Clinical reflective practice on critical incident In this contemporary nursing practice, reflection plays vital role in the development of student nurses’ education portfolios (Mali & McGowan 2007, O’Connor 2008). Reflective practice is a tool used in clinical environment to describe, analyze, and evaluate practice so as to inform changes where necessary (Gibbs 1988). This essay will discuss a critical incident of an institutionalized patient who planned to take an over-dose of medication.
The domains used are: interpersonal relationship/organizational and management of care along tit professional/ethical practice. Gibbs (1988) reflective circle will be used to describe what happened including feelings, evaluation, conclusion, analysis and action plan. Centimeters will be used for to protect patient confidentiality. Introduction Reflective writing forms a vital part of student nurse’s portfolio (Chapel & Mueller 2004, Gustafson & Bagger, 2004; Role Gardner, 2005). Reflective practice is a framework that aids nurses in their day to day work (Peeped-Mescaline et al. 2005).
Reflection is a vital tool for developing quality services, allowing ruses to be flexible in their approach and to incorporate changes where/when necessary (Pullman, 2004; Pullman & Scouts, 2009). Without reflection nursing care can become automatic and no longer tailored to the individual’s needs. Reflection helps to examine experiences to see if there is something to learn and/or transferable to similar situations in future (Chapel & Mueller, 2004). Reid (1993) describes reflection as a method of evaluating experiences in the clinical practice environment so as to inform learning that will improve practice.
Reflective practice is guided by different models which includes Johns (1994 & 005) model of reflection, Gibbs (1988) reflective circle, Drills (2007) reflective circle to mention a few. I chose to use Gibbs (1988) model of reflection as my guide because it gives a lucid description of the incidence and is straight forward. This model identifies different stages people pass through when learning from experience. Reflection helps me to determine what has been good and bad in the action taken in a particular situation in my clinical practice.
Reagan & Facets (2006) and Egan-Bookmobile & Gunny (2008) asserted that reflection as a part of learning experience that can be used to organize, manage and improve professional skills. According to McMullen (2006) and American Nurses Association (ANA) (2007), reflection can be used to improve future performance through evaluation of a situation and the mistakes made. It is a tool that promotes development of critical thinking in nursing students. Chon (1983) and Jasper (2006) distinguished three types of reflection 1. Knowing in action 2. Affliction in action 3. Reflection on action Reflection in action happens when an individual reflects on behavior as it occurs; whilst knowing-in action is a direct observation of the incident. Reflection n action occurs after the event; and allows the nurse to review, describe their feelings about events, analyze and evaluate situations. The disadvantage is that it relies on memory which could easily fail and/or become unable to recall events (Andrews et al. 1998). Search Strategy Different electronic databases and manual searches were made.
These include the Cochrane library, CANAL, COPRA, PROTEST, Pumped, British Nursing index and Blackwell Science. Key words used were ‘reflection’, ‘portfolios’, ‘reflective practice’, ‘personal reflective writing’, and ‘professional development’. Description of incident During clinical practice in my first year, I was posted to an acute psychiatric ward that operates a system of “assigned nurse”. I was asked to look after few patients on each shift. This gave me an opportunity to interact with these patients on a daily basis.
It also served as a catalyst for me to have interpersonal/ therapeutic relationships with this group of patients. This system afforded me great opportunity to relate with and engage my patients in conversation on every shift. At times I asked about their mood, sleep, appetite and their general welfare with empathy; at times they voiced concerns, other times they voiced no concerns. Sometimes I asked them what their favorite meals and drinks were and what they like doing when they were younger; just to help them relax. One day after my conversation with one of these patients, who I will like to name ‘Mrs.. Y’ for the purpose of confidentiality. She said “Solomon you are very compassionate and understanding, you will be a very good counselor”. I looked at her with amazement; she said ‘that is a good complement for you”. I said “thank you” and left. Mrs.. Y was a 59 years old widow diagnosed with depression; other of four children – three girls and one boy. The health of Mrs.. Y had been good until the demise of her husband. Mrs.. Y has been so used to me that she told me almost everything about herself, and her family. One Monday morning, during the handover report, we were informed that Mrs.. Y was in bed for spells; she refused dinner/supper which was very unusual of her. My duty of care was holistic; therefore it was my restorability to find out what went wrong with her. I went to see Mrs.. Y in her room and found her less reactive and apprehensive. I asked her if I could sit down, reluctantly she said yes of course; sit down”. I sat on the chair looking at her, but there seemed to be less eye contact. I said “what is the problem”? There was no response rather she was silence, subbing and tearful. I allowed her to ventilate and then gave her tissues to wipe her tears.
