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50 august 5 :: vol 29 no 49 :: 2015 NURSING STANDARD

Abstract Teamwork requires co-operation, co-ordination and communication between members of a team to achieve desired outcomes. In industries with a high degree of risk, such as health care, effective teamwork has been shown to achieve team goals successfully and efficiently, with fewer errors. This article introduces behaviours that support communication, co-operation and co-ordination in teams. The central role of communication in enabling co-operation and co-ordination is explored. A human factors perspective is used to examine tools to improve communication and identify barriers to effective team communication in health care.

Author Heather Gluyas Associate professor, School of Health Professions, Murdoch University, Mandurah, Western Australia. Correspondence to:

Keywords Communication, co-operation, human factors, patient safety, revalidation, structured communication tools, team briefing, teamwork

Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

Revalidation Prepare for revalidation: read this CPD article, answer the questionnaire and write a reflective account. Go to

Online For related articles visit the archive and search using the keywords above.

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E�ective communication and teamwork promotes patient safety NS805 Gluyas H (2015) Effective communication and teamwork promotes patient safety. Nursing Standard. 29, 49, 50-57. Date of submission: March 15 2015; date of acceptance: May 14 2015.

Aims and intended learning outcomes This article aims to inform the reader about effective teamwork and communication. The behaviours required for effective teamwork, the key elements of effective communication and common tools that support successful communication within a team are discussed. After reading this article and completing the time out activities you should be able to:  Explain the pivotal role of effective

teamwork in promoting patient safety and quality care.  Describe the behaviours that are required for

effective teamwork.  List the barriers to effective communication

in health care.  Describe common tools that can be used to

improve team communication.  Relate effective communication to your own

practice.  Develop your communication skills in your

team environment.

Introduction Teamwork involves a group of people working together to achieve a common purpose (St Pierre et al 2011). Teamwork requires co-operation, co-ordination and communication between members of a team to achieve desired outcomes. In industries where there is high risk, such as health care, effective teamwork has been shown to achieve team goals successfully and efficiently, with fewer errors. Conversely, poor teamwork has been shown to result in errors and suboptimal outcomes (Walker 2008, Donohue and Endacott 2010, Lee et al 2012, Lyons and Popejoy 2014).

This article introduces behaviours that support communication, co-operation and co-ordination in teams, and explores the central role of communication in enabling

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NURSING STANDARD august 5 :: vol 29 no 49 :: 2015 51

co-operation and co-ordination. A human factors perspective is used to identify barriers to effective team communication in health care and to examine tools that improve communication. Complete time out activity 1

In health care, teamwork is integral to providing safe and effective care to patients. The importance of effective teamwork in response to the growing complexity of care involving chronic conditions and associated comorbidities is increasingly recognised (St Pierre et al 2011). Most patient encounters involve more than one healthcare professional and may involve many people, depending on the type of healthcare problem. These individuals may include doctors, nurses, allied health professionals and other specialist professionals. Teams from different healthcare sectors, such as primary care, acute care, mental health or chronic care, may also be involved. Effective communication – both verbal and written – between team members and between different teams is essential to ensure co-operation and co-ordination of care.

Ineffective communication, which leads to poor co-operation and co-ordination of care, is a major cause of errors and adverse events in patient care (World Health Organization 2009). Communication errors occurring at handover, either between team members or between different teams, may lead to inaccurate diagnosis, incorrect treatment and/or medication errors (Wong et al 2008). Poor communication in teams leads to team members having different perceptions of situations and of what is required to manage them (Brady and Goldenhar 2014). Such differing perceptions of a situation among team members may be viewed as the lack of a shared mental model, and this has been shown to contribute to serious safety events (Gluyas and Morrison 2013, Brady and Goldenhar 2014). Moreover, a lack of effective team communication has been shown to contribute to delayed response to deteriorating patients (Endacott et al 2007). Patient safety in surgical interventions may be compromised if there is poor team communication (Lyons and Popejoy 2014). This may result in serious adverse events such as wrong patient, procedure and/or site; retained instruments; infections; and unanticipated blood loss (Treadwell et al 2014).

