Using Gibbs’ (1998) model of reflection, updated by Bulman (2012), reflect on a challenging experience from your practice and analyse the strategies used to manage it. 3276 Words
The purpose of this essay is to reflect on a challenging situation I experienced during clinical practice as a student nurse. The essay will discuss my thoughts and feelings surrounding the situation and analyse the coping strategies I used in managing the situation, linking to relevant theory throughout in order to provide evidence for practice. The essay will also consider person-centred care and whether this was delivered to the patient. To conclude, the essay will discuss what I have learnt from the experience and how this experience will improve my future practice. The essay will first discuss a model for reflective cycle, before going on to describe the situation and my feelings about it. The essay will then go on to evaluate and analyse the situation before discussing an action plan for future practice and concluding with what I have learned from my reflection. This essay will use Gibbs’ reflective cycle (Gibbs, 1988) updated by Bulman and Schutz (2013) (Appendix 1) as a framework for reflecting on a challenging situation I experienced whilst on placement, involving a patient with dementia. Gibbs’ reflective cycle consists of six stages; description, feelings, evaluation, analysis, conclusion and an action plan. These stages allow an individual to methodically reflect upon, analyse and consequently learn from any situation. The model can be adapted to any situation and is simple and easy to follow, giving cue questions at each stage and allowing for in-depth reflection of an event. Reflection is a key skill for all healthcare professionals, allowing them to learn from experiences and adapt their practice accordingly. By incorporating both a description of the event as well as considering the feelings of the individuals involved it maximises the potential to learn from the event and develop future action plans for practice (Bulman and Schutz, 2013). Although widely used, McCabe and Timmins (2003) argue that Gibbs’ model of reflection prompts individuals to focus on negative aspects of the event rather than the positive. Reflection occurs through analysis and interpretation of the event, rather than simply describing the event. Schön (1987) identified two different types of reflection; reflection-in-action and reflection-on-action.
Reflection-in-action is defined by the individual reflecting on their actions whilst working and making adjustments if and where necessary. However, this method of reflection can be seen as an unconscious and intuitive process rather than a deliberate reflective activity (Jasper, 2003). Reflection-on-action is a cognitive process which requires an individual to reflect on the situation retrospectively, in order to discover how their actions contributed to the outcome (Schön, 1987). Both methods of reflection allow for an individual to explore and learn from events as well as applying knowledge to the event about what was or was not effective. Reflection-on-action, demonstrated in Gibbs’ reflective cycle, has the potential for more in depth analysis as the individual can reflect once they have finished the task, therefore focus fully on the reflection. The challenging situation occurred during my initial placement as a student on a general medical ward. The patient in question was an elderly lady with dementia who had been admitted after a fall at home. As stated in the NMC Professional Code of Conduct (2008), patients have the right to confidentiality, therefore to maintain the patient’s anonymity she will be referred to throughout this essay by another name, Mrs Smith. Mrs Smith would repeatedly ask staff when her husband would be coming to take her home, although he had passed away a few years prior to her being on the ward. I followed the practice of other staff by advising the patient that her husband would be visiting her the next day, despite this not being the case. Mrs Smith spent a lot of time walking around the ward and asking other patients, staff and visitors if they had seen her husband, often opening curtains around bed spaces and disrupting the privacy of other patients. This would also happen during the night when patients were sleeping. She was often tearful, and at times she would become very distressed and attempt to leave the ward. Due to her having been admitted because of a fall, she was considered high risk for falls, so it was deemed necessary, where possible, to have one member of staff with her at all times to ensure that her safety was not compromised. There were other incidents and challenging behaviours with Mrs Smith, but I have chosen to focus on the situation where she was distressed about the absence of her husband as it was such a fundamental issue for her and a focus for her dementia, therefore a huge challenge for me as a student nurse in knowing how to properly respond.
During a late shift on the ward, my mentor asked if I would stay with Mrs Smith whilst she gave out medication in order to ensure she wouldn’t be left on her own and fall. I introduced myself to Mrs Smith and sat with her in her room. It became apparent to me quite quickly that she was obviously very confused and she was not fully aware that she was in a hospital, as she repeatedly asked me where she was. On being told she was in hospital she would say no and shake her head. It wasn’t long before she asked me when her husband would be there to take her home, to which I replied that he would be in the next day. I declined from telling Mrs Smith that her husband was no longer alive on the advice of my mentor and other staff, who told me that hearing this may have confused and upset her even more.
Mrs Smith was upset on hearing that her husband would not be collecting her that day, became tearful and began walking around the ward looking for him and calling his name out. I walked beside Mrs Smith and attempted to diffuse the situation by trying to persuade her to come back to her room and offering her drinks, both of which she refused. I could see that Mrs Smith was tiring from the walking around and she eventually returned with me to her room. Although less agitated at this point, Mrs Smith was still tearful. I sat with her and put my hand over hers, but was unsure of what to say to console her. My mentor returned once Mrs Smith was back in her room to check that Mrs Smith was okay.
