Introduction
Nursing is a profession that aims to uphold every client’s health by preventing diseases, and by maintaining or improving one’s health status (Sundean, et al., 2019). Nurses play different roles in providing health care – the role of an educator, a caregiver, patient advocate, and counsellor are some of the numerous responsibilities they carry on their shoulders; not to mention the complex environment where they play their part as well as the assortment of patients, they render their service to (Royal College of Nursing, 2018). According to Cardillo (2013), nurses may function independently in delivering nursing care and would also have to function in collaboration with other health care professionals, physicians and pharmacists, for instance.
The nursing process, which includes assessment, planning, interventions, and evaluation, is an approach used by nurses in providing efficient nursing care. It is critical that the nursing interventions delivered to patients are harmless and effective. In the UK, like in any other country, the nursing and midwifery sector is directed by rigorous standards and guidelines, ensuring that every nursing intervention is safe, patient-centred, culturally sensitive, and evidence-based.
The Nursing and Midwifery Council (2018) has to work towards The Code for nurses and midwives in a constant basis, with the main values of prioritising people, practising effectively, preserving safety, and promoting professionalism and trust. This is to set the principles and guidelines of how nursing professionals should function, and what the public should expect from them (Brown, 2014). The standards of nursing practice should be well implemented for the profession to maintain quality care and deliver the best health outcomes possible. Also, this is to halt incidences of negligence, medical accidents and malpractice made by Registered Nurses in the care field.
Furthermore, PASC (2015), in their investigation on the clinical incidents in the NHS, has reported that there are about 12,000 avoidable hospital deaths in the UK every year. Worldwide, some of the causes of nursing malpractice are errors in medication, failure to properly monitor, routine procedures such as starting an IV, and documentation errors (The Oshman Firm, 2019). These avoidable health care related incidents should be stopped, or at least kept at the very minimum, and it is crucial that health care providers look for ways to improve their practice.
One of the most efficient ways to improve nursing interventions and care processes is through reflective practice, which is described as the process where a health care professional reflects on their previous experience from a certain clinical practice. This experience may either be a good experience or a distressing and difficult one, as long as there is something that the professional could acquire learning and insights.
Reflective practice is done to be able to look back at a specific previous clinical experience, pay critical attention to one’s actions, and to examine whether such actions are helpful or not (Galutira, 2018). In essence, this is an activity to promote the process of continuous learning and health care improvement. There are many models of reflective practice, which is widely used by many health care professionals, including the models of Borton (1970), Gibbs (1988), and Johns (1995).
In this paper, I aim to reflect on a certain clinical experience which commenced on my first placement in a surgical ward setting. I would also discuss group clinical supervision where I would shed light on the importance of speaking up and posing a challenge in the process. However, at the same time, it is also important to work under supervision because doing things on your own may not be aligned with the objectives of group clinical supervision. Throughout the process, I will be utilising Graham Gibbs’ Reflective Cycle (1988) as the model for my reflective practice. I believe this model would help me demonstrate my understanding of the implications and consequences of my previous actions in a certain experience, and how nursing principles influence nursing practice. Furthermore, my values and beliefs, as well as my feelings and realisations from experience, will also be recognised. Finally, my learning from reflective practice and its impact on my future nursing practice will also be exemplified.
Gibbs’ Reflective Cycle (1988)
The Gibbs’ Reflective Cycle includes 6 phases of reflecting from a previous experience which includes: (a) description of the event; (b) the feelings of the one reflecting regarding the experience; (c) evaluation of the event, including what transpired good and what did not; (d) analysis of the event or what could be learned from the previous experience; (e) conclusion of what could have been done in the event that could have improved the outcome; and (f) action plan or the strategies and actions to be executed should the same nature of the event arose in the future practice.
Description
The particular event took place during my first placement in Year 2. I was given a chance to handle a post-surgery patient in the Surgical Ward, Patient A, a 38-year-old female who had undergone the procedure hysterectomy. It was on her first-day post-surgery when I first encountered her on a night shift.
