Development of Competent Nursing Skills

This essay focuses on a reflection on the development from novice, to competent beginner, to skilled practitioner in the light of my own development in clinical nursing practice. It is based on the signposts identified within my clinical learning portfolio and focuses on the notion of the helping role and caring skills within nursing practice. It utilises a reflective framework to better identify and reflect upon the journey from novice to practitioner.

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The model for reflection I have chosen is Gibbs Reflective Cycle (see Appendix). Reflection has been described as as a process of internally examining and exploring an issue of concern, triggered by an experience which creates and clarifies meaning in terms of self, and which results in a changed conceptual perspective (Boyd and Fales, 1983). Therefore, the experiences of my three placements are explored under three rotations of Gibbs Cycle. Meretoja et al (2004) state that nurses’ self-recognition of own level of competence is essential in maintaining high standards of care. I have chosen the caring role based on my own recognition of the level of competence achieved in this area.
Cycle One
Novice to Advanced beginner
What Happened.
I had to assist a patient in with personal care; make them comfortable in bed and collaborate in pressure area management; assist with toileting, washing, mouthcare, and application of emollient cream. I also had to document care and any deviations from the norm.
I was very aware of my inexperience and of the trust this patient placed in my and the nursing team. I was also aware of the intimate nature of the care I was providing, and the fact that it was basic care also highlighted the fundamental role such care has in supporting health promotion and patient wellbeing.
I was uncomfortable at first, and clumsy in the provision of the various aspects of care. However, my mentor was informative, supportive and helpful, which assisted me in doing the various tasks. However, I found it difficult to complete these as quickly as I should have. I did learn to communicate with the patient and provide a sensitive approach.
This situation required fundamental aspects of the caring role. It also demonstrates the link between basic nursing care an every other aspect of nursing. The NMC (2004) requires nurses to provide individualised care for their patients. The care for this person was based on their own needs and adapted as those needs changed. I was able to identify those needs and develop competency in providing care at this level. The caring role was very rewarding but physically and emotionally taxing However, I was still in the process of identifying particular needs and responding to them, such as toileting, which required me working with others in a collaborative manner, which I did not find easy. I also realised how much I did not know about nursing.
In this situation, I could have developed more collaborative working skills and modelled myself on those around me more actively ie., copied the ways in which other nurses and healthcare assistants provided care. When I did do this, it was effective. But I found that despite my enthusiastic approach, my knowledge base meant that I did not always understand the rationale for what I was doing.
Action Plan
The action plan from this was to take the confidence and competence I had developed in the practical skills and incorporate them into all aspects of the caring role. It was also to identify areas where my knowledge base was lacking, and seek out this knowledge. Keeping knowledge up to date is a requirement of the NMC code of condut (NMC, 2004). Working collaboratively is another NMC requirement (NMC, 2004). Taking this knowledge forward into practice made this process of reflection a learning activity.
Cycle Two
Advanced Beginner
What Happened
As part of my role assisting with patient care, I had to monitor pain levels and assist with providing analgesia as prescribed, along with monitoring its effectiveness. This was a surgical placement, and I also discussed with elderly patient their coping and wellbeing after hospital discharge. I engaged in health education and support to enable clients to be self-caring.
I was also responsible for monitoring wellbeing through performing and recording clinical observations, recording fluid balance and reporting any abnormalities. I was also involved in providing personal care to patients in a safe manner, especially in the disposal of waste products.
To begin with, I felt glad to be working at a more advanced level of competency, and felt confident in my basic nursing skills including performing clinical observations. However, the increased demand also meant increased pressure and I was aware of this. Again, I felt that I had developed a degree of competency but was very aware of my need to develop further knowledge and skills. The caring role involved supporting people and I had to access other professionals to ensure I gave the right information and that my care had been effective.
