Portfolio of Learning Outcomes through Self Assessment

Portfolio of Learning Outcomes through Self Assessment This portfolio provides evidence of achieving learning outcomes. To provide this evidence I attended tutorials envisaging interactive methods and student cantered teaching strategies (Hinchcliff 2004), self-directed learning, group work and discussion. I also did further reading, utilizing library facilities, the cinnahl, Athens and other web sites available. To make this learning achievement possible I engaged in mentee / student relationship with the support and guidance of an approved mentor (NMC 2000). I chose this module due my interest in teaching. Since qualification, I have worked in specialist areas and have been actively involved in associate mentorship. I feel this module will be beneficial in my professional development and within the clinical areas, I choose to work. I have written this portfolio in first person (Webb 1992), as it is a reflective account, of experiences, thoughts and feelings, learning through critical analysis and evaluation. This kind of reflection enables us to take account of what has happened and to make sense of the outcome (Boud and Miller 1996). Many models of reflection may be used, Ghaye and Lilyman (2000) refer to structured models leading learners through stages and questions useful as a guide and others are flexible taking into account the reflective process and can start at different points then there is the focused model giving meaning to events improving practice. I have used an adaptation of the Reflective Cycle Model (Gibbs 1988) as it is simple and easy to interpret. Learning Outcomes 1. Assist students to identify current learning needs. ___ Self-assessment of current practice and identification of learning need(s) in relation to this outcome. Current practice: à ¢Ã¢â€š ¬Ã‚ ¢ Knowledgeable of student nurse curriculum. à ¢Ã¢â€š ¬Ã‚ ¢ Have a willingness and commitment to teach. My learning needs: à ¢Ã¢â€š ¬Ã‚ ¢ Gain an understanding of the FDA programme. à ¢Ã¢â€š ¬Ã‚ ¢ Review and critically analyze literature. à ¢Ã¢â€š ¬Ã‚ ¢ Critical reflection. Learning Outcome 1. Assist students to identify current learning needs. _____ Examples of evidence that could be provided by the end of the module to show how this outcome has been achieved. Produce evidence of placement learning opportunities suitable to meet the needs of specific students. Give at least one example of how you have helped the student to identify his/her learning needs, set goals and develop action plan for learning. ___________ Summary of Evidence for summative assessment of what you have achieved during the module. Cross- reference as appropriate. à ¢Ã¢â€š ¬Ã‚ ¢ I obtained copies of Sandras job description and FDA Mentor Pack. à ¢Ã¢â€š ¬Ã‚ ¢ Reviewed literature. à ¢Ã¢â€š ¬Ã‚ ¢ Critical reflection. Description The vascular surgical ward I work encounters many Nursing, Medical, Foundation Degree Studies, National Vocational Qualification students and newly qualified nurses all needing support. I have been asked by Sandra a 2nd year FDA student to be her mentor to take on this role effectively I attended a meeting with Sandra and her Practice trainer. Through discussion, we were able to complete a negotiated learning contract documenting the learning and achievements Sandra had gained, outlining what her current learning needs were to devise an agreed action plan. Feelings I take my role seriously, committing myself in assisting and supporting junior colleagues and students. I am genuinely interested in their stage and level of learning and enjoy having an active role in their learning experience. Analysis I agree with Hincliffe (2004) that learning is seen as a change in behaviour that is brought about to enable enhanced care for patients/clients, an event from experience and practice causing relative permanent change in students behaviour. Curzon (1990) enhances this view considering learning as modification of behaviour through activities and experiences so that knowledge, skills, attitudes and process of adjustment to the learners environment is changed. Quinn (1995), Welsh and Swann (2004), and Nicklin and Kenworthey (1995) all have similar descriptions. A successful teacher has knowledge of different learning theories and learning processes using them as framework to base teaching maximizing opportunities of learning (McKenna 1995, Nicklin and Kenworthey 1995). Raynor and Riding (1997) and Snelgrove (2004) refer growing need for teachers to understand the learning process to facilitate individualized learning reducing academic failure. There are many different theories of learning mentioned within the literature (Hincliffe 2004, McKenna 1995 a/b/c, Nicklin and Kenworthey 1995, Welsh and Swann 2004), no single theory has all the answers, some theories view humans as extensions of the animal species, whereas others see humans as separate, distinct, with intellectual characteristics of their own (Nicklin and Kenworthey 1995). Early theories of behaviourism such as Pavlov, Watson, Thorndike and Skinner used animals whose behaviour resulted from a stimulus. Much of the literature suggests that such learning