Coca Cola Supply Chain Analysis

The Coca-Cola Company is selected for this project because it has one of the largest supply chain systems in the world. The Coca-Cola Company is a beverage retailer, manufacturer and marketer of non-alcoholic beverage concentrates and syrups. Coca-Cola currently offers more than 500 brands in over 200 countries or territories and serves 1.6 billion servings each day. [1] The company is best known for its flagship product Coca-Cola. The Coca-Cola Company headquartered in Atlanta, Georgia is the world’s largest beverage company. Along with Coca-Cola, recognized as the world’s most valuable brand, the Company markets four of the world’s top five nonalcoholic sparkling brands, including Diet Coke, Fanta and Sprite, and a wide range of other beverages, including diet and light beverages, waters, juices and juice drinks, teas, coffees, energy and sports drinks. Coca-Cola is the best-selling soft drink in most countries. The Middle East is one of the only regions in the world where Coca-Cola is not the number one soda drink.

SUPPLY CHAIN GRAPHIC

The generic supply chain graphic of the beverage industry is generally the same as any other industry with manufacturers, distributors, retailers and end consumers playing their respective roles. We will further delve into Coca-Cola’s customized and somewhat complex supply chain model in the proceeding diagrams.

SUPPLY CHAIN MANAGEMENT

Due to the vast nature of the company’s operations and its several product lines spread throughout the world, we shall restrict the scope of this project towards the most important brand produced by the company, its flagship brand Coca-Cola. This section will entail a brief overview of the company’s supply chain.

The Coca-Cola Company follows a unique supply chain management system where the company only produces syrup concentrate which is then sold to various bottlers throughout the world who hold an exclusive territory. The Coca-Cola Company owns its anchor bottler in North America by the name of Coca-Cola Refreshments. Other Coca-Cola bottlers, who hold territorially exclusive contracts with the company, produce the finished product in cans and bottles from the concentrate in combination with filtered water and sweeteners. The bottlers then sell, distribute and merchandise the resulting Coca-Cola product to retail stores, vending machines, restaurants and food service distributors.

The Supply Chain of the company is divided into different levels. This report will mainly be focusing on the downstream activities of the product which entails partnerships with different bottlers, distributors and channels used to reach different retailers.

Upstream Activities

Upstream activities are limited to the manufacturing of the concentrate only. The actual formula Coca-Cola uses to manufacture the syrup is a very tightly held trade secret so there is little information regarding the exact ingredients and thus little information on the costs of their supplies. The original copy of the formula is held in SunTrust Bank’s main vault in Atlanta. The company’s 2009 income statement revealed that the cost of goods sold was in excess of $10M [2] and the operating margin was around 25%. Sugar (sucrose or high-fructose corn syrup depending on country of origin) may be the largest known ingredient used in the manufacturing of the syrup and the company uses several systems to track the daily variation in the global price of this ingredient. Some of the systems that the company uses will be discussed later in the report. In addition to sugar, some of the other ingredients used in the manufacturing of the syrup are Carbonated water, sucrose, high-fructose corn syrup, caffeine, phosphoric acid v. Caramel (E150d) and Natural flavorings. [3] Coca-Cola has different supplier partnerships to procure these ingredients and these partnerships are out of the scope of this project.

Downstream Activities

The downstream activities of The Coca-Cola Company focuses on the franchised distribution system where The Coca-Cola Company only produces syrup concentrate which is then sold to various bottlers throughout the world who hold an exclusive territory. Apart from owning its anchor bottler in North America (Coca-Cola Refreshments), it has minority shares in some of its largest franchises, like Coca-Cola Enterprises, Coca-Cola Amatil, Coca-Cola Hellenic Bottling Company (CCHBC) and Coca-Cola FEMSA, but fully independent bottlers produce almost half of the volume sold in the world. Independent bottlers are allowed to sweeten the drink according to local tastes. The Coca-Cola Company develops products, produces related marketing and advertising programs, and sells syrup concentrate to independent bottlers.

Due to the commoditized nature of its products, Coca-Cola Company follows an intensive distributing system whereby it partners up with local bottlers operating in different countries and territories. Most of these bottlers have exclusive rights to distribution to their predefined geographic areas. The Coca-Cola Company sets up the basic guidelines to do business in terms of operational procedures, customer relationship management and query management and these bottlers have some degree of freedom to develop other SOPs relating to delivery, fleet management and developing credit lines.

To simplify the entire Supply Chain Management of the Coca-Cola Company, let’s review a small channel flow process which will help us in developing a better understanding of how Coca-Cola Company’s supply chain works.

The Coca-Cola Company headquartered in Atlanta manufactures the syrup and sells it to one of its bottling partners like Coca-Cola Enterprises (CCE) which is responsible for selling the product in North America and Canada. Coca-Cola Enterprises combines the product concentrate with other ingredients to manufacture and package the beverage and then markets its products to retail customers and consumers.

The Coca-Cola Export Corporation (TCCEC) is the entity responsible for selling the concentrate to other bottlers around the globe. TCCEC along with its regional offices located throughout the globe establishes partnerships with local bottlers who manufacture the beverage using the syrup provided by Coca-Cola Company and then distribute it to their respective markets.

One notable exception to this general relationship between TCCC and bottlers is fountain syrups in the United States, where TCCC bypasses bottlers and is responsible for the manufacture and sale of fountain syrups directly to authorized fountain wholesalers and some fountain retailers.

Operations

In this section, we will describe the bottling operations used by different bottlers in manufacturing and then distributing the Coca-Cola brand in their respective markets. The Coca-Cola Company establishes the basic guidelines of operations for all of its bottling partners and suppliers so most of the operations are standardized and there is a certain degree of centralization to most of their strategic decisions.

Each bottling partner services the assigned geographical area through a head office which controls most of the operations and it serves as the hub for different entities in the supply chain. The bottler’s head office is working in close collaboration with a regional office which is under the direct supervision of The Coca-Cola Export Corporation. The bottler’s head office links the production plant with different distribution and sales centers and multiple trade zones together to form a complete supply chain.

After receiving the concentrate from The Coca-Cola Company (Atlanta) through one of the regional offices under the supervision of The Coca-Cola Export Corporation, the bottler ships it to one of its manufacturing facilities. The facility produces the final drink by mixing the syrup with filtered water and sweeteners, and then carbonating it before putting it in cans and bottles, which the bottlers then sell and distribute to retail stores, vending machines, restaurants and food service distributors. The bottling production plant has its own supply chain which mainly consists of two types of items.

General Items

Key Ticket Items

Sugar

Empty bottles (Procured on contractual basis from different vendors)

Crowns

Caps

Crates.

The production information including forecasting measures, the capacity management, multiple vendor management and other sales figures are kept at the production plant as well as the head office.

Enterprise Resource Management Software used by the Coca-Cola Company

Coca-Cola Company uses proprietary software known as BASES and some specific modules of SAP to manage all their operations in the world. This software performs the functions of the entire ERP for the company and its worldwide operations. Information related to geographical sales, per capita consumption trends, response from new product introduction, sales forecasting, seasonal variations, customer relationship management data, fleet management data and all other related information is managed using this software. All entities affiliated with or doing business with the Coca-Cola Company use this software to communicate with the company. All query management and customer problems are handled using this software.

A process depiction of the sales module of this software is described as under as an example to further facilitate the understanding of the sales process at Coca-Cola’s bottling partners.

Distribution:

From the production plant, the beverages (in the form of cans or bottles) are shipped to distribution and sales centers using the bottlers’ own fleet of commercial vehicles.

The distribution centers are responsible for storing and managing the inventory comprising of different SKU and dispatching them off to the market to different retailers. The distribution and sales centers have multiple predefined zones and sub divisions of areas to capture all the retailers and contact points in the market. Generally this distribution and sales centers have the following departments.

Sales and Dispatch.

Customer Service and Query Management.

Logistics Dept. or Fleet Management.

Storage or Warehousing.

IT Dept.

Each distribution center is responsible for the implementing the “push strategy” in the supply chain. Each zone in the distribution channel has a zone head who is responsible for the performance of his zone and to increase the per capita consumption of his zone. Each zone is further divided into different routes and each route has different territories assigned to each vehicle. In addition to the Coca-Cola beverage, the bottlers also provide other complementary merchandise as an incentive to key accounts like free chillers and coolers for beverages, pop materials and relaxed credit lines. The bottlers execute several competitive strategies to maximize sales like inter-zone competitions and give generous incentives to top performers. The sales data from each zone is calculated on a regular basis and it helps to form sales reports which in turn help develop short term quarterly sales strategies and forecasts by the regional office and also helps The Coca-Cola Export Company identify market gaps for new product development and other business development strategies.