I felt extremely challenged in this situation, as prior to this placement I had no experience of caring for anyone with dementia, therefore dementia behaviour was very new to me. Due to the situation resulting in Mrs Smith becoming both agitated and upset, I felt that I had provided inadequate care and consequently let the patient down. The situation was frustrating, for both Mrs Smith and myself. Mrs Smith seemed frustrated at not knowing where her husband was or why she could not go home. I felt stress at seeing an elderly lady in obvious distress and being unsure as to what actions I should take to manage the situation. I felt out of my depth and that I was not given sufficient support from my mentor both prior to the situation and during it. I was uncomfortable about keeping the truth from Mrs Smith about her husband, as it felt ethically wrong to lie to her, however I also didn’t want to cause her more upset. Being so inexperienced meant that I felt I couldn’t cope with such a huge task as telling a patient that their spouse had passed away, as I would not have known what to say or how to cope with Mrs Smith’s reaction. I felt unsure of whether to ask for assistance from other staff members, as I could see that they were all busy with other tasks and I did not want to burden them. I also felt embarrassed to ask for help as I thought that in asking for help they would regard me as incompetent.
This situation was extremely challenging for me, especially as it was my first encounter of an individual with dementia. I do not feel that I handled the situation very well because I did not have a positive impact on Mrs Smith’s well being and the situation resulted in Mrs Smith becoming upset. My lack of knowledge about dementia and its effects combined with a lack of communication between my mentor and I meant that I did not have a good understanding of Mrs Smith and her needs. I did not know how to deal practically with the situation and was unsure of what to say to her in order to prevent her from becoming agitated and tearful in searching for her husband. With Mrs Smith being assessed as at risk of falling I was worried that she may fall and injure herself whilst looking for her husband. My feelings of helplessness meant that I was unable to cope with the situation and resulted in stress for both the patient and myself.
Coping is an individual process by which people manage stressors (Folkman and Lazarus, 1988). When stressors cause pressure which exceeds that of an individual’s ability to cope, they become stressed. Individuals will cope with stress in their own unique way and adopt preferred coping strategies. Taylor (2012) describes two different coping styles; avoidance related coping and approach related coping. With approach related coping, the individual takes direct action or seeks knowledge in order to cope with a situation. This style of coping allows the individual to focus on information and actions required to reduce the stressor, therefore taking the focus away from their own emotions. With avoidance related coping, the individual attempts to minimise or avoid stressors. This style reduces the stressors encountered by the individual, therefore reducing their stress. However, stressors cannot always be minimised or avoided, so it is beneficial for the individual to adopt an approach related coping style in some instances in order to cope with unavoidable stressors. When caring for Mrs Smith, I adopted the avoidance coping style. Rather than seeking information or assistance from my mentor, I attempted to handle the situation alone and minimise Mrs Smith’s agitation by asking her to return to her room. Folkman and Lazarus (1988) identified social support as an effective method of coping in certain situations, therefore speaking to my mentor prior to spending time with Mrs Smith and asking for assistance from others when I felt stressed would have helped me to cope with the situation. This would have been beneficial to both myself and Mrs Smith. I would have had been more prepared for what behaviour to expect from Mrs Smith and would also have had another person to assist me in caring for her, which would have reduced my stress levels significantly. This would have improved the quality of care for Mrs Smith, which may have reduced or prevented her agitation and also reduced her stress levels. Taylor (2012) proposes that the ability to cope with a situation reduces stress levels, but in situations where individuals do not have the ability to cope, then the likelihood of experiencing stress is increased. Rungapadiachy (2008) suggests that an individual’s ability to adjust to stressful demands can result in them experiencing stress. By having the ability to adjust well to stressors an individual can experience either little or no stress, whereas not having this ability may potentially lead to high levels of stress. With regards to my experience with Mrs Smith, I believe that I experienced stress because it was the first time I had experienced a situation caring for a patient with dementia and I had not developed an efficient coping style. My lack of knowledge was also a factor in my becoming stressed. Had I been more informed about how dementia can affect an individual and what sort of behaviour to expect from Mrs Smith then I may have been more emotionally prepared to cope with the situation.
The NMC Professional Code of Conduct (2008) states that healthcare professionals must use the best available evidence when caring for patients. This highlights the importance of having up to date and relevant underpinning knowledge when delivering patient care. In the situation with Mrs Smith I did not have the necessary knowledge about dementia and its effects on an individual in order to cope with caring for a patient with dementia. Speaking to my mentor about Mrs Smith’s condition and illness
prior to spending time with her would have given me a better understanding of her behaviour and how best to deliver care for her.
