This essay will address the importance and significance of reflection and the skill of reflecting. I will be addressing this in the healthcare setting using a scenario from my clinical placement. The influence of reflection and the models and frameworks of reflection will be considered and adapted to my practical first-hand clinical experience.
I would like to start by looking at the Gibbs Model (1988). I will be using this to reflect upon my clinical experience. I have chosen to use Gibb’s Model due to its straightforwardness and the vast number of professionals that have used this model to reflect upon their own work, hence giving the model a large amount of creditably. I will also consider where, if any further learning is required to improve my future practice. In accordance with The Code: Professional Standards of Practice and Behavior for Nurses and Midwives, hereafter referenced as ‘the Code’. The Nursing and Midwifery Council (NMC 2015) section 5.1 states that we must all as health care professionals respect a person’s right to privacy and confidentiality even after death. Therefore, in line with the aforementioned guidelines to maintain confidentiality, the names of patients, staff, the hospital ward and trust have all been altered. The pseudonyms Lilly and Kate will therefore be used within this piece of writing to address the patient concerned.
The Oxford English Dictionary (Murray, Bradley, Craigie & Onions 1961) defines reflection as ‘a serious thought or consideration, an idea about something, especially one that is written down.’ Upon expansion of this definition, The Oxford Dictionary of Nursing (2014) defines reflection as ‘the careful consideration of one’s own professional practice, including the ability to review, analyze and evaluate situations during or after an event. It is an essential part of the learning process that can result in new methods or approaching and understanding nursing practice. In nursing practice reflection is particularly important in allowing us to make links between theory and practice, through our clinical experiences (Jasper 2003), suggested that reflection is based on the principles of experience-refection-action. He suggested that reflection starts with an experience, it relates to revisiting the event with fresh eyes and action refers to the improvements that could be made. In everyday life reflection enables us to look back on past experiences, evaluate what was positive and negative about the situation, helping us to move forward using the experience to improve further situations. Reflection is a vital part of any profession particularly important in nursing and health care, we aim to continuously improve the healthcare that we provide, and reflection allows us to do so. Reflection enables a person to look back upon a critical incident or procedure during their practice. This may be a positive or a negative incident, it is simply something that sticks out in one’s memory or is significant to us. The idea of reflection is to review a situation and consider what is good or what needs to be done in order to further improve clinical practice. Reflection in nursing practice, is more than instrumental; for learning, change and improvement and for understanding. Reflection is a useful tool for a nurse, supporting them to deal with the at times the near impossible working environment of caring for people of all ages, all degrees of sickness and disability.
There are copious numbers of studies carried out into the impact of reflection in clinical nursing practice, both supporting and refuting the use of reflection and reflection models. A meta-study concerning the reflective practice in Nursing (Gustafon et al. 2007, as stated in Reflection in night nursing 2009) used qualitative studies. It was revealed that many assumptions about reflective practice were mainly based on theory and not on observed research, this may show a correlation, but correlation does not necessarily mean causation. However (Hansebo and Kihlgren 2001, as stated in Reflection in night nursing 2009), using evidence found that reflection aids careers in developing and improving their skills through personal experiences. In support of this (Issitt 2003, as stated in Reflection in night nursing 2009) found reflection in practice to be empowering to the individual, promoting self-awareness, confidence and therefore growth, this can surely only benefit nursing practice and the profession itself.
‘Reflection requires effort of attentive consideration to thoughts and feelings and memories to make appropriate changes’ (Taylor, 2010 p6.) The use of models is mainly seen when reflecting upon a critical incident such as seen in the nursing practice.
Models are frameworks that encourage the individual to reflect on a certain event in a structured yet personal way. In professional development reflection frameworks are greatly used. Schön (1991) put forward his idea of professional reflection, in terms of two categories; reflection-in-action and reflection-on-action. Schön (1983) suggested that to main way in which professionals learn is in action. Reflection-in-action is more experimental, the process of learning occurs through adaptation of an experience, during the actual experience. Schön suggested that this had some limitations, in that it might create some barriers if the action is thought about too much and over considered. He suggested that analysis after the action would lead to better understanding and learning, leading to future improvements. This is known as reflection-on-action Schön (1991). A second example of reflective frameworks comes from Dewey (1938), who suggested that we learn by the realization of our actions when doing something, the cause and effect of something, he suggested that every action we do is related to a previous action that we have subconsciously reflected on and learnt from.
