Journal of Neonatal Nursing (2005) 11, 58e64

www.intl.elsevierhealth.com/journals/jneo

A journey of transition

Julie Parker*

Neonatal Intensive Care Unit, Ninewells Hospital, Dundee, UK

Available online 2 June 2005

KEYWORDSProfessionalaccountability;Respiratory care;Reflective practise

Abstract This explores the transitional process of a neonatal midwife from noviceto expert, achieved by the implementation of reflective analysis and by thedevelopment of professional and personal accountability, thus enabling optimumcare to be provided for the respiratory compromised neonate.ª 2005 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.

Introduction

This essay is a critical reflection of the transitionprocess and the evidence which facilitated thetransposition of a midwife, from level A to level Cas defined by the Clinical Competency Standardsand Continuous Assessment of Practise Booklet

Key points

A Professional accountability e the progres-sion from novice to expert neonatal mid-wife.

A Respiratory care e the exploration of oral/naso-pharyngeal suctioning.

A Reflective practise e implementation ofthe concepts of reflection.

* Tel.: C44 1382 633840.E-mail address: stuart@sparker64.freeserve.co.uk

1355-1841/$ - see front matter ª 2005 Neonatal Nurses Associatiodoi:10.1016/j.jnn.2005.04.002

assigned to the module: Preparation of Practi-tioners in Neonatal Nursing. To begin this journeyit is essential to define the foundation of thistransition. It is tripartite, compromising of fixedpractise-based competency standards, relatedtheory and professional role development. Eachhas an independent role but is only fully ex-pounded when related within the context of theothers. The competency standard I have chosen asthe basis of my reflection is No. 2:

‘‘The neonatal/midwife, while demonstrating ap-propriate knowledge, skills and attitudes, adoptsan integrated family focused approach to providesafe nursing management and care for the neonaterequiring respiratory support’’.

I have focused on this standard because this is theone which I know I have had to work hardest toattain, and one which I believe is paramount toworking as a safe practitioner. Throughout myprofessional training and career I have learned andused the A. B. C. of resuscitation and respiratory

n. Published by Elsevier Ltd. All rights reserved.

A journey of transition 59

management, Boxwell (2000), in both the adult andneonatal context.

AZ airway clearBZ breathing/ventilation establishedCZ circulation/oxygenation to body

A neonatal nurse must have the skills, knowl-edge and experience to achieve these principles ofresuscitation, whilst also creating an environmentwithin which the family of the infant feels safe andcared for holistically.

To illustrate the strategies that I employedto develop my ability to provide this optimumcare, I will reflect on and analyse the rationale for,the care that I provided to an individual baby atthe beginning of the module in August 2002.

Reflection

What is reflection?

In a professional context reflective writing formsthe framework for reflection to be undertaken.Marks-Marann and Rose’s (1997, p. 118), state that:

‘‘Reflection is an activity to develop, personnel,practical or intuitive knowledge’’.

Through reflection I have learnt to evaluate theappropriateness of my care and the actions I havetaken. Marks-Marann and Rose (1997) promotereflection-in-action and reflection-on-action asways of identifying, testing and changing some-one’s theories-in-use. For reflection to be accom-plished effectively it must be considered in thelight of current research and evidence. An openand honest self-appraisal is a key component,which will empower the individual/group to eval-uate their actions and become more aware of thepractical knowledge gained from an experience.Through reflection the theory-practise gap canbegin to be bridged. The model of reflectionI have chosen to use is the one by Marks-Marannand Rose (1997), see Appendix.

Description of baby

In the interest of confidentiality (Nursing MidwiferyCouncil, 2002), I have used pseudonyms whenreferring to the baby, the parents, and nursing/medical staff. The circumstances I have chosen toplace my reflection in involve a baby to whom I willrefer to as Sam and his parents whom I will callMr. and Mrs. Smith.

Past history

Sam was born at 27 weeks’ gestation by loweruterine caesarean section. His mother had nosignificant medical history and had been wellduring her pregnancy.