The distribution and sales centers are in close contact with the retailers through the zone managers who give them constant feedback about the changing market trends and to help them become more responsive to the needs of the end consumers and their purchase patters. The retailers can place orders with their respective zone managers or they can call the distribution and sales centers if they require addition stock. A procedural illustration of the payment process from the retailers is shown below as it appears in the BASES software of the Coca-Cola Bottlers.

Demand forecasting is important for Coca-Cola. Therefore, the company uses quarterly sales data to forecast future fluctuations in demands and identify future variations. Since the Coca-Cola beverage is a highly commoditized product there are no such end consumer segments. However, there are different retailer segments within the supply chain based on their level of operations and consumption figures. The retailers (like Wal-mart, Kroger and other restaurants chains) have been assigned specific Marketing Development professionals or ASMs to avoid any inconvenience and minimize lead times.

Channel Flows

Following are the channel flows that occur throughout the supply chain from the manufacturing plants to the distributors to retailer and thus the final consumers.

Manufacturer

Distributor

Retailer

Consumer

Financing

->

Financing

->

Financing

Financing

Risking

->

Risking

->

Risking

Risking

Negotiation

->

Negotiation

<–>

Negotiation

Negotiation

Physical Possession

->

Physical possession

->

Physical possession

->

Physical possession

Ownership

->

Ownership

->

Ownership

->

Ownership

Promotion

->

Promotion

->

Promotion

->

Promotion

Ordering

<-

Ordering

<-

Ordering

<-

Ordering

Payment

<-

Payment

<-

Payment

<-

Payment

Information

<–>

Information

<–>

Information

<–>

Information

Financing, Risking physical possession and ownership transfer at each step of the chain. Order taking and payment travels backwards from consumer who demands the product from the retailer who places an order at the distributor. Information travels both ways where the Company disseminates information about the product to each entity in the supply chain and needs information in the form of feedback from the end consumer.

Service Outputs

The following are the service outputs that The Coca-Cola Company provides throughout its supply chain.

Integration and Conclusion

The Coca-Cola Company has one of the largest supply chain management systems in the world and due to its volume there are certain problems and improvement areas that need to be rectified. TCCC is taking necessary steps to constantly improve its ever growing supply chain by partnering with different suppliers and bottlers. Several integration efforts are under way to maximize TCCC supply chain efficiency. TCCC made considerable changes to their supply chain in 2004 by combining its three business units in North America in an attempt to consolidate them into one more efficiently integrated unit [4] . An evidence of TCCC’s continued efforts can be seen by their 2006 decision when TCCC decided to bypass most of its bottling partners and to deliver its products directly to Wal-Mart to reduce lead times [5] . By making this change and delivering directly to the warehouses, TCCC changed a 100 year old operational practice.

Another recommendation that TCCC could use is that it could try and create some transparency in its bottling partners. Requiring transparency from its bottling partners could remove domain conflict problems that arise when one bottler tries to sell its merchandise it another bottler’s territory to meet its sales quotas (this problem has been seen in Coca-Cola’s Asia Pacific market).

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Climate Change Essay

Climate change in the world can be caused by various activities. When climate change occurs; temperatures can increase a dramatically. When temperature rises, many different changes can occur on Earth. For example, it can result in more floods, droughts, or intense rain, as well as more frequent and severe heat waves. Oceans and glaciers have also experienced some changes: oceans are warming and becoming more acidic, glaciers are melting, and sea levels are rising. As these changes frequently occur in future decades, they will likely present challenges to our society and environment.

During the past century, human activities have released large amounts of carbon dioxide and other greenhouse gases into the atmosphere. Most of the gases come from burning fossil fuels to produce energy. Greenhouse gases are like a blanket around the Earth, trapping energy in the atmosphere and causing it to warm. This is called the greenhouse effect and it is natural and necessary to support life on earth. However, while greenhouse gases buildup, the climate changes and result in dangerous effects to human health and ecosystems. People have adapted to the stable climate we have enjoyed since the last ice age which ended several thousand years ago. A warmer climate can bring changes that can affect our water supplies, agriculture, power and transportation systems, the natural environment, and even our own health and safety. There are some climate changes that are unavoidable and nothing can be done about it. For example, carbon dioxide can stay in the atmosphere for nearly a century, so Earth will continue to warm in the future.

Global warming has really taken effect in the world over the last century. It is the unusually rapid increase in the Earth’s average surface temperature over the past century primarily due to the greenhouse gases released as people burn fossil fuels. Global warming is due to the enhancing greenhouse gases emission and build-up in the Earth’s environment. The gases that have an influence on the atmosphere are water vapor, carbon dioxide, dinitrogen-oxide, and methane. Almost 30 percent of incoming sunlight is reflected back into space by bright surfaces like clouds and ice. In the other 70 percent, most is absorbed by the land and ocean, and the rest is absorbed by the atmosphere. The absorbed solar energy heats our planet. This absorption and radiation of heat by the atmosphere is beneficial for life on Earth. Today, the atmosphere contains more greenhouse gas molecules, so more of the infrared energy emitted by the surface ends up being absorbed by the atmosphere. By increasing the concentration of greenhouse gases, we are making Earth’s atmosphere a more efficient greenhouse. Climate has cooled and warmed throughout the Earth history for various reasons. Rapid warming like we see today is unusual in the history of our planet. Some of the factors that have an effect on climate, like volcanic eruptions and changes in the amount of solar energy, are natural. Climate can change if there is a change in the amount of solar energy that gets to the Earth. Volcano eruptions can really affect climate, because when it erupts it spews out more than just lava and ash. Volcanoes release tiny particles made of sulfur dioxide into the atmosphere. These particles get into the stratosphere and reflect solar radiation back out to space. Snow and ice also have a great effect on climate. When snow and ice melts Earth’s climate warms, less energy is reflected and this causes even more warming. There are many different ways that plants, animals, and other life on our planet can affect climate. Some can produce greenhouse gases that trap heat and aid global warming through the greenhouse effect. Carbon dioxide is taken out of the atmosphere by plants as they make their food by photosynthesis. During the night, plants release some carbon dioxide back into the atmosphere. Methane is made while farm animals, such as cattle and sheep digest their food. Cars and trucks can effect climate by releasing carbon dioxide when fossil fuels are burned to power them. When wildfires occur, carbon dioxide is released into the atmosphere. However, if a forest of similar size grows again, about the same amount of carbon that was added to the atmosphere during the fire will be removed. Some effects that scientists have predicted in the past would result when global change was occurring: loss of sea ice, accelerated sea level rise, and more intense heat waves. Scientists have confidence that global temperatures will continue to rise for decades to come, largely due to greenhouse gases produced by human activities. The Intergovernmental Panel on Climate Change (IPCC) stated that the extent climate change effects on individual regions will vary over time and with ability of different societal and environmental systems mitigate or adapt to change (The Intergovernmental Panel on Climate Change). This has been the warmest decade since 1880. According to the National Oceanic and Atmospheric Administration, 2010 and 2005 has been the warmest years on record. The earth could warm by an additional 7.2 degrees Fahrenheit during the 21st century if we fail to reduce emissions from burning fossil fuels (The National Oceanic and Atmospheric Administration). The rising of temperature will have great effects on the earth’s climate patterns and on all living things. Industrial activities that our modern civilization depends upon have raised atmospheric carbon dioxide from 280 parts per million to 379 parts per million in the last 150 years (The Intergovernmental Panel on Climate Change).

In conclusion, we need to take part and try to stop global warming and other effects on climate change. If the earth’s temperatures continue to rise in the future, living things on earth would become extinct due to the high temperatures. If humans contribute to control global warming, this world would be cooler and the high temperatures we currently have would decrease. If everybody as one take stand and try to end most of the climate changes that are occurring, this world would be a safer place to live on.

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Causes, Effects And Solutions to Global Warming Essay

Introduction

What is global warming? Global warming is the average temperature of Earth has increases since 1950 until now the temperature continuing increasing. Global warming can also refers to climate change that causes an increase in the average of temperature. However global warming are causes by natural events and human that are believed to be contribute to increase in average temperatures.

Causes of Global Warming

Global warming is a serious issue and is not a single issue but a number of environmental issues. Global warming is a rise in the surface temperature of the earth that has changed various life forms on the earth. The issues that cause global warming are divided into two categories include “natural” and “human influences” of global warming.

Natural Causes of Global Warming

The climate has continuously changing for centuries. The global warming happens because the natural rotation of the sun that changes the intensity of sunlight and moving closer to the earth.

Another cause of global warming is greenhouse gases. Greenhouse gases are carbon monoxide and sulphur dioxide it trap the solar heats rays and prevent it from escaping from the surface of the earth. This has cause the temperature of the earth increase.

Volcanic eruptions are another issue that causes global warming. For instance, a single volcanic eruption will release amount of carbon dioxide and ash to the atmosphere. Once carbon dioxide increase, the temperature of earth increase and greenhouse trap the solar radiations in the earth.

