented at the 108th annual convention of the American Psychological Association, Washington, DC.

Gladding, S. T. (2017). Counseling: A comprehensive profession (8th ed.).Columbus, OH: Merrill.

Gerig, M. S. (2014). Foundations for clinical mental health counseling: an introduction to the profession (2nd ed.). Upper Saddle River, NJ: Pearson.

Laughlin, P. R., & Worley, J. L. (10010. Roles of the American Psychological Association in the development of internships in psychology. American Psychologist, 46, 430-436.

Linhorst, D. M. (2006). Empowering people with severe mental illness: A practical guide. New York, NY: Oxford University Press.

Plato. (n.d.). The laws (Vol. 5). (G. Burges, Trans.). London, England: George Bell & Sons.

Resnick, R. J. (1997). A brief history of practice expanded. American Psychologist, 52, 463-468.

Rogers, C. (1961). On being a person. Boston, MA: Houghton Mifflin.

Smith, H. B., & Weikel, W. J. (2011). Professional counseling comes of age: The first 35 years. In A. J. Palmo, W. J. Weikel, & D. P. Borsos (Eds.), Foundations in mental health counseling (4th ed., pp. 5-280). Springfield, IL: Thomas.

Sokal, M. M. (1992). Origins and early years of the American Psychologist Association, 1890-1906. American Psychologist, 47, 111-122.

U.S. Department of Labor. (2016). Retrieved from the Bureau of Labor Statistics website:

Viney, W., & King. D. B. (2003). A history of psychology: Ideas and context (3rd ed.). Boston, MS: Allyn & Bacon.

Whitbourne, S. K., & Halgin, R. P. (2014). Abnormal psychology: Clinical perspectives on psychological disorders (7th ed.). Boston, MA: McGraw-Hill.

Whiteley, J. M. (1984). A historical perspective on the development of counseling psychology as a profession.In S. Brown & R. Lent (Eds.), Handbook of counseling psychology (pp. 3-55). New York, NY: Wiley.


Clinical Skills Reflection: Gibb’s Model

The skill that I will reflect on in this essay is the administration of an intramuscular Injection (IM). An IM is an injection deep into a muscle (Dougherty & Lister, 2008). This route is often chosen for its quick absorption rate and often medication cannot be given via other routes. The reason I have chosen to reflect on this skill is because I have had many opportunities to perform this skill, and at my current practice placement this is the most commonly used method of drug administration. I have undertook many IMs at this placement but I am going to reflect on the first one I undertook which was the administration of Hydroxocobalamin commonly known as vitamin B12 (BNF, 2007)

