The Reflective Practice in Nursing

Categories: First Impression Can Be Misleading First Impressions

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Clinical placement is a good chance for nursing students to practice clinical skills, as well as experience the real working environment. However, the process of actually bringing theories and knowledge learned from university into practical application is not simple; this requires not only patience and determination but also various learning skills. For myself, after an unpleasant experience of involving an argument between a nurse and patient’s family, I came to realize that reflective skills are crucial not only for my current status as student but also for my future professional development (Sharon, 2014) as registered nurse.

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The reflective practice helps nurses to maintain and constantly update their knowledge, as well as construct clinical skills by learning from real practice (ANMC 2009). As described by O’Donovan, reflective is “a process of deliberative thinking, looking back, examining oneself and one’s practice in order to improve future practice” (Chris & Sue, 2013, p.4). In this essay I will reflect on my unpleasant experience and demonstrate how this could be used as an evidence to prove how reflective activities effectively assist nurses with professional development.

This reflection will follow Gibbs reflective model, which describes the experience, my personal feelings; then analyze and evaluate on my actions, indicate what were my strengths and weakness. Finally, a detailed action plan will be formed for future practice.

In the textbook “Reflective Practice in Nursing” it is recommended that each reflector should choose and use reflective technique that suits their learning style (Chris & Sue, 2013). I chose Gibb’s reflection model as it was the most suitable technique for both my learning style and my pattern of thinking.

As a visual learner, I learn best with visualization and mind mapping. My thoughts and actions are easily affected by my feelings. Derived from the principle of experiential learning of Kolk, Gibb’s model of reflection (1988) includes six steps: description, feelings, evaluation, analysis, conclusion, and action plan.

The first step enables my thought to flow, allowing me to picture the whole experience while putting aside my own judgment. By doing this I can review the situation with a clear non-biased mind. The second step helps me to explore my pattern of thinking and how my emotions effect my actions. These two steps will supply me with comprehensive subjective information for the following steps of the model. For this reason I decided to use the Gibb’s model to reflect on my following situation.

The situation happened when I was doing my placement at the pulmonary rehabilitation ward in a hospital. Mr X was admitted to hospital about few days ago with exacerbation Chronic Obstruction Pulmonary Disease (COPD). As per my normal routine I was taking the patient’s vital signs. When I came to Mr. X bed, I saw Mr. X was siting straight up on his bed; his wife was feeding him. The BiPap machine was taken off, and he was on normal nasal cannula. I asked Mrs. X what happened and why he stopped using the BiPAP machine, due to the fact that Mr. X oxygen saturation was a bit low so he would be on BiPAP machine for today, which I heard during the handover activity meeting this morning, Mrs. X told me that it was because Mr. X was very hungry, and the Bipap’s machine mask is too large, covering both his nose and mouth, which prevent him from eating.

So she took the BiPap mask out and put the normal nasal cannula on in order to feed him. She said she would put the BiPap machine back immediately after the breakfast, and it would not be long. I was convinced by her words and confident. Then I started taking Mr. X’s vital signs. The result was 90% for his oxygen saturation, lower than the standard one. I checked his medical record and found out that he has modified oxygen saturation rate, and his current one was still in the safe range. I observed Mr. X appearance, asked him a few questions to confirm his physical and mental condition. Mr. X looked quite stable, his voice was clear, and he ate a lot of food. However, I was still worried for Mr. X’s safety, so I decided to stay there, waiting for Mr. X to finish his meal, to ensure that nothing went wrong and the prescribed equipment would be used.

During that time, I regularly checked his oxygen saturation. I notice that Mr. X’s oxygen saturation started to drop very slowly. I raised the concern to Mrs. X, but she told me to not worry, as Mr.X nearly finished his meal. She claimed that they were using that machine at home so she knew it very well. As I did not know much about BiPap machine, I didn’t know what I should do. I was wondering whether I should report to the RN, when the RN came by and saw it. The nurse was very angry. She rushed in, quickly took off the nasal cannula, put the Bipap mask on Mr. X, and blamed me loudly in front of all patients. Mrs. X and I tried to explain that it was her who removed the Bipap mask because she wanted to feed him. The nurse said “But your husband needs oxygen more than food.” Mrs. X claimed that she was taking care of her husband for years and knew her husband condition very well. She said if he doesn’t have breakfast on time, his blood pressure will drop.

The nurse seemed to be so annoyed with the whole situation, she ignored what Mrs. X said and kept on checking on Mr.X and blaming me for not reporting to her immediately. Approximately a few minutes later with the Bipap machine on, Mr. X’s oxygen saturation began to rise. When his oxygen saturation was up to 93%, the nurse left. Mrs. X told me that nurse was always unfriendly, and that she was sorry about what happened to me. I reassured her that I was fine and told her to take good care of Mr. X then returned to my work.

At the beginning of the whole things, I did feel that I should not let Mrs. X remove the Bipap machine, but I was not confident enough to stop her from doing so. I could not deny that I felt Mrs. X action might cause some harm on Mr.X’s health, otherwise I would have not stayed with him and somehow I did feel I also should take responsibility for letting the whole situation happen. Therefore, when the nurse came and found out the situation and put the machine back on Mr. X face I felt much relieved, as I knew that was how things should be. However, when the nurse kept on blaming me loudly in front of others and ignoring the fact that I was not the one who actually removed the mask, my feelings changed from initially feeling guilty to feeling defensive.

After all it was not me who removed Mr. X’s Bipap mask and I felt I did all the things that I could by checking the patient, and following up his condition closely. But the nurse did not take any into account. I started to agree with Mrs. X comment about the nurse’s unfriendliness. When I left the patient’s room that day, I was so angry, and believed that I did nothing wrong at all. However, when my anger subsided, I reflected on the whole situation and sadly admitted that I was the one at fault.

