INTRODUCTION The Oxford Concise Medical Dictionary (1998) defines a nurse as ' a person trained and experienced in nursing matters and entrusted with the care of the sick and the carrying out of medical and surgical routines. ' In reality, however, nursing is much more than the physical and medical areas of health care it is also about the more emotional and psychological areas. One of the main objectives of this assignment will be to demonstrate the wide variety of skills and characteristics required to work in the caring profession. Much research has been done in to the foundations of nursing practice. As a result many ideas on how optimum nursing care can be achieved have been put forward and guidelines produced taking these in to account. During the course of this assignment we will address the theories behind these ideas and how things are most productively learnt.

Recognise and demonstrate the importance and implications of cultural diversity for professional practice Due to the increasing numbers of ethnic minority families in Britain today the country has become one of multiculturalism, made up of many different cultures and therefore many different cultural practices, beliefs and values. The modern system of health care needs to reflect these differences in order to provide equality of care to all. This quote is taken from an article published in Focal Point, a national bulletin published by the Research and Training Centre on Family Support and Children's Mental Health. Although this is an American charity I feel that their guidelines are applicable to any health care system. WHAT IS A CULTURALLY COMPETENT HEALTH CARE SYSTEM? It is a system that acknowledges the importance of culture and incorporates the following into its daily operations: o The assessment of cross-cultural relations o Vigilance towards the dynamics of cultural differences o Expansion of cultural knowledge o Adaptation to meet the unique needs of our patients (Smith, 1998) In order to achieve the points above and therefore the proposed equality of care the health service needs to inspire co-operation between all professions of the multidisciplinary team.

In our problem based learning work groups we were given a problem which consisted of an unspecified clinician working in an inner city community setting who was very obvious about his views on certain issues. As a group we discussed stereotyping, prejudice and discrimination and this led on to how this clinician's behaviour could affect his or her patients and their health care. 'Practitioners exercise considerable power and discretion, their attitudes towards patients in terms of age, gender, ability or ethnicity do matter... Ideological, professional and personal prejudices can, and do, lead to discriminatory outcomes.

Ideas about belonging and distinctiveness influence practitioners' judgement of individual and group rights to state welfare' (Petersen and Waddell, 1998) If a practitioner holds certain views about a person and / or their situation or background then, as the quote above suggests, it is likely to affect the quality of care or treatment that is given. Ahmad et al (1991) and Wright (1983) both conducted research into how ethnic minorities were viewed by health professionals. Both reports described negative attitudes held by General Practitioners towards Asian patients. They found evidence of many common stereotypes including fussing over trivial complaints, inappropriate consultations, lack of care over own health and abuse of services. Ahmad continued his research in 1993 looking at a similar topic area.

This piece further commented on his previous work by claiming that medical professionals are often willing to accept explanations for many medical conditions which place the blame on culture. According to Ahmad many illnesses and diseases including Rickets, Poorer birth outcome and Tuberculosis have all been explained by criticising cultural practices and deeming them harmful. Although many pieces of research have concluded that ethnic background can be a big determinant of health this is only in certain circumstances and should not be used to generalise. All of the fore mentioned medical conditions have a wide range of causes any of which could be responsible, by simply blaming culture and ethnicity the real cause could be being ignored and this could, in turn, lead to further problems. I was particularly interested in the affect that practitioners views could have on health care and have to admit that it was not something I had considered before.

In my college work we looked at the inequality of health and how certain illnesses are more prevalent amongst certain races and ethnic backgrounds, for example higher prevalence of diabetes in the Asian community, however we never looked at the psychological aspects of belonging to a minority group and how this might affect health as looked at in this assignment. Outline the professional, legal and ethical principles underpinning confidentiality, consent and professional codes of conduct As we have said nursing is evolving and as a part of this evolution the responsibilities are increasing and the legality and ethics of health are becoming more and more prominent in nursing. As well as a duty to provide equality of care, as talked about in the previous section, the main areas of legal and ethical practice in health care are the practices of confidentiality and consent. Confidentiality is, according to the Brockhampton Reference Dictionary and Thesaurus (1995), 'the quality or state of being confidential' In terms of health care it refers to the act of keeping all patient information, whether it be big or small, confidential unless specified by the patient. Confidentiality is a very difficult issue as it's boundaries are unclear for example the depth of information shared in one circumstance may not be appropriate in another.