After the handover, we proceeded to the bay to meet the patients that were appointed to our care. Patient A, who was lying on her bed at the time, greeted us with a smile where I enthusiastically introduced myself as a student nurse assigned to her care for the shift. Subsequently, I asked my mentor if I could assess her for her vital signs, but my mentor told me there’s no need for it since Patient A’s vital signs were taken by a staff an hour ago. It was a good beginning when I and my supervision group started to provide care to the patient. In group supervision, the importance of a mentor is very high. My mentor helped me during the treatment procedure. My mentor was guiding and instructing me to do things right, and she also pointed towards my responsibilities being the group member.
After that, I instructed Patient A just to call our attention should she need any assistance or if she has any concern, then we left her room. My mentor went with another student nurse to another patient to do a procedure. I asked my mentor if I could go with them so I could assist with the procedure or observe at least; however, I was told by my mentor to go back to Patient A instead and provide her with a washing bowl for her to use. My mentor was relaxed, and she did not advise me to take any special action when I was about to provide the patient with medical treatment. When my mentor sent me to Mary, she did not state anything. She might have thought that I knew all that should be done.
I gave the patient a washing bowl and asked her to call my attention after she finished. When she was done, she started to complain that she felt dizzy, nauseated, and claimed that she felt like she was about to faint at any moment. I immediately asked for help, and we assisted her to go back to her bed to rest. When my mentor and other staff members were already in the room, I assessed the patient’s blood pressure, which was extremely low at 88/49 mmHg. Her blood pressure was recorded and she was subjected to other examinations by the physician.
After the incident, my mentor told me that she was very upset with my actions, in which a patient following gynaecological surgery, especially Patient A who had undergone a surgical procedure, should never be allowed to get out of bed unless their blood pressure level was assessed to be at the normal range. I told my mentor I was extremely sorry for what had happened, but I also voiced out my position- I was told to assist Patient A without any supervision and to teach proper procedures and protocols. Also, I asked my mentor if the incident will be reported to the ward manager, in which my mentor sadly told me she needs to report it, and she was sorry. I realised that after the mistake, there was a series of suggestions for me, and I found it difficult to adjust to the situation. There should have been proper communication plan before starting the task
During my placement in year 2 in the surgical ward, I learnt the importance and impact of group clinical supervision where a group of students communicate together for the betterment and reflect on their experience. There is a need for fast communication in group clinical supervision where all of the information cannot be communicated all the time. I present, the case of Mary and her assistance can be taken as a case where she feels dizziness in an attempt to come out of the bed. I was abiding by the advice of my advice as she told me to assist Mary. The reason for dizziness was low blood pressure of Mary, and my mentor said why I did not check the blood pressure before Mary leaving the bed. It is always the case to check the blood pressure of gynepatient before getting the patient out of bed. I should have abided by general rules, and I should have followed my mentor’s directions after following these general guidelines. Moreover, we took charge of the night staff, and we should have communicated with the staff about conditions and precautionary measures for the patient. It is fundamental in group clinical supervision to keep communicating about all details in the group.
There was not much discussion when we took the tasks from the night staff. Group supervision could not be effective if there was no communication in the group. My mentor and my colleagues did not share their views, and I was also not able to share my views because of lack of communication. It made things worse because there was no communication. My mentor also told me to get help from the ward manager if such an incident happened. I said after the incident that we should have a meeting before getting the responsibility from night shift. It gave me the lesson that sharing, and communication are always helpful, and it should have been there in the group supervision.
Feelings
My thoughts and feelings regarding my experience were a mixture of embarrassment, guilt, ire, and appreciation.
After the event with Patient A, I felt embarrassed for my actions where I was not able to follow protocols and the nursing process in my nursing interventions. Before our placement, I already learned during the lectures about the nursing process, which includes the assessment, planning, interventions, and evaluation. According to Stonehouse (2017), the Nursing Process is a valuable tool that is utilised by nurses to facilitate successful nursing care, which would subsequently promote better health outcomes.
I also felt some resentment about the action of my mentor at the time. I felt like it was not my fault because I was just asked to assist the patient without providing me proper instructions, and in return, the incident was reported to the ward manager where I felt like the blame was directed at me.