Reflective models comprise of a series of headings or questions, designed to focus the practitioner onto their experience in a semi-structured way. An example of this is Gibb’s Model of Reflection (1988), developed from Dewey’s (1938) model of reflective learning and Kolb’s (1984) experimental learning cycle. Gibb’s model is a more commonly used, especially in healthcare for many reasons, however most often due to how simple and easy to use it is and the fact that is a model developed from education, which is ideal for the purpose of the model which is experience and further learning. Gibb’s Model is a cyclical model comprised of 6 stages, the use of prompt questions, guide the reflective process. The first stage is ‘description’, what happened in the critical incident or procedure? This is very basic and simply refers to what occurred during the action. This leads on to the second stage ‘feelings’ at the time what were you thinking and feeling? You might need to consider how you dealt with an emotionally difficult situation. Next is ‘evaluation’ what was good and bad about the experience? This refers to the main issues or points reflected upon. This leads onto ‘analysis’ what sense can you make of the situation? You might consider what knowledge you already had and where your knowledge was lacking, providing an indication of what needs further learning. Followed by ‘conclusion’ what else could you have done. Were there any points that you would change if the same situation was presented again? Finally, ‘action plan’ if the situation were to arise again, what would you do? This should be developed from the analysis part, what if any further learning is required. Gibbs Model of Reflection is most commonly used due to its simplicity and due to the fact that this model was devised from the learning observed between physicians and their students. It is however arguable that John’s (1995), developed from the work of Carper (1978) model with the use of structure and que questions, is much simpler to use. I have referred to the simplistic and easy to use nature of these models, but when evaluating anything you must look at many factors to get a full picture.
Bulman and Schutz, suggest that whilst there are many different models of reflection, with noticeable differences, there is however some similarities between them. The importance of analysis, feelings and the influence of one’s own learning, understanding and development, with the main emphasis on learning from experience. Bould et al. (1985) ‘Reflection in the context of learning is a broad term that encompasses the activities that create an individual’s experiences, which leads to new understanding’. However, Bulman and Schutz went on to suggest how each model is individual, this creates differences between them. Not all models recognise the need for change once an event has been reflected upon. They also suggest that some models outline the importance of reflecting with another individual, whereas academics put an influence on the importance of reflection in solitary, Johns 2009.
Coward (2011) suggested that the use of models has been proven to be beneficial in nursing, especially in clinical practice. The question, does the use of models for reflection restrict critical thinking and therefore learning? Especially in nurse education. Scanlan and Chernomas (1997), suggested that nurse education may simply be using reflection and models of reflection because, all other educators of nursing are doing so. The students themselves may not actually understand the philosophy, behind it, they are simply told to reflect in order to achieve academic grades. It may be possible that the process is over complicated, with the many different aspects involved, such as analysis and evaluation. Burrows (1995, p.347) suggests that the skill of reflection has become “pre-requisite”. It is also possible that reflection in nurse education is viewed in a negative way, as students are expected to reflect in a certain way in order to achieve the grading requirements.
Confidentiality is protected by common law as well as statue law under the Data Protection Act (1998) and the Human Rights Act (1998). This means that confidentiality is protected by professional codes of conduct and is a clear clause within all employment contracts, within the National Health Service (NHS) and the private sector. Confidentiality in the NHS can only ever be breached in exceptional circumstances, for example with the consent of the patient, if the law or courts dictates that the consent of the patient is not required, or through the Computer Misuse Act (1990). A further example of when confidentiality can be breached is in public Interest, this may be an individual or a group of people. This allows for discretion in certain circumstances, the law however does not state that the potential threat needs to be disclosed to the public, however it may be in the publics best interest to disclose the potential threat, this may be a terror attack or a notifiable disease such as Dysentery.
Consent is essential in Health Care, adults have the right to decide what happens to their bodies, they have the right to refuse treatment. There are legal and professional standard of consent to treatments for patients, whether this is as simple as applying a blood pressure cuff, or consent for open heart surgery, an adult has the right to decide for or against any procedure. There are however some requirements for consent to be accepted, the individual must have mental capacity; they must be able to understand the instruction or information given, believe the information, retain this information and then be able to repeat it. The individual giving consent must also do so without fraud or duress. Consent can be obtained in a number of ways, either; written consent, used for most procedures, patient must understand the risks and likelihood of any further procedures needed. In the case of Bolam 1957 (professional negligence), the risks to the patient (Mr Bolam) were not explained by the doctor. The patient received many fractures after his Electro-Convulsive Therapy treatment (ETC), where the doctor did not administer a muscle relaxant. The Case was taken to trial, but the doctor was not found negligent as he was able to gather supporting competent doctors, to testify that they support his method. Verbal consent, used for less risky procedures, such as taking blood. Alternatively, implied consent may be gained, this may be a patient removing their hearing aid for you to take their temperate. Consent usually only applies to adults, here classed as 16 years of age and older, however under the Gillick competency and Fraser Guidelines an individual under the age of 16 is able to make their own decisions of they are assessed to be competent enough. The Gillick competency comes from the case of Gillick v West Norfolk and Wisbeck Area Health Authority (1986), where Mrs. V Gillick took her local authority to court in order to prevent doctors being able to give out contraception advice and treatment to under 16s. The individual must be able to understand the advice and for it to be in the best interest of the child.
(in the second paragraph you say all the ward name have been altered, is it alright to say children’s outpatient department below?)