Section five of the Nursing and Midwifery Council (NMC) Code of professional conduct (2002) states ' You must treat information about patients and clients as confidential and use it only for the purposes for which it was given. ' One of the main legislation regarding confidentiality is the Data Protection Act (1998). This act gives individuals certain rights in relation to computer held personal data. Under this act an individual has the right to know whether a data holder is using personal information and the right to access to this information. Individuals can also claim compensation if the information held is inaccurate and have the right to have it corrected all personal data held must be registered on the Data Protection Registrar. There are also two acts designed particularly for confidentiality in health care the Access to Health Records Act (1990) and the Access to Medical Records Act (1988).

The Access to Health Records Act establishes the right of access to health records by individuals to whom they relate and other authorised persons. It allows the correction of inaccurate health records and the avoidance of certain contractual obligations. The Access to Medical Records Act is much more detailed. A full description of this act along with the Access to Personal Files Act (1987) is included as Appendix One. My younger brother has cerebral palsy and as a result is mentally impaired and unable to give consent or be responsible for his own health.

It is important therefore that my parents are given all the information they need in order to make the right decisions on his behalf. However this does not mean that he is not entitled to the same right to confidentiality and consent. At the end of last year he went in to hospital to have an operation where medical professionals seemed to negate these rights by feeling it appropriate to use him as an example to other parents considering the operation for their child. The term consent is defined as meaning 'to agree; give approval or permission' (Brockhampton Reference Dictionary and Thesaurus, 1995) As technology progresses medicine follows allowing doctors to develop increasing numbers and complex treatments and procedures. The increasing number of developments along with patient's increasing confidence in pursuing complaints has resulted in even more importance being put on obtaining consent. There are several guidelines on consent and the boundaries are much more defined than confidentiality.

The NMC Code of Professional Conduct (2002) also goes in to detail providing eleven different points, all of which are included in full as Appendix Two. As a future nursing professional it is important that I embrace these concepts in my nursing practice in order to ensure the utmost holistic care for my patients. By this I mean that it is important that I consider not only the physical consequences of my actions such as exposure to treatments with out full knowledge of the risks but also the emotional consequences such as pressure and worry from other family members etc. Use self evaluation and portfolio development as tools in the management of learning 'A professional portfolio is a record of goals, growth, achievement and professional attributes developed over time and in collaboration with others' (Windsor, 1998) In nursing a professional portfolio is a collection of visible documentation of credentials and contributions to the practice of nursing. A professional portfolio is an arrangement of materials and accomplishments that communicates achievements both inside and outside the nursing vocation.

A portfolio serves to demonstrate all of the elements in the quote above in order to demonstrate that a nurse is still competent to practice and in order to facilitate Continuing Professional Development Many professional sources recommend approaching the portfolio development as if it were a step-by-step process consisting of six successive steps. These being: Self evaluation The development and continuous development of a portfolio involves a lot of focus on self evaluation. In this step the nurse or nursing student needs to consider their own qualifications, characteristics and talents and which of these are needed in the nursing profession. Selection of evidence In the second step they then need to think about how they can represent or prove that they have these qualifications, characteristics and talents this could be through certification, awards and evaluations. Reasoning behind everything included In the third step the nurse or nursing student must develop some kind of reasoning behind all of the inclusions therefore all inclusions must represent a specific characteristic, qualification or talent and each qualification, characteristic or talent claimed must be proven. Goal setting The forth step involves setting personal goals, looking at goals already achieved and how these can be built upon and reflecting on how these achievements and goals have lead to either personal or professional development or both.

Creation of a less detailed portfolio for show A portfolio demonstrates both professional and personal development and though some personal development may be suitable to show other people some is not. The fifth step therefore is to create a less in-depth portfolio which shows only main achievements and is less personal and more professional. This portfolio is the one taken to interviews. Portfolio development throughout career One of the most challenging thing about nursing and healthcare in general is that it is always changing new treatments and medications are being introduced all the time and, due to a rapidly changing society, so are legislations. It is essential that nurses remain up to date on all changes this means that qualifications are becoming defunct, new ones are being introduced and nurses are constantly building on them. Portfolios must also be up to date and reflect these changes and this is the sixth and final step.