For about two minutes we were both silent, I watched her body language. Then held her right palm with my two hands and said “Mrs.. Y, say something to me”. I reminded her of the compliments accorded me in the previous week, in which she said I was compassionate and understanding. I said “if you weren’t flattering me then prove to me now, please talk to me”. Then she looked at me and said “l wish my husband was alive, am fed up with life”. Asked why she was fed up with life. She said “I’m in financial crisis and I would soon be thrown out of their house with her four children, I can’t pay our mortgaged again”.
I felt sorry for her; I encouraged her and said “don’t let that bother you too much; your care team will do something about it”. She appeared delighted. Before I left, said “do you need fluid, water or juice to drink? ” she said “water”; as I took the jug of water that stood on her locker, saw what looks like a sachet f medicine, half covered with a magazine on the table. I said “please can I look through your magazine”? She quickly took the medicine from under the magazine, unfortunately for her, as she was putting it under her pillow, a sachet of Zimmerman dropped on the floor.
I quickly picked it up and I said “please, can see what you put under your pillow’? She became apprehensive and brought out Diagram. I asked her where she got them from; she said “l brought them in from home”. I asked her whether she showed them to nurses on duty. She said “no”; I said “why didn’t you show them’? She kept quiet. I said “what do you want to do with them”? She said “use them to sleep and rest”. I said “please, give me the medication”, she refused and promised to send them back home or alternatively destroyed them herself. I pleaded with her; she said “promise that you won’t tell anyone”.
I said “you give them to me first”; eventually she handed- over the medications to me. I said ‘the nurse in-charge has to hear about this”. She begged me not to inform the nurse in charge. Said “if I fail to inform the nurse in-charge, it will amount to betraying the professional trust bestowed on me”. I reported the incident to the nurse in-charge; the nurse in-charge was very pleased with my action. Immediately, she went to interrogate her and further search her room to make sure she was not in possession of other medication/ harmful things. She was relocated to another bay and placed under nursing observation.
Mrs.. Y became very upset because I informed the nurse in-charge. At the multi-disciplinary team (MAT) meeting, new goals and interventions were put in place which eventually resolved her problems. On my part I repaired the interpersonal relationship between us by clarifying reasons for my action and he was delighted. Feelings My feelings were mixed with fear, surprise and confusion because I have never experienced such an incident in practice before. I was shocked and short of words, but then I felt sorry for her; I was glad I saw her and was able to collect the medication from her.
I felt her case needed prompt attention/ urgency. My thoughts were that, if she had succeeded in committing suicide, this would have caused horror to other patients. Initially, I thought I was in control of the situation but when I made the decision to report the incident, my feeling changed because Mrs.. Y was upset instead f having remorse for her action/behavior. I now have to argue with her and defend my clinical/professional decision. I felt intimidated and this made me uncomfortable and I was unsure of what my reaction or response was going to be next.
I thought she would not trust me again; but then, I remembered the group contributions to this topic during the reflective session could help retain the trust/relationship between us. I said to myself this is a good example of management of care, interpersonal/therapeutic relationship and trust philosophy clashing with professional/ethical practice decision making. I was uncertain what exactly to do or say but then knew that the outcome and my decision would have a huge impact on my clinical reputation. Moreover in few months’ time I would graduate from being an internship student to a registered nurse and with it independence.
I will be expected to be proficient, confident and competent in handling critical situations and to make the correct professional decision. All these were very stressful thoughts for me because professional/ ethical practice of nursing principles is about practicing in accordance with legislation hence protecting and ensuring patient safety is crucial (WHO 1996, An Bored Altruism, 2000). Furthermore, the Nursing and Midwifery Council (NC) (AAA) instruct every nurse and midwife to make professional decisions on every issue, in the course of their duty, in the interest of their patient.