Finally, methane is another issue that causes global warming. Methane is also a greenhouse gas. Methane is more effective in trapping heat in the atmosphere that carbon dioxide by 20 times. Usually methane gas can release from many areas. For instance, it can be from cattle, landfill, natural gas, petroleum systems, coal mining, mobile explosion, or industrial waste process.

Human Influences on Global Warming

Human influence has been a very serious issue now because human do not take care the earth. Human that cause global warming are more than natural causes global warming. The earth has been changing for many years until now it is still changing because of modern lifestyle of human. Human activities include industrial production, burning fossil fuel, mining, cattle rearing or deforestation.

First issue is industrial revolution. Industrial have been using fossil fuels for power machines. Everything that we use is involved in fossil fuel. For example, when we buy a mobile phone, the process of making mobile phone have involve machines and machines uses fossil fuels, during the process carbon dioxide is releasing to the atmosphere. Besides industrial, transportation such as cars is also releasing carbon dioxide from exhaust.

Another issue is mining. During the process of mining, the methane will trap below the earth. Besides, rearing cattle will also cause methane because cattle released the form of manure. However, cattle is important because it make the latter equally responsible for the occurrence of global warming

Next is the most common issue that is deforestation. Deforestation is a human influence because human have been cutting down trees to produce papers, wood, build houses or more. If human continuing deforestation, carbon dioxide will concentrate in the atmosphere because trees can absorb carbon dioxide from atmosphere. Besides, human also release carbon dioxide when breathe. Therefore the amounts of millions of people breath have release carbon dioxide to the atmosphere. If human continue deforestation, human breathing that release carbon dioxide will stay at the atmosphere.

The Effect of Global Warming

The greenhouse gases will stay in the atmosphere for many years since hundreds years ago. However, the effect that global warming will cause on earth are extremely serious. There are many effects that will happen in the future if global warming continues. That includes polar ice caps melting, economic consequences, warmer waters and more hurricanes, spread of diseases and earthquake

First effect is polar ice caps melting. As the temperature increase, the ice at the North Pole will melt. Once the ice melt the first effect will be raise on sea levels because the melting glaciers become oceans. According to the National Snow and Ice Data Center “if the ice melted today the seas would rise about 230 feet”. It affects many low lying areas such as the Netherlands. In future, the Netherlands will be cover by water once the North Pole is melted. However, it is not going to happen so fast but the sea level will continue rise.

Another effect is the species loss of habitat. Species that include polar bears and tropical frogs will be extinct due to climate change. Besides, various birds will migrate to other places because animals are not like humans. They cannot adapt the habitat that changes their living or temperature.

Next effect is more hurricanes will occur and economic consequences still affect as well. Hurricane causes damage to houses and government need to spend billions of dollars in damage and people need places to stay or have been killed. Once a disaster happens many people have died and diseases happen. Diseases are more serious because it can spread to other people very fast and more people will get the disease and the disease maybe come more serious because of different weather.

Solution to Stop Global Warming

Now there are solutions that we can stop global warming. However we human and governments need to move forward to implement the global warming solutions. To reduce global warming we can do to reduce the contribution of greenhouse gases to the atmosphere. Therefore, the solutions that we can reduce global warming are reducing gasoline, electricity and our activities that cause global warming.

To reduce gasoline mean we have a choice to choose a hybrid car that reduce using gasoline. Besides, petrol price are increasing. If a person everyday drives to work they need to pump petrol after 3 days and causes carbon dioxide. Another way to reduce gasoline is take public transport or carpool to work. It can help reduce carbon dioxide and save cost.

Another way to reduce global warming is recycle. Recycle can reduce garbage by reusing plastic bags, bottles, papers or glass. For instance, when we buy foods, we can use our own containers instead of plastic bags. Another example is after finish drinking the water from the bottle; we can reuse it or use our own bottle. If all this is being reuse, human can reduce deforestation and help save environment. Besides, turn off electricity if unused. It can save thousands of carbon dioxide and buy product that have energy saving because it saves cost and save environment.

Finally, human should stop open burning such as burning dry leafs or burning garbage. It will release carbon dioxide and toxic if burning garbage with plastic. Besides, government should reduce deforestation because the earth temperatures are increasing. Trees will help to improve the temperature on earth.

Conclusion

Overall of this assignment, I have understood that our earth is “sick”. We humans need to “heal” the earth. Global Warming have causes many problem for human but we human who make global warming happens. Many people have died because of disease or disaster. It also affects the economics of the country. However, we need to be reduce the global warming by using less gasoline, recycle and human should help to reduce global warming instead of making the earth temperature increased. Our generation should start taking care of the earth because in the next generation they will suffer if we do not do reduce global warming. Therefore, global warming is a serious issue now. As a business student we are learning it because we need to understand the effect of climate change that will affect us when we have our business and we can start saving the earth.

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Gibbs’ Reflective Cycle

Gibbs’ Model of Reflection is commonly used in education, healthcare and psychology. You can find a full description of Gibbs’ Reflective Cycle along with both student and professionally written examples in this guide.

We have a number of expertly written examples of reflective essays here

What is Gibbs’ Reflective Cycle?

Introduction to Critical Reflection

Central to the development of reflective theory was interest in the integration of theory and practice, the cyclic pattern of experience and the conscious application of lessons learned from experience. Since the 1970s, there has been a growing literature and focus around experiential learning and the development and application of reflective practice.

As adult education professor David Boud and his colleagues explained: “Reflection is an important human activity in which people recapture their experience, think about it, mull it over and evaluate it. It is this working with experience that is important in learning.” When a person is experiencing something, he or she may be implicitly learning; however, it can be difficult to put emotions, events, and thoughts into a coherent sequence of events. When a person rethinks or retells events, it is possible to categorize events, emotions, ideas, etc., and to compare the intended purpose of a past action with the results of the action. Stepping back from the action permits critical reflection on a sequence of events.

Gibbs’ Reflective Cycle Flow Chart

The 6 Stages of Gibbs’ Reflective Cycle

• 1. Description
  A description of the events that took place or “What happened?”
• 2. Feelings
  What were your reactions and feelings to the situation?
• 3. Evaluation
  Evaluate both the good and bad points of your experience
• 4. Analysis
  What sense if any can you make from the situation? What ideas from your outside knowledge can you apply to this analysis. try to ascertain what was actually going on and not just how you felt about the situation. Look at difference and similarities in other people’s perception of the situation.
• 5. Conclusions (general and specific)
  What can be concluded about your specific situation or the way that you worked?
• 6. Personal Action Plan
  This section is used to outline the steps you are going to take to apply what you have learnt from your experience and how you would approach a similar situation in the future.

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Critical Reflection FAQs

Question: Why is Gibbs a good reflective model?
Answer: Gibbs’ Reflective Cycle has proven to be a good model of reflection due to its clear and precise nature. Gibbs’ Model of Reflection is now the most common type of reflection used in the education system, particularly within healthcare and education.

Question: How do you start a reflective essay?
Answer: When writing a reflective essay using Gibbs’ Reflective Cycle the essay starts with a detailed explanation of experience or event that is being reflected upon. This may typically be a patient encounter or a description of a particular placement.

Question: What does a reflective essay mean?
Answer: The purpose of a reflective essay is to provide insight into a particular event or situation. By reflecting upon the details of the event, a practitioner or student can learn from the experience considering all the various factors that led to a particular outcome. For areas such as nursing it is not adequate to simply learn from experience, the experience must be analysed and reflected upon so that positive and negative elements of an experience can be used to improve future interactions.

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Reflecting on Individual Professional Practice with Gibbs cycle

For the purpose of this essay, I will use Gibbs (1988) Reflective Learning Cycle to reflect on an aspect of individual professional practice, which requires development in preparation for my role as a Registered Nurse. Gibbs (1988) Reflective Learning Cycle encourages a clear description of a situation, analysis of feelings, evaluation of the experience and analysis to make sense of the experience to examine what you would do if the situation arose again.

To keep within the Nursing and Midwifery Council (NMC) Code of Professional Conduct guidelines (2008a) and to maintain confidentiality the use of names or places will not be used throughout this essay.

Description

Whilst on placement working on a general ward during my third year I was asked to research a drug I was unsure about by my mentor. On my way to research the drug I was approached by a health care assistant who asked me if I could assist her with a patient who was lying in a soiled bed. I chose to help the health care assistant as I thought this was priority as I could look up the drug at any point in the day as it was for my own learning and development and wasn’t urgent. After I had helped the health care assistant, my mentor asked if I had researched the drug. I explained that I had gone to help the health care assistant and would now look up the drug, which I then did. My mentor then told me that I needed to improve on my time management, as I had not looked up the drug when she asked me to. She carried on explaining that when I become a Registered Nurse I would need to know drugs and what they are used for. This situation left me questioning which was the priority, the patient’s needs or my own professional learning and development.