Thomas et al (2013) examined data from 459 patient safety incidents relating to clinical handover in acute care settings. They found

that 28.8% of incidents (n=132) involved transfer of patients without adequate handover, 19.2% of incidents (n=88) involved omissions of critical information about the patients’ condition and 14.2% of incidents (n=65) involved omission of critical information in patients’ care plans.

Poor communication is not limited to incidents in the acute sector. It may also be a factor in poor outcomes when transferring care between sectors, such as from primary care to the acute sector and back again (Russell et al 2013). There is a convincing case for investing time and resources in improving communication and teamwork in health care to improve patient safety. Complete time out activity 2

Teamwork behaviours Teams are composed of individuals with different knowledge, skills and attributes, who all contribute particular characteristics to team performance. However, for a team to perform successfully, individuals must share an understanding of what is required to achieve the desired goal (Endsley 2012). This means team members must work individually to carry out their duties while maintaining an awareness of the need for the collective contribution of team members (Gluyas and Morrison 2013). The skills that contribute to successful teamwork include team leadership, mutual support, situation monitoring and effective communication (Baker et al 2012). Table 1 indicates the knowledge and behaviours that are required to demonstrate these skills.

Communication Communication is necessary in each of the skills team members require to contribute to an effective team (Table 1) and may be considered as the basis for effective teamwork. It may involve spoken communication, non-verbal (gestures, facial expression) and/or written language. It involves one person initiating a message, along with receipt of this message by another person or persons (St Pierre et al 2011). However, the powerful effect of cognitive processes on the communication process should be understood and recognised, since this is central to promoting effective communication. A human factors perspective provides a framework for understanding these effects and considers the

2 Read the case study in Box 1. Draw a diagram indicating the different teams that may have been involved in Mary’s care in the community and in hospital. Identify specific points where effective teamwork and communication were required between team members and teams.

1 Before completing this article, recall a time when you were part of a team that did not work well together. Write down the factors and behaviours that may have contributed to this. Once you have completed the article and reviewed Table 1, add any factors you may have omitted from this list.

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effect of systems, environments, equipment and processes on human cognitive abilities and limitations (Catchpole 2013).

Human cognition is a dynamic process that allows people to perceive, interpret and make decisions about required actions (Gluyas and Morrison 2013). The cognitive load is relatively low when undertaking well-known tasks in familiar situations. In such instances, humans are able to carry out tasks in a somewhat automatic manner with little conscious thought. However, in unfamiliar or complex situations, humans must use increased conscious attention to process what is going

on around them and what actions are required. Cognitive overload may occur if the situation is complex, for example where constantly changing circumstances require intense cognitive attention to process what is happening (Endsley 2012). Several cognitive processing failures may then arise, including attentional tunnelling, confirmation bias, memory failures (slips and lapses) and inaccurate mental models (Endsley 2012) (Table 2). These limitations in cognitive processing may be precipitated or exacerbated by workload pressures, time pressures, stress, anxiety, fatigue, poor team relationships, constant interruptions and changing situational requirements (St Pierre et al 2011).

The cognitive load of the individuals involved in the communication may affect their processing of the information. Communication failures may occur if an individual is in a situation where there is cognitive overload, for example because of the volume of data they are trying to process. Transmission failures may arise from incomplete, incorrect, ambiguous or unclear messages, while reception failures may arise because the message is misinterpreted, disregarded or not processed and retained in memory (Endsley 2012). Therefore, it is important to recognise the context of communication and the individual stresses that might affect the communication process. The communication process itself is only one aspect of effective communication; there are additional barriers that may lead to communication failures.

Barriers to e�ective communication General factors that can increase the likelihood of communication failures in any setting include differences in gender, culture, ethnicity, education and styles of communication. Also, there are contextual and cultural issues specific to healthcare settings that may affect communication in healthcare teams.

One major difference between health care and many other environments is the existence of a hierarchical system, both among different health professional groups and among senior and junior staff in the same professional group (Nugus et al 2010). This hierarchy results in an authority gradient; those further down the hierarchy may be hesitant to challenge those further up the hierarchy, raise concerns or ask questions. In a situation where one member of the team feels there may be a patient safety issue, or has concerns of some kind, they may not feel comfortable raising this or discussing their concerns with the team (Makary et al 2006, Reid and Bromiley 2012).