Therefore, it will be unprofessional, incompetent, illegal and unethical if I failed to inform the nurse in charge about the incident (Young, 1981; Edwards & Ellen 2009). Evaluation To start with, I felt lack of financial support for Mrs.. Y triggered the incident. As a student nurse my hallmark was to achieve the best possible management of care and provide comfort for Mrs.. Y, while maintaining a good relationship through professional/ethical practice (ABA 2000; NC, AAA). The scope of Nursing and Midwifery Practice (2000) states that decision making involves consideration of number of important factors.
This includes organization and management of patient care, responding appropriately to instances of unsafe situations, as it is the case in this scenario. A vital skill in nursing practice is the ability to make professional judgments (Rush et al, 2001). Considering the impending threat of a death wish [suicidal thoughts, it was good that I acted the way I did. It was good hat I was vigilant and sensitive whilst in her room otherwise she would have secretly committed suicide before the nurses knew.
Interpersonal/therapeutic relationship skills helped me to elicit her intent to commit suicide; which consequently led to my actions. On reflection, the good thing about my actions included: 0 it prevented self-harm/suicide she was moved from a room to a bay much closer to the nurses station for visual observation/monitoring C] it prevented litigation against the staff and the hospital boundaries being set for her because of her behavior including her week-end leave being suspended for a while earned me a good reputation with the ward manager, my preceptor and colleagues felt good in myself.
It was good that I collected the drugs and reported it to the nurse in-charge. The incident was deliberated and solved at the MAT meeting; alternative accommodation was provided for Mrs.. Y and she was very happy and later thanked me; I felt good as it was sign of trust/good relationship. Conclusion On reflecting on this incident, I felt my judgment and action matched my professional beliefs and I am pleased the way I handled this critical situation. It was obvious that I did all I could at my level to intervene in the situation.
I felt nothing was left to be done that I did not do to assist Mrs.. Y; unfortunately she was upset because I informed the nurse in-charge. I did what did in her best interest (ABA 2000; Mental Health Act (AMAH), 2001; NC, 2008 & Mental Health Commission (MUCH), 2009). Not only would it be callous of me and unprofessional, if I failed to report the incident but also tarnish my reputation. Reporting the incident bridged and improved the communication gap between nurses’ and Mrs.. Y, especially at this critical time (Anderson, 2001; Sully & Dallas, 2005).
The need for closer nursing observation was obvious in this situation. Analysis This is incident is important to me because it is what nursing intervention/ judgment and/or decision making is all about. Although Mrs.. Y wasn’t pleased with my action, one thing was clear; my action was in her best interest (ABA, 2000; Nursing & Midwifery Council, (NC) 2008). When I was making my decision, it did cross my mind that the outcome might upset Mrs.. Y. However, after weighing up the consequences of the incident, I decided not to risk/endanger her life.
I was ready for the consequences of my actions and decided to put my professional integrity and accountability first (ABA 2000). I felt that it really id not matter what Mrs.. Y thought of me as far as my action was in her best interest. This does not mean that should not listen to her. My priority was based on the situation at hand i. E. Her safety. If I failed to take the right decision and she succeeded in causing harm to herself, I will be held responsible/ accountable.
Having reflected on this incident over and over again, I still felt that I did the right thing. My action conforms to European (EH)/WHO Human Right Law and Code of Professional Conduct for each nurse and midwife (ABA 2000; Leavening & Lateness, 2001; WHO, 2001; Mills 2002). In relation to the Renville of non-maleficent/beneficence there is an obligation to protect and prevent the patient harming him/herself; and to remove whatever could cause harm to promote good (Béchamel & Childless 2009).
It would be professional misconduct and therapeutic failure if I failed to report the incident. This may have a profound effect/impact on the nurses on duty at the time (Nightingale, 1969). The loss of a patient by suicide can be psychologically traumatic and result in characterization for nurses that were on duty at the time. Failure to take accurate professional/ethical decisions can lead to legal action against me as well s the hospital (Collins 2003).