Feelings

I automatically assisted the health care assistant in making the patient comfortable as I felt that this was the priority over researching the drug. I remember thinking that I could do this at home if the ward became busy. I felt annoyed with myself for not speaking up to my mentor about the issue as I had thought I had made the right decision to help the patient. I was concerned about the patients comfort and felt I could not justify leaving the patient lying in a soiled bed because I had to research a drug. Nurses need to be able to justify the decisions they make (NMC 2008a).

After the incident, being told by my mentor that I needed to improve on my time management skills because I chose to assist the health care assistant confused me a little. This practice experience made me feel as though I needed to learn and develop more regarding my time management skills. I decided I would have to research into the meaning of ‘time management’ as I thought that my time management skills were fine. I was always on time for my shift and I would make a list of the jobs I needed to do and prioritise them. This experience made me question how I was prioritising my workload at present.

Evaluation

I chose to assist the health care assistant in ensuring the patient was clean and comfortable and felt that this was the priority in this situation. As an accountable practitioner the NMC (2008a) states ‘you must make the care of people your first concern, treating them as individuals and respecting their dignity’ which I did. I could understand what my mentor was explaining to me, that as a Registered Nurse I must be able to know what different drugs are and what they are used for. As an accountable practitioner, I must have the knowledge and skills for safe and effective practice when working without direct supervision, recognize, and work within the limits of my competence. I must also keep my knowledge and skills up to date throughout my working life and I must take part in appropriate learning and practice activities that maintain and develop my competence and performance (NMC 2008a). Post-registration education and practice (Prep) is a set of Nursing & Midwifery Council standards and guidance, which is designed to help you provide a high standard of practice and care. Prep helps you to keep up to date with new developments in practice and encourages you to think and reflect for yourself. It also enables you to demonstrate to the people in your care, your colleagues and yourself that you are keeping up to date and developing your practice. Prep provides an excellent framework for your continuing professional development (CPD), which, although not a guarantee of competence, but is a key component of clinical governance (NMC 2008b). Following this experience my concern was which is the priority and which was not and that if I had have researched the drug I would have been leaving the patient in a soiled bed until I had done it.

Analysis

As Individuals, we do not invent the concept of time, but we learn about it, both as a concept and a social institution, from childhood onwards. In the Western world, time has been constructed around devices of measurement, such as clocks, calendars and schedules (Elias 1992). A study by Waterworth (1995) explored the value of nursing practice from the viewpoint of practitioners, she identified that time with patients is important, but raises the question of how nurses manage their time.

The importance of time management will strike me at some point in my career as a Registered Nurse. I will be inundated with work and I will need to evaluate how to manage my time effectively. Time management is a dynamic process. It is constant actions and communications between you and your goals and dealing with changing situations (Brumm 2000). Time management tends to go hand in hand with good prioritisation skills, which mean managing your time, deciding upon priorities and planning accordingly, this can be one of the most difficult skills to acquire (Hole 2009). Managing time appropriately will reduce stress and increase productivity.

There are three basic steps to time management. The first step requires time to be set aside for planning and establishing priorities. The second step requires completing the highest priority task whenever possible and finishing one task before you start another. In the final step the nurse must reprioritise what tasks will be accomplished based on new information received (Marquis and Huston 2009).

We use planning in all aspects of our lives. In nursing, we often call it a ‘care plan,’ and nurse’s use this process to guide their practice. The nursing process, or ‘Assess, Plan, Implement and evaluate (APIE),’ can be used successfully as a time management tool. ‘APIE’ is a systematic, rational method of planning and providing care but if you change, the meaning to read it is a systematic, rational method of planning and accomplishing a workable time management plan this can be a great tool for nurses to use to manage their time effectively (Brumm 2000).

Assess/Analyze – Collect and organise data and form a statement of actual or potential time management needs.

Plan/Prioritize – Formulate your plan. This involves devising goals and expected outcomes, setting priorities, and identifying interventions to help reach the goals.

Implement/Intervene – Put your plan into action.

Evaluate – Assess your outcomes and see how you measure up against your goals.

There will be constant demands on my time and attention and it may be difficult to identify exactly what my priorities should be. In patient care, priorities can change rapidly and I will need to be able to constantly re-assess situations and respond appropriately. Priority setting is the process of establishing a preferential sequence for addressing nursing interventions. The nurse begins planning by deciding which intervention requires attention first, which second and so on. Instead of rank-ordering interventions, nurses can group them as having high, medium, and low priority. Life threatening problems such as loss of respiratory or cardiac function are designated as high priority. Health-threatening problems, such as acute illness and decreased coping ability, are assigned medium priority because they may result in delayed development or cause destructive physical or emotional changes. A low-priority problem is one that arises from normal developmental needs or that requires only minimal nursing support (Kozier et al 2008).

The assumption is that priorities can be determined, and decisions made as to what is most important, and that this can be followed by appropriate nursing actions. To establish priorities is to question what will be the consequence if this is not done immediately.

During this experience questioning ‘what will be the consequence of not helping the health care assistant?’

The patient would have had to wait whilst I researched the drug and would have been left lying in urine and faeces. This could cause skin excoriation to the patient and they would have been left uncomfortable and undignified. I would not have been providing a high standard of practice and care as stated in the NMC (2008a) and I could be held accountable for this as a Registered Nurse. Urinary incontinence and faecal incontinence should be managed in a manner that is unobtrusive, reliable, and comfortable. The patient will need to be attended to quickly, in order to prevent skin damage, relieve discomfort and restore dignity. Nurses need to be aware of the potential skin problems that may result from incontinence (Baillie 2005). The presence of moisture from urine and sweat increases friction and shear, skin permeability and microbial load (Jeter and Lutz 1996). If a patient has been incontinent of urine and faeces, their interaction can result in the formation of ammonia, leading to a rise in pH and an increase in the activity of faecal enzymes that damage the skin (Baillie 2005). The importance of changing a soiled product promptly in cases of faecal incontinence to prevent skin excoriation has also been emphasised by Gibbons (1996). I must act at all times to identify and minimise risk to patients and clients (NMC 2008a).

A research article and news story about student nurses and bedside care produced a phenomenal response on nursingtimes.net. The study authors Helen Allan and Pam Smith (2010) speak out saying that given the current pressures, qualified nurses are unable to deliver bedside care. The perception is that technical care is valued over and above bedside care as a source of learning for students’ future roles, leaving them feeling unprepared to be registered nurses. Their research showed that students conceptualize nursing differently to qualified staff because of an intensified division of labour between registered and non-registered nursing staff. As students, we often observe health care assistants performing bedside care and registered nurses undertaking technical tasks. The absence of clear role models leads students to question bedside care as part of their learning and to put greater value on learning technical skills. In relation to my reflective experience my mentor suggested the technical task in researching the drug was the priority in relation to the bedside care of the patient therefore it is not surprising to find that student nurses are unclear as to what is a source of learning in preparation for our roles as Registered Nurses. Helping patients with personal hygiene is one of the most fundamental and crucial relationship-building skills available to nurses, regardless of their seniority and clinical experience, student nurses should embrace these opportunities while we do not have the other time pressures and we can then reflect on our experiences. These skills will prove invaluable in delivering, overseeing and evaluating meaningful, holistic care (Bowers 2009).

Registered Nurses hold a position of responsibility and other people rely on them. They are professionally accountable to the Nursing and Midwifery Council (NMC), as well as having a contractual accountability to their employer and are accountable to the law for their actions. The NMC (2008a) code states that ‘As a professional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions’.

The NMC (2008a) code outlines the standards that I must work according to, what is expected of me as a registered professional by colleagues, employers, and members of the public. It also outlines what my professional responsibilities and accountabilities are. I may sometimes be faced with situations, which will require me to challenge, and question things that they are asking me to do if I feel that these things are unsafe or are not in the best interests of the patient or organisation. It is well recognised that it can be difficult to address these issues due to factors such as fear of the consequences, embarrassment, and lack of support like in my experience as mentioned above. Semple and Kenkre (2002) point out that the UKCC (2001) [now the NMC] reported the research of Moira Attree, which highlighted that fact that nurses are often reluctant to raise concerns about standards of care because they feared either inaction or retribution from employers. Nurses may also be inhibited by fears of being ostracised by the team if deciding to speak out against poor practice. This is another aspect of my individual professional practice, which requires development, and I will try to question situations in the future if I feel they are not in the best interests of the patient.

Being overwhelmed by work and time constraints will lead to increased errors, the omission of important tasks and general feelings of stress and ineffectiveness. Time management is a skill, which is learned and improves with practice (Marquis and Huston 2009).