Teamwork skills and required behaviours TABLE 1

Skill Required behaviours

Leadership  Communicate awareness and understanding of the desired outcome.

 Communicate understanding of purpose, team roles, responsibilities, task requirements and plan.

 Plan and allocate tasks.

Mutual support  Provide feedback to other team members when required.

 Provide and request assistance when required.  Trust in other team members and have confidence

in their actions and intentions.

Situation monitoring  Review ongoing team performance.  Adjust, adapt and reallocate tasks and

responsibilities as required.

Communication  Share information with other team members.  Communicate clearly using objective language,

correct terminology and structured processes or tools, where available.

 Acknowledge communication and check for correct interpretation (closed loop communication).

(Miller et al 2009, Baker et al 2012, Gluyas and Morrison 2013)

Case study 1: Mary BOX 1

Mary presented to the GP feeling unwell, with pain in her right leg of several days’ duration. On examination the GP identified that Mary had tenderness and swelling in her right calf; she denied any falls or other incidents that may have caused this. Since Mary had recently taken a flight overseas, the GP suspected a deep vein thrombosis (DVT). The GP ordered an ultrasound scan and blood test, which were positive for DVT, and Mary was commenced on oral anticoagulation therapy. Later that day, she presented to the emergency department with acute shortness of breath and was admitted with a diagnosis of pulmonary embolus. She was commenced on parenteral anticoagulation and respiratory support. After several days, Mary improved and was discharged into the care of the GP for monitoring of ongoing anticoagulation therapy, and the community nursing service, which would provide home visits and support during the recovery phase.

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An example that illustrates this authority gradient is provided in Reynard et al (2009). A child experienced facial burns from a dry swab that caught fire from the diathermy machine during maxillofacial surgery. The surgeon immediately changed his practice to using wet swabs, but ascertained from colleagues that they previously changed to this practice because the risk of using dry swabs had already been identified. When the surgeon asked nursing staff why they did not inform him of this practice, they indicated that he had discouraged suggestions in the past, so they did not feel comfortable raising issues about his surgical practice (Reynard et al 2009).

Other studies confirm that reluctance to speak up about possible patient risk is an important factor in communication errors (Leonard et al 2004, Makary et al 2006, Mackintosh and Sandall 2010, Carayon 2012, Lyndon et al 2012, Okuyama et al 2014). Lyndon et al (2012) reported that 12% of staff were unlikely to speak up even when there was high risk; this reluctance was related to previous rudeness or intimidation from other staff. Other factors that contribute to this hesitancy include poor leadership and relationships in the healthcare team, fear of the responses of others, and concerns about appearing incompetent in ambiguous or complex clinical situations (Okuyama et al 2014).

Differing communication styles between doctors and nurses may exacerbate authority gradients that exist in health care. Doctors are educated on a scientific basis that emphasises cure and treatment in the management of patient care. This results in a communication style that tends to be succinct, with a focus on scientific facts. Nurse education is informed by science but has a holistic focus on caring linked to treatment and management. Nurses’ communication style differs from that of doctors in that it tends to be more narrative, rather than concisely factual (Wachter 2012). Communication between different professional groups can lead to misunderstanding and misinterpretation of the message being communicated, because different professional staff have expectations of others that are not explicitly communicated (Donohue and Endacott 2010).

Implicit expectations, or those not explicitly communicated, may also be described as a ‘hint and hope’ dialogue. This can result in the sender and receiver failing to communicate, with the sender

hinting at what is required and the receiver completely missing their message. One example of this is the case of Elaine Bromiley, a patient who died following a failed intubation for a surgical procedure (Reid and Bromiley 2012, Bromiley 2014). During the emergency situation, the medical staff involved were focused on continuing to try to intubate; the patient became severely hypoxic, resulting in her death 13 days later (Walker 2008). The authority gradient discouraged any direct assertion by the nurses that the situation was an emergency. When a nurse brought in the tracheostomy tray (without being asked) and stated that it was ready, the implicit message was: ‘I have brought in the tracheostomy tray because you need to look at alternative airway access for oxygenation.’ This was not the message received by the medical staff, who remained focused on the task of intubating the patient and ignored the interruption (an example of attentional tunnelling, Table 2). A second nurse was also ignored when she stated that she had contacted the intensive care unit (ICU) for a bed. The implied message was: ‘I have contacted ICU because this is an emergency and I am worried about the patient’s deteriorating observations.’ However, the nurse’s comments were not interpreted in this way. The communication failures were a result of differing communication styles, as well as the authority gradient and the cognitive overload of the medical staff attempting to manage the situation.