Also, during my reflection of the event, I felt guilty about what could have possibly happened to the patient. Hysterectomy is described as the surgical procedure of removing the uterus (NHS, 2019). It is a gynaecological procedure, which, according to Fleisch, et al. (2015), involves precautions in positioning. Furthermore, positioning injuries to post-hysterectomy patients could pose great harm; such instances could be identified as negligence or malpractice and therefore, should be prevented.
After realising it, I felt a great feeling of guilt for the outcome of my action since I realised that I was not able to follow the recommended guidelines for safety. According to the Principles of Nursing Practice (Royal College of Nursing, 2019), there are 8 principles that constitute safe and efficient nursing practice. Some of the principles that I could relate with the event are the principles: (1) nurses should be vigilant about risks and have to keep every patient safe; (2) nurses and nursing staff should be able to facilitate a coordinated care; (3) effective communication processes should be practiced, employing assessment, proper documentation, reporting, and referral, and (4) nurses and nursing staff should take responsibility for their actions and the care interventions they provide to the patients, and should act based on their rational judgment.
After reflection, I felt appreciative of what had transpired in such a way that the consequences of my actions and poor judgment were not extreme. I also appreciate the action of my mentor about the need for reporting the incident to the ward manager because it is the proper thing to do. According to the National Patient Safety Agency (2010), such events should be properly documented and reported to the concerned staff, which could be utilised in improving safety in practice in the future.
The feelings have been mixed because it was not my direct mistake. It is the collective responsibility of the whole group because the outcome or failure is collective asset or loss for the group. My colleague and staff members were present, but they were only observers. My mentor was upset, and she was consistently saying to me that you have not done things right. There was low communication in the group because of barriers to communication. Mary was not feeling well, and the whole staff was there. I feel that if all staff members were gathered there after things went wrong, then why they did not gather at the start of taking responsibilities. Moreover, I also felt that I was not quick when Mary started to feel wrong. My mentor also said that I should have consulted with the ward manager in such a situation.
Evaluation
In the evaluation of the event, I have realised what transpired good and what did not. For the actions that led to outcomes that are not proper are: firstly, my failure to communicate, in which I was not able to communicate my concerns in the first place; specifically, where I was not able to ask for specific instructions regarding the procedure even how simple the task would be. According to the World Health Organization (2009), communication is the exchange of information through various means which may be verbal or non-verbal.
The Royal College of Nursing (2019) states that communication is an indispensable factor in ensuring better health outcomes and should be present in every aspect of health care – from prevention of an illness to treatment and rehabilitation, as well as it should encompass to all members of the health care team, the patient, and their families. Aside from ensuring safety and better health care outcomes, it also helps in making the patient feel that they are valued, at ease, and in control of their health.
Another is my failure to follow the nursing procedure, where I was not able to follow the basic steps of the assessment. According to the Ackley &Ladwig (2017), the assessment phase is the first step in the nursing process where nurses gather relevant information that is vital to the patient’s care, involving the physical, psychological, sociological, and spiritual aspects of the individual.
Also, my failure to ask for direct clinical supervision where I immediately went to the patient and performed what had asked me to do without asking for clarifications or supervision. According to the Nursing Times (2018), the Nursing and Midwifery Council is constantly evolving and improving its standards on the nurses’ proficiency and education, and one of which is the strong assessment and supervision of student nurses, the future health care providers, in the clinical area.
Furthermore, my failure to communicate and ask for direct supervision in carrying out a nursing intervention is considered a failure to follow safety guidelines. Another, I also recognise that my failure to research before the interaction with the patient and the failure to utilise critical thinking skills are included on the things that didn’t go well.
Lastly, and although I am not proud of this, it was my attitude at the time where I was trying to put blame too other people instead of focusing on what had happened and learning from it. According to the guidelines for a safe and effective practice (Royal College of Nursing, 2019), nurses and nursing staff should take the responsibility of the outcomes of the nursing interventions they have provided and should be accountable for their actions and judgement. Gladly, that was before, and right now, I learned to make every experience a source of learning and wisdom.
