Reflective Practice

Dawn Clark

Diploma level 5 in Leadership for Health and Social Care

Unit SHC52 – Promote Reflective Practice

Outcomes: 4.1, 4.2, 4.3 and 4.4

Within my role as Manager of a Nursing Home I am frequently involved in situations whereby I need to make decisions and act quickly. The role demands strong leadership skills, financial management skills, and the ability to deal effectively with many people from many different backgrounds and on different levels.

The manner in which I deal with each situation that presents can be influenced by many extrinsic factors such as the individual person at the centre of the event, including the manner in which they present themselves, their capacity to understand and make decisions, time and financial constraints and pressure from others involved.

I find reflective practice useful to identify what went right or wrong and to consider how things could be improved for future experiences. It is crucial that I develop professionally and learn through these experiences by reflecting on them. If I did not reflect on them I would not learn from them, and consequently not develop on a professional level.

Whilst working in an extremely busy environment it is necessary to move quickly from one task to another giving little or no time for immediate reflection. It is important that I consider what I am doing whilst I am doing it, to ensure it is done effectively. It is easy to be distracted by thinking about the tasks that will follow which will affect the effectiveness of the task in hand.

Reflective practice enables me to identify shortfalls in my knowledge and skills, analyse the effectiveness of my communication and strength of my relationships with others.
This allows me to improve collaborative working.

I find de-briefing an effective way of reflecting for the whole working team, especially following a particularly upsetting or disturbing event has taken place. It is vital that we allow those involved and affected by the event the opportunity to air their thoughts and feelings. Regular supervisions and annual appraisals with all staff members enable me to monitor their progress as individuals and highlights which areas they require support and development within their job roles, to allow them to reach their full potential.

As professionals we reflect on our practice on a daily basis and ask ourselves questions relating to incidents and events, such as:

Did I make the right decision?
Do I feel good or bad about the outcome?
What else could I have done?
If it happens again will I do the same or do it differently?

Dawn Clark

Graham Gibbs (1998) developed six stages to reflective practice which make up a continuous cycle. Gibbs encourages us to take into account our feelings and emotions when reflecting on situations making this a popular model for use in health and social care reflective practice. See diagram of Gibbs Reflective Cycle below

[pic]

(www.mini.blogspot.co.uk/2011/03/gibbs-reflective-cycle.html)
Dawn Clark

Chris John’s model arose from his work in the Buford Nursing Development Unit in the early 1990’s. He envisaged this model as being used within a process of guided reflection. His focus was about uncovering and making explicit the knowledge that we use in our practice. The framework uses five cue questions, which are then divided into more focuses to promote detailed reflection. (www.communityhealthcarebolton.co.uk)

1. Description of the experience • Phenomenon – describe the here and now experience • Casual – what essential factors contributed to this experience? • Context - what are the significant background factors to this experience? • Clarifying – what are the key processes for reflection in this experience?

2. Reflection • What was I trying to achieve? • Why did I intervene as I did? • What were the consequences of my actions for: o Myself? o The patient / family? o The people I work with? • How did I feel about this experience when it was happening? • How did the patient feel about it? • How do I know how the patient felt about it?

3. Influencing factors • What internal factors influenced my decision – making? • What external factors influenced my decision – making? • What sources of knowledge did / should have influenced my decision – making?

4. Could I have dealt with the situation better? • What other choices did I have? • What would be the consequences of these choices?

5. Learning

• How do I now feel about this experience? • How have I made sense of this experience in light of past experiences and future practice? • How has this experience changed my ways of knowing o Empirics – scientific o Ethics – moral knowledge o Personal – self awareness o Aesthetics – the art of what we do, our own experiences

Dawn Clark

My following reflective piece refers to a true to life experience which placed pressure on my nursing team to make immediate decisions at the end of a service users life in order to carry out their personal wishes.

The service user was terminally ill and suddenly deteriorated to end of life stage. The service user became quite agitated and no medication was available to alleviate their symptoms. The sudden decline was not anticipated and was consequently traumatic to staff members and the service user. Staff had no alternative but to call the emergency services for support and assistance as the event occurred outside of GP hours.

This was done in the hope that the appropriate medication would be administered to allow the service user to settle and pass away peacefully within familiar surroundings surrounded by family and familiar care staff.