Cognitive processes to manage challenging situations

Cognitive process Description

Attentional tunnelling Focusing cognitive attention on one aspect of a situation that is proving challenging in terms of understanding or task completion, while ignoring other information from the environment or context.

Confirmation bias A tendency to consider only confirming evidence and to disregard evidence that does not confirm.

Memory failures (slips and lapses)

Memory failures are associated with automatic behaviour, where we intend to do something but our attention is focused elsewhere. We either forget to carry out an action (lapse), or undertake steps of an action in the wrong order or leave out a step entirely (slip).

Inaccurate mental models

Erroneous mental models of events and what decisions or actions are required, resulting from flawed perception or comprehension of a situation.

(Adapted from Endsley 2012)


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In health care, teams are often not fixed or established, but have come together for a specific purpose. They have not had time to establish roles and responsibilities or to articulate clearly the apparent objectives of the team (Wachter 2012). This can lead to different perceptions or mental models of the situation and the required outcomes. Shift work, long hours leading to fatigue, and other common factors in health care, such as distractions, interruptions, workload and time pressures, add to these different perceptions. Therefore, it is not surprising that poor communication within teams contributes to errors and poor patient outcomes. It is imperative to develop strategies that decrease the likelihood of communication failures arising from authority gradients, from differing professional communication styles and from cognitive failures such as those listed in Table 2.

Strategies to improve team communication in health care Many strategies to improve communication rely on organisational structures and processes. These strategies include education and training programmes that focus on improving communication in teams and developing an understanding of barriers to effective communication, such as authority gradients and different communication styles. Such programmes have been shown to improve teamwork and communication (Stead et al 2009, Gorman et al 2010, Baker et al 2012, Bunnell et al 2013). Other organisational strategies to improve communication include implementing practices such as checklists and read-back protocols for different clinical situations, instigating structured communication tools and introducing briefing and debriefing procedures in teams (Lepman and Hewett 2008, Gorman et al 2010, Knox and Simpson 2013, Brady et al 2013, Goldenhar et al 2013, Lyons and Popejoy 2014). These steps require commitment from the organisation’s leadership team and provision of resources. However, healthcare professionals can still use many of these strategies, even in the absence of formal organisational support, as is discussed in this article.

Team brie�ng and debrie�ng The purpose of team briefing, huddles and debriefing is to diminish authority gradients and enable common agreement on the team’s objectives and intended outcomes (Wachter 2012, Goldenhar et al 2013). Briefings may take the

form of a pre-procedure or pre-shift pause, during which team members articulate their roles and responsibilities and discuss the intended outcomes. This may identify agreed protocols that are intended to alert team members to changing conditions or other important information (Brady and Goldenhar 2014).

Huddles are ongoing team briefings that occur throughout the period the team is working together. They involve team members coming together frequently for short periods to review and make plans for ongoing care. If used effectively, this strategy addresses problems with overload or limited short-term memory capacity, establishes safeguards in the process and improves the effectiveness of communication in the team. The essential elements of a huddle are that it is short, it has a team facilitator, discussion is encouraged based on data and the focus is on problem solving and solutions planning (Goldenhar et al 2013).

Debriefings involve the team coming together at the end of a shift or procedure to discuss what went wrong and what went well (St Pierre et al 2011). Team performance is improved through the lessons learned. Debriefings enable team members to recognise opportunities to speak up in critical situations, or instances of communication failure, for example, attentional tunnelling, confirmation bias, memory failures and inaccurate mental models. Facilitation and leadership are essential to ensure a safe, blame-free environment for debriefing, in which all team members feel comfortable to discuss aspects of the team performance explicitly (Wachter 2012).