The University of Birmingham School of Health Sciences Professional Portfolio requires people to follow all of these steps but is also very tailored to provide maximum enhancement of these steps. In the process of self evaluation, for example, the portfolio not only requires us to come to our own conclusions about our qualities but also promotes the use of evaluation tools such as learning styles which will covered in more detail under the next outcome. The Professional portfolio is also very much centred on the process of reflection providing many opportunities for reflective statements in all sections. Continuing reflective practice is, like self evaluation, an essential part of portfolio development and professional development and it is through this practice that continuing professional development is achieved. Use the principles of experiential learning and reflective practice Learning styles are described as 'the different ways in which children and adults think and learn' (Lit zinger et al (1993) ) Much research has been done into learning styles and many people have tried to demonstrate the wide range of learning styles however perhaps the most well known is Kolb's Theory of Learning Styles, Experiential Learning.

In this theory he first separated learning into two parts perception and processing. Perception of information, according to Kolb, was acquired either through relevant senses (i.e. touch, sight, or hearing) or through visual or psychological images and concepts. In his theory processing was achieved either by actually doing or alternatively by thinking about. Through these ideas he developed four different learning dimensions which built on these ideas, perception through Concrete experience or Abstract Conceptualisation and Processing by Active experimentation or Reflective Observation. Concrete experience is based on the idea of perception through senses but extends to cover social experiences and relationships with other people.

Abstract conceptualisation also relates to experience but more in the aspect of learning from past experiences and how these affect how we perceive things in the present. Though the two types of perception are very closely related the two types of processing are very much two ends of a spectrum whilst Active experimentation means doing things and taking risks without thinking about it Reflective observation puts much emphasis on thinking and involves seeing things from all angles and looking at things in-depth before acting. Kolb's experiential learning theory is often linked to reflective practice 'professional practice guided by structured reflection on feelings, experience and empathy in order to make practice robust and enhance learning' (Houston and Simpson, 2002) Reflective practice is based on Gibbs Reflective Cycle, show in the diagram below, which outlines six stages of reflection. (web accessed on 29th Dec) This cycle allows the reflector to become aware of his or her own actions and the experiences and consequences of these actions during the first stages of the cycle. The second part of the cycle allows the reflector to look at this experiences in more depth and what can be learnt from them hence it's relationship with experiential learning. In the final stages the reflector considers what they, now having learnt from the experience, would do if a similar situation arose. It is important that I as both a student and future nurse reflect on all experiences both good and bad in order to replicate or rectify them in a similar situation.

It is also important that I inspire other people, such as patients, to do the same as this can be and sometimes is an important part of treatment. Most commonly Kolb's theory of experiential learning is seen as a diagram which is a lot more complex than this description with the introduction of four new terms accommodators, diverges, converters and assimilator's. A copy of this diagram along with my own explanations of the four terms is included as Appendix Three Kolb's learning styles is also combined with four new terms Activist, Reflector, Theorist and Pragmatist in Honey and Mumford's Typology of learners a diagram of which I have included as Appendix Four. According to Kolb's theory of learning styles I would be a diverge r I often have problems coming to a conclusion about ethical issues because I can see the strengths and weaknesses of all arguments.

I also have problems sometimes with essays because I tend to be too enthusiastic when it comes to data collection and end up with so much information that I don't know what to do with it. In terms of concepts I need to see them done in order to understand fully but would much rather watch someone doing it than do it myself. There are several other ways of finding your ideal learning style including the VAN (Visual, Auditory and Kinaesthetic) learning style questionnaire which I have completed and included as Appendix Five. I have also completed a Index of Learning Styles Questionnaire which I have included as Appendix Six. Relate organisational theory to the structure, culture and functioning of the NHS When the NHS was first introduced in 1948 it was designed as a universal system providing equality of care for all regardless of any social or physical circumstances.

Though there have been many changes to the organisation in the last 55 years this ideology of equality of care has remained central to the continuing culture and functioning of the NHS. The diagram below outlines the structure of the NHS in England since April 2002. (web accessed on 29th Dec) As a part of this structure it is important that I understand how it works and the ideological aims of the organisation. Appendix Seven is an explanation of how Drucker's theory on the structure of an organisation fits in to the NHS which I feel it does very well. However Drucker's theory is not classed as an organisational theory which I will now go on to explain. Organisational theory refers to how organisations are structured, how they are managed and the culture adopted within them. It attempts to explain how organisations work by defining the common features that organisations or groups of organisations share.