Literature on time management in nursing is mainly unreliable, providing a number of tips on ‘how to’ manage time, along with descriptions of processes or strategies. The order for thinking about the process varies, ranging from setting objectives as the first step to working out how time is being used with the aid of time logs (Waterworth 2003). Determining the importance of tasks or priorities is part of the process, although the stage at which this should occur varies between authors. The main theme in literature is that nurses need to think about their own time management, with the main message being that individual nurses can manage their time. The reality of time management in nursing practice has been subject to experimental investigations, although studies on nurses’ work organization have found time management problematic, with nurses compensating for lack of time by developing strategies in an attempt to complete their work (Bowers et al. 2001).

Conclusion

Time management is a dynamic process and tends to go hand in hand with good prioritising skills. If you cannot prioritise you, will waste time and be inefficient. This can cause stress to yourself and your fellow team members, as well as causing potential harm to your patients. An efficient way to organising your time can be to use the nursing process as explained in the essay to Analyze, Prioritize, Intervene and evaluate.

After my research into time management and prioritising, I believe that my mentor was wrong to question my time management skills. I had thought about which was the greater priority in this situation and I still believe that the patient was. The patient would have been at risk from skin excoriation and would have been left uncomfortable and undignified. As a Registered Nurse, I will be accountable for my actions and in the future, if the same situation arose again I feel that I would not do anything different other than to speak up and justify my decisions. I identified and minimised risk to that patient and as a Registered Nurse, I will hold a position of responsibility and other people will rely on me. Although saying this, my priorities as a Registered Nurse may be different to those as a student nurse and my continuing professional development will be extremely important. I must make the care of my patients my first concern at all times, treating them as individuals and respecting their dignity (NMC 2008a).

Action Plan

With the increasing emphasis on efficiency and effectiveness in health care, how I manage my time will be an important consideration. Time management is recognized as an important component of work performance and nursing practice. As a newly qualified Registered Nurse, I will have to have excellent time management skills and be able to prioritise care appropriately.

To achieve this I will:

Break down my day to find out how long it takes me to do certain tasks.

Using the nursing process as a tool, I will write a list in priority order and cross of tasks as they are completed and I will keep evaluating my list during the shift.

I will delegate tasks to other members of the team where necessary.

Through the reflection of this experience, I am now aware that I also need more development to challenge and question things that I feel are not in the best interests of the patients.

To achieve this I will:

I will speak up and justify my actions at all times.

I will research more into assertiveness and confidence skills.

Word Count: 2867.

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Gibbs Reflective Cycle 1988 Nursing Essay

I am a Paramedic registered with the health professions council and this essay will look reflectively at an incident I attended during the course of my duties. The assignment will look at the moral, ethical and legal aspects of pre-hospital care with which I was challenged during this particular emergency. Confidentiality has been maintained at all times and names of individuals have been changed, I have also gained permission from the family of the patient and for the purposes of this essay I will call the patient Mr Taylor (HPC 2008)

To analyse this critical incident I will use Gibb’s reflective cycle. (1988).

Description

As a Rapid response Paramedic working for the Ambulance service I attend life threatening emergencies during my tours of duty, I work alone and am frequently dispatched to jobs as a solo resource that is without ambulance back up. The incident on which I wish to reflect occurred part way through a shift that had been up to then quiet. I received a call to attend a patient who had collapsed and was semi-conscious. On arriving I was met by a lady who was obviously distressed and she showed me to the patient who turned out to be the lady’s husband, he was around 50 years old and was by this time unconscious with poor respiratory effort, I quickly requested a backup ambulance via radio and continued with my assessment of the patient and attempted to gain a history of his condition and what had happened that day. His wife told me that Mr Taylor had been well until 8 weeks before when he visited his doctor for abdominal pain and some rectal bleeding. The GP had sent him for tests at the local hospital within a couple of days he had been diagnosed with numerous tumours throughout his body, Bowel, liver & lung and was told it was terminal , he had been given between 3 and 6 months to live. Overall he had still been active and reasonably well until a couple of days before, when he started to deteriorate , that day she had been shopping and when she arrived home had found him in bed semi-conscious and with difficulty breathing. By this time I had gained some observations and placed oxygen on Mr Taylor. My back up ambulance arrived and I did a clinical handover to the paramedic on board it was at this point that Mrs Taylor called me to one side and told me that he wanted to pass away at home and not in hospital, he had expressed a wish not to be resuscitated, she explained that as she was alone with her son living in the south she felt she needed some help when she found him. I asked about a the Do Not Attempt Resuscitation (DNAR) paperwork and she told me there wasn’t any. I explained our position as Health Care Professionals and in the absence of the DNAR we had to act in his best interests. She again reiterated his wishes not to be taken to hospital or resuscitated. As my colleagues continued to assist the patient I contacted our on call Advanced Paramedic for advice , I was asked to verify there was no DNAR in situ with the patients palliative care team first, then if this was the case to contact the patients GP to see if he or she would attend as a matter of urgency. After confirming the absence of a DNAR I contacted the GP who was extremely understanding and attended within 15 minutes. Mr Taylor passed away within minutes of the GP attending.

Feelings

Situations that deal with someone losing their life are always hard to deal with and cause an array of emotions, in this case sadness, that this lady was losing her husband of 30 years and he was only 50, frustration and irritation of paperwork that should have been in place but was not. The Health professions council (HPC) list one of my duties as a registrant as , “act within the limits of my knowledge, skills and experience and if necessary , refer the matter to another practioner” (standards of conduct performance and ethics, p3 2006) on this occasion we did this and it is On occasions like this when there is a group of health care professionals I try to include everyone in the descsicon making process and it was agreed it would be wrong to ignore a person’s wishes in these circumstances. His wishes had been explained to me by his wife, his palliative team and his general practioner. The Lasting memory for this lady and her family would be that her life partner died at home with his wife, exactly as he had wished.

Evaluation

As with any emergency situation our priority is safety and ensuring we are aware of any potential danger on scene, and performing dynamic risk assessments during the emergency. My responsibility for safety covers myself, colleague, patient, relatives and any further agencies requested to attend scene. The health and safety at work act (1974) states I should take reasonable care for my own health and safety and also that of others who could be affected by my acts or omissions. On this occasion everything was safe.

Looking at the incident I feel there were lots of positives , these include fast and effective communication with the patients relative, and fast assessment of the scene, decision makimg was also quick and effective and minimised any further upset and stress to the patients wife. Conversations with our own AP and the Palliative care staff and GP all fell into place on this job and this is not the norm , we often encounter difficulties contacting various agencies within the NHS .

Negatives included understanding of the DNAR side of our advanced decisions policy. I’m sure most HPC’s would agree that with so many modern policies and proceadures we cannot be expected to know everything , let alone little used sections of certain policies.

Morally I was challenged too as my professional guidelines state that in the absence of a DNAR then you must commence resuscitation (JRCALC).2006).

Analysis

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Individual Reflective Report On Gibbs Cycle Of Reflection Education Essay

The Gibbs cycle of reflection is used in 2 incidences in the report. The first incident is the group project for CLS course on starch and second is the feedback given for the SIM course for the business report. In both of the incidences, problems are evaluated and necessary solutions are taken for the improvements. The solutions are action planed to make it achievable and measureable with in a specific time period.

INCIDENT ONE: THE STARCH POSTER SESSION

1.1 DESCRIPTION OF THE INCIDENT:

The incident happened during the starch poster session on the week 3 of commercialization of life sciences session. We were assigned a group project to commercialize the starch of a company. We were supposed to prepare a poster drawing the road for commercialization.

The starch had several importances like high in fibre and decreasing the obesity rate. The poster was prepared showing the treads of obesity and how the starch will help the people have a healthy lifestyle. The market for the starch was collected from varies websites like euro monitor. The product advantage of the resistant starch was shown to that of Competitor Company. The road for commercialization of product was drawn. The poster was presented in the class. The same process was done by other groups.

1.2 FEELING OF THE INCIDENT (ON THE SPOT ANALYSIS):

What I felt?

I felt that the poster was not good in the visual representation even before it was presented. There were lot of gaps in the poster, the combinations of colours were not good and the content was not to the level of master’s. During presentation, I managed the contents to give a good meaning yet I feared there was not enough data in the poster and I don’t know the answer if I was questioned. Luckily, there were not so many questions. The only question asked was about how to create value in this poster which I managed to answer.

What my group members felt?

My group members felt that the poster was not as good as they expected. The visual content was felt very poor. No group member felt that there effort was shown in the poster. But everyone in the group accepted that the presentation by me was well done even though we had poor contents in hand.

What did other group members feel?

The other group members felt that the poster was good and well presented. Indeed it was better than the other groups. The other groups didn’t proceed to take the starch to the market. They stopped at the point of analysing the importance of starch. The poster of other groups wasn’t complete according to assigned work.