Present history

Sam was now 11 days old and receiving 24e30%oxygen via nasal continuous positive airway pres-sure (NCPAP) administered using an Infant LowFlow Meter. Sam had been given oxygen via a nasalcannula during the night but he had not toleratedthis. His colour deteriorated and his monitoringindicated that his haemoglobin was desaturated ofO2 and he became bradycardic. He required tactilestimulation and the NCPAP had to be recom-menced to return him to a homeostatic state.The nasopharyngeal secretions were reported asthick and copious requiring six hourly suction. Samwas nursed in an incubator to provide an optimumthermoneutral environment.

Incident

The incidents took place over two consecutive dayshifts in a neonatal intensive care unit providinglevel IV care as defined by the Scottish Executiveet al. (2001). The timing of this incident is in thefirst month of the clinical placement of thiscourse. The personnel involved were two seniorcharge nurses (one responsible for day duty, onefor night duty), my preceptor, and me. Theenvironment was fraught with distress, a babyhad died and another baby had collapsed at thesame time also requiring resuscitation during thenight, which linked the two days.

The first morning I listened to the report on Sam,reviewed his observations, respiratory support andcare requirements. I gathered information, whichallowed me to plan appropriate care for that day. Inoted that respiratory and circulatory observationshad been recorded hourly and made a mental noteof the range of the oxygen percentage Sam re-quired. Care requirements had been undertaken sixhourly to facilitate minimal handling and had lastbeen done at 04.00 h. I planned to undertake careat 10.00 h. I knew the parents routine was to comein at 14.00 h. Therefore it would be timed well forthem to handle Sam again later in the afternoon.Being family focused is one of my aims. I was sentfor a break at 08.45 h.

On return to the nursery the senior charge nursewas attending Sam and informed me Sam had

60 J. Parker

experienced a profound desaturation of his hae-moglobin O2 and became bradycardic. His naso-pharyngeal and oralpharyngeal air passages hada copious amount of secretions requiring suction.Sam needed stimulation and extra oxygen. It wasemphasised to me that a baby’s airway passagesmust always be kept clear. I was left with theimpression that I had missed some obvious in-dicative sign that this baby had required attention.I reflected on this later to my preceptor, theobservations charted revealed no indicative signs(i.e. an increased O2 requirement), of airwayimpairment. Later in the day I undertook respira-tory assessment and nasopharyngeal and oralphar-yngeal suctions as I had been instructed andsupervised on previous occasions. A minimalamount of mucoid secretions was removed, whichI recorded. I finished my shift at 19.45 h andreturned the following day at 07.30 h.

The night nurse reported that the nasopharyn-geal secretions had been copious, sticky and yellowstained; this I noted as being purulent, different toyesterday. At the end of the Unit handover thecharge nurse from night duty voiced her concernloudly across the room of my care of Sam theprevious day and suggested if I was not confidentwith respiratory assessment I should get someoneto supervise my work. Through reflection I havetried to address these issues in a positive manner toenhance my professional development. Althoughthis has been often distressing and traumaticpersonally. As I have read Marks-Marann and Rose(1997), I have been reassured that this is notunusual. They describe professionals finding theprocess of reflection as a painful, stressful, timeconsuming, risky and de-skilling activity. I thinkI could identify with all of these as I moved throughthis embryonic stage of my neonatal career.

Reflective observation

As I reflected on this incident I perceived thesenior staff had made a fundamental challenge tomy integrity. First, through my reflective diaryI expressed my perceptions of the incidents. Then,to separate the thoughts and feelings this incidentevoked in me personally from those aroused in meprofessionally, I used a brainstorming techniqueFigs. 1 and 2. In doing this I was able to verbaliseand take ownership of my thoughts. This is thefoundation for identifying educational and devel-opmental needs.