Next of kin were contacted by the nurse in charge of the shift, but because they lived abroad it was evident that they were very unlikely to be able to reach the service user before death occurred. This meant that the decision to implement a “do not resuscitate form”(DNAR) had to be made immediately before the ambulance crew arrived. This is because of their policy and procedure which leaves them otherwise with no alternative but to attempt resuscitation.

The decision of the family was to implement a DNAR to follow the previously discussed wishes of the service user. The nurse in charge organised the appropriate form and submitted this to the ambulance crew upon their arrival.

When the ambulance crew arrived they were not entirely happy that the DNAR had just been completed and wanted to take the service user into hospital. This would have been against their wishes. I explained the history and the personal wishes of the service user and requested that appropriate medication was accessed to settle them.

By this time many family members were at the bedside and they too were clear in stating that they all knew the service user would not want to die in hospital or even worse, en- route to the hospital. They had already expressed that their preferred place of care was the nursing home. I gave them reassurance that I would do all I possibly could to ensure them that they remained at the home.

The conscious level of the service user at the time was variable, but when asked the vital question with regards to hospital admission they were able to convey their wish to remain at the home. They had full mental capacity to make this decision.

In light of this the ambulance crew turned their attention to accessing medication as soon as possible from an external source which was Marie-Curie Rapid Response Team. Between them they organised medication to be brought to the home as soon as they possibly could.

The service user died very peacefully surrounded by his family and care staff within the home.
Dawn Clark

Following this event I reflected intensely what lead up to it and the aftermath caused by it.
Using the Gibbs Reflective Cycle (1998) I began to reflect on the experience and the effect it had on all of the individuals involved.

Description

Service user at the end of life with no DNAR in place but wanted to remain at the home to die.

Feelings

I was anxious on behalf of the service user, fearful that the event may result in hospital admission against their wishes. I was also frustrated with the fact that the system could have overridden the service user’s personal wishes. The family and staff member’s involved experienced sadness but also relief that the service users wishes were upheld.

Evaluation

Within reflecting on this experience there were several negative and positive points.
I draw firstly on the negative points.
The event put the nurse on duty under great pressure to prepare a DNAR immediately.
Because the event could not be anticipated, family were put into a difficult position to make an immediate decision.
Service user became anxious and agitated at the end of life.
Conflict arose between my own staff and emergency services with regards to best interests of the service user.
Due to the sudden decline of the service user, some family members who lived abroad were unable to be with them when they died.
Nursing and care staff were extremely upset and disturbed by the experience.

On a positive note, the service user maintained their right to die naturally with dignity and within their preferred place of care, surrounded by family.
Staff members were able to provide quality care for the service user and give vital support to the family members.

Overall, the desired outcome was achieved but not without difficulties.

Analysis

Medical professionals exercising their roles and considering their own accountability meant that the service user was caught in between their differing priorities.
This would not have been the case if the correct medication had been available before the event.

The service user was suddenly in the last few hours their life but a vital document which would have avoided hospital admission was not in place due to family not making the decision to discuss end of life wishes at an earlier date.
Dawn Clark

This in turn left the service user, family and staff members in a vulnerable position.
Medication which could have settled service user was not available instantaneously for use by the nurse on duty due to sudden decline in service user’s health which could not be anticipated.
The result of the experience left staff members anxious and emotional whilst having to remain professional in order to provide support to the service user and the family members.
Family members displayed signs of anxiety and profound sadness.

Conclusion

Reflecting on this experience I have realised the importance of expressing the need to service users and their family to make decisions relating to end of life care.
Although this is a subject which many people prefer not to discuss, it is clear that decisions need to be made before the event occurs. This would avoid any undesirable outcomes.
As professionals we need to anticipate when to access just in case medications from the service user’s GP, to avoid the onset of symptoms which we could not manage otherwise.
This would have given me the opportunity to settle the service user at the onset of the symptoms. This would have met a more desired outcome for all involved.

It is plain to see why so many health professionals use the reflective models created by Gibbs and Johns. The models focus on emotional aspects of experiences which relates well to caring for people.

On a personal level I prefer to use the Gibbs model of reflection as I find it appropriate and easy to apply.

Action Plan

Discuss end of life decisions on admission.
Anticipate need for just in case medications at an earlier stage if appropriate.

Words - 1941
Dawn Clark

References

www.communityhealthcarebolton.co.uk

www.nursemini.blogspot.co.uk/2011/03/gibbs-reflective-cycle.html

References: www.communityhealthcarebolton.co.uk www.nursemini.blogspot.co.uk/2011/03/gibbs-reflective-cycle.html