Structured communication tools Structured communication tools address problems that may arise as a result of authority gradients, different professional communication styles and cognitive limitations. These tools establish safeguards in processes, reduce the steps and variability in processes and increase the likelihood of effective communication (Lee et al 2012). Many different tools have been developed to provide an objective framework for structured communication between clinicians in response to concerns about a patient’s condition (Gluyas and Morrison 2013). For example, the SBAR tool, where the mnemonic (Gluyas and Morrison 2013) indicates:  Situation: what is going on with the patient?  Background: what is the clinical background

or context?  Assessment: what do I think the problem is?

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 Recommendation or response: what do I think should be done in what time frame?

Practice is required to use this form of communication, to implement it and to overcome any hesitancy that may occur because of authority gradients. However, objective communication focused on data decreases the likelihood of misunderstanding and minimises problems with implicit communication styles (Lee et al 2012). Variants of the SBAR structured communication tool have been developed for use in handover of patient care to other clinicians (Porteous et al 2009). Complete time out activity 3

Managing the authority gradient can be difficult, and the CUS structured tool may be particularly useful in this situation. The tool provides a communication process for escalation, to focus attention when there are safety concerns that are not being acknowledged or addressed by other members of the team (Mackintosh and Sandall 2010). The CUS tool involves individuals using the following prompts to communicate:  I am Concerned.  I am Uncomfortable.  This is a Safety issue. For example, in a situation where a patient is deteriorating and the nurse has been unable to get a response for urgent review from a clinician, the nurse might contact that clinician again, or a more senior member of staff, and express their concern using the phrase ‘I am concerned’, stating the reasons for this. If there is still no timely response, the nurse could contact the team leader or a senior clinician and repeat their concern, using the phrase ‘I am uncomfortable’. If there is still no response, the nurse could contact the senior clinician or management and use the phrase ‘This is a safety issue’, again expressing their concerns about the patient’s condition and the lack of timely response.

The escalation in the CUS tool should be used only for serious and urgent issues, where the concern is significant. If the concerns raised are not addressed adequately, then it may be necessary to escalate them, bypassing the person with whom the concerns were initially raised. By using the objective language of the CUS tool, the focus remains on patient safety.

It is important to note that organisations have policies or procedures for escalation when urgent clinical concerns are not being addressed. The nurse should comply with

these protocols. The CUS tool is an ideal tool to guide the communications. Complete time out activity 4

There are several other structured communication tools that may be used to hand over the care of patients to other clinicians. These include the SHARED communication tool, where the mnemonic indicates Situation, History, Assessment, Risks, Expected outcomes and Documentation (Hatten-Masteron and Griffiths 2009), and I PASS THE BATON, where the mnemonic indicates ‘Introduction, Patient, Assessment, Situation, Safety concerns, THE Background, Actions, Timing, Ownership and Next’ (Youngberg 2013).

With the exception of CUS, all these communication tools can be used for both verbal and written communication (CUS is usually used in time-critical situations that require immediate response). The tools provide an objective framework for communication for both the sender and receiver of the message, decreasing the cognitive load that may lead to communication failures.

Checklists and read-back protocols Checklists and read-back protocols can be useful tools in assisting to prevent communication breakdowns, since they provide a visual format for standardised communication (Lyons and Popejoy 2014, Treadwell et al 2014). They act as ‘memory joggers’ to decrease the likelihood of cognitive slips and lapses associated with automatic tasks. They also provide a prompt

4 Review the case study in Box 2. Assume that the SBAR communication with the doctor has not elicited an appropriate response. Samuel’s respiratory rate is decreasing further and he can be roused only with difficulty. Using the CUS headings (‘I am concerned’, ‘I am uncomfortable’, ‘This is a safety issue’), write down how the nurse could objectively convey concern about the patient’s deteriorating condition.

3 Read the case study in Box 2. Identify the barriers to effective communication demonstrated in this situation. Using the SBAR communication tool – with the headings ‘situation’, ‘background’, ‘assessment’ and ‘recommendation’ or ‘response’ – write down how the nurse could communicate in an objective way the clinical information underlying concern about the patient’s condition. Ensure you note a time frame for expected actions when you complete the ‘recommendation’ or ‘response’ sections.