What did the course instructor feel?

The poster was appreciated by the course instructor for ‘showing the market and how it can be commercialized’. The course instructor felt improvements can be made in the poster especially in visual representation.

1.3 EVALUATION OF THE INCIDENT:

Although it was a group activity only 2 of the group members did the poster with minor contribution from others. The group did not well co-ordinate for the project. Many members of the group taught it was simply unnecessary waste of time. Many group members felt that this was not the group they intended to be in and some of their actions like not contributing to group activities demonstrated their disinterest in co-ordinating with the group. The poor visual effects and content were due to the fact that many were not happy to work in the assigned group.

Many conflicts were in the group on what content to put in the poster before the poster session. There was a conflict on ‘who will present the poster’ on the day of presentation. Everyone wanted to present the poster and everyone wanted every letter of them to be in the poster. This was not possible because many of the contents were same and some of the data were not in the scope of the assignment. The group members felt that their efforts were neglected.

Poor performance of the group was due to:

Improper co-ordination of group members.

1.4 ANALYSIS OF THE PAST:

This situation remembered me of the incident that happened once I was in my undergrad. The people were not happy to work in the group for the lab project. My team members went and stood with the friends in other groups. They used to chat and always my group had no results in the experiments. Out of 11 experiments in the lab we had result for only 2 experiments. The course instructor called each one in the group personally to know the problem. When he knew the problems he took the group to the dinner and helped us to know each other well. I remember he even assigned some nick names appreciating our good characters. We were taken for trekking to improve the co-ordination. After a month group members felt comfortable to work in the group and next semester we got 9 results out of 11 experiments in the lab.

1.5 ANALYSIS OF THE TECHNIQUE USED:

The technique my undergrad course instructor employed was Wheelan’s Integrated Model of Group Development.

Stage 1: Dependency and Inclusion

In the dinner we exchanged the stories our own self about our families, friends and past life. The special talents we had like singing and dancing.

Stage 2: Counter dependency and Fight

We were introduced to topics that will cause conflict I remember some topics like “Moral dress code made in colleges”; we had conflicts that went for days.

Stage 3 Trusts / Structure

We were taken for trekking in steep mountains where we have to hold each other in order to be safe. We helped each other and build the trust.

Stage 4 Works / Productivity

When we went to work for the group lab project we still had conflicts but we had greater trust and were willing to help each other. That made as have good results in the lab in the next semester.

Stage 5 Final

This didn’t apply to the lab group because we were in the same group till the end of my undergrad.

I applied this technique number of times during my undergrad in order to form groups for cultural events in the university.

1.6 ANALYSIS OF WHAT WE COULD HAVE DONE FOR THE STARCH PRESENTATION:

A similar approach like this should have been followed in the starch poster.

Stage 1: Dependency and Inclusion

We should have gone for dinner or indoor games. We should have known the individual’s talents and appreciated him. So that he would have felt the importance of him in the group.

Stage 2: Counter dependency and Fight

We should have conflicted on the topics that like gulf war where everyone can talk and will contribute in a different way.

Stage 3 Trusts / Structure

We should have gone for activities and games like trekking in steep mountains where we could have build the trust and resolved our conflicts.

Stage 4 Works / Productivity

Then we should have worked in the starch poster so that everyone is willing to put the important contents in the poster. They would have taught the importance of group/team beyond their individual works represented in the poster.

Stage 5 Final

This won’t apply to the group because we will be in the same group till the end of masters.

1.7 ACTION PLAN:

The action plan is done for the better performance of the group in February in deciding the project that can be taken for the business plan.

Step 1: Many group meetings are done not with motto of assignments but just to know each other better. (Have to be done before December.)

Step 2: Many common issues of conflict are discussed about favourite actors and actress. The cultural misconceptions are conflicted. (Have to be done before January.)

Step 3: The trust is developed in the individuals by trips to black pool and many places. (Have to be done before January.)

Step 4: we have done the next presentation better but we have to still build the team because there will be more conflicts as only one project have to be selected for the CLS course to make business plan and others should accept it. (Have to be done before January.)

1.8 CONCLUSION:

By following this technique I created high performance teams in my undergrad during cultural events. I believe the same management technique will work in the master’s level and we will be able to select the project with less conflict. On the course of the analysis of this technique, Wheelan’s Integrated Model of Group Development; we will understand the talents of each member. This will help each member to work in the area in which they have great interest on and which they know better than other group members in the business plan. Thus the technique Wheelan’s Integrated Model of Group Development will help us do an excellent business plan for the CLS course.

INCIDENT TWO: I GOT 54% IN SHAPING IDEAS FOR MARKET ASSIGNMENT.

2.1 DESCRIPTION OF THE INCIDENT:

This incident happened on 17 December 2010. It was the feedback given for summative course work on the topic “BUSINESS REPORT ON GENTRONIX” in the course shaping ideas for market.

Shaping ideas for market is one of my favourite subjects in my master’s course. In this course I had special interest in reading number of books as possible. I read books like competitive strategy and balanced scorecards which were beyond the reading list. In the formative feedback this was reflected as my instructor mentioned ‘your business model looks quite good and many things are just right’. My reading and knowledge was well reflected in the class room when I answered I was always right and I knew the answer for every question put forward by my instructor. Such reflection in formative feedback and classroom sessions made me feel I will do well in the business report. I did the business report and when I submitted I felt I will get good marks yet the result was not that; I scored 54%.

2.2 FEELING OF THE INCIDENT (ON THE SPOT ANALYSIS):

What I felt?

I just felt the mark was not mine. I read the feedback completely and when the word ‘Getronics’ came I was sure it was my mark.

What did the course instructor feel?

The feedback underlined area for low mark.

The business template was not used.

The referencing was not to the level of master’s.

Inappropriate usage of analytical tools.

But the feedback mentions, ‘A very confusing piece of work difficult after reading the whole assignment the markers could not understand what Gentronics really does and that makes it impossible to relate the analytical techniques used in the report’.

What my class members felt?

When I said my marks many of my class mates felt I was simply lying and I was sarcastic.

2.3 EVALUATION OF THE INCIDENT:

Understanding of what an assignment is; is derived from the past experiences in schools and colleges. The assumption I made in the assignment

The business model is only a graphical representation of the theory. I could make my own graphical representation of the business model.

I have referenced only a few articles in my undergrad when an assignment was given. Except for the literature review I didn’t reference more than 5-6 references.

The course instructor would clearly know what Gentronix really does before even reading the report as my undergrad supervisor knew, in and out the topic and checked whether I did it right.

Yet clearly as the feedback mentions all my assumptions were wrong. And my 3rd assumption made my assignment impossible to be even marked. The lesson I have learnt is never change the template, an assignment is just like a literature review and I need to explain things from the scratch the markers don’t know much about the company until I explain it in my report.

This lesson was learnt at a great cost i.e. I lost 46% marks. Yet I have an exam for the other 50% to get things on track

2.4 ANALYSIS OF THE PAST:

This situation remembered me of the incident that happened in my grad 10. It happened in the business mathematics course. I worked out hard for the exam I solved many questions as possible. I got answers for 8 questions out of 10 in exercises. In the main examination I failed to pass. In fact I got only 5 marks out 100. I remember the reason was I made a mistake in the critical equation that was the first step for every problem in the chapter. My course instructor could not give me marks because it was the first step of every problem in the examination. After I got the feedback I came to know, the mistakes I made was not only in the particular equation but I had mistake in number of equations.

This problem was every time I did the sum I had the equation in front of me in the study room beautifully inscribed in colours. But in the exam hall I had no such equations in front of me and I failed to remember the inscription. The parameters and variables in the external environment changed in both of the occasions the shaping ideas for market and grad 10 examinations. And I failed.

In my grad 10 I fought back the problem and I got 95 marks out of 100 in the final exam. The technique I used was improving my faith in the Napoleon Hill’s pyramid system mentioned in the famous book “Think and Grow Rich”

2.5 ANALYSIS OF THE TECHNIQUE USED:

The technique revolves around 3 important parameters for success. The 3 vertices of the triangle in the success pyramid desire, faith and action.

Napoleon Hill’s pyramid system

Action

Faith Desire

In my 10 grad even after I saw 5 marks in the feedback I had a strong desire to score 100/100 in the paper in the final exam. The desire is just a wish and can’t be converted into actions and goals unless I have faith in getting 100 marks. I had no faith in getting 100 marks after I got 5marks but I had faith in getting 10 marks. I made a goal that I will get 10 marks in the final exam I worked out problems and adopted techniques to get 10 marks. In a week I was very sure I will get 10 marks whatever the question paper and environment may be. With 100 marks as desire I had now faith to get 15 marks, I made goals and solved problems for getting 15 marks. I continued it till I increased my faith to get 100 marks.