is limited and has no real place in nursing education (Hincliffe 2004, McKenna 1995(c), Nicklin and Kenworthey 1995, Quinn 1995) yet I believe there are still situations where these theories are relevant but learning is limited. Curzon (1997) believes human behaviour is very different from that of animals questioning validity of behaviourism theories. Supporters acknowledge refinement of these works could shape intellectual development cognitivity being how we acquire information and what we need to know emotional responses learned in part by classical conditioning (Woolfork and Nicolick 1980). Lovell (1987) refers to emotional responses being positive or negative relating to Pavlovs theory. Repetition is useful in practice which relates to Thorndikes theory of trial and error (McKenna 1995a), but knowledge of the skill learnt is crucial. As teachers, we constantly use Skinners theory of positive and negative reinforcement, through praise and by giving information and cues prior to the task performed and by practising a skill repeatedly over till competent in practice (McKenna 1995a). Cognitive theories refer to meaningful approaches of learning, recognizing students knowledge, experience and stages of development. I believe that as a mentor it is my responsibility to establish these factors early in the student relationship (Andrew and Wallis 1999, Forrest 2004, Phillips et al 1994). I agree learning is a purposive process concerning perception, organization and insight. The learner actively seeks new information and uses past experience to gain understanding (Child 1986, Quinn 1995). Insightful learning occurs from modified experience or knowledge gaining new insight (Child 1986), the student relating to previous knowledge and experience to solve new problems. Experimental learning leads on from cognivitism; Allan and Jolley (1987) refer to learners becoming independent of their teachers eventually setting their own objectives initiating their learning using available resources and self-assessment. Burnard (1987) describes this as involving personal experience and reflection making sense of events transforming knowledge and meaning from them. I think Allan and Jolley (1987) are correct in saying that this type of learning is effective in demonstration and practice. Allan and Jolley (1987) also state that increased activity and involvement leads to increased learning. The Humanistic view is related to feelings and experience, including Maslow (1971) humanist approach cited in Wickliffe (2004), McKenna (1995c), Nicklin and Kenworthey (1995), Quinn (1995) and many more. The aim is to assist self-actualisation fulfilling maximum potential, this links closely to Knowles (1978) and Rogers (1983) works frequently cited within the literature (Burnard 1987, Mckenna 1995(c), Nicklin and Kenworthey 1995, Welsh and Swann 2000). I believe student centred approaches allow students to take active involvement in their learning enabling them to take ownership for it (Allan and Jolley 1987). Kauffman (2003) sees Knowles (1978) theory of andrology as a useful tool rather than a theory. Knowles acknowledges adult learners having vast ranges of experience, which they use as a basis for new learning, learning occurring through efforts made by the individual. Student and teachers need to treat each other as equals to allow student centred learning students taking responsibility and ownership of it (Bennett 2002, Hutchinson 2003 and Mckenna 1995(c). I agree that a partnership based on cooperation and interaction brings about mutual learning due to openness and trust (Atkins and Murphy 1995). I also agree with Ewan and White (1996) that it is important to know the students individual characteristics and needs being aware of the students current knowledge, competence and stage of training (Wickliffe 2004). A learning contract is a valuable tool (Calhoun et al 2000), utilizing optimum learning. It is a formal written agreement between the student and mentor specifying what needs to be done to achieve the students learning outcomes. Regular formative discussion enables skills and us to get to know each other allowing me to establish the students stage of training, previous experience. Regular discussions are necessary as part of the learning process (Cahill 1996) as through discussion we can identify strengths, weaknesses and any problems encountered by the student, measuring the level of competence revising our initial plan to achieve the rest of the students outcomes which utilises the student centred approach. Action Plan I need to hold frequent discussions with Sandra to monitoring her progress effectively promoting active involvement and ownership. I am aware that an effective mentor/student relationship enhances the level of learning accomplished to make this possible we need to have significant contact involving us to arrange our off-duty to make sure we frequently work together. Learning Outcomes 2. Develop self-awareness in order to be a role model. __________ Self-assessment of current practice and identifications of learning need(s) in relation to this outcome. à ¢Ã¢â€š ¬Ã‚ ¢ Acknowledge that self-awareness is important. I am