Reflective Practice in Nursing: An Analysis of Patient Care

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In the pursuit of enhancing my reflective skills as a nursing student, I have chosen to apply the Gibbs (1988) reflective model to guide my introspective process. This model offers a structured approach to examining past experiences, allowing individuals to dissect their thoughts and emotions during a specific incident. Reflective skills are invaluable tools that empower us to contemplate what could have been done differently. Such introspection is essential to prepare us for future encounters with similar situations in a professional manner (Palmer et al.

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, 1997).

Context of the Experience

In this essay, I will recount and analyze an episode involving a patient, whom I will refer to as "James" to protect his privacy, in accordance with the ethical guidelines outlined in the An Bord Altranais Code of Professional Conduct (2000). James, a seventeen-year-old boy, was admitted to our care with a fractured wrist and was diagnosed with schizophrenia. His condition manifested as delusions and hallucinations, leading to inappropriate behavior toward both fellow patients and staff members.

James struggled to relax, often pacing the ward restlessly. He frequently sought reassurance from others, questioning whether he was in trouble and if his eyes were alright.

James's queries typically received similar responses from staff and fellow patients, assuring him that he was safe and his eyes were fine. However, these verbal reassurances were often supplemented with a reassuring "thumbs up." When James became agitated, he occasionally resorted to kicking people, although his small size meant that these kicks were generally not injurious. This behavior prompted me to question my preceptor about whether James's kicking was a behavioral issue or a symptom of his illness.

I was also curious about why this issue had not been effectively addressed.

My preceptor informed me that the nursing staff had tried various techniques, including behavioral therapy, to curb James's kicking, but none had proven successful. Additionally, doctors had attempted different medications to manage his schizophrenia, but none had yielded positive results. Even a consultation at the prestigious Maudsley Hospital in England, renowned for its psychiatry research, failed to provide answers or effective treatment options for James. Mealtime interactions with James presented their own set of challenges. Given the opportunity, he would avoid eating, often playing with his food, questioning its safety, and attempting to divert the attention of the nurse responsible for him.

Challenging Encounter

One evening, during a particularly taxing day, I was assigned the responsibility of ensuring that James ate his dinner. As expected, this task proved arduous, as James showed little interest in eating. He even went so far as to spit out his food onto his plate, which I found rather repulsive. I endeavored to maintain professionalism despite my inner turmoil, repeatedly encouraging him with phrases like "come on now, James, just a little bit more." Yet, James persistently attempted to distract me with questions like "Am I dead? I've no eyes." As the ordeal stretched on, my frustration grew. In a moment of sheer exasperation, I uttered, "if you don't eat your food, I'm gonna have to feed you like a little baby." Without thinking, I took his fork, scooped up some food, and held it in front of him, instructing him to open his mouth.

It was only then that I realized the gravity of my actions and immediately halted. Overwhelmed by embarrassment, I cast a furtive glance around the dining area, relieved to find that neither the other nurses nor the patients had witnessed my lapse in judgment. My sense of relief, however, was tinged with deep shame at my own behavior. Surprisingly, James appeared unfazed by my outburst, continuing with his questions. I was relieved that he had not reacted negatively to my words, but I couldn't help but wonder if my actions had left an unintended impact on his psyche.

Overcoming Fear and Assertiveness

Upon initially encountering James, I had been intimidated and somewhat fearful of him due to his confrontational demeanor and tendency to lash out. However, this experience proved to be transformative in some respects. Challenging James to eat helped me overcome my initial fear, allowing me to feel more assertive and empowered in my role as a nurse. As Kilkus (1993) notes, employing assertive behavior in nursing can be empowering and is an essential component of the profession. However, the incident also revealed a negative aspect of my behavior – an excessive forcefulness bordering on dominance. My sarcastic remark, "I'm gonna have to feed you like a little baby," and my attempt to mockingly feed him may have inadvertently associated eating with negative emotions for James, potentially impeding the progress made by the nursing team in encouraging his dietary intake (Jacobsson et al., 2004).

While James may not have overtly reacted to my comments, it's crucial to recognize that individuals with schizophrenia often struggle to express their emotions due to impaired pathways connecting their brains to facial expressions (Kring et al., 1993). However, their emotions still exist internally. Human communication extends beyond verbal expression, encompassing non-verbal cues, gestures, and body language. Even when patients may not fully comprehend spoken words, they can still interpret the underlying emotions through non-verbal communication (Kozier et al., 2004).