When I when for the final exam my parents and course instructor prayed that I should pass the exam. Yet I knew I am going to do it great and I did it.

2.6 ANALYSIS OF WHAT I COULD HAVE DONE FOR THE BUSINESS REPORT:

I wish I could have got the assumptions right. Looked at business reports I could have got

What is referenced how and how many?

How business model template is used?

What degree of basic data do the markers need about the company and its products?

My next opportunity to employ my understanding would be my business plan.

2.7 ANALYSIS OF WHAT CAN BE DONE FOR SHAPING IDEAS FOR MARKET COURSE IN THE EXAMINATION:

Every time, when the mark is low it affects the faith vertex in Napoleon Hill’s pyramid. Now I have faith in passing the shaping ideas for market exam with 50% marks. I will employ short goals to improve my mark by 10% every week. Work out different past question paper to find every time and in every paper I am consistently increasing the marks. I will check my confirmation by self analysis and discussion with classmates. I will do this until I am sure that I will get 100 marks.

Personal SWOT to improve the shaping ideas for market marks

Strength

I have read Bragg and Bragg the course book.

I know what is being done in classroom sessions.

I have got good formative feedback and I was able to answer questions in the class.

Weakness

I have lost 46% marks in the business report.

I don’t understand where to use the tool and how to use them.

Opportunity

To look at past papers.

To collect articles to see the usage of tools.

Treats

The pattern of exam and question paper will be new.

I am writing an exam in the business course for the first time.

Need to spend time for other exams.

2.8 ACTION PLAN:

The 4 week plan to get high marks in shaping ideas for market

Week 1:

Revise course materials be confident to pass the exam.

Week 2:

See the past exam papers try to answer them within 30 minutes/question. Improve every time in answering the questions in time and content.

Week 3:

Discuss with friend on their views of exams and try to find the methodology adapted is same. Try to find what may be improved and what may be eliminated to score more marks.

Week 4:

Revise the work done for 3 weeks. Analyze all the possible risks. Be prepared a day before for the examination.

2.9 CONCLUSION:

This action plan is made combining the SWOT and pyramid approach. The view of getting high marks is writing the exact number of words and information the examiner expects to see in the paper. This information on what examiner might expect is got by critically analyzing every session of the course which is the first week plan. The second week puts the understanding into action. The third week checks for faults and other class members views of the content presented in class. Week 4 taking note of what is very important, important and less important. This is a way of managing time where in 1.5 hours the exam is completed writing the very important and important details. Thus in exam I will never miss the very important or important details whatever the factors may be. This strategy is adopted in getting high marks.

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Reflective Essay On Patient Encounters Using Gibbs Cycle Nursing Essay

In this essay, I will reflect upon a experience which I had with a patient using the Gibbs cycle of reflection (Gibbs, 1998) to help to signpost my answer and help the reader to read this essay with ease.

Description of the event: During my clinical placement I have encountered a number of patients, each one possessing a unique personality thereby required a slight adaptation of my professional behaviour in order to communicate most effectively with each individual. During one particular placement within my allocated hospital, I encountered a patient who was younger than the patients that I had previous met and conversed with over the previous months. The patient, aged 3 months, attended the clinic with his father regarding his physiotherapy for his Cystic Fibrosis (CF). I was asked to carry out a subjective assessment of the patient however, the setting of this encounter was rather different from the set-up which had been used in the past, and although I had seen patients who were younger in the past, this patient was different as it rapidly became apparent that he had been brought by his father who was unable to speak fluent English and was also unable to understand much English at all.

In the normal situation with young patients, due to the patients young age and the presence of her father, it would be typical to direct most of the questioning towards the patients parents or guardian with whom they attended rather than at the patient himself, despite the necessary inclusion of the patient in the discussion wherever possible. I would then physically assess the patient. However, in this setting, it was very difficult to ask any questions to both the patient or to their parent and instead, most of the information about the health of the patient and their physiotherapeutic interventions which they required was gained from the examination of the patient and not from any information which they provided.

Feelings: Upon reflection, I feel that although, at first the situation did both feel and appear new and challenging, my ability to communicate with the client was not helped by the fact that I was unable to think of a new way to phrase the questions, which I had. In addition, the patient’s father kept looking at the trained physiotherapist (my mentor) for reassurance and guidance with the language being used and thus, this made me also look towards my mentor for help. When my mentor took over the line of questioning, and the conduction of the assessment, his approach was to ask the patients the questions in a loud and slow voice. This appeared to aid the patient’s fathers understanding greatly. I felt, at this point however, that I had let myself and the mentor down, as I was unable to conduct the procedures which I was expecting to and I also felt that I had let the patient down, through my inability to communicate effectively with them.

When examining the patient, my tutor made sure that he looked at the patients father at all times when speaking and also that he used body language to highlight the meaning of what he was saying also. This again, helped the patient’s father to understand the meaning of what was being carried out and what was being said. Visual aids were also used to ensure that the patient’s father understood. For example, when my tutor was asking whether the patient had taken his antibiotics for his CF and what physiotherapy he thought his child required. When asking such questions, he pointed to a prescription on his desk, which helped the father to understand what was being said. This clearly made the difference between the patient not understanding what was being said to gaining an appropriate understanding and being able to answer the questions properly and accordingly.

Evaluation: From this experience I also learnt that in the case of younger patients, particularly babies, it is important to be able to talk to the parents, as the patient themselves would be unable to provide information. This is because when a child has a condition such as CF, it is regularly the parents who will be worried and concerned about this and additionally; it is the parents who deal with the physiotherapy and the treatments, which the child receives. Additionally, it will be the parents of the child who will manage the symptoms that their child has, and conduct the physiotherapeutic interventions on the child until they come of age where this can be continued by the child. In the case of the patient who was not fluent in speaking English, I have noted the importance of speaking both loudly, and slowly and using all the different sorts of body language possible in order to ensure that the patient’s parents were put at ease and were able to comprehend the questions, which were being asked.

Analysis: My experience has taught me that in order to improve my communication skills with patients of different languages, I will need to increase my interaction with a range of patients with different native languages and those who are not fluent in speaking English. This will most likely be achieved through increased exposure to patients within my clinical placement and I will try to ensure that I increase my exposure to individuals of a variety of nationalities wherever possible within my placements. Meeting this patient and his father also highlighted the requirement to adapt not only the language used when asking questions, but also the language tone and the nature of my body language used throughout the assessment.

Conclusion: In conclusion, due to the presence of both the patient (the baby) and his father, not only did this patient encounter bring with it the challenge of the language barrier, but it also brought the experience of needing to integrate multiple people into a conversation without loosing the flow of the conversation. For example, it was clear that there was a need to build a rapport with the patient themselves, despite their young age, in order to put them at ease during their physical, physiological examination. This is important for physiotherapists to establish a good patient rapport, especially with children, in order to make physical assessment easier. This was clear because when the patient first entered the room, he was looking around the room and not smiling very frequently. After being within our company for a small amount of time, and after I had smiled at the patient and looked at him to engage him when speaking to his father it was clear that he felt much more relaxed and comfortable as he began to smile and look at us when we were talking. He was less interested in his surroundings and appeared to be much more at ease.

Action plan: The experience also showed that I must work on my communication skills and my coping strategies in different clinical situations. Thus, in the future, I aim to increase my level of exposure to patients of all ages by attending a variety of physiotherapy clinics and talking to patients. This should help in the development of such skills and make experiences such as this, much easier to manage effectively.

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Gibbs’ reflective cycle

Gibbs’ reflective cycle has 6 stages. They are usually given the following headings:

1. Description

2. Feelings

3. Evaluation

4. Analysis

5. Conclusion

6. Action Plan

As part of my Overseas Nurse program, I am required to make a reflective essay. This essay is based on my experience in clinical placement in the Operating Theatre. The aim of this essay is to discuss my learnings about the importance of team briefing, principles of asepsis, and Surgical Handscrubbing, as well as experiences throughout my placement. I have come to select the Gibbs reflective framework for this for I feel that through this framework I can better express in a systematic manner the describe the incidents, feelings, and how I was able learn.

Learning Outcome 1: Team Brief and WHO Surgical Safety Checklist

In June 2008, the World Health Organization (WHO) implemented a second Global Patient Safety Challenge, ‘Safe Surgery Saves Lives’, to reduce the incidence of surgical deaths across the entire world. The initiative was developed to strengthen and improve the commitment of clinical staff to address safety issues within the surgical setting. This included improving anaesthetic safety practices, ensuring correct site surgery, avoiding surgical site infections and improving communication and teamwork within the team. The WHO Surgical Safety Checklist is a core set of safety checks, identified for improving performance at safety critical time points within the patient’s intraoperative care pathway. It is for use in any operating theatre environment, including interventional radiology with the expectation that it can be adapted to fit local practice. The three steps in the checklist (sign in, time out, sign out) are not intended as a tick box exercise, but as a tool to initiate meaningful and purposeful conversation between relevant members of the clinical team to improve the safety of surgery.