knowledgeable. à ¢Ã¢â€š ¬Ã‚ ¢ It is my professional responsibility to provide best care. à ¢Ã¢â€š ¬Ã‚ ¢ It is my responsibility to be good role model. My Learning Needs à ¢Ã¢â€š ¬Ã‚ ¢ Gain greater awareness of how others view me. à ¢Ã¢â€š ¬Ã‚ ¢ Further reading. à ¢Ã¢â€š ¬Ã‚ ¢ Become self aware through reflection. Learning Outcome 2. Develop self-awareness in order to be a role model. _____________ Example of Evidence Recognize the impact of own professional behaviour and actions on students learning. _____________ Summary of Evidence summative assessment of what you have achieved during the module Cross-reference as appropriate. à ¢Ã¢â€š ¬Ã‚ ¢ Understand others views gaining insight of how Im seen. à ¢Ã¢â€š ¬Ã‚ ¢ Now familiar with the terms self-awareness and role model. à ¢Ã¢â€š ¬Ã‚ ¢ Critically reflected, becoming increasingly self aware of my actions. Description As an E grade, I have a responsibility for junior colleagues and student nurses and am involved in their learning and teaching. I am competent and skilled trying to act in a professional manner at all times. Feedback from my colleagues and students shows Im respected and liked but at times of stress, I can come across as harsh and abrupt not tolerating fools gladly. Feelings I am proud of my achievements and think I am a good role model but am aware that I can be abrupt on occasions. . Analysis The former U.K.C.C (2000) standards for preparation of teachers of nursing and midwifery state clearly that as nurse I must be a good role model enabling me to build effective relationships with patients and clients and contributing to an environment in which effective practice is maintained ensuring safe and effective care through assessment and management. Nursing relies on clinical staff to support and teach rationale being the student learns from an expert in a safe, supportive and educationally adjusted environment (Andrews and Wallis 1999). As a senior nurse students and junior colleagues see me as a role model. Students see a good mentor as someone who teachers, guides and assesses having a genuine interest in student learning (Andrews and Chilton 2000, Gray and Smith 2000, Neary 2000). Good role models are knowledgeable and skilful professionals who are respected and trusted. Taylor (1997) suggests novices copy or imitate professionals modelling themselves on nurses with varying standards of practice, observation being an important part of their learning. Spouse (2001) small longitudinal study utilised various data collection methods that found evidence of students observing and relating to actions and behaviours they believed as good. My actions evidenced by tone of voice, comments made and enthusiasm and interest shown have an impact on learning, inappropriate behaviour is noticed and at worst copied because the learner see it as acceptable to do so. Findings of this study would be more valid and a claim made stronger if repeated on a grander scale literature supports these findings. Banduras (1977) theory of social learning and vicarious conditioning (cited by Mckenna 1995) involves this observation of behaviours and consequences of this to the learner this theory differs from others, as learning is instant therefore role modelling can be highly effective and positive or destructive. Self-awareness is being aware of what is taking place in oneself learning experience and self-concept changing over time as we see ourselves in many different roles influenced by others and the media (Quinn 1995). Reflection of events and actions increases self-awareness giving insight of behaviour and response enabling us to examine relationships with others in the practical and social setting. Haddock and Bassett (1997) suggest that use this in self-management and improvement. To be a self-aware practitioners we need to reflect on the way we come across to others implementing required changes (Stuart 2003). Self is as all thoughts, feelings and experiences of an individual, arising from biological and environmental influence. It is the way individuals see and feel about themselves (Quinn 1995). The major resource that a helper brings to the relationship is himself, the more complete his understanding of himself, the greater his capacity for self awareness and more effective he will be as a counsellor Nicklin and Kenworthey pg 120. Self-awareness also implies to individuals being aware of their limits of knowledge and ability reflected by the individual partaking in further training or seeking help from experienced colleagues. Quinn (1995) and Burnard (1990) refer to two main ways we can be self aware, introspection and feedback from others. Introspection is looking within oneself and attempts to recognize own feelings and reactions, this is not easy and can cause feelings of discomfort and fright but allows identification of our emotions good and bad assessing their impact. Palmer (2001) states a highly developed sense of self worth comes about within a person who can identify his/her emotions, learning to manage and contain them when inappropriate. Being self-aware give insight of what we can change. Feedback is a way of seeing how others see us, ability to give and receive