It was good to find that I had the clinical competence to effectively monitor clinical status. However, the complex nature of patient needs meant that I still didn’t always know the answers to their questions. Being involved in discharge planning was an enabling activity for myself and the patients. I developed competence in the administration of medications, under supervision, including controlled drugs, but felt I still needed more practice and skill in this area. Colleagues noted my competence and qualified staff were happy to delegate a range of appropriate tasks to me.
It would appear that the caring role means the provision of patient centred, holistic care. This was achievable in this situation but required a lot of knowledge and the ability to provide focused attention and empathic care whilst carrying out complex clinical nursing tasks. This was harder to achieve, and I was made aware of my continued learning needs around medication and surgical care, for example. However, I must have developed some competence as qualified staff were happy to delegate to me and to act on my feedback.
It is hard to see what else I could have done, except perhaps done more reading around surgical care, discharge planning and the nurse-patient relationship.
Action Plan
It was possible to identify future learning needs, and so my action plan included building on my current competence by engaging in more advanced practice, under supervision. Having the confidence to engage in more complex nursing tasks will help me to achieve more competence in advanced practice in the future. Recognising the demands of the caring role means that I will view future practice as based upon this role.
Cycle Three
Competent Level
What Happened.
I monitored patients with chronic pain and helped with analgesia. I also supported patients with freedom of choice for their own care (NMC, 2004) and provided personal and palliative care in sensitive manner. I mastered more advanced practical nursing skills including aseptic technique and safe disposal of sharps. I fully documented all care given, and recorded medication given, and communicated to staff at shift change during the nursing handover.
During this experience, I felt that my knowledge and experience in the caring role was finally coming together. I was confident and happy in engaging with patients and providing empathy and a supportive manner, whilst also carrying out more complex clinical tasks appropriately and effectively. It was very nerve-wracking giving handover, but I became more confident as I had more practice.
I was able to provide care of a high standard, and recognise my sphere of competence and seek help when needed. I was able to engage in effective caring relationships with clients, meet their individual needs, but also value my own input into their wellbeing.
It was obvious that I had moved on to a level of nursing competence which allowed me some autonomy. I was able to act with less direct supervision, but still access the support of the whole care team. The caring role extended to the provision of all care, including end of life care, and I was able to utilise my knowledge and experience and also identify my learning in action, and my future learning needs, which have changed since the first reflection.
The change from novice to competent practitioner in the caring role has demonstrated not only the acquisition of skill but the incorporation of clinical abilities into what is really a way of being with patients.
Action Plan
Signposting future learning needs is important following this reflection. I was able to identify the need to still learn advanced clinical skills and perhaps know more about the range of other professionals who could enhance care in individual situations.
This reflection has signposted my development towards competent nursing practice. The caring role encompasses provision of basic care, advanced techniques, medication and pain relief, health promotion, end of life care and collaborative care. It seems to be the fundamental and most important part of nursing practice.
Collaboration and coordination, as well as the holistic management of the situation, are highly recognized as meaningful characteristics of competent nursing practice (Meretoja et al, 2002).
Boyd E, Fales A. (1983) Reflecting learning: key to learning from experience. Humanist Psychol 23 (2) 99–117.
Gibbs, G. (1988) Learning by Doing. A Guide to Teaching and Learning Methods Further Education Unit, Oxford Polytechnic, Oxford
Meretoja, R., Leino-Kilpi, H. & Kair, A. (2004) Comparison of nurse competence in different hospital work environments Journal of NursingManagement.12(5) 329–336
Meretoja, R., Eriksson, E. & Leino-Kilpi, H. (2002) Indicators for competent nursing practice Journal of Nursing Management 10(2) 95-102
Nursing and Midwifery Council (2004) Code of Conduct Available from Accessed 30-4-07.

