Reflection using Gibbs Reflective Cycle
I undertook a full assessment on a patient with a sacral pressure sore. The patient had limited mobility, dementia and does not speak. I completed the assessment using observation as a primary source. The care assistants were reluctant to engage with the nursing process rendering some specific measurements as ineffectual compromising the eventual Waterlow score.
I conducted the assessment with my mentor and gave a logical explanation how I administered the wound and gave rationale for the dressings I chose. I spoke to the care assistant to reiterate my action plan as it was pivotal to a successful wound healing.
Initially I felt confident. I had observed pressure sores before and I had prior knowledge of dressings and pressure relief. When I discussed about the patient with the care assistant, I ensured we were outside the bedroom as it unprofessional to talk over a client. The health records were of poor quality and had not been updated. When I mentioned this, the carer’s attitude became abrupt and I began to get defensive and made an inconsequential remark, “It does not matter”, just to reengage the carer. This remark I regretted as it undermined my authority and I appeared amateurish. Care records are a legal working document in progress. Poor record keeping will be detrimental to a client’s recovery and must always be challenged. I felt overwhelmed and looked to my mentor to support me.
My role in the nursing process enabled me to evaluate the patient’s wound and give an accurate descriptive account to my mentor. I provided evidence that consolidated my evaluating skills and put my basic wound knowledge into practice, within a safe nurturing environment. I rushed the assessment and regretfully completed it away from the nursing home. I found this frustrating as I could not explore the holistic process in greater depth and it simply became a checklist without breadth to the other client’s needs; dementia and poor communication, which I acknowledged fleetingly.
Payne (2000) identifies that professional partnerships are at risk if a nurse has insufficient knowledge required to perform ethically, thus undermining their own authority. The care assistant knew I was a student nurse and treated me, not as a partner in care but as a learner.
I failed to develop the partnership more and relied on my mentor too much when I conversed with the carer. I was looking for affirmation which was lacking within me. If I had communicated how significant the carer’s role was, this would have earned me more respect and empowered the carer.
Crawford et al (2005) believe empowerment inspires the self determination of others, whilst Fowler et al (2007) identifies listening skills and the encouragement in the participation of care motivates nurses to actively support changes in patient care. Entwistle and Watt (2007) remind practitioners that participation requires communication skills that are not universally possessed so nurses must be flexible in their approach to champion the participation of others. Using these concepts I could have built a rapport with carers, praising them for the care they provide, promoting partnership in care whilst emphasising the importance of the care plan.
I found it difficult to disengage from the patients many problems and only to focus on the wound. When choosing a suitable nursing framework, Roper et al (2000) describe care planning as a proposal of nursing intervention that notifies other nurses what to do and when. This model is used throughout the community and is thought to be a simplistic, easy to use everyday tool that enables nurses to identify actual and potential problems. Page (1995) had reservations about Roper, Logan and Tierney’s model, comparing it to a checklist which, if not used as the authors intended, can be restrictive in clinical practice as fundamental problems can be missed.
I used some of Page’s model as a checklist and not as a holistic assessment due to time constraints, the patient’s profound dementia, poor record keeping and being a novice assessor; however I was directed by my mentor to focus on the wound alone. It could be argued that community nurses working within care homes only prioritise physical needs from adapted assessments, as the care home provides the patient’s psychosocial needs. I identified from the patient’s assessment she was at the end stage of the dependence continuum, but I still recognised the importance of holism when completing the package of care and I identified that the promotion of comfort was as important as healing.
The main strength of my care plan was in identifying specific measurable outcomes exclusive to the client that were adaptable. I used evidence from reputable sources to identify suitable dressings to promote granulation and healing by sourcing up to date journals from the Cinahl and current trust policies. My weakness was relying on my mentor too much to confirm the evidence I collated on pressure care to the carer’s. Prioritising delegation and assertiveness as part of my learning needs I will now create an action plan that will ensure my future mentors will recognise the effort I extol to succeed in practice.
I conclude my implementation of the care plan was successful. The wound healed and the patient was discharged from the community case load. I demonstrated I can assess patients holistically, but require further practice when addressing client and carer concerns. To use nursing frameworks effectively nurses have to create an inclusive partnership with the client, family, professionals and care providers and demonstrate a broad knowledge of basic nursing care. Successful care plans are universal tools that empowerment others, giving them the direction to advocate safe holistic care based on evidence.
To encourage the participation of others I will become conversant in wound care. I will learn to identify the stages of healing by researching the biology of wound care. I will disseminate this to peers, as the sharing of knowledge is a fundamental part of holistic nursing care. As I develop from a supervised participant to a participant in care delivery I will continue to read research and reflect my practice on a daily basis. Creating new action plans that identify my learning requirements will address my limitations and by acknowledging them I will generate achievable goals to become a competent practitioner.
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1. Client pen portrait.