James frequently faced challenges in articulating his thoughts, a common characteristic of his illness (Kring et al., 1993). His statements often seemed disjointed and nonsensical to those unfamiliar with his condition. He might say something like, "Am I dead? I've no eyes," which, to others, appeared meaningless but actually conveyed a sense of worry. Experienced nurses who had interacted with James over time could decipher the meaning behind his words. In my case, during that particular evening, when he uttered the same phrase, I dismissed it as another random utterance with no significance. I failed to delve deeper to understand its underlying meaning, demonstrating a deficiency in my communication skills as a novice nurse.

Importance of Effective Communication

If I aspire to become an effective nurse in the future, I must prioritize developing strong communication skills with my patients. Effective communication is the bedrock of nursing practice (Taylor et al., 2008). It enables nurses to identify a patient's preferred mode of communication and recognize any communication challenges they may face. Furthermore, it requires treating each patient as an individual with unique needs and concerns (Taylor et al., 2008).

My comment, "I'm gonna have to feed you like a little baby," was belittling and insensitive. It's possible that a subconscious part of me harbored frustration toward James's condition and a reluctance to confront it directly. As I progress in my career and encounter more psychiatric patients, whether dealing with schizophrenia, bipolar disorder, or any other mental illness, I must learn to approach each patient with an open mind, devoid of prejudicial thoughts or perceptions. Demonstrating acceptance and respect for every individual is paramount (Browne, 1993).

On the evening of the incident, I was fatigued, which likely contributed to my irritability. The emotional state of nurses, especially when they are tired, can negatively impact their judgment and increase the likelihood of errors in patient care (Townsend & Anderson, 2009). As a future staff nurse, I anticipate encountering days of extreme fatigue, but I must never allow my personal feelings to justify unprofessional behavior. Nursing is a dynamic, constantly evolving profession (Fasoli, 2010), demanding unwavering professionalism regardless of one's emotional state.

Understanding the Patient's Perspective

As a student nurse, it is imperative that I attempt to comprehend James's perspective. One of the hallmark signs of individuals with schizophrenia disorders is a decline in self-care skills. These individuals may exhibit disinterest in eating, harbor distrust toward food, or become preoccupied with other matters, neglecting their own well-being (Brooking et al., 1996). Unfortunately, I failed to consider these factors when attempting to encourage James to eat, which can be attributed to my inexperience as a novice nurse (Benner, 1984).

Effective communication is not just a fundamental aspect of nursing practice; it is the most crucial element in nurse-patient interactions (Taylor et al., 2008). Instead of trying to force James to eat, I should have persisted in convincing him to do so in a positive and understanding manner, as I had observed his experienced nurse do. My coercive approach made me come across as a bully and potentially engendered negative associations between eating and unpleasant feelings for James (Jacobsson et al., 2004).

Furthermore, I could have displayed greater patience and empathy toward James. As a student nurse, I must cultivate patience and empathy for all patients, in addition to being attuned to their psychological needs (Scully & Dallas, 2005). In retrospect, I recognize that my actions that evening were belittling and insensitive.

Reflection and Future Improvement

Should a similar situation arise in the future, I would begin by engaging in self-awareness, as suggested by Bulman & Schutz (2004). Self-awareness serves as the foundational skill upon which reflective practice is built. It allows nurses to analyze their role in a specific situation, evaluating the impact they have on it and the influence of the situation on them. Nurses with heightened self-awareness are better positioned to positively influence patient care.

Self-awareness is also essential for establishing therapeutic relationships with patients. It enables nurses to communicate with knowledge and awareness, thereby striving for the best outcomes (Taylor et al., 2008). Through self-awareness, I would have recognized my fatigue and consciously endeavored to prevent it from adversely affecting my patient's care, exemplifying "reflection in action" as described by Schon (1987).

Additionally, I would draw upon the lessons learned from this experience in future encounters. My interaction with James provided me with valuable insights into self-awareness, effective communication, empathy, patience, understanding the patient's illness, respect, empowerment, and the importance of prioritizing the patient's needs over personal feelings. While I initially wished to erase this incident from my memory, I now appreciate it as a profound learning opportunity.

The application of the Gibbs Reflective Cycle model (Gibbs, 1988) has allowed me to dissect the events and delve into my own perspective, offering a comprehensive analysis of the situation. This experience, though challenging, has enhanced my understanding and self-awareness as a novice nurse. It underscores the importance of learning from experiences and using reflection as a powerful tool to guide personal and professional growth (Benner, 1984).

In conclusion, the encounter with James, the schizophrenic patient, presented a multifaceted learning experience. It exposed both the strengths and weaknesses of my nursing practice. Moving forward, I am committed to further developing my communication skills, cultivating empathy, and prioritizing the patient's well-being above all else. This reflective process has affirmed the significance of self-awareness and the continuous quest for improvement as I embark on my journey towards becoming a proficient and compassionate nurse.