Whilst on a children’s outpatient department in a local hospital, as a student nurse I was introduced to a regular patient of the department. Eighteen-month-old Lilly, accompanied by her mother Kate. Lilly is an ex-premature baby, who has Downs Syndrome and chronic lung disease. Lilly was visiting the department to have her second out of four RSV (Respiratory Syncytial Virus) injections. This is an injection given to prematurely born babies during the winter period. The course of injections, usually last four to sixth months and helps to protect the babies against lung infections mainly bronchiolitis, which is an infection of the small airways in the lungs. Due to Lilly’s size, she requires a large dose of the Palivizumab, which is the medicate term for the RSV injection, this meant that she would have to receive two injections of Palivizumab at once. It is not vital for the two injections to be administered at once, but it is kinder for the child as they only have to receive the sudden sharp pain of an injection once.
Using Gibb’s Model of reflection, I will discuss the practical first-hand experience of an intramuscular (IM) injection of Palivizumab, addressing in particularly the topics of consent, communication, dignity and respect. My role in this procedure was to administer one injection along with my mentor. Whilst Lilly and her mother waited in the waiting room, my mentor and I drew up the solution into a 1mL syringe. Both syringes were checked by a community nurse working in the department to ensure that the dose was correct for Lilly’s weight. Once the RSV injection was checked to be correct, I called Lilly and her mother through into the treatment room. Due to the fact that Lilly is only 18-months-old she is not able to give consent to the procedure. Under the Gillick competence guidelines, Lilly’s mother must do so, even though Lilly was not able to understand I made sure to talk and smile to Lilly in order to try and keep Lilly calm. Whilst Lilly sat on her mother’s lap my mentor and I followed the correct procedure to administer the IM injection.
Firstly, I collect Lilly from the waiting room. I then showed Lilly and her mother to the treatment room and closed the door behind us. I then explained why Lilly was in the department that day, to receive her next RSV injection. I then procedure to ask Kate if she would allow me to give Lilly one the two injections she would be receiving that day.
Throughout the procedure, I felt very nervous as this was my first IM injection, due to the fact Lilly was so small I was not able to tell her what was going to happen, due to this I was not able to gain consent from her and I felt worried as she wouldn’t know what the procedure was or why she had to have the injection. After I had administered the injection Lilly became very upset, which made me feel worried that I had hurt her. The main point that I can pick up from that I believe I did we was I made sure to introduce myself, giving my name and explaining that I was a student nurse. Throughout the procedure, I believe that I maintained Lilly’s privacy and dignity by closing the door after she and her mother had entered the room. I communicated well with Lilly’s mother Kate, explaining why Lilly needed the injection and the potential side effects.
The Gillick competency 1984 guidelines set out by Lord Fraser, originally related to whether doctors could give contraception to girls under the age of 16 without their parents’ permission, however is now more commonly in any situation that would require medical consent. If a child of 16 was to be given an injection like the RSV injection that Lillie received, the health care professional would have to gain consent from that child to receive the injection. Due to Lillie’s age and lack of communication the consent must be gained from her mother. I made sure to explain again that I was a student nurse and that this would be my first injection I had given, I made sure that Kate would consent to allowing myself to administer the second injection. Even though Lilly had received previous RSV injections, which her mother had consented to. I made sure to ask if Kate would consent to Lilly receiving the injection. Once Kate had verbally consented to the injection I communicated to her the reason why Lilly was having the injection, to help protect her from Bronchiolitis which could be very serious for a baby such as Lilly. I explained what some of the side effects of the injection were and reassured Kate that they were unlikely. I made sure to protect Lilly’s dignity by closing the door after she had entered the treatment room. I believe that I effectively communicated with her mother to prepare her for the procedure and attempted to communicate with Lilly to reassure her. As previously mentioned to maintain Lilly’s dignity and privacy I made sure to close the treatment door behind us and only partially removed her trousers to her knees so that the injection could be safely administered in the correct place, but Lilly was still covered up.
I did talk to Lilly and try to communicate with her I believe that I could have communicated more effectively with her, this is something that I believe will develop as I work more frequently with children of a young age. After the injection, Lilly was understandably upset, my mentor helped to calm her down and made her smile, this is something that I would like to develop to help children such as Lilly have a positive experience of hospital.
If the situation was presented to me again I would ensure that I asked Kate if she had any questions or concerns about the injection itself or the possibly side-effects, communicating more effectively to her how low the risk of a side-effect is and reassuring her. I would also ensure that I would communicate more effectively with Lilly herself, working on how I deal with an upset child after an injection. I would like to reflect how my mentor calmed Lilly down and enabled her to leave with a smile on her face by smiling at her and through the use of toys and play reassuring her.
In conclusion, the main points that I can draw upon from this essay is the importance discussed by many academics of reflection in nursing practice and health care sector. The use of models and reflective frame works allow us to structure our recollection of an event or procedure leading to better analysis and understanding, highlighting areas where knowledge is lacking and providing a direction for learning and to improve future practice. The most common of which is Gibbs Model of reflection, due to its simplicity it allows for effective reflection and learning. This is something that I found when writing about my reflective account. Gibb’s model allows for an easy direction of flow for reflection and highlighted areas that I need to focus more on to improve my practice. Whilst other models and frame works have their strengths I believe that overall the simplicity of Gibb’s model is very effective in the nursing and healthcare sectors.