A Reflective Account
Reflective practice has been a familiar topic in nursing journals and the term is regularly used in professional nursing practice. However, it was not until I used Johns’ (1994) model to analyse and explore my feelings and actions in daily practice that I fully understood the concept of reflective practice and discovered how it can enhance professional development.
This article describes a reflective experience related to caring for a patient with chronic obstructive pulmonary disease in the community. The professional implications of this experience are explored through reflection. This exploration raised two main issues: the development of a therapeutic nurse-patient relationship and the feelings of guilt experienced when reflecting on whether I had let the patient down when most needed, in the final stages of her life. obstructive pulmonary disease (COPD) in the community.
This has enabled me to explore the meaning and significance of my clinical practice and to recognise the complexities within it. The experience raises a number of issues frequently encountered in daily nursing practice. However, for the purpose of this article, two issues will be discussed in depth. These relate to the development of a therapeutic nurse-patient relationship and dealing with feelings of guilt. The reflective process allows practitioners to question and analyse their experiences and actions as a means of developing their knowledge, skills and behaviour, to enhance clinical practice.
Author Margaret Barnett is COPD nurse specialist, Derriford Hospital, Plymouth. Email: margaret. [email protected] swest. nhs. uk Description of the experience My work as a specialist nurse involves caring for and managing patients in the community with COPD. I had been caring for Mary (not her real name) for two years. She was in her early 50s but had severe COPD. Initially, Mary was fairly stable and during exacerbations of COPD she could be managed at home effectively. She had a caring and supportive family and husband.
Last year we had discussed her being referred to Harefield Hospital in London for consideration for a lung transplant, but after her first visit for assessment she withdrew and said she could not go through with the investigations. Over the last six months her condition showed signs of deterioration with frequent chest infections that required management in hospital. Because of her deterioration she had been receiving weekly visits from the COPD home care service. I visited Mary at home a week after she had been discharged from hospital, as she had an exacerbation of her COPD.
On my visit she was in good form and cheerful. She looked well, in fact the best I had seen her in some time. may 18 :: vol 19 no 36 :: 2005 41 Keywords Reflective practice; Respiratory system and disorders These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit the online archive at www. nursing-standard. co. uk and search using the keywords. THE ESSENTIAL purpose of reflective practice is to enable the practitioner to interpret an experience in order to learn from it (Johns 1995).
It is a process that involves examining individual personal thoughts and actions in daily practice (Somerville and Keeling 2004). This reflective account relates to knowing-in-action (everyday practice), which Schon (1983) identifies as reflection-on-action. This article describes a reflective experience while caring for a patient with chronic NURSING STANDARD art & science reflective practice Nevertheless, she stated that her panic attacks were more frequent, occurring at least two to three times a day, mainly after minimal exertion.
We discussed how to manage these by keeping her oxygen in place and using her salbutamol inhaler (Bellamy and Booker 2003), to try pacing herself and to develop a coping strategy that would help her to manage her panic attacks. She said she would try this. When I completed my clinical assessment and documented her spirometry, which was unchanged, I felt satisfied that her condition was stable. I explained to her that I was going on leave the next day but that I would visit her on my first day back at work the following week.
If she had any problems, she had the office telephone number to contact other members of the respiratory team. On my return from leave my colleagues informed me that Mary had died four days after my visit, on her way to the A&E department. Mary’s husband had left me a message several days after she had died asking me to contact him on my return. This I did and arranged to visit him that afternoon at home. He informed me that she had been unwell for a couple of days. He had contacted Mary’s surgery to request a doctor to do a home visit. However, the doctor visiting was a locum GP and did not know Mary’s history well.
Hospital admission was offered but Mary declined and stated that she would wait for the GP to visit the next day. Meanwhile, the locum GP advised Mary’s husband to continue with the treatment. In the early hours of Friday morning Mary informed her husband that she felt unwell and requested an ambulance. As he was making the call he described Mary as having some form of fit and she appeared to stop breathing. Her husband had some first aid experience and was able to revive her. The ambulance crew arrived soon afterwards, but she arrested as they were transporting her from the house to the ambulance.
They were unable to revive her and she was pronounced dead on arrival at the A&E department. Mary’s death certificate stated that the cause of death was COPD. On learning of Mary’s death I felt sad and guilty that I had not been with her and her family at the final stages of her life. & (1985, 1988), Benner and Wrubel (1989) and Atkins and Murphy (1995). However, Johns (1996) identifies the patient’s individual needs and the nurse-patient relationship as paramount to nursing care, which represents my beliefs and values in nursing.
