Reflective Account – nursing
This essay demonstrates the significant learning that resulted as a consequence of using critical reflection on my practice. The reflective process helped me to realise how my practice needed to change after I experienced a personal and practice-related issue during and after my clinical placement. Reflective practice is an important component of all nurse education programmes. The Nursing and Midwifery Council’s (NMC) The Code: Standards of Conduct, Performance and Ethics for nurses and Midwives (NMC, 2008), states that nurses must continue to keep knowledge and skills up to date during their professional careers.
Reflection can improve a nurses ‘repertoire of skills’ (Matthews, 2004). Reflection is a term much talked about yet there is no single, universally agreed definition (Chirema, 2007). However, there are many prominent thinkers and writers in the area who have made considerable contributions to the ongoing dialogue. As a learning process, reflecting on practice and turning experience into learning requires a framework or model in which to understand the experience and make sense of it. This may include other people with whom to interact and share experiences with.
Indeed, much of the literature enthusiastically encourages reflection on experiences in nursing. It expects that by doing so, it will improve the professionalism of the practitioner by automatically transferring the new knowledge, skills and expertise into practice (Wallace, 2010). After trialling a few models of reflection, I eventually settled on Gibbs’ (1988) model (refer to figure 1). I find this a simple and easy to use model and it suited my personal style of learning. However, reflection often reveals shortcomings and it has potential to leave the practitioner feeling insecure and demotivated.
Yet O’Callaghan’s (2005) reflective writing described how a student managed to break down ritualistic practice in wound dressings and improve the patient’s recovery with evidence-based practice. Mooney and Nolan (2006) claim that reflection helps nurses to better understand and build on a body of nursing knowledge, which benefits the profession. Figure 1 Gibbs’ (1988) Reflection Cycle Reflection of any sort is difficult: it requires the learning of new skills that may lead to positive outcomes.
It demands effort, ongoing commitment and motivation in order to prioritise an additional work activity in an already demanding role as a children’s nurse (Schutz et al, 2004; Schon, 1991; Argyris, 1999; Marcos et al, 2009). There has been a growing concern among many employers of registered nurses that new recruits lack the ability to think critically and broadly about their work (Castledine, 2010). This could be due to the difficulties mentioned and the personal nature of reflection and so may be a barrier to truthfully accounting the story (Schutz et al, 2004).
As a previously experienced nurse, this was a major dilemma in my own reflective writing. I was, in effect, exposing my failings to a total stranger. However, I decided to be as truthful as possible in order for the process to work. What happened (my story)? The focus for my reflection was post-appendectomy care. In my placement, I nursed a female teenager through an appendectomy. Within a month I had to undergo the same procedure myself. Appendectomy is a common treatment performed on the children’s ward where I undertook my placement.
This is usually carried out by laparoscopic surgery. Advice that I gave pre- and post-operatively to the child and parents/carers are included in the care plans, pre-operative care and post-operative care which can be found in appendices one, two and three. For the first stage of the cycle, Gibbs encourages a description of the events. What was I thinking and feeling? When I gave the pre- and post-operative advice to the teenager and her mother I felt as though I was doing a good job. I was following the plans and procedures.
My supervisor was happy. However, once I had undergone the whole experience of having a retrograde appendix removed myself, I discovered that the pre-operative preparation and post-operative care that was given to me, and I myself would have given something similar, inadequate. Although my experience as an adult on an adult ward would have been slightly different to the teenager that I cared for, the principles of care are similar. Differences in care may have been due to staff-patient ratios and policies around visiting and family-centred care.
In my experience I suffered an inability to cough, anorexia, changes in taste and diet, being limited in walking and mobilising and general and mental malaise. I even surprised myself by worrying about my body image due to the size of the scar on my abdomen. Although these experiences were personal to me, I assumed that many of these conditions and thoughts are typical and would have been equally suffered by the teenager that I cared for. Nothing was mentioned at any time to me pre- or post-operatively about any of these experiences.
I never saw any leaflets at the time of my appendectomy but I discovered a patient information leaflet for the Gloucestershire Health Community regarding coughing after surgery. It states that it is important that you can cough post-operatively so that you can clear any phlegm that has accumulated whilst being intubated during surgery. It gives you guidance on how to get rid of phlegm comfortably. I can honestly state that I have never been instructed to talk to a patient about this in the two hospitals that I have worked in and therefore I have never considered it has a significant problem.
I have observed it in patients but it has been brushed aside has a minor nuisance due to the tubing used in the anaesthetic. I have in the past encouraged a teenager to cough holding a pillow to their wound but that was pretty much it. To my embarrassment, I took the lead from my colleagues. However, I now know from my own personal experience, that the process of being able to cough and clear phlegm is a bigger problem than most nurses’ think. It used to be that a child would not be able to commence food and fluids for a few days in order to enable the bowel to regain normal function.
However, now there are no dietary restrictions but children are recommended to eat lightly for the first day or two and if nausea or vomiting occurs, they are encouraged to stick with clear liquids until it passes. I suffered with dreadful nausea (I believe this was due to the antibiotics) and this was not helped with being positioned in a bay with other patients that were eating or one patient in particular that had a bowel condition that meant that he had to sit on a commode for lengthy periods. What was also less appreciated by me is that the body appears to go through a detoxification process.