For the things that went well, it includes chiefly that the outcomes of my shortcomings as the health care provider at the time are minimal and considerably less grave. Another was that I was able to call for assistance immediately after the concern was raised by the patient. Finally, was that there was proper reporting and documentation of the event because I realised that that was a very valuable action. Proper documentation, including the adverse events, does not only serve as a documentation per se; rather, it could be utilised as a basis for evaluation of the care interventions provided to patients by the care providers, as well as it could be used as the basis for the need to improve care interventions and guidelines.
It is also the responsibility of the mentor and every member in the group to be open to communication. When medical care setting faced some challenge and things went wrong, then going upset might worsen the situation further. There was a lack of communication in the group before the event occurred and then, after Mary faced negative health, then it was further upsetting to receive comments from everyone.
Analysis
Aside from the minimal consequences of the incident, one of my realisations during the analysis of the event is that numerous learning could be drawn from the experience. I would like to base my analysis of the event on The Code (Nursing and Midwifery Council, 2015), which is the foundation of professional standards of practice and behaviour of nurses and nursing associates who practice across the United Kingdom.
The Code is the ultimate guideline for nursing practice, which is based on four principles – to prioritise people, to practice effectively, to preserve safety, and to promote professionalism and trust. It is useful to everyone concerned about safe and efficient nursing and midwifery, such as the nurses, employers, patients and their families.
To practice effectively, I learned that communication is an important skill to be learned and practised in every aspect of health care. The Health Foundation (2016) states that effective communication is essential in coordination and teamwork. There is numerous evidence that communication enhances health outcomes; hence, nurses and other members of the health care team should enhance their communication skills and strategies, utilising a communication toolkit, for instance. Moreover, a study conducted by the Institute for Healthcare Communication (2011) suggests that through good communication, patient safety will be enhanced, and malpractice risk could be halted.
In fact, there are numerous circumstances of poor health care outcomes which could have been avoided through efficient communication, such as in the studies of Keers, et al. (2013) where ineffective communication was linked to the medication administration errors in many hospitals; miscommunication and lack of communication that leads to patient death (Latner, 2015), and poor nursing communication that caused needless hospital deaths and injuries (Painter, 2010).
To prioritise people, I realised that I should have been a pro-active team player, critically thinking of my actions and nursing interventions. Aside from treating every patient with kindness, respect, and compassion, nurses should also ensure that they can provide care efficiently. One of the ways that could ensure effective nursing care is through the nursing process; assessment as the most fundamental part of the process would influence the succeeding phases of the care delivered.
The proper practice of the nursing process, especially proper nursing assessment, is deemed to be one of the most useful practices that lead to better health outcomes. According to
To preserve safety, I also learned that supervision is very important, especially if I am still a student. Since the activity was just to assist the patient in washing, what came to my mind by that time is that it was just a simple activity where no supervision required. That was incorrect because I was not able to look beyond the activity, such as the assessment of the patient’s vital signs before assisting her in going out of bed; therefore, a mentor or any qualified nursing staff is recommended to supervise student nurse in any given nursing procedure.
However, direct supervision of student nurses in the clinical area is one of the challenges in the health care field today. According to Aston &Molassiotis (2013), proper clinical supervision and mentorship in student nurses at present is becoming an alarm as a result of various reasons, some of which are the heavy workload of nurses, and the high patient but how nurse’s ratio which is true in almost every health care facility. This is a concern that should be addressed as soon as possible (Clifton, 2012).
Finally, to uphold professionalism and trust, I learned that I should adhere to and uphold the standards and values set out in The Code. This could be achieved by upholding the reputation of the nursing profession at all times.
Conclusion
From the reflection, the things that could have done in the situation which might have led to improved outcomes may include better communication, clinical judgment and critical thinking skills, utilisation of the nursing process, coordination of care, and proper research.
As a fundamental rule in the nursing process, assessment should be made before any given procedure – simple or complex. Only if I was able to assess Patient A’s vital signs before the activity, I could have assessed if her blood pressure was low and had not permitted her to go out of bed. Also, if only I were able to check both suitable and inappropriate activities for post-surgery and gynaecological cases, the activity could have been avoided.