Holistic and Culturally Competent Care

According to World Health Organization, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Holistic health care is not only concerned with the absence of disease, but with a positive state of well-being. Working in culturally diverse environment and providing quality care is challenges because body, mind, and spirit are associated and interrelated. Therefore, suffering physically illness is more likely suffering emotionally and spiritually too that are influenced by different cultural background like culture, ethnic group, race, age, gender etc. The focus of health care has expanded to multiple dimension of person and their contribution to client health or disease. High quality care should always focus on holistic approach and required culturally competent care. In nursing, also, providing care in holistic approach, culturally competent care is very essential nowadays that are affected by client’s and nurses’ cultural values, beliefs, and behavior. So, nurse need to become aware when assessing and providing care to different cultural background client that practices should integrated with respect of the client cultural belief and related to health care. (Blais & Hayes, 2016)
Latino or Hispanic in America
Latino and Hispanic population is one of the fastest growing population in the United State of America. Latino denotes to a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Nearly 17 % of population are Latinos or Hispanics in America and that is estimated to increase 30% by 2050 (Census Bureau Report, 2016). They have various ethnic group that comprises many different cultures, races, and nationalities. Hispanic population are highly increasing in the largest number in Texas since July 1, 2014 (250,495). California had the largest Hispanic population of any state (15.2 million) in 2015.New Mexico had the highest percentage of Hispanics at 48 percentage (Census Bureau Report, 2016). Latino populations are progressively combined into suburban and rural communities all over America. About 23 percent of Latinos in the United States live in poverty (Juckett, 2013). Healthcare providers are facing challenges in both hospital and community to provide quality care for these people due to language barrier, people with no insurance, different cultural value and beliefs on disease condition and management, illegal immigration status, mistrust, and illiteracy. So, it is very important for health care provides including nurses to know and study about Latino and Hispanic culture to provide quality care and maintain safety for theses patient.
Latino or Hispanic Culture
Family is an essential part of Hispanic culture and primary source of support. They usually have extended family including parent, grandparent, uncles, aunts and cousins. The eldest member of the family has main authority. Gender role are traditional here: male role made decision, female role hold family together and passing tradition and culture to next generation and children are taught to avoid confrontation and to be obedient to their senior. Spanish is primary language of Hispanic society, sense of personal space is close and consider less than arm length where modesty and privacy are important. Relationship between people is more important than time as well as present is more important than future. Taboo or offensive occur when directly expressed negative attitude. Direct eye contact may be not acceptable while talking to authority member within the family. Silence during the conversation mean either failure to understand or embarrassment about asking question or disagree. Religion wise, most Hispanics in the United States belong to the Roman Catholic who attend church regularly, pray to God, Jesus, the Virgin Mary, and saints. They also observe baptisms and confirmations and celebrate religious holidays, including Christmas, Easter. In holy days, some Latinos maintain home memorials and visit shrines throughout Mexico or Latin America when possible. Compare to other culture, Latino accept death and dying more naturally. Religion, faith and spirituality play a significant role in the acceptance of death.
Health Values, Beliefs and Practice
Supernatural powers are also thought to reason for disease. An example of this is “Mal de Ojo” or the evil eye. With diseases caused by supernatural forces, non-supernatural treatments are not supposed to be helpful where repeatedly find poor compliance with nontraditional treatment. Traditional Latinos believe in protective and promotive health by balancing hot and cold foods, such as treating a cold with hot food. Most of the time meal contain rice, bean, tortilla and bread. Even though including is healthy ingredients, adaptation of diet pattern of Latinos or Hispanic in America tends to be low in fruits and vegetables and high in flour tortillas, white rice, and processed foods. In pregnancy and childbirth, husband is not allowed to see his wife and new born baby until delivery is completed. Attending delivery is part of female role, generally mother attend them in labor. Hispanic Americans report fewer pain conditions compared with non-Hispanic white or black Americans, might these gaps be due to variances in pain processing, pain-coping strategies, cultural factors or a combination of these factors. Cultural Affected Common Health Issues and Practices
Both cultural and economic factors affect the access of Hispanic American to health care in the United States. Hot and cold illness in traditional medicine. Herbal therapies play a major role in Latino folk medicine