After one week of eating very little and losing about 8lbs due to the ongoing nausea, my palate had adjusted and I couldn’t bear to eat the foods that I was used to. A favourite curry tasted that someone had literally poured a tablespoon of salt onto it! I couldn’t bear anything other than ice cream and water. This second stage of the Gibbs cycle provides a section to explore how I felt and the thoughts I had. This section was the most important part of my exploration and learning process. My comments were not directly restricted to my ‘thinking’ and ‘feeling’.
It felt natural to analyse my incident and evaluate it, supported by evidenced-based research. What were the thoughts and feelings of others involved? How do you know? The teenager that underwent the appendectomy was clearly in pain, despite analgesia following examination, and was clearly concerned about the forthcoming operation. It was clear because of the questions that they were asking and their body language. Preventing distress for children, young people and their carers when they are admitted to hospital is a fundamental goal of children’s nursing.
Glasper and Richardson (2005) state that children, young people and their families need to know what is going to happen and how it is going to happen. Vague and unclear information is far more upsetting than what is known and understood. Surgery is a planned procedure which aids itself very well to good preparation. This helps children to cope, reducing anxiety and allowing them to know exactly what to expect, such as what will happen post-appendectomy. Thus, at the time, I followed this advice. I felt that I adequately prepared the teenager that underwent the appendectomy and her mother for this procedure.
My supervisor was alongside me and appeared happy with everything that I had done in my caring for the teenager and her mother. I had given detailed information about what was going to happen and answered all of their questions comprehensively. The third section of the Gibbs process required me to look into what others thought. As such it demanded that I put myself in their shoes. This stage is incredibly useful because it allowed me to reflect on what I observed e. g. body language, the things that were said, and the way I might have viewed things if I was in their situation.
I was able to analyse how I perceived the motives and reactions of others. What other options were open to me? I do not feel that many other options were open to me when caring for the teenager at that time. I had nursed many, many teenagers through appendectomies and despite being supervised through this caring situation, nothing much had changed since I was nursing full-time. What would I do if the situation arose again? I feel I need to re-learn and understand more about the dilemmas of children and their families/carers when going through any period of hospitalisation.
Clearly, dealing properly with the aftermath of abdominal surgery is important; it has significant implications, not only for physiological reasons, but also from a psychological perspective e. g. considering the wound. The nursing process was the first move towards a systematic way of assessing the patient’s nursing problems, their priorities, reasons for nursing interventions and care. This was closely followed by the process of setting standards and carrying out quality assurance measures to see if the quality of nursing care had been achieved.
Although all these attempts have tried to encourage more critical thinking in nursing, there is still a problem in getting nurses to break away from the comforts of routine and become more assertive in their contribution to the health team’s decisions (Castledine, 2010). A lot is written about ‘nursing rituals’. The term ‘ritual’ is often used in a derogatory sense in nursing literature to refer to unthinking, routine actions by nurses, which lacks any empirical foundation. For example, Walsh and Ford (1989): “The nurse does something because this is the way it has always been done.
” I believe that nursing care plans are an example of this routine behaviour. I believe that I have been following the same nursing plan for pre- and post-appendectomy care for many years. They have changed recently but the change is minimal and only includes appendectomies carried out via keyhole operations or the insertion of a three-fibre optic camera through the stomach (laparoscopy). Therefore, my first step would be to re-look at the nursing care plans on the ward. I have included the care plan used on the ward that I was placed on in appendix 1.
As you can see, this is a generic form used and nursing staff are able to add plans to suit different types of general surgery. I believe that it would be more efficient to include specific care plans for the more common types of surgeries seen on the ward, appendectomies included. A letter published in a popular nursing journal: “Nurses who believe that nursing care is all about managing drips and administering medicines are nothing more than technicians…It is inexcusable to concentrate on the technical and give care without empathy, touch or time to talk” (Bolger, 2007). The nurses that ‘cared’ for me were guilty of being ‘technicians’. I believe that empathy, touch and time to talk should be emphasised more and clearly written in the care plans. I personally tried to look at the teenager as an individual and not as a condition. I feel that the care plans should reflect this. For example, a discussion about the wound should be more in depth and the female teenagers response noted for future intervention.
Evidence-based practice encourages observable and measurable assessment and evaluation through quantitative means (Taylor, 2006). It requires that decisions based about health care are based on the best available and most up-to-date evidence. Nurses must also be able to scrutinise research findings to evaluate their clinical applicability, and use clinical practice guidelines to disseminate proven and therapeutic knowledge (Timmermans and Berg, 2003).
It is my intention that the care of children undergoing any form of treatment, appendectomies included, is based on current evidence and experiences that includes those of the children nursed. In the fifth and final stage of the Gibbs reflective process, I was able to explore the implications of following nursing rituals and inadequate nursing plans and care. I hope to apply what I have learnt from my own personal experience to future situations through redesigning leaflets, care plans and considering the environment that the children are nursed in.