2. Plan of care
3. Wound evaluation
4. Activities of Daily Living
5. Waterlow Pressure Score
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Gibbs Nursing Model on Reflection
rodrigo | September 3, 2016
WritePass - Essay Writing - Dissertation Topics [TOC]
There are a number of different models of reflection that are utilised by professionals to evaluate past experiences. The two main types of professional reflection are reflection-on-action and reflection-in-action (Somerville and Keeling, 2004). Reflection-on-action encourages individuals to re-live past events, with an emphasis on developing a more effective action plan for any future, similar events that may occur. However, this type of reflection does tend to focus more on the negative aspects of our actions rather than the positive behaviours that were demonstrated during the event that is being reflected upon (Somerville and Keeling, 2004). Reflection-in-action is a deeper and more interactive form of reflection that encourages individuals to observe and reflect on past situations from the point of view of themselves and of others around them at the time of the event. Self-reflection and reflection upon events that happened within a work environment are important for individuals within the nursing profession (Paget, 2001). Reflection allows medical professionals to challenge and develop their existing knowledge, maximising the opportunity for learning and to avoid mistakes that may have been made in the past (Royal College of Nursing, 2012).
The Gibbs (1988) model of reflection suggests that the process of reflection is systematic and follows a number of specific steps in order to be successful. This model of reflection is a type of formal reflection, which draws on research and puts forward a theory as to how most effectively put into practice to process of reflection. The process can be broken down into six key steps:
- Description: this step explores the context of the event and covers fine details such as who was present at the event, where it happened and what happened.
- Feelings: this step encourages the reflector to explore their thoughts and feelings at the time of the event.
- Evaluation: this step encourages the nurse to make their own judgement about the event and to consider what went well and what went less well about the event.
- Analysis: this step delves even deeper into reflection on the event and encourages the nurse to break the event down into smaller episodes in order to facilitate analysis.
- Conclusions: this step explores the potential alternatives that may be used to deal with the situation that is being reflected upon.
- Action Plan: this is the final step in the reflection process. The action plan is put into place in order to deal more effectively with the situation if or when it may arise again.
The Royal College of Nursing (2012) believes the Gibbs (1988) model of reflection to be particularly superior because emphasises the role of emotions and acknowledges their importance in the reflection process. Nursing can often be an emotionally charged career, especially for nurses working in areas such as psychiatric health and palliative care. Therefore, reflection on these emotions and exploration of how to manage them and improve management of them in the future is of particular importance in the nursing profession.
Step One (Description)
A young male patient aged 16 years came into the clinic around three days ago. He complained of low self-esteem and is feeling fed up and depressed because of pimples and spots on his face. The patient was worried that girls would not be attracted to him because of the spots. The consultation took place with just myself present, no other nurses were in the room at the time of the appointment. The consultation lasted around half an hour, during which time myself and the patient discussed the history of his problems with his skin and the emotional distress that the spots were causing him. The patient disclosed that he had begun to get spots at around age 14 when he had started puberty and that it had begun to make him feel extremely self-conscious. The patient described the negative effect that the acne was having. For example, he has been bullied at school and is feeling apprehensive about starting sixth form in September because he believes that he will be the only sixth former with spots. Based on the reasonably lengthy history of the acne, the presence of acne on the face and the negative emotional effect that the acne was having, a three month dosage of oxytetracycline was prescribed for the patient.
Step Two (Feelings)
During the consultation I had a number of feelings. Primarily I felt sympathy for the client because his situation reminded me of my own time as a teenager. I suffered from bad skin from the ages of 14 to about 20 and it severely affected my own self-esteem. In a review of the literature, Dunn, O’Neill and Feldman (2011) have found that patients suffering from acne are more at risk of depression and other psychological disorders. However, the review also found that acne treatment may lead to improvement of the psychological disorder that are so often co-morbid. This made me feel re-assured that prescribing oxytetracycline had been the right thing to do. My own experiences of acne also meant that I was able to relate well to the patient. I also felt some anger during the consultation. This anger was directed at the patient’s peers who had been cruel enough to taunt and tease the patient because of his acne. I also felt regret and guilt. I regretted not referring the patient onwards for emotional support and for not exploring the psychological impact of the acne in more detail. I also felt a sense of pride that this young man had the courage to come to the clinic by himself to seek help for his acne. I remembered how upsetting acne was as a teenager and I remembered that I would have been too embarrassed to have ever gone to a clinic or to have sought help from an adult. In turn, I also felt happiness. I felt happy that this young man had come to the clinic and I felt happy that I was able to help him.
Step Three (Evaluation)
On evaluation, the event was good in a number of ways. Firstly it added to my experience of dealing with young people and in dealing with the problems that are unique to this population of patients. I have not had many young patients during my nursing career and I welcome the opportunity to gain experience with this group. Furthermore, it re-affirmed my career choice as a nurse. During your career you always have doubts as to whether you have chosen the correct path. However, there are points in your career when you feel sure that you have made the right choice. However, there were also some negative elements. Firstly, the appointment was quite short and I am worried that this may have made the patient feel rushed and uncomfortable. After the consultation I did some research into the effects of acne in young people. Purvis et al. (2006) have found that young people with acne are at an increased risk of suicide and that attention must be paid to their mental health. In particular, the authors found that directly asking about suicidal thoughts should be encouraged during consultations with young people. This information only served to make me feel more anxious and I wished that I had bought this up with the patient.
