Reflective)Journal)) Regan Preston - 20825201 Unit: NURS8823 Prac Scholar: Vanessa Hicks 1 August 2012 )
Table of Contents Clinical Placement Reflection...3 Reflection...3 References...6 2
Clinical Placement Reflection This journal is to reflect on the situations that have taken place during my clinical placement at Sir Charles Gardiner Hospital, Emergency Department. This reflection is based on the Gibbs Reflective Cycle (1988) model. 1,2 The Gibbs reflection model consists of six stages to complete one cycle, which facilitates in my ability to improve my nursing practice continuously and learning from the experiences for better practices in the future. 1,2 The cycle starts with a description of the situation, analysis of the feelings, an evaluation of the experience, an analysis to make sense of the experience, a conclusion of what else could I have done and final stage is an action plan to prepare if the situation arose again. 2 Reflection is to generate practice knowledge, assist an ability to adapt new situations, develop self-esteem, adding value and professionalizing practice. 1,2 However, O Connor 2 explain that reflection is about gaining selfconfidence, identify when we need to improve, learning from our own mistakes, looking at other perspectives, and improving the future by learning from the past experiences. 2 Using a model of reflection enables me to explore and evaluate all previous clinical experiences. The model allows me to develop the skills to evaluate and navigate myself through the reflection process and identify areas of weakness or vulnerability, and laying a platform to upgrade skills to overcome these deficiencies. Cornerstone to the reflective process is the understanding of the Australian Nursing & Midwifery Council (AMNC) national competency standards for registered nurses. These core competency standards by which a nurse s performance is accessed in obtaining and retaining a license to practice. 1,3 Linked together with evidence based theory and practice, reflection will assist me in my professional development towards becoming a more competent nurse. 4 Reflection On an early morning shift, I was placed in resuscitation section of the emergency department (ED). During the shift, the ED ward clerk advised the trauma team that a category 1 emergency was scheduled to present within five minutes, via ambulance. The patient was a 74-year-old male, who had suffered a suspected heart attack. I assisted and observed the trauma team assemble and prepare in trauma bay one, in anticipation of the patient arrival. The atmosphere was very calm, although extremely dutiful, with all members of the team performing there tasks very purposefully. As the patient arrived, the entire team sprung into action and received 3
handover from the ambulance paramedics. It was confirmed that the patient had suffered a heart attack, and Cardiopulmonary resuscitation (CPR), had been commenced by ambulance paramedics. Unfortunately the patient presented with a non-shockable heart rhythm, so a defibrillator could not be used. After administration of fluids and cardiac drugs, and continued CPR, the patient was still unresponsive. At this time nursing students, and I, were given the opportunity to perform CPR on the patient, and gain valuable experience in performing this intervention. Nevertheless, after five minutes the head emergency consultant advised team to seize CPR, and called the time of death of patient. This was my first experience with a trauma death. Following this trauma, and subsequent death of the patient, for a period of time, it seemed surreal, as the entire trauma team went about their business performing bereavement procedures in a professional clinical way. The emergency consultant approach me and fellow students and asked if we all felt okay, and ran through the CPR process with us, offering us valuable critique on our CPR methods. As we left the trauma bay, I reflected with my fellow nursing student piers on the death, and briefly discussed our mixed emotions. I felt very sad for patient, thinking of the grief and pain this loss would bear on his family. In addition I was very surprised to notice how as a student group, no one displayed any emotional anxiety or distress. This made me feel in somewhat guilty, due to my lack of emotion at time of patient death. On evaluation and analysis, themes and feeling of dread and terror, anxiety, feeling scared, helplessness, guilt, sadness, frustration and emotional breakdown are part of providing care to patients in the dying period. 5-8 Caring and treating dying patients is a major stressor in nursing practice. 9,10 Nurses in critical care environments are constantly faced with patient death and in addition face stressors such as fast paced work settings and extensive levels of stress associated with high tech complex care. 6 Nurses experience and are confronted with death in every day work, and hence as exposed to many emotional aspects of grief. 6,10 Studies done with female nursing students facing patient death for the first time, four major themes were evidenced. 11 These were namely the uniqueness of the new experience of patient death, overwhelming sense of awe at moment of death, sadness due to patient death and reflection and evaluation of own personal beliefs with regards to death. 11 4
