Neurological observations in infants, children and young people: part two
Intended for healthcare professionals
CPD    

Neurological observations in infants, children and young people: part two

Kelvin McMillan Assistant professor, Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, England
Hannah Shaw Teaching fellow, College of Medical and Dental Sciences, University of Birmingham, Birmingham, England
Alice Hemesley Paediatric intensive care staff nurse, Birmingham Children’s Hospital, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, England
Waheeda Zaman Lecturer, Faculty of Health Education and Life Sciences, Birmingham City University, Birmingham, England
Nabisah Qazim Assistant lecturer, Faculty of Health Education and Life Sciences, Birmingham City University, Birmingham, England

Why you should read this article:
  • To enhance your knowledge of the elements of neurological assessments in children

  • To improve your understanding of when to perform neurological observations and when to escalate them

  • To contribute towards revalidation as part of your 35 hours of CPD (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

Neurological observations are a vital part of the assessment of infants, children and young people with a suspected or confirmed acquired brain injury (ABI). They are designed to identify neurological deterioration and inform the management of ABIs. Children’s nurses may perform many of these neurological observations, including by using tools such as the AVPU scale, the Glasgow Coma Scale, pupillary response and limb assessment. This is the second of two articles that aim to encourage accuracy and consistency when performing neurological observations in infants, children and young people with a suspected or confirmed ABI to optimise their care. The article explains how to undertake various elements of a neurological assessment, how often to perform neurological observations, when to escalate concerns and why it is important to use family-centred care.

Nursing Children and Young People. doi: 10.7748/ncyp.2023.e1473

Peer review

This article has been subject to open peer review and checked for plagiarism using automated software

@CYP_UOB_Kelvin

Correspondence

k.mcmillan@bham.ac.uk

Conflict of interest

None declared

McMillan K, Shaw H, Hemesley A et al (2023) Neurological observations in infants, children and young people: part two. Nursing Children and Young People. doi: 10.7748/ncyp.2023.e1473

Published online: 17 July 2023

Aims and intended learning outcomes

The aim of these two articles on neurological observations in infants, children and young people is to explore the risks and complications associated with acquired brain injuries (ABIs) and to support children’s nurses to perform consistent and accurate neurological observations in patients at risk of deterioration. The first article explained why infants, children and young people are vulnerable to ABIs and outlined the pathophysiology and effects of ABIs in infants, children and young people.

This second article aims to describe the main elements of a neurological assessment in infants, children and young people, explain how to escalate concerns and highlight the importance of involving the family. It also aims to explore the physiology of neurological observations, linking with the first article.

After reading this article and completing the time out activities you should be able to:

  • Recognise the importance of performing accurate and consistent neurological observations when caring for infants, children and young people with suspected or confirmed ABI.

  • Outline the physiology behind neurological observations.

  • Explain how to use the AVPU scale, the Glasgow Coma Scale and other elements of a neurological assessment.

  • Understand when it is important to escalate care in response to signs and symptoms of neurological deterioration.

Introduction

Infants, children and young people may require a neurological assessment for various reasons, for example in case of a suspected or confirmed ABI, and they are at high risk of deterioration. If neurological deterioration is not identified early it can, in severe cases, result in death (Holland and Brown 2021). The early identification of deterioration and the prevention of further neurological damage require accurate neurological assessments (Derbyshire and Hill 2018). Therefore it is essential that children’s nurses develop and maintain their skills in conducting neurological assessments.

Time Out 1

Identify three factors that you think can make it challenging to perform neurological observations in a child in a hospital setting. How might these factors be addressed?

Physiology of neurological observations

Neurological observations are a crucial part of a full body assessment in children at risk of neurological deterioration due to a suspected or confirmed ABI, whether due to traumatic or non-traumatic causes. Physiologically, neurological observations are intended to assess the ability of the patient’s nervous system to manage sensory and motor information.

Injuries to any part of the brain can negatively affect the transmission of neural signals within the brain and to other parts of the body (Mckee and Daneshvar 2015). A particular brain structure that is necessary for the coordination of neural activity is the reticular formation. It is a complex network of brainstem nuclei and neurons that acts as a major integration and relay centre for numerous brain systems (Mangold and Das 2022). The term ‘reticular’ relates to the reticular formation’s role in integrating, coordinating and influencing a variety of regions in the central and peripheral nervous systems. The reticular formation influences functions such as arousal, consciousness, circadian rhythm, the sleep-wake cycle, somatic and motor movements, cardiovascular and respiratory control, and pain modulation and habituation (Mangold and Das 2022).