Adjustment reaction, obesity, hypertension and diabetes mellitus are common health problem in Hispanic people (Juckett, 2013)
Many Latino immigrants experience tremendous stress once they are in the United States. Emotional distress often presents with headache (Juckett, 2013).
Even though including is healthy ingredients, adaptation of diet pattern of Latinos or Hispanic tends to be low in fruits and vegetables and high in flour tortillas, white rice, and processed foods (Juckett, 2013).
Compare to other cultural people, Hispanic complain fewer pain, gaps due to variances in pain processing, pain-coping strategies, cultural factors or a combination of these factors and seeking alternative methods include traditional and nontraditional: traditional like hot team herb and massage; nontraditional like brought out dated or off label pain medicine from outside the Unites State. (Indiana University-Purdue University Indianapolis School of Science, 2016)
Female play supportive role throughout the pregnancy, child birth and child rearing
The elder group, those who are terminally, getting hospice care and end of life support are significantly lower that included lack of knowledge about Hospice programs, the use of Hospice services would denote “giving up hope and faith” in the life of the dying patient. (Miller, & Pinzón, 2013)
Getting lower access of care treatment due to low education level and Spanish is primary language, lack of insurance, and distrust in the provider or health care system.
Prayer and ritual may be a part of the end-of-life process for your patient and the family members. Some families may want to honor their deceased relative by cleansing the body. Autopsies and organ donations are usually resisted, especially by Catholics, but also by others. (Miller, & Pinzón, 2013)

Nurses Responsibilities While Providing Care to Hispanic patient
Nurses responsibility not only aware of cultural difference but also to integrated and respect the client culture when providing care, the nurse should know, in advance, the services that are available through the clinical facility and assist with obtaining the needed interpreter (Blais & Hayes). It is important to explore the use of alternative therapies and belief in traditional folk illnesses, recognizing that health beliefs are dependent on education, socioeconomic status, and degree of cultural changes. (Juckett, 2013). Family involvement is very important and maintain modesty, respect and privacy while providing care; older patients should be addressed as señor or señora instead of their first names (Juckett, 2013). Health issues or problem should not be talk directly with family member but, can be discussed with interpreter. Explore health related issues in different way instead of asking direct question. Hispanic culture people do not prefer direct question. If family member is involving in care of patient, discuses important issues and problems to family first then gradually disclose to patient. Cultural values are important in the process of educating families about advance care planning. (Miller, & Pinzón, 2013) The family-centered model of decision making is highly valued and may be more important than patient itself. When involving family members in the care of their loved one, ask about preferences for their involvement. Provide the necessary education to prepare the family members for any technical care they may need to give. Nurses also need to be educated on how to begin the process of advance care planning with Hispanic / Latino families in a culturally respectful and sensitive way.
Nowadays, transcultural nursing care is key component in Health care where nurse should provide culturally competent care maintain quality of care. Latino and Hispanic population is one of the fastest growing population in the United State of America. Many researches reflect that Hispanic people not getting adequate and significant care where they supposed to due to various reasons: different value and beliefs on disease condition and management, language barrier, illiteracy, illegal immigration status and mistrust, healthcare provider facing changes. Healthcare provider including nurse should aware about cultural difference and understand others’ values and beliefs along with integrated and correlated this to health and health care with respect.

Blais, K. & Hayes, J. (2016). Professional Nursing Practice Concepts and Practices (7th ed.). NJ: Pearson
Census Bureau Report, (2016). Sumter County, Fla., is Nation’s Oldest, Census Bureau Reports. Retrieved from
Indiana University-Purdue University Indianapolis School of Science, (2016). Psychologists explore pain in Hispanic Americans. ScienceDaily. Retrieved March 6, 2017 from
Juckett, G., (2013). Caring for Latino Patients. American Academy of Family Physicians. Retrieved from
Miller, S., & Pinzón, H. (2013). Nursing’s role in advance care planning for hispanic / latino individuals. Salud Uninorte, 27(1) Retrieved from