John’s (1994) model provides a systematic structure with a series of questions that help individual practitioners to explore the meaning of various experiences. The framework allows practitioners new to reflection to examine personal thoughts and actions with a structure that is easy to apply and understand. The questions outlined in the model helped me to analyse my clinical practice and provided a framework for reflection (Box 1). This related to the development of a therapeutic nurse-patient relationship and the feelings of guilt I experienced in that I may have let the patient down when most needed, in the final stages of her life.
Questions in the model asked why I responded in the way I did and the consequences of this for myself and others involved, how I felt about the situation and whether I could have responded to the situation in a different way. Johns’ (1994) framework provided a valuable tool, which is easy to understand and can be adapted to most situations. Development of a therapeutic nurse-patient relationship Knowing and understanding the patient as an individual is pivotal to establishing a therapeutic nurse-patient relationship and sets a particular patient apart from other patients with the same medical diagnosis (Radwin 1996).
My understanding of knowing the patient relates to Mary’s symptoms, how she coped from day to day with her condition and how it affected her daily life. Mitchell (1995) emphasises that patients who feel understood and accepted also feel cared for. As I visited Mary weekly at home, I witnessed the effects that living with COPD had on her – how minimal exertion caused her severe breathlessness, which affected her daily life and her role in the family. I was able to make sense of Mary’s world and respond to her subjective experiences by treating her holistically.
According to Benner and Wrubel (1989), theory relates not only to theoretical and formal knowledge, but also to experiential knowledge of the real-world experience. To make sense of Mary’s experiences, I related them to the knowledge and skills I acquired over the years in caring for patients with COPD, to gain a deeper understanding. Heidegger (1962) acknowledges that this is essential to be able to interpret and understand the patient’s real world.
Establishing a relationship and knowing the patient influences clinical decision-making and NURSING STANDARD Process of reflection To analyse and explore my feelings and actions, I used Johns’ (1994) structured framework to make sense of, and to gain a deeper understanding of, this experience. There are many frameworks available for reflection offered by theorists such as Boud et al (1985), Eraut 42 may 18 :: vol 19 no 36 :: 2005 BOX 1 Johns’ (1994) model of structured reflection What was I trying to achieve?
To develop a professional nurse-patient relationship To empower Mary to manage her panic attacks To enable Mary to die at home Why did I respond as I did? During the two years of caring for Mary an open and honest relationship had developed and I respected her as an individual I felt I had a good understanding of how living with COPD affected Mary’s daily life The consequences of my actions: I felt sad and frustrated that I had not been with Mary or her family at the time of her death. I felt guilty that I may have let Mary down.
If I had been on duty would the result have been the same? Mary and her family trusted me as a professional My weekly visits enhanced Mary’s confidence How were the patient and family feeling? Mary often expressed how frightened she got during a panic attack, but she was not afraid of dying Mary’s husband and family were very supportive, but often felt helpless. Following her death they were devastated but felt that she was now at peace, which comforted them How do I know how the patient felt?
Mary told me that she looked forward to my visits. She felt I really understood how she felt and what she was experiencing How did I feel about the situation? Very guilty that I had not been around at the time of death, when I was most needed When Mary died I experienced sadness and grief at the loss of someone with whom I had shared a great deal regarding her illness I felt disappointed that I had not been able to experience the closure of her care What factors influenced my decisions and actions?
External: Understanding how disabling Mary’s condition was and her daily experiences Guilt that she had been let down by the service which does not provide 24-hour cover NURSING STANDARD Internal: A trusting nurse-patient relationship had evolved with mutual respect. A strategy had been discussed on my last visit of how Mary should manage her panic attacks What sources of knowledge influenced my decision-making? My personal and practical knowledge of Mary’s condition and how it affected her life Could I have dealt better with the situation?
The final stages of Mary’s life were totally out of my control. Although Mary had reported an increase in her panic attacks, her condition was unchanged clinically Mary and her family were fully aware of how to contact my colleagues in my absence What other choices did I have? I could have requested my colleagues to either telephone or visit the patient What were the consequences of this choice? I do not feel that these choices would have altered the course of events How do I now feel about this experience?
I have mixed emotions, as Mary did not die peacefully at home as she had wished. However, had I created a vision of a perfect death and the end result had not been as I had visualised? What have I learnt from this experience? I have learned that no matter how well managed Mary’s care was, I could not influence unplanned events Mary’s husband took appropriate action when she collapsed How has this experience changed my ways of knowing in practice?