While the reticular formation has an overall action on the nervous system, it also contains substructures that directly influence specific nervous system functions. The most clinically significant of these substructures are (Mangold and Das 2022):

  • The cardiac and respiratory centres in the medulla.

  • Descending pathways in the pons and medulla, which are involved in motor control and muscle tone.

  • Ascending pathways in the upper pons and midbrain, which contribute to consciousness.

  • The ascending reticular activating system, which is associated with the sleep-wake cycle and wakefulness.

  • The locus coeruleus, which is the primary site of noradrenaline (norepinephrine) release.

Approach to neurological assessments in children

Neurological deterioration is associated with raised intracranial pressure, which can disrupt neural activity and lead to brain herniation, affecting consciousness, cognition and arousal (Munakomi and Das 2023). As part of a neurological assessment, the ABCDE (airway, breathing, circulation, disability, exposure) approach (Resuscitation Council UK 2023) should be used to assist in identifying any factor that may alter neurological function, increase intracranial pressure or reduce mean arterial pressure. The signs and symptoms of raised intracranial pressure are detailed in the first of these two articles.

When performing neurological observations in children, nurses need to consider each patient’s (Jevon 2008a):

  • Communication ability.

  • Ability to localise to pain stimuli (motor coordination).

  • Cognitive development.

  • Awareness and understanding of their surroundings.

Box 1 lists further important considerations when conducting a neurological assessment in children.

Box 1.

Important considerations when conducting a neurological assessment in children

  • Pain can increase intracranial pressure and neuron metabolism, which encourages oxygen consumption, with a subsequent increase in the risk of neuronal death

  • Hypoglycaemia can alter consciousness, particularly in infants, so it is important to monitor the patient’s blood glucose level

  • Signs and symptoms of an acquired brain injury (ABI) can develop hours, days or even weeks after the event, including cerebrospinal fluid leakage from the nose and ears, bleeding from the ear canals, lacerations and periorbital bruising (‘raccoon eyes’)

  • There may be signs of cardiovascular instability such as tachycardia, reduced urine output or altered perfusion in the limbs. It is also important to note any change in skin colour; a bluish tinge, for example, may indicate cyanosis

  • If the patient has other injuries, limb perfusion checks are necessary to identify any sign of compartment syndrome – a condition in which increased pressure within one of the body’s anatomical compartments results in insufficient blood supply to tissue – which can be caused by bleeding resulting from a fracture

(Adapted from Warren 2010, National Institute for Health and Care Excellence 2019a, 2019b, 2022)

One challenge when conducting a neurological assessment in children is that they may appear well at the time of the assessment but show delayed signs and symptoms of an ABI hours, days or even weeks later. Taking an accurate and thorough patient history is therefore crucial to supplement observations and support the assessment. Using a family-centred and person-centred approach can help elicit important information from the family about the patient, including the event(s) that prompted presentation to healthcare services (ideally recounted by family members or others who were present), the last time the patient ate, allergies, current medicines and medical history (Mc Auley et al 2023).

Key points

  • Neurological deterioration is associated with raised intracranial pressure, affecting consciousness, cognition and arousal

  • The aim of neurological observations is to assess the nervous system’s ability to manage sensory and motor information

  • The ABCDE (airway, breathing, circulation, disability, exposure) approach assists in identifying altered neurological function

  • Neurological observations in children require the consistent use of assessment tools such as the Glasgow Coma Scale

  • Nurses need to be aware of the required frequency of neurological observations and when to escalate them

  • Involving families can help children’s nurses to identify neurological deterioration in their patients

It is essential that nurses use professional curiosity to identify vital information that will help establish what has happened and whether or not the patient has sustained an ABI. For example, if a child presents with a persistent headache, nurses should ask the patient and/or their family questions such as:

  • Has there been a recent head trauma?

  • Is there a family history of headaches or migraine?

  • How does the headache feel? Is it a throbbing or a stabbing pain?

  • Is the headache always present?

  • Where on the head is the pain located? Does it radiate?