There are four main types of organisational theory classical theory, systems theory, contingency theory and human relations theory. Classical theory was the first published theory of management and has a very scientific and traditional basis focusing on the structure and mechanics of an organisation. As with all organisations the NHS is very dependant on it's hierarchical structure without which it would not function effectively however classical management theory is very basic and, as I will show in the rest of this section, the NHS is a complex organisation which is better explained by a more complex organisational theory. Classical theory ignores the effect that individuals, groups of individuals and systems have on an organisation. Systems theory suggests that all organisations are made up of many different but interrelated systems all with a common objective that is the function of the organisation.

Therefore all actions of individuals in one system directly affect the actions of individuals in other systems. In the context of health care an example of a common objective would be the efficient care of patients. In order for this common objective to be met we not only need the co-operation of the medical multidisciplinary team but also the co-operation of the senior management team in order to allocate resources and the estate team in order to provide a safe and comfortable environment for that care. Contingency theory also considers the different parts of an organisations but rather than systems within the organisation looks at the various factors which make up an organisation. This involves factors such as size, structure and the individual requirements of the environment which that organisation is in. Like systems theory contingency theory views that an organisation cannot function without interdependence of all these factors.

The contingency theory is particularly relevant to the organisation of the NHS in that it is centred around the perception that there is no one best or appropriate way to organise and that organisations are diverse and therefore need diverse and particular designs. The NHS is a unique and unparalleled organisation and as a result has very different needs to any other organisation, it therefore needs a very different structure to that of any other organisation. The final theory, human relations theory, takes in to account human behaviour and looks in particular at the relationship between employer and employee. It considers issues such as leadership and motivation which will also be looked at under the next outcome. The Human relations theory becomes very pertinent when applying management theory to the NHS due to the organisation's immense dependence on people, both patients and staff.

The NHS cannot run without specifically trained staff and therefore in order to run an effective service it needs to listen to the wants and needs of these people. It also needs to listen to the wants and needs of the service users without whom there would be no justification for the service. Apply an understanding of motivation theories to your working practice as an individual and as a member of a caring profession Extensive research has been carried out to try to understand people and why they behave in a certain way. The most well known and often referred to area of this research was conducted by Abraham H. Maslow (1943) who suggested that there were five groups of needs that drove us onwards: (web accessed on 31st Dec) According to this theory, once the lower needs are satisfied, the next level needs become the motivators. For example if you have enough food, water and air more will not motivate you. You will only be motivated by the next level of needs, safety needs.

However, should the lower level needs become unsatisfied, for any reason; then they, once again, become the motivators Only in the moments when all of the first four levels of needs are met do people move on to self actualization, and direct their energy into becoming the best that they can be, that is realising their full potential. It is important to remember that the level of satisfaction varies from person to person depending on previous experience, environment and expectations. In other words what one person might see as satisfying a need one person will not. When applying Maslow's theory to my understanding of the work place and being a part of a multidisciplinary caring team it is important to remember the differences in people's perceptions of satisfactions. In terms of patient care in the NHS people will be entering the hospital setting from all walks of life and with many different medical and emotional conditions as a result they will, invariably, all have different views on what satisfies a need.

To a homeless man a simple meal would quite easily satisfy their physiological needs to others a more complex nutritional meal is needed. To a man who has not been able to walk for months after a car accident taking just one step will fulfil his esteem needs however to a man who has full use of his legs one step is nothing. Maslow's hierarchy applies not only to patient's in the health care system but also the staff who need things such as money in order to motivate them. Another theorist, Fredrick Herzberg adapted Maslow's hierarchy in order to further apply to the staff of an organisation which he called the relationship of needs to work. In this Herzberg divided people's needs into two factors hygiene factors, such as wages, job security, fair treatment, safe working environment and motivation factors, such as challenging work, responsibility, self improvement opportunities. Herzberg claimed that effective management of hygiene factors ensured minimum job dissatisfaction whilst effective management of motivation factors ensured maximum job satisfaction.

He claimed that hygiene factors on their own would not lead to motivation but would inspire an environment in which motivation factors could occur.