As I have considered the impact that this in-cident had on me personally I have tried to peelback the layers that shrouded this experience. At

the epicentre I identified my own ethics of care,which are founded on the principles of non-malef-icence and beneficence (McBean, 2000). I chal-lenged myself ‘‘Had I operated out with theseboundaries?’’ What senior staff thought I had doneI found alarming, as I would never knowingly put mypatient at risk. I evaluated the care I had providedin the light of my current knowledge and experi-ence. I believed I had honoured my principles ofcare. I had executed my clinical skills as previouslyinstructed and supervised then recorded and re-ported my observations honestly and accurately asI had made them. I had done my best. What I nowneeded to face was, ‘‘Was my best good enough?’’and if not how could I change to achieve this level?My interpretation of the feedback from my seniorcolleague suggested that I needed to re-analyse mylevel of competency. I looked at the competencystandards and examined the role components;clinical practise, critical judgement and decision-making, communication, management and educa-tion and development in relation to this incident. Inall components I was working within level ‘‘a’’ inthis context. I reflected on the skills and expertise

Figure 1 Perceptions of self.

Figure 2 Perceptions of professional identity.

A journey of transition 61

I had developed as a midwife, which were trans-ferable and used them as a foundation to build on.This I had not found easy, as the neonatal intensivecare context and setting was very different. Spe-cialist knowledge and experience are the twoelements, which have unlocked my understandingand role development in all components of thecompetency. I formulated an immediate and sus-tained plan of development.

Development plan1. Closer supervision by preceptor (allocated to

me, each shift).2. Discussion at the beginning of each shift to

identify and plan priorities of care for eachbaby in my care.

3. Develop a firmer understanding how the tech-nological equipment functions and thus usedeffectively and efficiently.

4. Gather researched evidence facilitating ‘‘BestPractise’’ when caring for a baby requiringrespiratory support.

5. Ask for intensive care allocation if possible toincrease my experience.

6. Discuss with unit manager the option of extraworking hours to achieve clinical competency.

I have carefully thought about the context ofthe mode of communication that was used tocontest my standard of care, and I conclude thatthe anger and frustration expressed was a manifes-tation of many issues, many of which were out ewith the incident involving me. Issues of grief,medical/nursing staff conflict, staffing level/mixand sheer exhaustion. At the time I was shockedinto silence and deemed that discussion was not anoption. As I reflected on the pressures of working inthe neonatal intensive care unit I resolved tobetter equip myself to serve in this area. By movingon to the related theory part of the reflectivecycle, my mode of learning moved up a gear.

Related theory

First I tried to identify the rationale for the care Igave. This is often based on the information sharedfrom senior colleagues and an acceptance of theirrationale. As every person is different so istheir interpretation of evidence I often receivedvariations on the same principle. Also as each babyis unique the application of rationale also varies.Therefore I looked for evidence which wouldcollaborate or reshape my theories-in-use. I recog-nised that the plumbline of my understanding thiscompetency was rooted in the normal physiology of

the initiation and maintenance of respiration in theneonate. Kanneh and Davies (2000) address thisissue and concludes that

‘‘Knowledge acquisition of biological theory pro-vides a tool which can be applied to informpractises and ultimately influence decision makingfor the benefit of the baby and family’’. (Kannehand Davies, 2000 p. 53).

Conscious of this background I now scrutinisedthe rational used when nursing a baby requiringrespiratory support. The issues I investigatedwere:

1. What is CPAP?2. How does CPAP work?3. CPAP technology. (Eden Medic, 1999; theory De

Paoli et al., 2003).4. Nursing issues. (Blease, 1997; Litchfield, 1998).5. The effectiveness of CPAP. (Ho et al., 2002;

Subramaniam et al., 2003a,b).6. Infant positioning when using CPAP. (Balaguer

et al., 2003).

I found an assessment tool, a proficiency eval-uation package produced by Kalamazoo ValleyCommunity College (2002) which facilitated mylearning style. As nasopharyngeal suctioning hadbeen the central issue of this incident, I will makethis the focus of this section of the essay.