  • What makes the headache better, for example lying in a dark room?

  • Is the headache worse when lying or standing?

  • Does the patient vomit first thing in the morning?

  • Are there factors that trigger the headache, for example stress or certain foods?

  • Are there any sinus issues such as congestion?

  • Does the patient have any other symptoms?

  • How is the patient’s school performance?

Neurological assessment tools

A consistent approach to neurological assessments will improve their accuracy. There are assessment tools that nurses can use to ensure consistency, notably:

  • The AVPU scale.

  • The Glasgow Coma Scale.

  • Decorticate posturing and decerebrate posturing.

  • Pain stimuli.

AVPU scale

The AVPU scale – shown in Box 2 – can be used to make a rapid initial assessment of a patient’s level of consciousness (Hoffmann et al 2016, Resuscitation Council UK 2023). Its use is advised for any hospitalised child as part of a full body assessment (Royal College of Nursing 2017).

Box 2.

AVPU scale

  • A – The patient is Alert and fully awake. They can easily be aroused or woken up. They are aware of and can respond to their environment. They can open their eyes spontaneously

  • V – The patient responds to Vocal stimuli. The patient’s eyes only open in response to a verbal stimulus. The patient can react to that verbal stimulus directly and in a meaningful way. It is acceptable to shout to try to elicit a response

  • P – The patient responds to Pain stimuli. The patient’s eyes only open in response to the application of a pain stimulus. The patient may move, moan or cry out directly in response to the pain stimulus

  • U – the patient is Unresponsive to all stimuli

(Adapted from Romanelli and Farrell 2022, Resuscitation Council UK 2023)

Glasgow Coma Scale

The Glasgow Coma Scale (GCS) is used to assess consciousness and function in patients at risk of neurological deterioration. It was developed by Teasdale and Jennett (1974) and later adapted by Tatman et al (1997) for use in children. The GCS is best used to determine a trend – that is, whether the patient is improving or deteriorating – and therefore needs to be administered on admission to obtain a baseline score. Regularly checking a patient’s GCS score enables nurses to assess the severity of intracranial hypertension (Munakomi and Das 2023).

The GCS comprises three parts: eye opening (Table 1), verbal or grimace response (Table 2) and motor response (Table 3). The scores for each of these parts are added to obtain a total score of between 3 and 15. A score of 3 indicates that the child is completely unresponsive and a score of 15 indicates that the child has normal neurological function (Warren 2000, Salah et al 2019).

Table 1.

Eye opening

ResponseOlder childrenInfants
4 – eyes open spontaneouslyThe patient is awake and opens their eyes spontaneouslySame as for older children
3 – eyes open to voiceThe patient only opens their eyes when you say their name or talk to themSame as for older children
2 – eyes open to painThe patient only opens their eyes when a pain stimulus is appliedSame as for older children
1 – no eye openingThere is no eye opening in response to verbal or pain stimuliSame as for older children
Table 2.

Verbal or grimace response*

ResponseOlder childrenInfants
Verbal response5 – orientatedThe patient can accurately answer questions and coherently talk to youThe patient is alert, babbles, coos and/or forms words or sentences as per their usual ability
4 – confusedThe patient may be confused as to where they are or what has happenedLower than usual ability to babble, coo or form words or sentences, spontaneous irritable crying
3 – inappropriate wordsThe patient answers questions with words that are not appropriateCries to pain
2 – inappropriate soundsThe patient cannot form words and only produces soundsMoans to pain
1 – no verbal responseNo response to pain stimulusNo response to pain
Grimace response5 – normal facial activityNormal facial movements, normal oromotor (movement of the mouth) activitySame as for older children
4 – decreased facial activityDecreased facial activity, decreased oromotor activitySame as for older children
3 – vigorous grimaceFacial activity only when a pain stimulus is applied – the patient grimaces vigorouslySame as for older children
2 – mild grimaceFacial activity only when a pain stimulus is applied – the patient grimaces mildlySame as for older children
1 – no facial activityNo response to pain stimulusSame as for older children

*Verbal response should be used as standard unless the child is normally non-verbal or if the child has an artificial airway such as a tracheostomy or endotracheal tube that impairs their ability to speak, in which case the grimace response should be used

Table 3.