According to the National Patient Safety Agency, NHS, there are five steps to safer surgeries.

Namely Briefing, Sign in, Time out, Sign out and Debriefing.

During my placement, I was assigned to circulate in theatre two. One of the five running theatres that our hospital has. The there was only one case. Patient Keiser (not the real name). 63 year old male consented for a Primary Total Knee replacement under general anesthesia using a Zimmer “NexGen” Knee system. I was nervous because it was a major case and I needed to be quick with my actions and be focused. I did my reading a day before so I had an idea of about the sequence of the operation.

Before the patient was escorted to the theatre, the surgical team together with the anesthesia team had a team brief. In the briefing the patient details, laterality of site were confirmed as well as medication allergies, number of staff and availability of implants were all discussed. Everything went smoothly. The patient was then escorted to the anesthetic room and additional checks, verifications, and the sign in was done in the anesthetic room. The patient claimed that he had a nickel allergy and that he would get mild rashes when in contact with the metal property. The ODP (Operating Department Personnel) the person who is responsible for assisting the anesthetist and initiating the WHO Checklist was fully aware of this metal allergy as it was also reflected in the care plan and preassessment. The incident happened when the ODP and anesthetist failed to inform the scrub team about the specific allergy because they thought a nickel allergy had no significance. They were only concerned with medication allergies. So they continued and put the patient to sleep with propofol and other anesthetic agents. The patient was then brought in the theatre with use of the trolley and placed safely on the Operating table. The scrub team on the other hand was almost done preparing the field and assembling equipment needed for the operation. When everything was ready. Being the circulating nurse, I then continued the WHO checklist and initiated the Time-out. The consent, patient verification and allergies were then reviewed but this time the ODP informed the team about the nickel allergy. The surgeon went ballistic! And ordered that the patient be woken up. There was a heated discussion between the surgeon and anesthetist and it they eventually had to wake the patient up. It was then explained to us by the surgeon that the System and implants to be used during the operation had a very small percentage of nickel present in its components which could cause a reaction if used to the patient. He was angry because it was the second time it happened to him and he did not want to go through all the paper works again. The patient was brought to recovery and woke up in a few minutes. The surgeon then explained the incident and unfortunately the operation was cancelled. The opened sterile instruments, supplies, and consumables were all put to waste.

As I analyzed what happened, the mistake clearly rooted back to the team brief. There were vital information that the anesthetic team knew about the patient that was not shared to the scrub team because they did not see it as important. I personally think every allergy, be it medication, metal or objects should be taken into consideration. It was a major case and the team had to know everything relevant. I realized how important the team brief was. Often I would observe other teams not taking the team brief seriously. They would just breeze through it as if was just some unimportant routinely work. After the incident I learned a lot and the view I had on the team briefing and the importance of the WHO checklist drastically changed. It is a very important tool in ensuring a safe, effective and successful operation. I now plan to practice a thorough team brief as well as executing a proper WHO checklist. You never know, missing out on one important fact could mean a life of a patient.

Learning Outcome 2: Principle of asepsis:

Asepsis can be defined as the absence of pathogenic microorganisms that cause disease. It then can also be referred to as clean technique (Phillips, 2013). However, elimination of infection is the goal of asepsis, not sterility. (Ayliffe et al. 2000) suggest that there are two types of asepsis: medical and surgical asepsis. Medical or clean asepsis reduces the number of organisms and prevents their spread; surgical or sterile asepsis includes procedures to eliminatemicro-organismsfrom an area and is practised byhealth care workersand nurses in operating theaters and treatment areas.

There are several principles of surgical asepsis. Although all are equally important, I have come to be more cautious and alert of specific principles more often than others. One principle I have chosen to share with is a principle stating that People who are sterile touches only sterile items or areas. (reference) It may seem as a very simple principle to follow but it could be at times difficult to imbed in our system. May it be a scrub role or circulating role this is one of the key things one should always keep in mind.

I had one incident during placement relating to this. It happened during an early shift of a busy Friday. There were 52 operations to be done that morning. Everyone was on the go. For some time now I have been with an orthopedic team but this time I was assigned with my mentor to assist a list of over 6 cataract extractions with ocular lens implantation. She was to scrub and I was to assist with the circulating role. Coming into this list I had not assisted a cataract extraction in the last 4 years. My knowledge was very minimal although I knew the purpose and roughly the length of time needed to finish the procedure in general but I did not know much about the fine instruments needed, supplies and set up of the Centurion Vision. Everything was new to me and I felt much pressured to deliver and I was uncomfortable knowing I could make mistakes. As the operation began my mentor scrubbed in and she was too busy to guide me thoroughly at the moment. The surgeon and scrub started asking me to position the machine according to the surgeon’s preference. I was reprimanded for being slow and hesitant since the surgeon was ready to start. After finally connecting the plugs, foot pedals as well positioning the Centurion Machine above the patients head, the surgeon placed sterile plastic covers over each of the handles of the machine. These sterile plastic handles where used as a sterile field so that the surgeon can hold the machine. Like the principle states, only sterile people should touch sterile things and the other way around for unsterile. Already being reprimanded I was nervous that I would make another mistake and unfortunately I did. The surgeon wanted me to reposition the machine yet again to his preference but this time I unconsciously forgot my principles and touched the sterile handle and I compromised the sterility of the field. The surgeon requested for another sterile handle and the case was delayed.

I felt very bad knowing that I knew the principle but still it just slipped my mind and I committed an error which compromised the operation someway. After the incident I knew what I needed to do and how to position the machine efficiently and quickly. I already knew the preferred position and supplies needed. I just needed to be more focused, less anxious and hesitant and be more confident this way I would not make mistakes of that degree. The first case finished and I was able to effectively circulate on the remaining cases with carefulness, confidence, focus and efficiency.

Learning outcome 3: Surgical Hand scrubbing

Microorganisms transfer from the hands of health care providers to patients; this is an

Important factor with regard to health-care associated infections (i.e. nosocomial). Skin is a major source of microbial contamination in the surgical environment. Although the scrubbed members of the surgical team are wearing surgical gloves and gowns, their hands and forearms are to be cleaned preoperatively to significantly reduce the number of microorganisms (AORN 2006)

According to the WHO Guidelines on Hand Hygiene in Health Care, Surgical hand scrubbing is the surgical hand preparation with antimicrobial soap and water performed preoperatively by the surgical team to eliminate transient flora and reduce resident skin flora (2009, World Health Organization).There are two methods of scrub procedure. One is a numbered stroke method, in which a certain number of brush strokes are designated for each finger, palm, back of hand, and arm. The alternative method is the timed scrub, and each scrub should last from three to five minutes, depending on facility protocol (Deborah Gardener 2011). In the operating theatres there are three most probable routes of infection transmission between successive/sequential surgical patients are via the air, from instruments, or from environmental surfaces. Journal of Hospital Infection (2002)

I have always felt and understood the importance of keeping our hands clean even since I was a little boy. This was a practice taught to me by my parents. As I studied nursing in my country I got to know more about it and how it was properly practised in the wards and theatre settings. During my placement I would always observe my mentor thoroughly before gowning and gloving. I knew the importance of this. She would use repetitive strokes on the hands and arms to further remove any microorganisms. She would be very meticulous and patient while stroking her hands and arms with soap and an antimicrobial agent but as Ive observed, along with most of the scrub nurses, together with my mentor did not use brushes when doing surgical hand scrubbing despite brushes being available just at the side of the scrubbing area. This made a big question mark in my head and I was really confused. I wanted to know why they didn’t bother to use the brushes. So I decided to research about it.

There was a study that compared surgical hand scubbing with and without the use of brushes. Two groups were involved during this study. One group to scrub without a brush and another group to scrub with brushes. According to Life Science Journal 2014, the result showed that the group which used brushes had slightly higher bacterial counts, this could mean that brushes traumatize the skin creating an environment where bacteria thrived. Whereas using no scrub brush resulted in no skin damage and significantly lower bacterial count. (AORN journal, 2004. 79: p. 225-30). Based on this research, I was amazed on how the United Kingdom healthcare setting applied evidence based practice. I applied this research findings to how I scrub. I learned more about because of research and from that moment on I have been scrubbing without using a brush. Surgical site infections (SSIs) are the second to third most common site of health care associated infections. When providing health services, it is essential to prevent the transmission of infections at all times. (Engender Health 2001). I applied this research findings to how I scrub. I learned more about because of research and from that moment on I have been scrubbing without using a surgical brush.

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Clinical Skills Reflection: Gibbs’ 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)

Description

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.

Evaluation

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.

Analysis

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.

Conclusion

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.

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