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Introduction: Reflection is defined as an individual process which can lead onto new perspectives for nursing students and support contemporary means of gaining knowledge whilst developing clinical reasoning (Peate 2016). According to the Nursing and Midwifery Board of Ireland (NMBI 2015) reflective practice in nursing promotes and improves learning whilst providing high quality and safe patient care. Reflection can also be described as the cognisant synthesis of diverse perspectives which can be emphatically useful in developing professional confidence and competency (Sarikaya and Nalbant 2014).
In mental health nursing, reflection should be specific to the care which we confer on our clients and how it impacts on us both professionally and personally (Sumner 2010). This reflective assignment aspires to critically evaluate my own performance as a rostered nursing student during internship. I will analyse and evaluate my performance under three skill competency headings utilising the Gibbs Reflection Cycle (1988). Gibbs (1988) devised a theoretical framework which uses six stages to encompass the reflective process (Appendix 1). Applying Gibbs Reflective Cycle (1988) allows us to make sense of a particular situation by assessing our feelings, evaluating our effective practice and also understanding what can be improved on for future clinical practice (Ritchie 2012, Husebo et al. 2015). For the purpose of this personal reflection all names of staff and service users have been changed to protect confidentiality rights in line with NMBI’s Code of professional Conduct and Ethics (Nursing and Midwifery Board of Ireland 2015).
Case Scenario: Margaret is a 61 year old female who was admitted to an approved centre for clients suffering with dementia. Following an accumulation of worrying events two years previous, Margaret’s family decided to seek medical help. Margaret had become very withdrawn, forgetful, easily agitated and distressed, and eventually became quite aggressive which was extremely out of character for her. Margaret has a history of diabetes but had always managed it herself with no problems up until her recent cognitive decline. Margaret’s signs and symptoms of dementia progressed at an alarming rate and it has been very difficult for her family. Margaret no longer recognises her family, has developed dysphasia and has difficulty swallowing, has become doubly incontinent and her mobility has rapidly declined. A complication due to Margaret’s immobility are pressure sores on the sacral area which requires daily dressing, pain management and help to relieve pressure on the area.
Establishing Priorities of Care: In order to determine priorities of care the nurse must first establish specific treatment goals (Urden et al. 2016). By assessing the patient as a whole the nurse establishes clear therapeutic objectives, becomes aware of potential risk factors and can then begin to plan, implement and evaluate an effective and therapeutic care plan for the client (Kendall and Bergenstal 2001, Townsend 2014).
Description: On my first day as a rostered intern nurse I was immediately handed my own case load and informed that I was now Margaret’s key worker. I took a few moments to read over Margaret’s file and discovered that she was at a very restless and agitated phase of her illness. I then proceeded to enter Margaret’s bedroom to introduce myself and observed that she appeared to be quite distressed and felt that I would have a difficult task in establishing her priorities of care through verbal interaction.
Feelings: Digesting the fact that I was now Margaret’s key worker I felt suddenly nervous. As I entered Margaret’s bedroom and comprehended how advanced her illness was and how distressed she appeared, I felt an overwhelming rush of anxiety through my body and immediately began to doubt my abilities. As I held her hand and spoke softly to her I also became very emotional regarding how young Margaret was and how quickly her dementia had drastically changed her life forever.
Evaluation: While conversing with Margaret I could not gauge any valid information due to her dysphasia and hence used observatory assessment tools and previous clinical documentation to determine what her main priorities of care were. I felt that my use of assessment tools was a better approach to prioritise Margaret’s needs and my preceptor agreed and commended my clinical decision making skills. While discussing my emotional reaction to Margaret’s distress with my preceptor, she reassured me that it was a natural response and not to be embarrassed by it (Mafullul and Morriss 2000, Youssef 2016).
Analysis: The Waterlow Scale (Appendix 2) allowed me to assess Margaret’s pressure sore and her risk of developing more. As a diabetic, Margaret is also more susceptible to pressure wounds due to poor circulation and neuropathy along with her inability to move independently (Waaijman et al. 2014). My preceptor commended me for acknowledging such and my confidence in my knowledge was beginning to be restored. Margaret’s pressure sore needed a daily dressing change following specific guidelines set out by a tissue viability nurse, continued daily assessment for further pressure wounds, frequent rotational positioning, close blood sugar level (BSL) monitoring, medication management and full nursing care with regards to dietary and fluid intake and incontinence care.
Conclusion: I feel I could have handled the situation better by voicing my anxiety to my preceptor sooner. On reflection, although my learned knowledge on dementia, diabetes and pressure wound care from lectures and from evidence based research was highly applicable in this scenario, I also strongly feel that no amount of study can prepare a student for the direct experience and overwhelming feelings that are summoned by participating in clinical placement (Rassouli et al. 2014).
Action Plan: Going forward I endeavour to make my feelings and anxieties known to my work colleagues and will try to remember that I am after all still a nursing intern on a steep learning curve.
Medication Management: Nurses are perceived as pharmaco-vigilant intermediaries in the management of medications (Johnson-Pajala et al. 2015). Dementia clients in particular are seen to be at an increased risk of pharmaceutical misadventure and must therefore be appropriately assessed to determine their capacity for managing medication (Lehane et al. 2016). In many dementia cases medication is fully monitored and administrated by the nurse and has been found to be beneficial to patient outcomes both physically and mentally (Sorensen et al. 2016).
