The concept of reflection as a learning tool in workplace education can enable the student to problem solve in practice. By exploring the individuals own unique situations and past experience they can, in order to learn, consider past thoughts and memories to achieve a desired outcome. (Rolfe, 1998). Taylor (2000) suggests that, to reflect on action from an event, we must remember our thoughts and memories. Then we must use the ability of contemplation, meditation and consideration, which will enable us to make sense of them in order to modify our behaviour, should we encounter a similar experience in the future.
The following reflective account aims to explore specific complications and difficulties encountered after obtaining a history and performing a physical examination on a young patient that presented to the Accident and Emergency (A&E) Department. The incident that I have chosen to look at took place whilst on a placement in the Minor Injuries Unit based in an A & E Department following a theoretical module on Patient Assessment. Confidentiality has been preserved throughout in accordance with the Health Professions Council (HPC) Code of Professional Conduct (HPC, 2002).
To achieve and understand the use of reflection in a structured manner, the Gibbs (1988) Reflective Cycle will be utilised. Bulman and Schutz (2004) believe that reflection is a dynamic progression, and using a cyclical framework is of an advantage in providing structured guidance through a learning experience.
I was told by one of the Doctors in the A&E department, there was a young boy in one of the cubicles that had fallen over and bumped his chin on the seat of a chair as he fell. The Doctor thought that this would be of interest to me, as the child would need some sort of intervention i.e. a steristrip, glue or suture. When I found the little boy, Jamie, he was 6 year old and sitting quietly on his mother’s knee. He looked frightened and his eyes were red as if he had been crying. I introduced myself as an experienced paramedic, but on placement to gain some extra experience in a controlled setting, with the aim to become an Emergency Care Practioner (ECP). I sought permission from Jamie’s mum to obtain a history and examination Epstein et al (2003) state that by gaining a concise, methodical history will guide you to a diagnosis in 80% of cases.
Jamie’s presenting problem was that he had fallen against a wooden chair, sustaining a cut under his chin approximately 2 cm in length that had now stopped bleeding. He had his accident at school during lunchtime and the teacher had immediately contacted mum, who was at work, and she had brought Jamie straight into the A&E department. Apart from the odd cough and cold the child was normally fit and well and had used Calpol to good effect to relieve those symptoms. Jamie lived at home with both Mum and Dad and had an older sister, who attended the same school. He was not known to have any drug allergies. His initial observations were, respirations 20 per minute, pulse 104 per minute, temperature 37degrees centigrade. Blood pressure not taken. He assured me that although the wound felt painful he was coping very well and did not want anything for the pain.
Piaget’s (1993) theory of cognitive development in children aged two to seven is linked to 4 stages, and that they may have trouble in distinguishing real from unreal. In this they lack the ability to generalise about things or to make deductions. Meaning that the child may not realise the need to complain formally about their pain in order to get relief from it. However, this is contested by Castiglia (1992) who suggests that there are 8 stages of these hypotheses and by the age of six, the child can relate to the pain resulting in the perception and response to previous similar stimuli.
This was the first day of my second set of placements, and although the A&E staff knew the objectives of my purpose in the department, I had met with some resistance from the Emergency Practice Nurses (EPN’s) who opposed the idea of ECP’s and they had been reluctant to monitor/mentor me. Hawkins and Shohet (1989) identified this behaviour as destructive and that we should learn to manage these individuals and attempt to understand how they operate. Holloway and Whyte (1994) agreed with this concept, and the apparent behaviours were not the qualities expected from enablers (mentors). However, the Doctors in contrast were very supportive and interested that I should gain as much valuable experience as I could.
I felt unsettled, although I tried not to show it to Jamie or his mum. The fact that I had been a state registered paramedic (HPC) for thirteen years and had attended many paediatric 999 calls, and felt mostly comfortable in dealing with children, seemed along time ago. Benner (ref) might have suggested that there was a conflict of feelings due to being a student, and that I was struggling to comprehend why I felt so out of my depth, was probably the fact that I had to take over the responsibility of treatment instead of leaving it to the hospital staff. i.e. novice to expert. I was really unsettled with the idea of having to perform a procedure that I had very little experience of, on a child. Jamie was in fact the first child I had examined in my placements. Burnard (1994) suggests that some practitioners find the treatment of children to be somewhat difficult.
This may be due to our (as adults) perception of the fact that they are smaller, and speak using differing language and expressions. However, it is important for the children to be given the opportunity to express themselves and they need a practitioner that is able to relate to them, in order to install a sense of trust and understanding of their needs. With this in mind, I think my main objective was not to upset Jamie and make him cry, so I had to make use of the skills I had gained as a mother. I knew how important it was to get down to the child’s level and to incorporate distraction techniques to good effect. I also knew the importance of not rushing and the initial interaction with Jamie would be vitally important to a successful outcome. (Pantell et al 1992). I also tried to find common ground to discuss, and soon found out he liked football and his favourite team was Arsenal.
I realised that it was not just Jamie I had to deal with but his mother as well (Pantell et al 1992), particularly as she was going to be present throughout. It was just as important to keep mum relaxed so she would not convey any negative anxious feelings to her son. This however, did not appear to be a major problem as mum and her son appeared to have a good rapport. I also understood the importance of addressing Jamie and not focus my attention to his parent (Pantell et al 1992), it was important for him to tell me the story of what had happened.