Nasopharyngeal suctioning

I sought evidence that would guide me; why, whenand how this element of care is undertaken? First Ilooked to see if there was a procedure fornasopharyngeal suctioning within the hospital pol-icies and protocols. I found a comprehensive pro-tocol for endotracheal suctioning but not onespecifically for nasopharyngeal suctioning. Theinformation was clearly presented and referencedarticles were available for reading (Young, 1995;Wallace, 1998; Wrightson, 1999). As I moved on toexplore databases; cinahl, cochrane and mediline,it became apparent that research specific tonasopharyngeal suction is limited. This may ex-plain why in practise I have seen the principles ofendotracheal suction applied to nasopharyngealsuctioning and experienced the controversy, whichcircumvents this issue. Czarnecki (1999) proposeda question that I asked myself following thisincident: what are the assessment parametersused to identify when suctioning is required andhow accurate are they?

Doubts expressed during this incident as to mycompetency had undermined my confidence in the

62 J. Parker

rationale I had utilised in the delivery of my care.But as I have explored MacMillan (1995) andCzarnecki (1999) I have been reassured that a largepercentage of my actions were consistent withtheir findings and opinions. Research by Czarnecki(1999) identified three parameters of assessmentwhich showed a significant improvement followingsuction. These were pulse oximeter readings, a re-duction in visible secretions and audible secretion.

Nasopharyngeal suction is a beneficial proce-dure. But the potential risks: mucosal trauma,hypoxia, vagal stimulation, increased blood pres-sure, pneumothorax, atelectasis tachycardia, in-creased intracranial pressure, discomfort andemotional distress to the baby, cannot be dis-counted although most that would contend aresecondary to a unobstructed airway. Thus ways ofminimising the risks have to be addressed. Taquinoand Blackburn (1994) evaluated the effect ofcontainment during suction and they concludethat heart rates are improved, oxygenation isincreased and fewer behavioural stress cues areexhibited during suction with containment. This isa theory I have not seen applied regularly.

Future actions

The fourth part of this cycle of reflection focuseson my learning and how this will impact on myfuture actions. As this incident happened in thefirst month of this course I have been able toimplement my development plan and am now ableto evaluate the strategies I employed to facilitatemy achievement of this competency. I will do thiswithin the framework of the five role components.These will be set in the context of my learningabout suctioning a baby such as Sam.

Management

I initially was so overwhelmed by the focus on taskachievement, I found it difficult to stand back andformulate a baseline assessment at the beginningof each shift. This influenced the effectiveness ofthe care I provided. This was highlighted when I didnot listen to Sam’s chest at the beginning of the firstshift. I now make my own baseline airway assess-ment when assuming responsibility for a baby’scare. With a firm understanding of the benefits andrisks associated with suctioning (Czarnecki, 1999) Iam equipped to assess the individual needs of thebaby. I am able to implement techniques, pre-oxygenation, shallow suctioning, and containment,which will reduce the associated risks. Risk assess-ment is rooted in the next component.

Critical judgement and decision-making

Clinical experience and knowledge are the base ofthis component. Confidence determines the extentit is used. Through looking at the research byCzarnecki (1999) I now have clear assessmentparameters for assessing if nasopharyngeal suctionis required. Positive experiences of making deci-sions and critical judgements in the neonatalintensive care nursery, based on my new knowl-edge have developed my confidence in my theoryand its application to clinical practise.

Clinical practise

In the execution of clinical skills the desire not toplace the baby at risk because of my inexperiencewas paralysing and I required maximum support toundertake straight-forward tasks. Asking for closesupervision helped me to feel I was a safe practi-tioner and revitalised my confidence. This hasreleased me to act with increasing independenceand communicate more within the neonatal, mul-tidisciplinary and interdisciplinary network.

Communication

In my self-assessment of my communication withparents and neonatal network I rated myself highlyat the beginning of the course. But I quicklyidentified part of this again related to experienceand knowledge, which I lacked, so there was a gapto fill. The areas that did not diminish were myability to establish a trust relationship with theparents, my honesty with them and the level ofempathy I was able to demonstrate. I was able toacknowledge and respect their autonomous role asSam’s parents and facilitate their right to beheard. My role as an advocate was not reducedbecause of my inexperience, although the pathwaywas different. ‘‘If I am not able to answer you I’llfind someone who does.’’, was how I approachedfulfilling the needs of Sam and his family. I nowfind that less and less do I need to find someoneelse as now I am able to answer questions myself.My communication skills with interdisciplinarycolleagues and multidisciplinary agencies havedeveloped as I have been exposed to theseexperiences.