Also, if I was able to communicate my uncertainties with my mentor at the time, then I could have been assisted. One of the principles of nursing practice is to ensure that proper and efficient communication should exist among the health care providers and the patients themselves, to promote better and quality nursing care. Moreover, every member in the group supervision and the mentor should be on one page, and they should be engaged on several issues and events so that situation can be made better. Open communication and the lack of effective transition from the night staff are the reasons why the situation got bitter.
Action Plan
As an action plan, I would like to employ my learning of this event in my future practice. First and foremost, I plan to share my learning with my co-student nurses for them not to make the same mistake as I did. No matter how simple a nursing intervention could be, it is a basic rule that a mentor or a nursing staff should supervise a student nurse. The action of sharing previous experiences and learning is a part of reflective practice, which Dale et al. (2013) stated that it facilitates good learning experiences.
Also, I will be practising NMC’s The Code by heart to serve as the foundation of my nursing practice. By providing nursing care that is based on the principles of prioritising people, practising effectively, preserving safety, and promoting professionalism and trust, I believe that I will be an efficient nurse providing safe and quality nursing care.
Furthermore, I would also like to apply the eight principles of nursing practice as advocated by the Royal College of Nursing. These principles do not only influence the nursing interventions provided by the professional, but also their attitude, behaviour, and approach towards nursing care.
Essentially, these principles of nursing practice support the aim of The Code (NMC, 2015) towards safe and quality nursing care. Specifically, it guides nurses and other nursing practitioners to treat everyone in their care with respect and dignity, provide compassionate care, becoming responsible and accountable of own actions, becoming vigilant of the risks in health care, keeping everyone safe in the places where they receive health care, promoting a patient-centred nursing care, utilizing effective communication to facilitate care, encouraging nurses to continue learning and updating knowledge and skills, and to efficiently work with colleagues and other members of the health care team.
Conclusion
Reflective practice is the process of critically assessing a previous clinical experience, taking not of the details of the incident, identifying the advantages and disadvantages of a certain action, recognizing what went right and what went wrong in the situation, what could be done in order to improve the situation, and what could be learned from that certain clinical experience.
CIPD UK (2019) described reflective practice as the foundation of professional development, where a health care professional makes meaning from experience and transforms these learnings into valuable strategies and skills. In return, the individual will not only develop their skills and clinical practice but will also be able to grow as an individual and as a health care professional. The care providers that perform reflective practice could contribute a great and positive impact on the health care they function.
Registered nurses, together with the nursing associates, are one of, if not the main health care providers that closely and regularly interact with patients. Shortcomings from the health care providers are unavoidable but could be lessened at a significant rate if the reflective practice is performed by health care professionals. It promotes great benefits, including the facilitation of self-awareness, enhancement of emotional intelligence, as well as the improvement of critical thinking skills.
The previous clinical experiences shared is about a post-hysterectomy patient whose health was put at risk as a result of miscommunication and misjudgment. Since the patient’s situation involve gynaecological cases, one of the precautions is to watch out for activity injuries; this is a situation that I did not know beforehand that caused the outcome, which was influenced by several factors such as the lack of supervision. This is a situation that I was able to extract learning from and will be employing in my future nursing practice.
Furthermore, it is also critical that nurses and nursing associates practice the profession guided by The Code. It is the principal guide for nursing care providers which works under the principles of prioritising the patients and their families, providing an efficient nursing care, preserving the safety of the patient as well as the care providers and everyone in the health care environment, and to preserve the nursing profession, and to maintain the service user’s trust to the profession and to the different health care providers. The Royal College of Nursing (2019) has also advocated eight specific principles that would guide nurses and nursing associates in their nursing practice towards safe and improved nursing care.
In a nutshell, nurses in the UK are expected to maintain the standards of the nursing profession and practice as guided by the Nursing and Midwifery Council’s Code. However, it is also understandable that nurses and other health care professionals are prone to negligence; one of the most efficient ways to decrease such instances is through reflective practice. Evidence suggests that reflective practice is a very efficient way to avoid errors in the clinical practice; it is recommended to all health care professionals as well as it ought to be shared. In my reflection of my previous clinical experience, I have recognised the strengths and weaknesses of my actions, and I was able to draw valuable learning from it.
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