Motor response

ResponseOlder childrenInfants
6 – obeys commandsWhen asked, the patient squeezes your hand or movesNormal spontaneous movements, patient withdraws to touch
5 – localises to pain stimulusWhen a pain stimulus is applied, the patient uses their limb to actively try to remove the source of painReduced spontaneous movements but patient withdraws to touch
4 – withdraws to painWhen a pain stimulus is applied, the patient’s only response is to try to withdraw their limb or head from the area to which the pain stimulus is appliedSame as for older children
3 – abnormal flexion to painDecorticate posturing (Figure 1) in response to a pain stimulusSame as for older children
2 – abnormal extension to painDecerebrate posturing (Figure 1) in response to a pain stimulusSame as for older children
1 – no motor responseNo response to verbal or pain stimuliSame as for older children

Verbal response should be used as standard, unless the child is normally non-verbal or if the child has an artificial airway such as a tracheostomy or endotracheal tube that impairs their ability to speak, in which case the grimace response should be used.

Nurses need to be aware that motor responses differ between infants and older children. While infants are able to show nociceptive perception of pain, their cognition of pain is limited, which reduces their ability to localise to a pain stimulus (Goksan et al 2015). An optimal motor response can be obtained even from a patient who has quadriplegia: the nurse can ask the patient to stick their tongue out; if they understand what the nurse is saying and are able to stick their tongue out, they will do so (Glasgow Coma Scale 2023).

Before administering the GCS it is best practice to talk to the parents and establish the child’s normal abilities and what they are like at home when they are well. This is particularly important for children who have conditions that may cause a global developmental delay. Spending time with the family to explain the GCS is crucial to enable them to understand the purpose of the assessment. Family members can also advise on how to best stimulate their child.

Teasdale (2015) made several recommendations about the use of the GCS and Table 4 shows Teasdale’s (2015) recommended approach.

Table 4.

Recommended approach to using the Glasgow Coma Scale (GCS)

CheckCheck for factors that could interfere with the patient’s ability to communicate with you, such as medicines, injuries, underlying neurological conditions and language barriers
ObserveObserve from a distance what the patient is doing. Are their eyes open? Are they interacting with people, such as family members or other healthcare professionals? What is their left and right movement like?
StimulateUse any necessary verbal or pain stimuli to trigger the patient’s best possible response
RateRate the patient’s responses on the GCS chart

(Adapted from Teasdale 2015)

Decorticate and decerebrate posturing

There are two types of posturing that are indicative of decreased neurological function: decorticate posturing and decerebrate posturing (Figure 1).

Figure 1.

Decorticate and decerebrate posturing

ncyp.2023.e1473_0001.jpg

Decorticate posturing typically shows as rigid and flexed arms drawn onto the centre of the trunk, flexed wrists, hands turned inwards, clenched fists, internally rotated legs and rigid, flexed feet. It is a sign that there is damage to the motor cortex in the brain where the corticospinal tract originates. The motor signals sent through the corticospinal tract into the spinal cord have become damaged, causing unimpeded activation of the rubrospinal tract, which leads to flexion in the muscles (Knight and Decker 2022).

Decerebrate posturing typically shows as rigid and extended arms, flexed wrists, hands turned outwards and rigid, flexed feet. It is indicative of damage to the brain cortex extending down into the medulla and pons in the brainstem. The part of the brain where the corticospinal tract and the rubrospinal tract are located has become damaged and is no longer sending signals down the spinal cord, meaning that the vestibulospinal tract, which controls extension, is now unimpeded. This triggers excitatory effects on extensor motor neurons, resulting in abnormal extension of the muscles (Whitney and Alastra 2022).

Progression from decorticate to decerebrate posturing indicates that the injury is extending to the brainstem and is usually a preterminal sign of tonsillar herniation (coning) (Munakomi and Das 2023).

Time Out 2

Discuss with a colleague how you have approached the ethical issues related to the use of a pain stimulus in a child. Did you consult the child’s parent or guardian? How did you explain to them the need to use a pain stimulus?

Pain stimuli

Pain stimuli can be used to assess a child’s level of consciousness – for example, as part of the GCS – with the aim of eliciting an eye, verbal and/or motor response from the patient. There are challenges related to the method, notably because of variations in clinical practice and variations in children’s motor development. To avoid causing any unnecessary bruising or injury, caution should always be used and only the stimulus needed to elicit the best possible response should be applied. It is not necessary to use pain stimuli if the patient is responding to voice. There is no national guidance on what types of pain stimuli should be used in children, and nurses should always refer to local policy (Cook et al 2019).