Loftus (2004) 10 evidenced that many people grow up in western society, not exposed to death, and in most cases are protected or shielded as children from experiencing death. 10 Hospitals are viewed as institutions were patients only recover from illness, disregarding the reality that more patients die in hospitals than at home. 10 This concept in itself makes for very little preparation or insight of young students facing realities of patient death. 10 The reality is that nurses spend more time with patients that any other medical clinicians. Part of the nursing role it to provide compassionate care, and dignity to patients. As nurses we need to be adequately prepared for patient death, and training to deal with death is vital element in student preparedness for death. Solid base of training in this regard enables students to cope better and have a more positive outlook on dealing with dying patients. 5 Personal development, continued education, promoting ethical care, patient advocacy are practices, as nurses, we are bound by, as stipulated in the professional code of conduct umbrella we practice under. (ANMC Competency elements 1.1-3, 2.3 3.1-4, 4.2-4, 3.5, 9.3, 10.4). 3 Nurses repeated exposure to death and grief could lead to work stressors, and burn out. Furthermore this can lead to emotional care disengagement from dying patients, which has a serious impact of level and quality of care given to dying patients. 6 As nursing students we are bound by the ANMC professional code of conduct, to provide to out patients the highest level of care, and source help and assistance in coping with stressors faced in the workplace, and not letting these affect patient healthcare outcomes. (ANMC Competency elements 1.1-3, 2.3 3.1-4, 4.2-4, 7-1-4, 3.5, 8.1-2,9.1-5, 10.1-4). 3 Cooper and Barrett (2005) 12 highlight the importance of nurse education in dealing with patient death. 12 Education facilitates critical thinking and deeper reflection. Experiments preformed have shown that nursing students anxiety scores decreased significantly following patient death education. 7,8 Reflection is a key element in nursing practice, Freshwater et all (2005) 12 evidenced how reflective practice is a successful method used in nursing practice, and successfully can be integrated with nursing education. 8,12-14 Student nurses need to reflect of their personal experiences throughout their practice, and this reflection process will enable student to earn from past experiences. 10 Processes like storyboarding facilitate for deeper reflection and critical thinking. 10,12 Storyboarding is the process that encourages clinicians to use the right side of the brain to formulate ideas, expressed in a group, and critical analysis of these thoughts and reflections. 10,12,14 In future, my action plan will reflect that I have come to the realization and understanding that patient death is an integral part of nursing practice. Strong preceptor, mentors, and support from all members of the multidisciplinary team have positive implications of nursing students coping 5
with stressors of patient death. 11,13,14 Qualified nurses and experienced clinicians in the critical care environment are able to offer support to inexperienced nursing students, their life experiences with death, transferred to less experienced students. 9,13 Beck (2002) 7 evidenced that one of the most successful models of learning for nursing students is observing and emulating expert role models, who ultimately act as mentors and instructors to student nurses. 7 Part of our professional practice is to embark on gaining further and additional education in this area, resource education that raises awareness to factors that affect nurse s grief, developing appropriate coping strategies, adequately preparing student nurses for entry in practice as registered nurses, and an important aspect of critical care nursing. 8,11 In my future practice I will utilize continual reflection, trying to discover new ways of thinking about dying, overcoming old fears, and achieving self growth, so as to become a more professional and holistic nurse, delivering the highest level of quality care to my patients. References 1. Crisp. Potter and Perry's fundamentals of nursing, Jackie Crisp; Catherine Taylor; Anne Griffin Perry; Patricia Ann Potter; Amy Hall; Patricia A Stockert 2009, Chatswood, N.S.W. : Elsevier Australia 2009. 2009. 2. O'Connor E. Ellen O'Connor. Foundations in Nursing and Health Care: Beginning Reflective Practice. Association of Operating Room Nurses. AORN Journal. 2007 Feb 1;85(2): 429. In: Health Module [database on the Internet] [cited 2011 Jul 6]. Available from: http://www.proquest.com.ezproxy.library.uwa.edu.au/; Document ID: 1214516671.; 2007. 3. ANMC. In: Australian Nursing & Midwifery Council. National Competency Standards for registered nurse. 2011 4. Hoffmann. Evidence-based practice across the health professions,tammy Hoffmann Sally Bennett; Chris Del Mar c2010, Chatswood, N.S.W. : Churchill Livingstone, c2010.; 2010. 5. Huang X, Chang J, Sun F, Ma W. Nursing students' experiences of their first encounter with death during clinical practice in Taiwan. Journal of Clinical Nursing. 2010 [cited 30-07- 2012];19(15-16):2280-2290. Available from: jlh 6. Shorter M, Stayt LC. Critical care nurses experiences of grief in an adult intensive care unit. Journal of Advanced Nursing [Article]. 2010 [cited 30-07-2012];66(1):159-167. Available from: a2h 7. Beck CT. Nursing students' experiences caring for dying patients. Journal of Nursing Education. 1997 [cited 30-07-2012];36(9):408-415. Available from: jlh 6
8. Thompson GT. Effects of end-of-life education on baccalaureate nursing students. AORN Journal. 2005 [cited 30-07-2012];82(3):434. Available from: jlh 9. Hopkinson JB, Hallett CE, Luker KA. Everyday death: how do nurses cope with caring for dying people in hospital? International Journal of Nursing Studies. 2005 [cited 30-07- 2012];42(2):125-133. 10. Loftus LA. Student nurses lived experience of the sudden death of their patients. Journal of Advanced Nursing [Article]. 1998 [cited 30-07-2012];27(3):641-648. Available from: a2h 11. Kelly CT. The lived experience of female student nurses when encountering patient death for the first time: Adelphi University; 1998 [cited 30-07-2012]. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=jlh&an=2004134043&site=ehost-live 12. Lillyman S, Gutteridge R, Berridge P. Using a storyboarding technique in the classroom to address end of life experiences in practice and engage student nurses in deeper reflection. Nurse Education in Practice. 2011 [cited 30-07-2012];11(3):179-185. Available from: jlh 13. Parry M. Student nurses' experience of their first death in clinical practice. International Journal of Palliative Nursing. 2011 [cited 30-07-2012];17(9):448-453. Available from: jlh 14. Miyashita, M. "Nursing autonomy plays an important role in nurses' attitudes toward caring for dying patients." The American journal of hospice & palliative care 24.3 (2007). 7