constructive feedback is a skill; being told how you are perceived is hard but thought provoking. Crewe (2004) relates to research of the Duval and Auckland theory (1972), based on two distinct forms of conscious attention, attention focusing outwards towards the environment or inward towards oneself. The person receives and perceives feedback from the environment regarding their behaviours and attitudes. Perception of approval from others can increase confidence and self-esteem while perception of disdain or negative evaluation can have the opposite effect. Objective self-awareness is an individual being aware of the personal characteristics that distinguish them from the majority; the focus is exclusively on the self. Conclusion/ Action Plan I was not fully aware of my impact on others. It is critical for me to be conscious of my level of patience taking great care not to react negatively in times of stress, or when students or colleague fail to progress (Borgess and Smith 2004) as this can cause great harm to the learner. Learning Outcomes 3/6/7 Develop, maintain, and evaluate an environment for learning in your area of practice. Self-assessment of current practice and identification of learning need(s) in relation to this outcome. Current Practice à ¢Ã¢â€š ¬Ã‚ ¢ Have interest and commitment in teaching. à ¢Ã¢â€š ¬Ã‚ ¢ Im friendly and approachable supporting students in their learning. à ¢Ã¢â€š ¬Ã‚ ¢ Orientate students to environment. à ¢Ã¢â€š ¬Ã‚ ¢ Participate in assessment with formative feedback. My Needs à ¢Ã¢â€š ¬Ã‚ ¢ Increase awareness of what contributes to a good and bad learning environment. à ¢Ã¢â€š ¬Ã‚ ¢ Be involved in educational placement audit. Learning Outcome 3/6/7. Develop, maintain and evaluate an environment for learning in your area of practice. Examples of Evidence à ¢Ã¢â€š ¬Ã‚ ¢ Produces evidence of placement learning opportunities/resources suitable for meeting needs of specific students. à ¢Ã¢â€š ¬Ã‚ ¢ Give examples of how you create and sustain an environment for learning. Summary of Evidence for summative assessment of what you have achieved during the module. Cross-reference as appropriate. à ¢Ã¢â€š ¬Ã‚ ¢ Greater awareness of what contributes to a good learning environment. à ¢Ã¢â€š ¬Ã‚ ¢ I try to maintain adequate supervision and liaise with colleagues regarding my students progress. à ¢Ã¢â€š ¬Ã‚ ¢ Attend courses and study days for my personal development. à ¢Ã¢â€š ¬Ã‚ ¢ Students always have a designated Mentor. à ¢Ã¢â€š ¬Ã‚ ¢ There is a ward philosophy of care. à ¢Ã¢â€š ¬Ã‚ ¢ Students have access to the internet, journals, pt notes and policies/procedures. à ¢Ã¢â€š ¬Ã‚ ¢ Students attend spokes placements attached to the ward area, and have opportunities to spend time in theatre watching relevant procedures. Description Patients are admitted onto my ward from electoral and urgency lists or via A+E for vascular assessment, procedures or surgery. Wound care and management is a large part of our role as well as patient education and discharge planning. Feelings I feel this ward environment offers a lot of learning opportunities to students and new staff but has high patient demands, reduced staffing and skill mix due to high levels of sickness effecting team spirit and morale, which has a huge impact on our ability to teach, directly affecting the learning of students and junior colleagues. Analysis Finding a description of a clinical learning environment is not easy due to a complexity of numerous factors involved. Quinn (1995) uses holistic description, a broad definition referring to all factors influencing quality and effectiveness of a learning environment, Chan (2001) description is similar relating to the learning environment as a multidimensional entity with interactive networks of forces that can affect the learners learning outcomes. Literature cites numerous studies concerning social support for students and nursing staff. These studies include Fretwell (1982) and (1985), Lewin and Leach (1982), Ogier (1982) and Orton (1981) conclusively identify quality relationships between trained staff and students and support being crucial in creating a positive learning environment (Cahill 1996, Chan 2001, Saarikoski and Leino-Kilpi 2002). All studies conclude that an important determinant of an effective learning environment is the managers organisational and leadership style. Highly structured wards with rigid task allocation and hierarchical systems unlikely to meet the learning needs of students and staff (Chan 2001). It identified throughout the studies that team spirit, humanistic approach to students learning and teaching and learning support are influential factors of an effective ward setting. The frequent references to these studies show that their findings are seen as valid even though all were small sized. I believe team spirit comes from working as a team, best achieved through encouragement of the ward manager (Welsh and Swann 2002) giving a sense of group pride and self-esteem for all staff. We need to make students feel part of this team so that they feel accepted having a sense of belonging (Chan 2001, Quinn 1995 and Spencer 2003). A team approach with an appropriate leadership