Firstly, I was at fault for not firmly stopping Mrs. X from removing the Bipap machine at the beginning. If I did so, the situation would not have occured. I thought there must be reasons that a BiPap machined was prescribed for Mr. X. It definitely has some different functions than normal ventilation support equipment like a nasal cannula. But as I did not have any knowledge about that, I have no firm reason or proper evidence to argue with Mrs. X. In addition when Mrs. X stated that they were using it at home and she knew it very well, I was convinced, and gave up. As a nurse, I owe the patient a duty of care, but I indirectly put the patient in danger without recognizing it. Secondly, I was also at fault for not reporting it to the registered nurse in charge. I should always remember that nursing is team work. Each team member has responsibility to share information that he or she obtained to the rest of the team. It will ensure that a patient-centred care would be planned and delivered comprehensively.

The positive point in this whole situation was that I decided to stay with patient and closely follow up his condition. I did check his vital signs and compare with the patient’s medical record.

I also reflected on the nurse’s actions and picked out two mistakes. Firstly, the nurse did not educate the patient’s family about the BiPap machine. I was not sure about the nurse’s relationship with the patient, so I did not take into account Mrs. X comment about the nurse’s unfriendliness. But I realized that the nurse did not explain to Mrs. X that the biPap machine, called a bilevel positive airway pressure machine, will create a supporting pressure which will help her husband balancing the amount of his inspiration and expiration, to ensure a suitable heated humidified air flow to his lungs which a nasal cannula cannot. (Jamie, Cristina & Thomas, 2009).

I believe that if the nurse had explained, Mrs. X will understand thoroughly and will not repeat that action again in future. Secondly, the nurse did not actually listen actively to patient’s need. I cannot deny that the wife knew a lot about her husband’s routine, habits and even physical rhythm. She would be a very good source for the nurse in planning care for the patient. It should be noted from the patient’s wife that the patient’s blood pressure usually drops in the morning if he doesn’t eat at the regular time. The reason might be not having breakfast; it may be some side effects of a drug or be a symptom for some underlying condition that should be considered.

Then I started to analyse the whole situation, and think about what I should do differently. Firstly, I should explain to Mrs. X my concern. I should indicate the fact that Mr. X’s oxygen saturation was low. I should not feel embarrassing for not knowing about that machine. All I need to do is just simply bravely admit that I don’t know about Bipap machine, but I believe it is more necessary for Mr. X more than the nasal cannula. I should excuse myself for not being able to give her a detailed explanation and ask her to wait while I check with the registered nurse or doctor. I should use Mr. X safety to convince her. I believe if I had conducted myself in this way, Mrs. X would have listened to me and things would have turned out totally differently. Even If Mrs. X still insisted to remove the machine, I should report to nurse in charge immediately.

Secondly, I should practice to be more confident and actively take place in care team. I am student at the moment

Although I was student, I am still a member of care team. In future, I will graduate and become registered nurse, I should take this chance to learn from this situation as it is normal for me to not knowing everything.

From the whole experience, I have learned that good communication is very important in delivering care. Good communication will ensure the flow of information exchange not only between nurses with patients, but also between nurses and other members of the care team. In the relationship between nurses and patients, nurses need to actively listen to their patients, pick out necessary information, and build trust with them. In this situation, the nurse did not pay attention on Mrs. X statement about her husband’s blood pressure change. By the way Mrs. X took care of her husband, I can feel that she really wanted to be involved in caring for Mr. X. She definitely would be a valuable resource. If the nurse can communicate in a more flexible way, and provide her with proper education, the nurse will have a special and extremely useful assistant in taking care of Mr. X. In the relationship between nurses and other member of care team, nurses play a frontline role.

As the one who directly care for patient’s daily activities, in most cases, nurses will be the most suitable one to collect information and deliver this to the rest of the health care team. In this situation, although I collected all information about Mr. X, but as I did not deliver it, this information becomes useless. Despite how my mind worried and cared for Mr. X, if I did not express my concern, and put it into action it is meaningless. My anger at the end of that experience was very unreasonable. I cannot assume that the nurse understood how much I cared if I did nothing to show that. Hence, I can confirm again that good communication will be fundamental to build mutual trust between health care professionals and patients or patient’s family, which facilitate the delivery of care and improve the health outcome ().

After I reflected on the whole experience, I establish a proper action for the future. Next time, my goal will be establish good relationship with both patients and health care team by communicating effectively. Normally, the relationship between me and the patients seems good. The problem is I am not assertive enough. I will attend the presentation skill short course held by Learning Devlopment Center and the Presentation Club in building 11. My target is to improve my confidence, learn how to overcome being nervous when I state my opinion or argue with someone. I will also attend the online course Terminology for international medical students at website coursera.org to get used to medical jargon. Another of my problems is a lack of knowledge.

Before my next placement, I will try to make a list of medical equipment at my work place and commonly used medicine. I will do some research to obtain more thorough knowledge in order that I would not fall into the same situation. And in the case I that I am unsure, I will not hesitate to raise the questions. My expected outcome at the end of my next clinical placement will be a more confident me, who is equipped with updated knowledge, can communicate flexibly and integrate well with health care team.

In conclusion, using the reflective process, I have identified my strength (How much I care for patient), and weakness (lack of confidence, bad communication). In addition, I also reflect on other’s actions and learned from that. Before the reflective process, the whole situation was an unpleasant memory, but after reflection, it becomes a memorable lesson. As the science is developing non-stop, the reflection will push me to continuously update and broaden my knowledge.