There are currently around 800,000 people with dementia in the UK, with this number expected to double by 2040 (DH, 2013). With dementia increasing in the elderly population (Hoe and Thompson, 2010), it is inevitable that caring for dementia patients will become a major part of the nursing role in the future. Having the experience in caring for patients with dementia as a student nurse is vital in preparing me for this in my future practice. Common features of dementia include cognitive features, such as impaired memory, impaired judgement and insight, apraxia and agnosia, and non-cognitive features such as hallucinations, delusional ideas, changes in personality, disorientation and disturbances in mood (Redfern and Ross, 2006). Dementia related behaviours, such as the agitation and confusion shown by Mrs Smith, are often exacerbated by hospitalisation of patients. Factors such as the patient’s medical problem, hospital environments, disruption to normal routines and unfamiliar people are all contributing factors to this exacerbation of behaviour (Miller, 2009). Distress can be caused by excessive noise, harsh or low lighting, unfamiliar activity and unfamiliar people (DH, 2001). This is supported by evidence showing that dementia patients are often discharged from hospital in a worse state than they were in when admitted. Despite medical conditions being addressed, overall health and well being is often negatively affected by factors such as weight loss, reduced oral hygiene, mobility and skin problems (Dewing, 2001). This highlights the importance of delivering person centred care and caring for the person as a whole being, rather than just treating the physical condition. Dewing (2001) provides a framework to facilitate effective interventions for patients with dementia. These include interpretation of the patient’s behaviour, matching verbal communication to the patient’s cognitive ability and introducing a nursing need in a way that makes sense to the patient. With Mrs Smith, simply asking her to return with me to her room was likely to have made no sense to her and may have been the reason she declined, whereas asking her if she wanted to wait for her husband in a quiet room where she could sit and have a drink may have made more sense to her.
Mrs Smith’s admittance to hospital may have exacerbated her dementia related behaviour, although at the time I did not have a full understanding of this and assumed that her behaviour was normal for her. Webster (2004) suggests that there are certain factors relating to poor assessment in patients, one of which is ‘task-focused or ritualistic practice’. With Mrs Smith I was focused on helping her return to her room. It might have proven more beneficial to instead take the time to listen to her and involve her in a conversation about her husband. Communication can enable development of both short and long term relationships (Miller, 2002), therefore in listening and speaking to Mrs Smith I would have been more likely to put her at ease and gain her trust. Conversation offers the opportunity for patients to divulge their thoughts and feelings and to find solutions to problems (Arnold, 1999). This would also have contributed to my assessment of her and contribution to person centred care, as I would have gained more knowledge about her.
The NMC Professional Code of Conduct (2008) states that all patients must be treated as individuals, placing high importance on the value of person centred care. According to the National Service Framework for Older People (DH, 2001), person centred care requires healthcare professionals to listen to patients, respect privacy and dignity, recognise individual differences and enable them to make informed choices. Understanding the patient as a whole, considering them from a physical, emotional, psychological and spiritual point of view, is crucial in order to deliver holistic, person centred care. With patients who have dementia, this can prove more difficult, as the nature of the disease means that personhood seems to diminish as their disease progresses (Hoe and Thompson, 2010). Therefore, it may be necessary to speak to the patient’s family or carers in order to gain an insight into their routines, preferences, dislikes and individual differences. Providing person centred assessment and care is shown to enhance the quality of care for people with dementia and consequently improve their outcome (Webster, 2011). A person centred assessment of Mrs Smith would have allowed for better person centred care. In order to offer person centred care, healthcare professionals will often need to make an
effort to get to know their patents rather than just addressing conventional nursing care tasks (Ford and McCormack, 2000). If I had taken a holistic approach on meeting Mrs Smith and initiated a conversation with her, I would have gained an understanding of her personality and promoted her personhood. In doing so I would have been able to provide higher quality of care for her, for example by being aware of her likes and dislikes. Webster (2011) also states that patients have reduced levels of challenging behaviour if healthcare professionals take the time to listen and respond to them. Taking the time to speak to Mrs Smith and listen to what she had to say may have had a positive impact on her well being and made her less likely to become agitated and upset. With dementia cases becoming more prevalent, dementia care is an aspect which most nurses will inevitably experience at some point in their careers. Caring for patients with dementia can be a challenging and complex experience and requires good assessment, communication and coping skills. I have reflected on a challenging situation and in doing so I have learned the importance of incorporating person centred care into my practice, as without doing this it can be difficult to deliver the best quality of care for patients. I have also learned that a lack of underpinning knowledge and experience can lead to my becoming stressed and that having a coping strategy can help with managing challenging situations. In future practice I will aim to speak with my mentors prior to situations which I am unsure about, as this will minimise the likelihood of stressful situations. I have shown the need to reflect on future situations in order to enhance my skills as a healthcare professional and enable improved practice. I have demonstrated the importance of person centred care, using evidence from literature to show this. I have also discussed coping styles and their importance in practice. In future practice I will use the approach related coping style, rather than the avoidance related coping style as a strategy for managing challenging and potentially stressful situations. Where possible, I will attempt to gain underpinning knowledge in order to provide high quality, evidence based care. In order to promote person centred care, I will look at each patient holistically, taking into account their history, emotional, spiritual, cultural and psychological factors as well as their physical condition. This will enable me to deliver individual care for patients and ensure positive well being. I will continue
to use reflection as a method of analysing and learning from experiences, both positive and negative.
Appendix 1 – Gibbs’ Reflective Cycle (1988) updated by Bulman and Schutz (2013)
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