style on the part of the manager creates fertile ground for the development of an appropriate learning climate. (Welsh and Swann 2002 pg 117) Studies carried out post Project 2000 explored more in depth themes and perceptive related to the clinical learning environment and clinical supervision (Wilson and Barnett et al 1995) the meaning of nursing care and the teaching activities of nurses explored also. Saarikowski and Leino-Kilpi (2002) felt these studies demonstrated transition of individualised supervision and the role of the mentor. I agree with Lambert and Glacken (2004) that ward managers are no longer able to dedicate time to teaching due to managerial demands, therefore nurses now have this overall responsibility for teaching. Mentorship is favoured in facilitating learning (Chow and Suen 2001). Watson (2000) acknowledges that mentors need education and training to function effectively in this demanding role with preparation mentors are able to create opportunities for students identifying experiences that meet individual learning needs. Studies by Cahill (1996), Darling (1984), Earnshaw (1995), Hart and Rotem (1994) (cited by Chan 2001) and Spouse (2001) are again small sized but all use similar methods of valid and reliable data collection. The common theme throughout these studies is personal characteristics of the mentor, which include approachability, interpersonal skills, interest learning and teaching and supervision and support. These studies relate to students perspectives of the learning environment and mentorship, most of the findings viewing mentorship in a positive light and find it beneficial in reducing the theory practice gap for students. Staff attitudes and behaviour, the need of the student to belong and level of mentor contact highlighted throughout. Mentors need to make time for the student so that they can practice, develop and learn to be a nurse (Spouse 2002). Phillips et al study (1994) was of a larger scale, carried out throughout Wales commissioned by the D.O.H., a two-year research project concerned with the implications and impact of mentorship. This had qualitative and quantitative methodology information gathered through questionnaires, diary accounts, interviews and observation again the key elements of mentorship surrounded mentor/student relationships. Evidence of teaching, organisation of experiences consolidated with feedback and discussion that aided and enhanced the students experience. Significant mentor contact seen to directly affect activities students are involved in, this contact essential for building rapport needed in a good working relationship. Mentor presence provides emotional support to students allowing gentle introduction into the different and a difficult experience that exist and is crucial to students well being and learning potential, reducing anxiety (Jowett et al 1992). Feeling useful and part of a team are other important aspects. Chan (2001) and Welsh and Swann (2002) relate to this but feel that the students role needs to be understood acknowledged and clarified to prevent them being used as a pair of hands. Studies that concern nurses perspective of the learning environment and mentorship (Andrews 1993, Atkins and Williams 1995 and Rogers and Lawton 1995) highlight barriers of effective mentorship due to lack of time, inadequate planning and role conflict. Lambert and Glacken (2004) also view inadequate staffing, poor skill mix, lack of support and training of staff and poor management structure as barriers that reduce learning potential. Phillips et al study (1994) reflects the findings of Jowett et al (1992) which I agree that in clinical area where demands for care are high and resources stretched it is difficult to give adequate support and supervision to the junior student. When I am in charge of the ward, I am less involved in direct care of patients and have difficulty working closely with the student. Action Plan I need to liaise with my colleagues closely to make them aware of my students learning needs so that constant supervision and constructive support and feedback is ongoing when I am not available or am engaged in ward coordination. This will enable my student to be increasingly involved in the nursing team learning skills appropriate to their training preventing them feeling neglected, used or ignored. ________________ Learning Outcomes 4. Create and develop opportunities for students to learn, utilising evidence-based practice. _________________ Self-assessment of current practice and identification of learning need(s) in relation to this outcome. Current Practice. à ¢Ã¢â€š ¬Ã‚ ¢ Awareness of constant changes within nursing and medicine that initiates change. à ¢Ã¢â€š ¬Ã‚ ¢ I am familiar of protocols, standards and procedures regarding nursing intervention based on evidence-based practice. à ¢Ã¢â€š ¬Ã‚ ¢ I back up my teaching with evidence based on experience or acknowledged research. à ¢Ã¢â€š ¬Ã‚ ¢ Attend attending Pain Nurse Link meetings and wound care sessions providing me with current evidence for practice. Needs. à ¢Ã¢â€š ¬Ã‚ ¢ To develop skills of critical analyse, systematic review and evaluation of research. à ¢Ã¢â€š ¬Ã‚ ¢ Review literature increasing my awareness of this topic. Learning Outcomes 4. Create and develop opportunities for students learning of utilising evidence-based practice. _____________ Examples of Evidence à ¢Ã¢â€š ¬Ã‚ ¢ Produce evidence of the ability to meet own learning needs in relation to the facilitation of learning. à ¢Ã¢â€š ¬Ã‚ ¢ Give Examples of how you have identified and facilitated individuals or groups to learn. _____________ à ¢Ã¢â€š ¬Ã‚ ¢ Reviewed and critically analysed the literature. à ¢Ã¢â€š ¬Ã‚ ¢ I am increasingly aware of the importance of evidence-based practice. Description I have gained a great deal of experience throughout my career, which I use within my clinical practice and teaching. My knowledge has developed through practice, study sessions relevant to my area, advice of specialist nurses, reading journals and following clinical guidelines, standards and protocols that I encourage students to read. Students invited to attend relevant wound care updates and to spend time with many of our specialist nurses. Feelings I already base most of my practice on evidence but need to participate in literature reviews and develop skills to analyse and scrutinise research findings. Analysis I believe evidence-based nursing is a process in which nurses base clinical decisions using the best available evidence (The University of Minnesota 2005). The Editorial (1997) defines evidence-based practice as giving quantitative and qualitative meaning to a cause, course, diagnosis, treatment and economics of health problems managed by us nurses including quality assurance and continuing professional development which maintains and enhancing knowledge, expertise and competence to give best care (cited by Hincliffe 2002 pg 11). Curzio (1997) views it as the bridge between theory and practice agreed by White (1997) agrees with this suggesting it links personal intuition research and practice providing nurses with greater knowledge to base their care, our clinical decision-making and teaching must be based on evidence, expertise and highly importantly patients preference as referred to by Hincliffe (2002). The aims of evidence-based practice/nursing ensuring patients receive up to date care based on up to date knowledge. As we develop skill inquiry, we become more knowledgeable in our profession that improves standards of care (Hincliffe 2002). I agree with Welsh and Swann (2002) that there is a need for well-informed nurses using initiative, effective communication and clinical reasoning skills so that informed decisions are made through critical analysis of evidence available especially due to the constant changes within the NHS. The government introduced a framework of clinical governance in an attempt to achieve national clinical effectiveness within the NHS to guarantee quality services for patients and clients a key component being evidence-based practice. Behi (2000) states clinical governance requires every professional to use evidence-based practice. The New NHS: Modern, Dependable (D.O.H 1997), The Drive for Clinical Effectiveness (D.O.H 1996) and A First Class Service: Quality in the NHS (D.O.H 1998) shows quality improvements at the forefront of the NHS agenda. The NHS National Service Knowledge and Skills Framework (Hincliffe 2002 McSherry and Haddock 1999 and Welsh and Swann 2002) development tool promoting effectiveness through quality, staff and service development linking current and future research activity. The National Institute for Clinical Excellence (N.I.C.E) is responsible for assessment of technologies and for producing guidelines and the Commission for Health Improvement (C.H.I.M.P) monitors quality of services at a local level and ensure organisations are fulfilling their responsibility for clinical governance Health Care Organisations accountable for quality of services they provide, Chief Executives carry ultimate responsibility. The government also provides funding essential for research activity. Spector (2004) refers to evidence-based practice as being rigorous and time-consuming involving selection of all research done in an area, analysis and synthesis developing integrative reviews termed within the literature as a systematic or meta-analysis reviews (Renfrew 1997, University of Minnesota 2005). Completed reviews are available to taking some of the pressure of us; the Cochrane database has a wide range of these. Behi (2000) and Mcsherry and Haddock (1999) relate to clinical practice standards and guidelines produced by the N.M.C, R.C.N and local Health Authorities systematic review, recommendations and policy statements based on best evidence agreed by experts. There are also systematic reviews published in research journals and by the National Clearing House. Clinical appraisal is crucial in ensuring practice is evidenced based involving asking a clinical question related to practice and finding the research and literature to answer it, appraising evidence and deciding on its relevance and validity before applying findings to practice and evaluating effectiveness (Behi 2000 and McSherry and Haddock 1999). Castledeine (2003) refers to this as a three-stage process producing the