Empirics: Applying the different forms of nursepatient relationships (Morse 1991) and levels of involvement has challenged my involvement and made sense of my feelings of guilt Aesthetics: The theories that Benner (1983) held helped to make sense of my practice, acknowledging the patient’s world and needs from a holistic perspective Ethics: Raised a greater awareness of the moral aspects of patient care, as well as respecting a person’s dignity, values and beliefs Personal: It enabled me to examine and challenge my thoughts and actions involving embodied knowledge and experiential knowing may 18 :: vol 19 no 36 :: 2005 43 rt & science reflective practice the implementation of different interventions using empirical, aesthetic and personal knowledge (Carper 1978).
As an example of using my clinical skills and knowledge, I had recognised that Mary was developing early signs of cor pulmonale (right sided heart failure caused by primary lung disease), which is one of the complications of severe COPD. I had recognised this by clinically assessing the patient, recording her oxygen saturations and monitoring her symptoms: low oxygen saturations (below 90 per cent); increasing shortness of breath; and peripheral ankle oedema.
Consequently, longterm oxygen therapy was implemented following discussion with her consultant and blood gas analysis. She was grateful for this and felt it helped her to manage her symptoms and improve her daily activities of living (Roper et al 2000). Another example of using my clinical skills and knowledge is related to Mary’s panic attacks when breathless, which she reported. We collaboratively discussed how best to deal with these problems and developed a personalised intervention plan to address Mary’s concerns, fears and anxieties.
Webb (1995) acknowledges that listening and showing empathy is of great importance to patients because, for some patients, psychosocial needs were seen as more important than the physical aspects of their care, where action could be taken to deal with worries or concerns. & The ‘connected relationship’ The quality of the interaction between the patient and nurse is central to nursing and underpins good nursing practice (Luker 2000). May (1991) focuses on patient-nurse interaction and uses the term ‘involvement’ to describe such interaction.
Luker (1997) perceives the nurse-patient relationship as the means by which therapeutic nursing care can be delivered. In this context ‘therapeutic’ relates to meeting nursing needs to the mutual satisfaction of the practitioner and patient (McQueen 2000). However, according to Morse (1991), the length of time a nurse has known the patient, which is usually of short duration, determines the term ‘therapeutic’. Even though my relationship with Mary was longterm, I considered it ‘therapeutic’, based on mutual commitment and trust.
Through the establishment of a ‘connected relationship’ which is formed over time (Morse 1991), I viewed Mary as an individual before considering her as a patient. Mary trusted my judgement and abilities as a 44 may 18 :: vol 19 no 36 :: 2005 nurse and often told me how much better she felt once I had seen her. My visits gave her confidence and reassurance. At times her needs were extensive and she would call me in times of crisis when unwell. I had previously been available when needed and was dependable, therefore providing a sense of security to Mary.
Irurita (1999) describes this level of care and involvement as ‘soft-hand care’ contributing to being an advocate for the patient and developing an effective nurse-patient relationship. I was happy to do whatever I could to promote care and comfort, and to ease her suffering. Ramos (1992) describes levels of liking and bonding with patients. To develop such a relationship with Mary, I moved through the different levels, from Level 1 relating to task orientation, Level 2, care based on the nurse’s values and knowledge, through to Level 3 where a professional but close relationship is formed based on sharing knowledge and values (Ramos 1992).
Mary and I had established a bond and professional friendship, which was easy and comfortable. Ramos (1992) found that, at Level 3, nurses would give care above and beyond the call of duty. Providing Mary’s care was effortless and gave me a great sense of job satisfaction and reward professionally. Her care involved more than delivering treatments and performing tasks; it involved demonstrating an understanding of her experiences, her personal beliefs and what was important to her. Even though I felt my relationship with Mary was purely professional, my feeling of sadness may account for why I felt so guilty when I heard that Mary had died.
This led me to question whether I had become overinvolved with Mary without being aware of this. I was Mary’s advocate in discussing her care and management with the GP and the respiratory consultant, and she trusted my professional abilities and judgement. On closer examination of Morse’s (1991) description of over-involvement (caring for patients beyond the call of duty), I recognise that I became territorial about her care and management. However, I do not feel that I jeopardised the team network or allowed my relationship with Mary to affect my judgement.
As I was more closely involved in Mary’s care, both the GP and the consultant were happy to support any suggestions I made regarding her care, because they recognised my expertise in the management of patients with COPD. Dealing with feelings of guilt On hearing of Mary’s death I felt guilty that I might have let Mary down, mainly because I was not on duty to grant her request, which was to NURSING STANDARD die at home. This might have been because, without realising it, I had been overprotective and felt that I was the only professional that could deliver her wish to have a peaceful and dignified death at home.
Karlsen and Addington-Hall (1998) acknowledge that many patients would prefer to die at home rather than in a hospital setting. This had been discussed several months previously, following her decision not to go ahead with the assessments for a heart and lung transplant. Mary was aware of the severity of her condition and had said that, if she only had six months to live then, so be it. Glaser and Strauss (1965) confirm that patients’ awareness that they are dying is a crucial issue in relation to their psychological wellbeing and how they cope with death.