There are two types of pain stimuli: central and peripheral. The debate on whether peripheral or central stimuli should be used is ongoing. However, it has been pointed out that central and peripheral nociceptive pathways all end in the primary somatosensory cortex, resulting in similar perceptions of pain (Boore et al 2016).

Figure 2 shows locations for pain stimuli that may be used in children.

Figure 2.

Locations for pain stimuli that may be used in children

ncyp.2023.e1473_0002.jpg

One method of eliciting a response to pain that may be used in children is applying pressure to the supraorbital notch. However, this should be avoided in children with facial fractures and in those who have had surgery in that area. If supraorbital notch pressure cannot be used or fails to elicit a response, applying pressure to the fingertip or nail bed can be used instead. In the illustration, the grey shaded area represents a pen being held by the nurse, whose hand is on the left, and which is being used to apply pressure to the patient’s fingertip.

A trapezius squeeze is recognised in the literature as an alternative to supraorbital notch pressure (Cook et al 2019) but it must be used with extreme caution and is only advisable in children aged five years or more due to the risk of marking and bruising (Glasgow Coma Scale 2023), which is higher in infants than in older children and young people. It is important that nurses consult their local policy to determine whether a trapezius squeeze can be performed.

In paediatric settings, using the sternal rub technique to elicit a pain response is contraindicated, since children have a soft sternum and rubbing that area can cause bruising and cardiac arrhythmias (Teasdale 2014).

Time Out 3

Watch this video: www.youtube.com/watch?v=b58zU_mjAQc which explains how to perform nursing neurological observations. Make a note of how the pupils and limbs are assessed

Other elements of neurological assessments

Limb assessment

The left and right limbs should be regularly assessed and compared, and any new-onset weakness in one or both sides should be escalated (Rank 2010). To assess the patient’s grip and strength, the nurse can ask the patient to squeeze the nurse’s hand with theirs and/or use their foot to push against the nurse’s hand. When assessing the limbs, it is important to assess anti-gravity movement – that is, the patient’s ability to lift their arms or hands from a resting position into the air as opposed to only being able to move them around on the bed (Caton-Richards 2010).

Pupillary response

As part of neurological observations, is vital to regularly check the patient’s pupillary response. Pupil size and response is the most sensitive marker of raised intracranial pressure, since raised intracranial pressure usually disrupts pupillary sphincter muscle stimulation. Cranial nerve III (oculomotor nerve) has a particular role in pupil constriction in response to increasing light to protect the retina. As part of a parasympathetic response, cranial nerve III triggers the pupilloconstrictor muscles to reduce the size of the pupil, therefore limiting exposure to light (Adoni and McNett 2007).

The nurse will start by checking the size of the pupils, noting each pupil’s size and using a pupil size chart to compare them. The pupils should be equal in size. The nurse will then use a bright pen torch to stimulate the pupils, shining the light from the outside of the eye inwards. The pupils should react briskly, which indicates that the optic nerves are intact and not impeded by raised intracranial pressure (Jevon 2008b). If the pupillary response is sluggish or if there is no reaction at all in one or both pupils, this is an indication that there is a new or developing injury that could be related to increased pressure on the optic nerve, cranial nerve III and/or efferent pathways (Adoni and McNett 2007).

Any change in pupil size and response should be treated as an emergency and immediately escalated. New-onset fixed and dilated pupils is often a sign that the brainstem is herniating, so it should be escalated immediately to a medical professional. If possible, it is recommended to establish what the patient’s pupils normally look like and be aware that pupillary dysfunction in a child can be caused by a brain tumour lesion (Greenshields 2019).

Frequency and escalation of neurological observations

Neurological observations should be recorded immediately on admission to establish a baseline. The frequency of neurological observations should be agreed with the medical team and nurses should always refer to local policy about the frequency of neurological observations and when to escalate them.