I completed my initial assessment of Jamie, which had consisted of his presenting condition, his history of his presenting condition, past medical history. I then attempted, with a degree of success, to put in plain words what I was going to do and that afterwards I would have to have a good look at his wound.
My overall impression of Jamie was that he was a well-behaved sensible child, that he might not get too upset at my attempts to review his wound. I asked Jamie to look up and count the flies on the ceiling, hoping this distraction (ref) would be long enough for me to inspect the wound and assess how deep it was and whether I could see the base of the laceration. The wound appeared to be approximately 2 cm long and I could easily see the base of it, and it had not bleed now for about half an hour. Looking puzzled, Jamie then exclaimed there were no flies in the room. Fortunately, my distraction had worked. I was now able to leave Jamie with his mother whilst I documented my clerking notes to enable me to present the case to the A & E Doctor.
Once I had presented this case to the A&E Doctor, he asked me what my treatment plan was. Due to the nature of the wound, and its position under the fleshy part of Jamie’s chin, he was quite happy with the fact I had just decided to steri-strip the wound and not gone down the route of gluing or suturing. The Doctor continued to ask me why I had decided to do this. I answered by telling him that the child was only 6 years old and the laceration was not too painful, but he was however, a little bit frightened, as he had no previous recollection of pain. (ref). I also told him I didn’t want to startle Jamie, as he would only remember the negative part of the hospital treatment. The Doctor then asked one of the ENP’s to help get the items ready for me to perform the steri-stripping as one of the problems was finding out where the materials were kept. The ENP clearly was not amused at having to do this, however, she did relent and I went with her to get the bits and pieces ready.
I managed to find an old football annual in the waiting area that might help to distract Jamie whilst I performed the steri-stripping. When I had collected everything and assured the ENP that I could cope ok, I re-entered the cubicle where Jamie and his mother was. As I handed over the book, he started to grin, and understanding his facial expression, eye contact and his relaxed posture leaning against mum, I soon began to relax with him. I bobbed down in front of Jamie who was now flicking through the pages of the book.
As I unravelled the items required I explained to Mum what I was about to do. Jamie was not so keen to look for flies this time as he did not see any before and the book was distracting him too, so I got on and cleaned the laceration with a little difficultly because I couldn’t see it properly as Jamie was looking down. I asked him to just look up for a couple of seconds promising that he could look through the book in a moment, but he would have to be still and do it again in a moment so I could place the steri-strips in the exact places. At this stage his mum promised him a little treat, as he had been very good.
I felt elated as I placed the first strip squarely over the wound, more difficult than it appeared as my hands were shaking slightly. I started to relax when I had the last one completed. It looked quite neat and there was no residue of blood. I then asked Jamie how it felt. He said it was okay and shrugged his shoulders. Totally bored by the whole episode but still looking through the annual. I was very relieved and glad the incident was over, and what on earth I had been worried. I knew I was more than capable but it was one of the scariest moments in my career. In order to deal with more complex matters, that will arise in the future, I learnt so much through this simple encounter with Jamie.
Jamie was a 6-year-old boy, was brought in to the A & E Department where I assessed and examined him in my role as a student ECP. There were aspects of the consultation that I felt were good and bad but on reflection it was more successful than I anticipated it to be. The A & E Doctor praised me for my concise and accurate history taking skills and the conducting of a thorough physical examination of a child. Both the Doctor and myself went back to the cubicle to speak to Jamie and his mother to discharge Jamie with advice on what to expect in respect of his injury, and should they have any concerns, contact their General Practioner’s practice or return to the minor injury unit. Jamie and his mother thanked me and left the department to go home.
Bulman C., and Schutz S. (2004). Reflective Practice in Nursing. 3rd ed. Oxford. Blackwell Publishing Ltd.
Burnard P. (1994). Counselling Skills for Health Professionals. 2nd ed. London. Chapman and Hall.
Castiglia, C. (1992) Pain in Children and Adolescents. Elsevier, Amsterdam
Department of Health (2001). Good Practice in Consent Implementation : Consent to
Examination or Treatment. London. The stationery Office.
Hawkins, P. & Shohet, R. (1989) Supervision in the helping professions. Open University Press, Milton Keynes
Holloway, A & Whyte, C. (1994) Mentoring: The definitive handbook. Development Processes (Publication) Ltd/Swansea College, Swansea
Health Professions Council (2003). Standards of Conduct, Performance and Ethics. London. HPC.
Pantell RH, Stewart TJ, Dias JK, Wells P and Ross AW (1982) Physician Communication With Children and Parents. International Universities Press Inc., New York
Paiget, J. (1993) Psychology and Nursing Children. Macmillan. Basingstoke.
Rolfe, G. (1998) Beyond expertise: reflective and reflexive nursing practice. In: Transforming Nursing Through Reflective Practice, (eds C. Johns & D. Freshwater). Blackwell Science, Oxford
Taylor B. (2000). Reflective Practice : A Guide for Nurses and Midwives. Buckingham. Open University Press.