Education and developmental needs

As I have read the available literature on nasopha-ryngeal suctioning I have to agree with Czarnecki(1999) and MacMillan (1995) in their conclusion

A journey of transition 63

that there needs to be more research to providea base for national clinical guidelines to beestablished. I would also like to obtain a copy ofthe teaching package and protocol that MacMillan(1995) has implemented in her hospital.

Gaining experience and extending my knowl-edge base were the main educational and devel-opmental needs that I identified at the beginning ofthis course and the incident with Sam re-enforcedthis assumption. I endeavoured to address theseissues but my work allocation did not alwaysfacilitate this. Confidence became a major issue.I had to determine if my lack of confidence was dueto lack of knowledge, lack of experience or lack ofability. As part of my development plan I haddiscussed extending my part time working hourswhich I did for a short period. This gave me time touse my knowledge base and the support to over-come my fears associated with clinical practise.After this experience I eliminated lack of ability. Myself-confidence and self-esteem were boosted.

At the end of the course my understanding ofthe complex nature of caring for the respiratorycompromised baby rather than overwhelming me isnow the springboard for the next part of myneonatal role development.

Conclusion

Having reviewed the aim that I had at the begin-ning of this course; I conclude that I have nowattained a means of accomplishing this. My knowl-edge base of the physiology of initiation andmaintaining respiration has deepened and a keenerunderstanding of the pathophysiology of respira-tion in the preterm and sick neonate has beenestablished. I am now equipped to undertakeclinical practise, critical judgement and decision-making, communication, management and to de-fine my on-going educational and developmentalneeds. I have also reviewed the module learningoutcomes and know I am able to attain them in thecontext of respiratory support of the neonate.

Reflection is the mode of vehicle I have used totravel from level A to level C.

Experience has been the ticket. Education,knowledge and effort, the cost of that ticket.The neonatal team the travellers who have gonethe way before and shown me the route, relatedtheory the compass which has confirmed it. Babiesand their families, the passengers who have beencollected and safely cared for along their un-expected journey.

Through reflection I have developed an under-standing of the skills and knowledge which now

complement my existing ones. Finally transposi-tion of this midwife has taken place, I can now seeI have a new role as a ‘‘neonatal midwife’’.

Appendix

Model of reflection

The model of reflection I have chosen to use is oneby Marks-Marann and Rose. I have chosen thisparticular one as it has four defined and analysedareas.

1. The incident.A statement of what really happened?

2. Reflective observation.Thoughts and feelings arising from the in-cident.

3. Related theory.Making sense of the incident in the light ofcurrent knowledge.

4. Future actions.What was learned and how it will influencefuture actions?

I found this model particularly attractive be-cause it includes exploration and recognition ofintuitive knowledge. In my scope of practise I haveexperienced instinctive responses and used intui-tive knowledge in situations, to direct my actions.By using this model to structure my reflection Ihave developed a means of analysing and accred-iting my understanding of an event, empoweringme to act with confidence in similar circumstancesin the future.

References

Balaguer, A., Escribano, J., Roque, M., 2003. Infant positionin neonates receiving mechanical ventilation. CochraneReview; Oxford: Update Software.

Blease, Jackie, January 1997. Step by step guide: nursing careissues in CPAP. Journal of Neonatal Nursing 3 (1) insert.

Boxwell, Glenys, 2000. Resuscitation of the newborn. In:Boxwell, G. (Ed.), Neonatal Intensive Care Nursing. Rout-ledge, London.

Czarnecki, M.L., MarcheApril 1999. Infant nasopharyngealsuctioning: is it beneficial? Pediatric Nursing 25 (2),193e196.

De Paoli, A.G., Davis, P.G., Faber, B., Moreley, C.J., 2003.Devices and pressure sources for administration of nasalcontinuous positive airway pressure (NCPAP) in preterminfants. Cochrane Review; Oxford: Update Software.

