Reflective Writing on Intramuscular Injection

I am a first-year student, the nursing skill I am going to use in this reflective account is administration of IM Injection and the reflective model I will be using is Gibbs cycle. The name of the service user in this assignment has been changed to protect his confidentiality, in accordance with The Nursing & Midwifery Council (2018) code 5 which state that as a nurse or midwife, you owe a duty of confidentiality to all those who are receiving care.

IM injection could be long or short acting antipsychotic injections (LAAIs) that are indicated for the maintenance and treatment of Schizophrenia, Mania and other psychoses (Sussex partnership NHS, 2018).

The incident I am going to reflect on happened on an acute inpatient mental health ward I was posted to, as a student nurse for my 1B placement, Kevin (pseudonym) was admitted under section 3 of the mental health suffering from paranoia and acute psychosis. My mentor asked me to administer the IM injection because Kevin has been refusing his medication for a few days and he is now constituting a danger to himself and other patients on the ward and has been prescribed Lorazepam IM injection.

I felt confident and competent about the task because I have done lots of depot injection on my 1A placement at the depot clinic at Aylesbury and I will be able to fulfill one of my competencies, I was also apprehensive because I have never given IM injection in a ward environment. A control and restraint team was in attendance because of Kevin’s history of violence, although we were expecting compliance, because at that moment Kevin was settled and was with his family. As my mentor and I approached Kevin, he became increasingly agitated and paranoid, he jumped up trying to assault staff, he was held in restraint, moved to the de-escalation room and forcibly injected with the IM lorazepam by me, during the restraint he sustained fracture to his wrist and big bump to his head which necessitated calling out the Duty Doctor. His family was on the ward while all this commotion was going on, and it caused them much distress.

My initial feeling was shock and surprised at how the situation was unfolding, as this is the first time I am giving anyone an IM injection under control and restraint or even being involve in this kind nursing activity, I feared making mistake and giving the injection in the wrong place, I also feared mistakenly giving myself or my colleague needle stick injury because of the how chaotic the restraint was. I felt helpless and scared that either the patient or staff may suffer some injuries because of the control and restrain. I was also apprehensive that the patient could single my mentor or me out for retribution because my mentor and I were the only ward based staff involved during the restraint. At the end of the activity, we had a team debrief, although I was reassured that it is for the best interest of the patient to be medicated, I still felt doubt about the way the situation was handled by the team, which I expressed to my mentor later.

I understand that the process of gaining control over an unwilling patient for medication could be chaotic, messy, haphazard and sometimes dangerous, but in this case, the experience impacted on me negatively by the level of violence that was used and was concerned that the organizational policy was not followed. I believe it was irresponsible of the team to restrain Kevin while the family was around. The team and myself failed in our duty to protect Kevin and his confidentiality by restraining him in front of his family, this can be explained by Rutkowski’s (1983) theory of group cohesiveness. The theory showed that a group is more likely to act in accordance with the perceived social norms if there is a high level of group cohesiveness (Rutkowski’s 1983). The team have a low level of cohesiveness because the control and restrain team was formed by nurses from other ward and were not familiar with Kevin or the surroundings at which the control and restrain is to take place.

Further work by Koocher & Keith-Spiegel (2010) also demonstrated that irresponsible professional behaviour can be averted by informal interventions and the reality is that, not all nurses follow procedure correctly and if there is misconduct in the nurse’s actions before or during the restraint, it should be referred to the Ward Manager for formal action.

At the end of the nursing activity, I felt both physical and emotional responses, and all are important part of learning process. Having not given IM medication in that kind of situation before increased my anxiety and I felt physically sick, even though I have given IM injection a lot of time before, and I also felt I must hold my tongue and not voice my frustration so as not to be seen to be splitting the team, during the restraint. Both my mentor and I should have intervened quickly to stop the restraint when we saw that Kevin was with his family and delay giving the medication till when the family leave. The planning and execution of the whole administration of IM injection was haphazard bordering chaotic. I understand that an informal intervention as described by Koocher and Keith-Spiegel would have been appropriate to address this with all the staff involved situation.

Having witnessed the distress caused to Kevin and his family by the incident, I now understood my mentor and I should have assertive during the planning of the control and restraint and insisted either we wait till the family leaves or move them to other part of the ward where they would not hear what was going on, to minimize distress to Kevin and his family and not to breach Kevin’s confidentiality. It takes courage to be advocate for patient and I hope to do better next time and lastly, I learnt about giving IM Injection under a challenging environment like during control and restraint. If faced with this kind of situation again, I will insist on proper planning for all eventuality and insist on having regular ward staff to be present as part of the control and restraint team to reassure Kevin. Family Involvement is also important, if they were involved, they could have help to reassure Kevin and to encourage Kevin to take his medication. Lastly, I will report the issue of confidentiality to the ward manager.