Abstract

Clinical reflective practice on critical incident In this contemporary nursing practice, reflection plays vital role in the development of student nurses education portfolios (Malik & McGowan 2007, OConnor 2008). Reflective practice is a tool used in clinical environment to describe, analysed, and evaluate practice so as to inform changes where necessary (Gibbs 1988). This essay will discuss critical incident of institutionalise-risk-taken patient plan to take over-dose medications. The domains used are: interpersonal relationship/organisation & management of care and professional/ethical practice. Gibbs (1988) reflective circle will be used to describe what happened, feelings, evaluation, conclusion, and analysis and action plan. Generic-terms will be used for confidentiality reason.

Introduction Reflective writing forms vital part of student nurses portfolio (Chabell & Muller 2004, Gustafsson & Fagerberg 2004, and Rolfe Gardner 2005). Reflective practice is a framework that aids nurses in their day to day work (Peden-McAlpine et al. 2005). Reflection a vital tool for developing quality services, allows nurses to be flexible in their approach and to incorporate changes where/when necessary (Bulman 2004, Bulman & Schutz 2009). Without reflection nursing care can become automatic and no longer tailored to the individuals needs. Reflection helps to examine experiences to see if there is something to learn and/or transferable to similar situations in future (Chabell & Muller 2004). Reid (1993) describes reflection as a method of evaluating experiences in clinical practice environment so as to inform learning that will improve practice. Reflective practice is guided by different models; these includes, Johns (1994 & 2005) model of reflection, Gibbs (1988) reflective circle, Driscoll (2007) reflective circle to mention a few. I chose to use Gibbs (1988) model of reflection as my guide because it gives lucid description of incidence and is straight forward. This model identifies different stages people pass through when learning from experience. As a rostered year student, reflection helps me to determine what has been good and
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bad in the action taken in a particular situation in my clinical practice. ORegan & Fawcett (2006) and Ogan-Bekiroglu & Gunay (2008) asserted that reflection is part of learning experience that can be used to organise, manage and improve professional skills. According to McMullen (2006) and American Nurses Association (ANA) (2007) reflection can be used to improve future performance through evaluation of situation and mistakes made. It is a tool that promotes development of critical thinking in nursing students. Schon (1983) and Jasper (2006) distinguished three types of reflection- (1) knowing-in action (2) reflection in action (3) reflection on action. Reflection in action happens when a person reflects on behaviour as it occurs; while knowing-in action is a direct observation of the incident. Reflection on action occurs after the event; reflection on action allows the nurse to review, describe their feelings about events, analyse and evaluate situations. But the disadvantage is that it relies on memory which could easily fail and/or unable to recall events (Andrews et al. 1998).

Search Strategy Different electronic databases and manual search were made. These include Cochrane library, CINHAL, COPAC, PROQUEST, PubMed, British Nursing index and Blackwell Science. Key words used are Reflection, Portfolios, Reflective Practice, personal reflective writing, and Professional development.

Description of incident During my internship roster year, I was posted to an acute psychiatric ward that operates a system of assigned nurse. I was asked to look after few patients on each shift. This gives me an opportunity to interact with these patients on daily basis. It also serves as a catalyst for me to have interpersonal/therapeutic relationships with this group of patients. This system afforded me great opportunity to relate with and engage my patients in conversation on every shift. At times I asked about of their mood, sleep, appetite, affect and their general welfare with empathy; at times they voiced concerns, other times they voiced no concerns. Sometimes I asked them of their favourite meals and drinks and what they like doing when they were younger; just to make them relax.
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One day after my conversation with one of these patients, who I will like to name Mrs. Y for the purpose of confidentiality. She said Solomon you are very compassionate and understanding, you will be a very good counsellor. I looked at her with amazement, she said that is a good complements for you. I said thank you and left. Mrs. Y is a 59 years old widow diagnosed with depression; mother of four children three girls and one boy. The health of Mrs. Y had been good until the demise of her husband. Mrs. Y has been so use to me that she told me almost everything about herself, and her family. On one Monday, in the morning shift during the hand over report, it was reported that Mrs. Y was in bed for spells; she refused dinner/supper which was very unusual of her. My duty of care is holistic; therefore it is my reasonability to find out what went wrong with her. I went to see Mrs. Y in her room; I found her euthymic and less reactive and objectively appeared apprehensive. I asked her if I could sit down, reluctantly she said yes of course, sit down. I sat on the chair looking at her, but there seems to be less eye contact. I said what is the problem? There was no response rather she was silence, subbing and tearful. I allowed her to ventilate and then gave her tissues to wipe her tears. For about two minutes we were both silence, I watched her body language. Then I held her right palm with my two hands and said Mrs. Y, say something to me. I reminded her of the compliments accorded me in the previous week, in which she said I was compassionate and understanding. I said if you werent flattering me then prove to me now, please talk to me. Then she looked at me and said I wish my husband is alive, I am fed up with life. I asked why she was fed up with life. She said Im in financial crisis and I would soon be thrown out of our house with my four children, I cant pay our mortgaged again. I felt sorry for her; I encouraged her and said dont let that bothered you too much; your care team will do something about it. She appeared delighted. Before I left, I said you need fluid, water or juice to drink? she said water; as I was taking a jug of water that was on her locker, I saw what looks like a sachet of medicine, half-covered with a magazine on the table, I said please can I look through your magazine? She quickly took the medicine from under the magazine, unfortunately for her, as she was putting it under her pillow, a sachet of zimovane dropped on the floor. I quickly picked it up; and I said please, can I see what you put under your pillow? She became apprehensive, and brought out Diazepam. I
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asked her where she got them from; she said I brought them from home. I asked her whether she showed them to nurses on duty. She said no; I said why didnt you show them? She kept quiet. I said what do you want to do with them? She said use them and sleep off, so that I can just go and rest. I asked her whether she has used out of the medications; she said no, Im just feeling for my children. I said please, give me the medication, she refused and promised to send them back home or alternatively destroyed them herself. I pleaded with her; she said promise that you wont tell anyone. I said you give them to me first; eventually she handed-over the medications to me. I said the nurse in-charge has to hear about this. She begged me not to inform the nurse in charge. I said if I fail to inform the nurse in-charge, it will amount to betraying the professional trust bestows on me. I reported the incident to the nurse in-charge; the nurse in-charge was very pleased with my action. Immediately, she went to interrogate her and further search her room to make sure she was not in possession of other medication/harmful things. She was relocated to bay and was under nursing observation. Mrs. Y became very upset because I informed the nurse in-charge. At Multi-disciplinary team (MDT) meeting, new goals and interventions were put in place which eventually resolved her problem. On my part I repaired the interpersonal relationship between me and Mrs. Y by clarifying reason for my action and she was delighted.