In children and young people with an altered level of consciousness, the Royal College of Nursing (RCN) (2017) recommends performing neurological observations every half-hour until their GCS score is 15. In children admitted to hospital with a head injury who have a GCS score of 15 on admission, the RCN (2017) recommends assessing the level of consciousness using the GCS half-hourly for two hours, then hourly for four hours, then two-hourly. If a patient’s GCS score decreases to less than 15 at any time after the first two hours, the assessment frequency should revert to half-hourly and the frequency schedule followed from the start again (RCN 2017).

Any change in a patient’s neurological observations and any decrease in a patient’s GCS score should be immediately escalated, since they could be the first indication of new or worsening injury. To reduce inter-observer variability when recording neurological observations, a second healthcare professional should perform a set of observations to confirm deterioration (RCN 2017). The patient should be urgently reviewed by the senior medical team if any of the following signs or symptoms are observed (RCN 2017, National Institute for Health and Care Excellence 2019a):

  • Development of agitation or abnormal behaviour.

  • Decrease of 1 point in the patient’s total GCS score for at least 30 minutes, with greater weight given to a 1-point decrease in the motor response score.

  • Decrease of 2 points or more in the motor response score or of 3 points or more in the eye opening or verbal response scores of the GCS.

  • Development of severe or increasing headache or persistent vomiting.

  • New or evolving neurological signs or symptoms such as pupil inequality or asymmetry of limb or facial movement.

For consistent patient care, when handing over to another healthcare professional at the end of a shift or when preparing to transfer the patient to another ward or unit, it is important to perform a full set of neurological observations (Warren 2010).

Time Out 4

How would you explain the process of performing neurological observations to parents who are anxious about their child’s health? How would you address the psychological support needs of the child and their parents? What cultural factors might you need to be aware of?

Family-centred care

Family-centred care is crucial in children’s nursing because it recognises the important role of parents and carers. Nurses in children’s settings are responsible for identifying neurological deterioration in their patients, but involving families can enhance care because they know their child’s normal abilities, responses and behaviours.

Parental anxiety often increases in the hospital setting (Weis et al 2015), which means parents may find it difficult to express their feelings and forget to provide important information (Goubert et al 2012). Families under intense stress may find it challenging to understand the complexities involved in the assessment and management of ABIs, so the purpose of neurological observations, what nurses do and why, often need to be explained to them (Manskow et al 2018). Families also often need emotional and psychological support from nurses (Caus et al 2021).

To develop an optimal therapeutic relationship with families from minority ethnic backgrounds, nurses need to develop cultural competence (De and Richardson 2022). This will assist them in involving families and eliciting useful information from them such as the child’s ‘home name’ – home names are commonly used in many minority ethnic groups (De and Richardson 2022) – and ultimately assist with neurological observations and assessment.

Nurses’ skills and skill mix

It is essential that nurses have the competence and confidence to conduct effective neurological assessments in children and to inform and support families. Nurse consultant Gillian Robinson developed an assessment tool tailored to five specific age groups that was found to improve the accuracy of neurological assessments in children (Cole 2015). Having identified a lack of accuracy in neurological observations in children, Hill et al (2017) implemented a training scheme that led to positive outcomes among children’s nurses. Cook et al (2019) promoted the standardisation of neurological assessments across settings and emphasised that ongoing training would further improve nurses’ competence.

NHS Improvement (2018) has developed a resource to support safe staffing on children and young people’s inpatient wards in acute hospitals. The resource discusses the importance of having the right skill mix on the ward. It also suggests a staffing ratio of one nurse to four patients, or one nurse to three patients if there are any patients under the age of two years. However, this does not consider the high level of nursing required in certain specialties such as neurosurgery. There is a need for further research into the nurse staffing levels and skill mix required in paediatric neurosurgical settings.

Conclusion

Accurate and consistent neurological observations are fundamental to the identification of neurological deterioration in infants, children and young people with suspected or confirmed ABI. Having knowledge of the physiology behind neurological observations, alongside an understanding of the pathophysiology of ABIs, supports children’s nurses to conduct optimal neurological assessments. Children’s nurses also need to know when to escalate concerns, hand over the results of observations to colleagues, and involve and support families. Further research, education and communication are necessary to enhance the consistency and accuracy of neurological observations in infants, children and young people.

Time Out 5

Identify how performing neurological observations in infants, children and young people applies to your practice and the requirements of your regulatory body

Time Out 6

Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account

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