Description: Margaret was prescribed Insulin for diabetes, Memantin for dementia, Zimovane to aid sleep, Quetiapine for agitation, Clonazepam PRN for distress and Paracetamol PRN for pain due to her pressure sore. I felt confident in my abilities to monitor BSL’s and administer an insulin injection sub-cutaneously. However, I found that I did not have any knowledge of the medication Memantin used for dementia and I also became very aware of my inexperience in dealing with fluctuating BSL’s when checking Margaret’s BSL and discovering it was 3. 0mmols.
Feelings: I immediately reported the BSL of 3. 0mmols and was urgently advised to give Margaret Weetabix and a drink of Lucozade. I suddenly felt incompetent and frustrated with myself as I knew to do this theoretically but had never had any physical experience in treating a patient who had rapidly fluctuating BSL’s. I felt uneasy and anxious at how quickly Margaret’s BSL could change and how important frequent monitoring would be as her key worker.
Evaluation: Although I felt incompetent and anxious during this experience I also knew that I needed to report the low BSL reading to my preceptor immediately. During reflection, my preceptor asked me questions on when insulin is to be withheld, and when and why appropriate snacks are to be given to sustain BSL’s. I also relayed not knowing anything about the drug Memantin and my preceptor assured me that nursing staff are not always going to know every drug but must continue to educate ourselves as much as possible at every given opportunity (Sneck et al. 2016).
Analysis: I believe I could have been more assertive and clarified my knowledge of what BSL’s to take action on, when to withhold insulin and take a moment to look up the MIMS to gauge a proximate level of knowledge on unknown medications until I could conduct further research.
Conclusion: Margaret’s medication management proved to be more complicated than I anticipated and I soon learned once again that clinical practice and experience with physical patients would instil vital practical knowledge and improve my confidence and competency levels (Khalaila 2014).
Action Plan: For future practice, I will strive to ask questions at all times, report information especially if I am unsure or inexperienced in the area and I will try to ensure I am aware of all the medications that clients in my care are prescribed at my first given opportunity.
Teamwork and Collaboration: For successful integration of nursing care the identification of teamwork and collaboration is essential (Contandriopoulos et al. 2015). Teamwork helps preserve the fundamental principles of nursing values and supports evidence based practice and research (Evans 2015). Collaboration of multi-disciplinary teams is viewed positively by nursing staff and is seen as a major support in providing safer and high quality care for clients (Sollami et al. 2015).
Description: Margaret’s pressure wound was deteriorating and when changing her dressing I noticed a large amount of exudate at the wound site. Although Paracetamol PRN was administered 30 minutes prior to wound care, Margaret became very distressed and was obviously still in pain. As the day progressed Margaret refused to eat, drink, take oral medications and was observed to be flushed and perspiring. I immediately set about recording her vital signs. Margaret’s BP, SPO2 and respiration levels were all with normal rates however her temperature had spiked at 38. 3 degrees and her pulse was 122 beats per minute.
Feelings: I was immediately alarmed at Margaret’s increased temperature and pulse rate and instinctively felt that she had a possible infection. I quickly discussed a doctor’s review for Margaret with my preceptor who agreed and so I proceeded to ring the doctor on call. I was apprehensive as I had not carried out this particular procedure before unaided. I remained calm and reported over the phone on Margaret’s vital signs, her poor dietary and fluid intake and that I felt she needed immediate review.
Evaluation: Whilst awaiting the doctor’s arrival onto the unit I monitored Margaret’s vital signs closely, tried unsuccessfully to administer fluids orally and began to write a nursing note on these important facts. It was then I realised I had not reported on Margaret’s pressure wound, the excess exudate or how she became distressed during wound care to the doctor. I immediately panicked and confessed to my preceptor who assured me that all was in hand, proceed to do an Abbey Pain Scale Assessment (Appendix 3) and to ensure I relay all this vital information to the doctor during Margaret’s medical review.
Analysis: During the doctor’s review of Margaret I remained at the bedside and was sure to hand over all vital information. Due to the possible infection on Margaret’s pressure sore site, poor dietary and fluid intake, her increased temperature and pulse and the possibility that she was in great pain but could not communicate such, the doctor felt Margaret needed to be admitted to the general hospital for full blood tests, a swab of the infected site, and was a possible candidate for IV fluids, antibiotics and pain relief.
Conclusion: Margaret’s outcome was positive, her infection was treated appropriately and she returned to the unit 5 days later rehydrated and eating well. From now on, I feel that I will have more confidence in making decisions on when and why to ask for a medical review and will be more competent in relaying all the necessary information to the doctor present.
Action Plan: Although it was during a very busy time, I got a valued lesson in using the Abbey Pain Scale and will not hesitate to use this assessment tool on present and future clients of mine. It also made me realise how essential it is to carry out important assessments on clients, particularly when they cannot communicate appropriately themselves (Hadjistavropoulos et al. 2014).
Reflection conclusion: Reflective practice in nursing may be deemed a time consuming task to us as students and interns. However, when considering the process of the Gibbs Reflective Cycle as shown in this assignment, I now consider a reflective process to be a valid, effective and educational course of action. Reflection has vastly increased my self-awareness in that I always maintained good grades throughout college academically, but was still left personally and experientially unprepared for the different problems arising in Margaret’s case. I found that reflecting with one’s preceptor is also an essential part of the learning process as an intern. It gives ample time and a safe environment to disclose worries, ask questions, be constructively criticised but also commended where it is due. The reflective process as a whole can boost an intern’s confidence, increase vital competency in skills but most importantly allow an educational growth that will send us forth in our careers with a thirst for knowledge and new evidence based research and hence always seek the best way to care for our patients.
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