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During a morning clinic with the practice nurse, I was asked if I would like to administer an IM on the next patient, which was a 26 year old lady who has been suffering from crohn’s disease which can cause B12 deficiency due to lack of vitamin and mineral absorption (NACC, 2007). I agreed and she briefly went through with me how to do an IM as it had been a while since I had last done one. I called the patient in and asked her to sit down. The patient had come in for her first injection of B12. I chatted to the patient asking her how she was and if she had any concerns. I then gained consent asking her if it was ok for me as a student to administer it under the supervision of the practice nurse. The patient responded with “you have got to learn” I then prepared the equipment which included two needles, a sharps box, a piece of gauze and the medication. I checked the prescription with the practice nurse, and then checked the ampoule against the prescription. I then drew up the medication with one needle disposing of it in the sharps box and attached the other needle. I then proceeded to administer the medication, after completing the procedure I disposed of the needle in the sharps box and documented it in the patient’s notes. After the patient had left the nurse explained to me I had done it all correct except I had gone in too far so if the needle broke it would be hard to get it out and that I didn’t aspirate to check if I had gone into a vein.
Thoughts and feelings
After I was asked if I wanted to do the IM I felt very anxious as it had been more than 6 months since the last time I had administered one. But she explained the procedure to me which relieved some of my anxiety. When I first met the patient I was feeling allot more nervous as the patient was roughly my age and I haven’t had much experience of caring for the younger person. After the procedure when I was told I was wrong for not aspirating I felt annoyed as I was sure I had read that aspirating was no longer necessary.
Overall I feel that the clinical skill went well as a whole. I followed the instructions from my mentor and what the research has suggested other than feeling a little anxious I performed the skill confidently and correctly. What I feel was bad about the experience is with my communication, which reflecting on I believe was lacking. I communicated with the patient prior to the skill and after the skill, but during I felt I almost forgot there was a patient on the end of the needle. I was so focused on getting the skill right and not causing any pain I didn’t talk to the patient throughout the whole thing. Another point that I feel was bad is, I forgot to wear an apron. My mentor never mentioned anything about this although I do feel I should have worn one as it’s an aseptic technique and its part of the (DOH, 2006) guidelines.
The reason why an IM injection was chosen is because B12 can only be administered via IM (BNF, 2007). I gained informed consent off the patient as this is part the NMC guidelines. (NMC, 2008) As patients have the right to decline treatment. After gaining consent, I then checked the medication against the patients chart to ascertain the following: Drug, Dose, date, route, the validity of the prescription and the doctor’s signature. This is done to make sure the patient receives the correct drug and dose (NMC, 2008) I then washed my hands using Ayliffes six step technique to reduce the risk of infection and put gloves on as part of DOH 2007 Guidelines . The site that I chose was the mid deltoid site. Hunt (2008) Suggests that this is the best site to use as it’s easy to access whether the patient is sitting, standing or lying down, it also has the advantage of being away from major nerves and blood vessels. Although Roger (2000) states that only 2ml at most can be injected into the deltoid. I was able to proceed with this site as B12 comes in a 1ml dose (BNF, 2007). I asked her if she would prefer to sit or lie down, she said she rather sit, this was ok with me as I am not very tall and found this a comfortable position for me. As the patient was wearing a short sleeve top I asked her to move it up slightly instead of removing it thus allowing her to maintain her privacy and dignity. I then assessed the injection site for suitability checking for any signs of infection, oedema or lesions. This is done to promote the effectiveness of administration and reduce the risk of cross infection (Woorkman, 1999). Holding the needle at a 90 degree angle it is quickly pushed into the muscle. Workman 1999 says this ensures good muscle penetration. I inserted the needle leaving approximately 1/2cm exposed as Workman, (1999) says this makes removing it easier should it break off. At this point I decided not to aspirate as per research (DOH, 2006). After inserting the needle I allowed it to remain there for 10 seconds. As Woorkman (1999) suggest that leaving in situ for 10 seconds allows the medication to diffuse into the tissues. After 10 seconds had past I swiftly removed the needle and applied pressure according to Dougherty & Lister (2008) this helps prevent the formation of a haematoma. Immediately after carrying out the skill I disposed of the needle into a rigid sharps container. To ensure health and safety is maintained and the used sharps don’t present a danger to me or other staff members as stated by MRHA (2004). After the procedure I documented it within the patient’s notes as per NMC guidelines and to provide a point of reference if there ever was a query regarding the treatment and to prevent duplicate administration (NMC, Guide lines for records and record keeping, 2005). After the skill I discussed with my mentor that recent evidence suggest that aspirating is unnecessary. According to Workman (1999) the reason for aspirating is to confirm that the needle is in the correct position and to make sure that it has not gone into a vein. The most recent and up to date evidence, says that aspiration is only necessary if using the dorsogluteal site to check for gluteal artery entry (Hunter, 2008). But official guidance from the World Health Organisation and the Department of Health (DOH, 2006) (WHO, 2004) suggest that this site should no longer be used, thus making aspiration unnecessary. By not aspirating it makes the procedure simpler and less chance of adverse events. Furthermore pharmaceutical companies are making less caustic preparations and in smaller volumes. I discussed this with my mentor and she agreed but stated that it is PCT policy to aspirate, and she would have to continue to follow this practice until the policy was amended.
Using the Gibbs model of reflection has allowed me to thoroughly analyse the event and allowed me to explore my feelings. I have found out despite the evidence being constantly up to date that not all practitioners knowledge is as up to date, and that trusts are equally as slow to adopt new ideas within their policies and that nurses are governed by policy more than current research. I have also learned that there is a great deal of evidence behind such what on the outside seems to be a simple technique and what I thought I was doing correctly may not always be the case.
Action plan
I do not doubt I will be carrying out IMs for a long time in my career. I will not be doing much differently in the future as the evidence is underpinning my practice. I will not put the needle in as far as I did on this occasion. In the future I will continue not to aspirate, unless local policy indicates otherwise. In addition I will communicate with the patient throughout the entire skill and not just at the start and end of. What’s more from this event I have realised that learning never stops and what I know now may not be relevant tomorrow.