Step Four (Analysis)
On reflection, being able to relate to the patient increased my ability to deal more effectively with the situation. I feel that the patient was able to open up more to me because he sensed my sympathy for him and his situation. Randall and Hill (2012) interviewed children aged between 11 and 14 years about what makes a ‘good’ nurse. It was found that the ability to connect to them was extremely important and so I think this is why the patient felt comfortable opening up to me. On reflection, I am also now convinced that the patient coming to see me was a very positive event. The patient could have chosen to go on suffering and could have chosen not to open up and talk about the problems his acne was causing. In a review of the literature, Gulliver, Griffiths and Christensen (2010) found that young people perceived embarrassment and stigma as barriers to accessing healthcare. Therefore, it could have been very easy for the patient to have avoided coming and seeking help. I felt a range of both positive and negative emotions during the consultation, and I think this re-affirmed for me that I enjoy nursing and enjoy helping others. It is important to genuinely care about patients and to provide them with the best care possible. This would be hard to do if you did not feel empathy for patients. The experience also helped me realise that I need to actively search out training and learning opportunities regarding working with young people with mental health issues.
Step Five (Conclusion)
If the same situation was to arise again I think that I would approach it in a slightly different way. In particular, I would have offered to refer the patient to further support services. During the consultation the patient mentioned that he felt that the spots on his face made him unattractive to the opposite sex. In addition to providing medication to get to the biological and physiological roots of the problem, on reflection I think it would have been beneficial to the patient to have provided information about charities that offer self-esteem and confidence building. Such charities that offer these services include Young Minds (http://www.youngminds.org.uk/) and Mind (http://www.mind.org.uk/). In retrospect, I also believe that I should have given the patient a longer consultation time in order for us to have explored the psychological impact of his acne in more detail. Coyne (2008) has found that young people are rarely involved in the decision-making process when it comes to their consultations. Therefore, giving the patient more time to discuss his problems may have improved his sense of wellbeing as he felt more involved in his care process.
Step Six (Action Plan)
There are a number of elements to my action plan. Firstly, I will make sure that in the future the consultation room has leaflets and information pertaining to mental health problems in young people. This way, young people can access the information if they perhaps feel too embarrassed to talk about it. Hayter (2005) has found that young people accessing health clinics put a high value on a non-judgemental approach by health staff. Therefore, in future I would be sure to be aware of my attitude and make sure that either subconsciously or consciously; I am not making any judgements about the patient. Hayter (2005) also found that young people had serious concerns regarding confidentiality, especially during busy times at the clinic. Therefore, in the future I would be certain to reassure young people that their details and consultations are kept completely confidential. To re-assure young patients, I may ask them to sign a confidentiality form, which I will also sign in front of them. Furthermore, my action plan will include improving my knowledge and awareness of working with young people as a nursing professional. This will allow me to increase the tools and skills I have for dealing with young people with complex needs. During the consultation I felt anger toward the patient’s peers who had teased him. In the future, I will focus on being more objective when dealing with a patient who has been the victim of bullying.
Coyne, I. (2008) Children’s participation in consultations and decision-making at health service level: A review of the literature. International Journal of Nursing Studies, 45(11), pp. 1682-1689.
Dunn, L.K., O’Neill, J.L. and Feldman, S.R. (2011) Acne in adolescents: Quality of life, self-esteem, mood and psychological disorders. Dermatology Online Journal, 17(1). Available at: http://escholarship.org/uc/item/4hp8n68p [Accessed 20 October 2013].
Gibbs, G. (1988) Learning by Doing: A guide to teaching and learning methods. Oxford: Further Education Unit.
Gulliver, A., Griffiths, K.M. and Christensen, H. (2010) Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review. BMC Psychiatry, 10(1), pp. 113.
Hayter, M. (2005) Reaching marginalised young people through sexual health nursing outreach clinics: Evaluating service use and the views of service users. Public Health Nursing, 22(4), pp. 339-346.
Paget, T. (2001) Reflective practice and clinical outcomes: practitioner’s views on how reflective practice has influenced their clinical practice. Journal of Clinical Nursing, 10(2), pp. 204-214.
Purvis, D., Robinson, E., Merry, S. and Watson, P. (2006) Acne, anxiety, depression and suicide in teenagers: A cross-sectional survey of New Zealand secondary school. Journal of Paediatrics and Child Health, 42(12), pp. 793-796.
Randall, D. and Hill, A. (2012) Consulting children and young people on what makes a good nurse. Nursing Children and Young People, 24(3), pp. 14.
Royal College of Nursing (2012) An exploration of the challenges of maintaining basic human rights in practice. London: Royal College of Nursing.
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