Case study 2: Samuel BOX 2

Samuel, a 50-year-old man with no significant events in his medical history, was admitted to the surgical ward at 8pm following an appendectomy for a ruptured appendix. He was commenced on a morphine infusion for pain relief and two-hourly physiological observations. At midnight Samuel’s vital signs were 95% oxygen saturation on oxygen given at four litres per minute, blood pressure 140/80mmHg, pulse rate 60 beats per minute and respiratory rate eight breaths per minute. He was drowsy. Concerned that the morphine was having a respiratory depressant effect, the nurse contacted the doctor on call. The nurse stated that, although in considerable pain, the patient had been alert pre-operatively; now he was drowsy and difficult to rouse. The doctor, having been woken from deep sleep after a 16-hour shift, was annoyed and indicated in strong terms that he too was drowsy and difficult to rouse because he was tired.

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for actions when there may be cognitive overload related to situational factors, such as complex tasks or rapidly changing clinical situations (Beaumont and Russell 2012).

It is imperative that tools such as checklists and read-back protocols are used mindfully, with full attention from the participants involved (Gluyas and Morrison 2014). There are many examples in the literature of errors and adverse events resulting from automatic, non-mindful responses to checklists. Toft and Mascie-Taylor (2005) give an example in which a patient received the same dosage error ten times, despite three different staff members using a checklist to prevent this type of error.

Read-back protocols for telephone laboratory or radiological reports, medication orders, clinical handovers and surgical counts are imperative to prevent communication failures that may result in errors. It is easy to confuse the sound of one letter or number for another, especially in stressful and noisy environments (Youngberg 2013); repeating

back the information and/or checking for correct interpretation reduces the risk of confusion. The use of phonetic alphabets (for example, Alpha, Bravo, Charlie, Delta…) is not common in health care. However, their introduction and/or the use of standardised quotes or phrases could mitigate the risk of inaccurate communication and misunderstanding (Prabhakar et al 2012).

Checklists with check-off provisions are less prone to slips, lapses and omissions of essential items because they lead the checker through the correct sequence and identify all the items that should be checked (Degani and Wiener 1990). The challenge with checklists and read-back protocols is to design them to reduce the likelihood of automatic responses. Checklists and read-back protocols that require the checker to state ‘check’, ‘yes’ or ‘okay’ are susceptible to inaccurate automatic responses, whereas those that are designed so that the checker states what they are seeing are less prone to such errors (Dekker 2011). Complete time out activity 5

5 Review your organisation’s checklists and read-back protocols. Identify if they are designed to reduce automatic responses by ensuring that the checker is asked to state what they see or if there are check-off provisions.

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Checklists and read-back protocols are most effective when combined with team briefings. In this situation the team identifies each aspect of the required performance and notes current status, responsibility and actions required or completed. This works well in non-emergency situations but may also be adapted to emergencies (Gluyas and Morrison 2013). The combination of checklist and team briefings provides the opportunity to overcome authority gradients, to acknowledge communication and to check for correct interpretation, a technique known as ‘closed loop communication’.

Conclusion Teamwork is an essential component of delivering safe and effective patient care. Teams comprise individuals who must work together to co-ordinate care. Effective teams require leadership, mutual support and skills for monitoring the ongoing situation. However, effective communication is the crucial factor, required to achieve team co-operation

and co-ordination. Communication is a process of sending and receiving messages that is prone to failures related to cognitive processing, arising from human fallibility. Communication failures may occur in any context but there are pervasive barriers to effective communication that are specific to health care. These include a hierarchical culture that leads to authority gradients, differing professional communication styles and fragmented care delivery across multiple departments and settings. Organisational strategies to improve communication involve teamwork training initiatives and the adoption of structured communication tools, checklists and team briefing processes. Patient safety and high quality care should be the goals for all healthcare professionals. Practitioners committed to improving patient safety can use structured communication tools and checklists to facilitate effective communication in teams, even in the absence of organisational support NS Complete time out activity 6

6 Now that you have completed the article, you might like to write a reflective account. Guidelines to help you are on page 62.

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