I often refer to the stages of dying – denial and isolation, anger, bargaining, depression and acceptance – that Kubler-Ross (1973) identified, when patients are entering the terminal phase of illness. Although patients may not experience these feelings in this order, they enable practitioners to help patients to cope with dying and death. In contrast, Benner and Wrubel (1989) suggest that the way these psychological stages have been used has led to the concept of a perfect death. In reality, we know that the experience of dying is sometimes less than perfect, as demonstrated in Mary’s case.
Benner and Wrubel (1989) state that nurses who develop and use appropriate skills such as empathy and understanding with a caring attitude help people to open up and address the needs of individual patients. However, as I discovered, developing a close and open relationship with patients increases the risk of experiencing personal and emotional pain. A phenomenological study conducted by Loftus (1998) explored nurses’ lived experiences of the sudden death of patients. Although this study relates to the experiences of novice nursing students, it can also be related to nurses with more experience.
I can relate to the feelings of guilt, shock and letting the patient down that many of the students experienced, but perhaps on a different level. As qualified practitioners, we develop skill, knowledge and expertise over time to enable us to relate theory to practice and deliver expert care. We learn through our experiences and by coping with a variety of situations. Such skills are acquired over time with experience related to ‘skilled know-how’ (Benner 1983). The most common explanations were that student nurses really liked the patients (Loftus 1998).
They had developed good relationships with the patients, finding them easy to talk to, especially as there was openness concerning their condition and prognosis. This may be related to NURSING STANDARD the nurse and patient forming both a professional and a personal relationship, which may explain why I responded the way I did to Mary’s death. Maybe this is also why we sometimes feel different levels of sadness when patients die. Watson (1988) acknowledges that sharing and experiencing the highs and lows of a patient’s illness is an inter-subjective experience.
Inter-subjectivity relates to the notion of embodiment; in other words, where the nurse is wholly immersed in the experience of the patient (Maeve 1998). On reflection, this is possibly the reason I felt guilty – I had let Mary down in terms of embodiment – the experiences of caring for Mary and seeing her struggle with her breathing were not separate to our relationship. When she died I shared the sadness of her dying and the possibility of being denied the opportunity to close the relationship by being with her at the end of life.
Murray Parkes (1988) provides a possible explanation that the death of a person, and the nature and quality of the attachment formed, determines the intensity of grief experienced. Integration of reflective experience Nursing ethics relates to moral issues and choices concerning questions about morally right and wrong actions in connection with care and management of patients (Carper 1978). Fry (1989) suggests that nursing ethics concentrates on the nature of the nurse-patient relationship, of which nursing care is central, rather than on decision-making claims of moral justification.
The relationship Mary and I shared was based on the principles of honesty, integrity and trust, identified by McCormack (1996) as essential for a caring and committed relationship. I believe the care and support I gave Mary was to the best of my abilities. It was based on our values and beliefs, which were expressed with empathy and through sharing knowledge. However, when Mary died I questioned my actions of care on my last visit before I went on leave. I initially questioned if I had rushed my visit because I had things to tie up before going on leave and had missed some vital evidence in her clinical assessment.
This is a natural reaction that any professional might experience. Nonetheless, after evaluating my documentation and reflecting on my visit, I felt that I acted correctly and competently. I was also concerned about the fact that her husband had made the decision to resuscitate Mary while waiting for an ambulance because Mary had said she wanted to die at home. However, on reflection I feel his decision and actions were right. To take no action would have been wrong.
He could not have known that she may 18 :: vol 19 no 36 :: 2005 45 art & science reflective practice as dying and that it was not another exacerbation of COPD that required medical intervention in hospital as on previous occasions. & Conclusion The use of Johns’ (1994) structured framework has been thought-provoking, and enabled me to explore and make sense of this reflective experience. It has allowed me to develop a new understanding of why I felt guilty when Mary died, and the reasons why her wish to die at home was not achieved, by exploring issues of concern triggered by this experience. As a novice to reflective practice, I found this particular model valuable and easy to apply to my experience.
It allowed me to focus and critically appraise my thoughts and actions, which resulted in a new understanding of the development of the nurse-patient relationship. As Boyd and Fales (1983) suggested, it has helped clarify and resolve my original feelings of guilt and doubt. Using reflection in everyday practice can be beneficial in dealing with stressful or emotional situations. Reflective practice can enhance professional development as well as clinical practice and can also help practitioners to identify new ideas and ways of working when caring for patients.