Eden Medic, 1999. The Infant Flow System. Electro medicalequipment, Brighton. Document, pp. 672e830 (2).

64 J. Parker

Ho, J.J., Henderson-Smart, D.J., Davis, P.G., 2002. Early versesdelayed initiation of continuous distending pressure forrespiratory distress syndrome in preterm infants. CochraneReview; Oxford: Update Software.

Kalamazoo Valley Community College. Procedure (task): con-tinuous distending pressure therapy (CPAP) (neonatal/pedi-atrics) Respiratory Therapy Program Proficiency Evaluation.!http://puma.kvcc.edu/ralbreecht/4PRSTHROOpdfO.

Kanneh, Agnes, Davies, Frances, 2000. Physiological features ofthe full term neonate: theory practice integration. Part 2.Journal of Neonatal Nursing 6 (2), 49e54.

Litchfield, S., March 1998. Nasal continuous positive airwaypressure: does it increase handling in preterm infant?Journal of Neonatal Nursing 4 (2), 30e34.

MacMillan, Caroline, December 1995. Nasopharyngeal suctionstudy reveals knowledge deficit. Nursing Times 91 (50),28e30.

Marks-Marann, D., Rose, P., 1997. Reconstructing Nursing:Beyond Art and Science. Balliere Tindall in association withthe RCN, London, pp. 110.

McBean, H., 2000. Ethics and neonatal nursing. In: Boxwell, G.(Ed.), Neonatal Intensive Care Nursing. Routledge, London.

Nursing Midwifery Council, 2002. Code of Professional Conduct.Nursing Midwifery Council, London.

Scottish Executive, et al., 2001. A Framework for MaternityServices in Scotland. Crown, Edinburgh.

Subramaniam, P., Henderson-Smart, D.J., Davis, P.G., 2003a.Prophylactic nasal continuous positive airways pressure forpreventing morbidity and mortality in very preterm infants.Cochrane Review; Oxford: Update Software.

Subramaniam, P., Henderson-Smart, D.J., Davis, P.G., 2003b.Nasal continuous positive airways pressure immediatelyafter extubation for preventing morbidity in preterminfants. Cochrane Review; Oxford: Update Software.

Taquino, L., Blackburn, S., 1994. The effects of containmentduring suction and heelstick of physiological and behaviouralresponses of preterm. Neonatal Network 13 (70), 55.

Wallace, J.L., November 1998. Suctioning e a two-edged sword:reducing the theory-practice gap [corrected] [publishederratum appears in J Neonatal Nurs 1999 Jan; 5 (1), 21].Journal of Neonatal Nursing 4 (6), 14e17.

Wrightson, D.D., February 1999. Suctioning smarter: answers toeight common questions about endotracheal suctioning.Neonatal Network 18 (1).

Young, J., July 1995. To help or to hinder: endotracheal suctionand the intubated neonate. Journal of Neonatal Nursing.

Further reading

Bachman, T.E., JulyeAugust 2000. Evidence based medicine:NCPAP in weaning preterm infants from ventilators. Neo-natal Intensive Care 13 (4), 15e19.

Bachman,T.E., JaneFeb2002.Nasal CPAP for thepreterm infant:recent advances. Neonatal Intensive Care 15 (1), 19e21.

Cameron, J., Haines, J., 2000. Management of respiratorydisorders. In: Boxwell, G. (Ed.), Neonatal Intensive CareNursing. Routledge, London.

Hutchinson, A.A., September 1999. Advances in nasal continu-ous positive airway pressure (NCPAP): validation of animproved design. Neonatal Intensive Care 12 (5), 16e18.

Orleans, M., et al., 2002. Evidence-based clinical practicedecisions. In: Merenstein, Gerald B., Gardener, Sandra L.(Eds.), Handbook of Neonatal Intensive Care, Fifth ed.Mosby Inc, St. Louis.

Symington, A., Pinelli, J., 2003. Developing care for promotingand preventing morbidity in preterm infants. CochraneReview; Oxford: Update Software.