Feelings My feeling was mixed with fear, surprise and confusion because I have never experienced or encounters such an incident in practice before. I was shocked and short of words, but then I felt sorry for her; I was glad I saw her and was able to collect the medication from her. I felt her case needed prompt attention/urgency. My thought was that if she had succeeded in committing suicide, this would have cause horror to other patients. Initially, I thought I was in control of the situation. But when I made the decision to report the incident, my feeling changed slightly because Mrs. Y was upset instead of having remorse for her action/behaviour. I now have to argue with her and defend my clinical/professional decision. I felt intimidated, and this made me uncomfortable, and I was unsure of what my reaction or response was going to be next. I thought she would not trust me again;
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but then, I remember that group contributions to this topic at the reflective session could help retain the trust/relationship between us. I said to myself this is a good example of management of care, interpersonal/therapeutic relationship and trust philosophy clashing with professional/ethical practise decision making. I was uncertain what exactly to do or say. But then, I knew that the outcome and my decision would have huge impact on my clinical reputation. Moreover in few months time, I will graduate from being an internship student to a registered nurse, an independent level. I will be expected to be proficient, confident and competent in handling critical situation and to make correct professional decision. All these were very stressful thoughts for me. Because professional/ethical practice of nursing principle is about practicing in accordance with legislation hence protecting and ensuring safety of patient is very crucial (WHO 1996, An Bord Altranais 2000). Furthermore, Nursing and Midwifery Council (NMC) (2007a) instruct every nurse and midwife to make professional decision on every issue in the course of their duty in the interest of their patient. Therefore, it will be unprofessional, incompetence, illegal and unethical if I failed to inform the nurse in charge about the incident (Young 1981, Edwards & Elwyn 2009).

Evaluation To start with, I felt lack of financial support for Mrs. Y triggers this incident. As student nurse my hallmark was to achieve the best possible management care and provide comfort measure for Mrs. Y, while I maintain a good relationship and professional/ethical practice (ABA 2000, NMC 2007a). The scope of Nursing and Midwifery practice (2000) states that decision making involves consideration of number of important factors. This includes organisation and management of patient care, responding appropriately to instances of unsafe situation, as it is the case in this scenario. A vital skill in nursing practice is the ability to make professional judgement (Rush et al. 2001). Considering the impending danger and risk involved especially death wish /suicidal thoughts it was good I acted the way I did. It was good I was vigilant and sensitive while in her room, otherwise she would have secretly committed suicide before the nurses know.

Interpersonal/therapeutic relationship skills help me to elicit her intent to commit suicide; which consequently led to my actions. The good things about my action
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are (1) it prevents self-harm/suicide (2) she was moved from room to bay closer to nurses station for observation/monitoring within eyesight (3) prevented litigation against staff nurses and the hospital (4) boundary was set for her because of her behaviour, week-end leave was suspended for a while (5) earns me good reputation with the ward manager, my preceptor and my colleagues. I felt good in myself. It was good I collected the drugs her; and reported to the nurse in-charge. The incident was deliberated upon and solved at MDT meeting; alternative accommodation was provided for Mrs. Y. She was very happy and later thanked me; I felt good as it was sign of trust/good relationship.

Conclusion On reflecting on this incident, I felt my judgement and action matched my professional beliefs and I am pleased the way I handled this critical situation. It was obvious that I did all I could at my level to intervene in the situation. I felt nothing was left to be done that I did not do to assist Mrs. Y; unfortunately she was upset because I informed the nurse in-charge. I did what I did in her best interest (ABA 2000, Mental Health Act (MHA) 2001, NMC 2008 and Mental Health Commission (MHC) 2009). Not only will it be callous of me and unprofessional, if I failed to report the incident but also tarnish my reputation. Reporting the incident bridged communication gap and improved communication between nurses and Mrs. Y, especially at this critical time (Anderson 2001, Sully & Dallas 2005).The need for closer nursing observation was obvious in this situation.

Analysis This is incident is important to me because it is what nursing

intervention/judgement and/or decision making is all about. Although Mrs. Y was not pleased with my action, but one thing was clear; my action was in her best interest (ABA 2000, Nursing & Midwifery Council (NMC) 2008). When I was making my decision, it did cross my mind that the outcome might upset Mrs. Y. But after weighing up the consequences of the incident, I decided not to risk/endanger
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her life. I was ready for the consequences of my actions. I decided to put my professional integrity and accountability first (ABA 2000). I felt that it really did not matter what Mrs. Y thought of me as far as my action is in her best interest. This does not mean that I should not listen to her. My priority was based on the situation at hand i.e. her safety. If I failed to take the right decision and she succeeded in causing harm to herself, I will be held responsible/accountable. Having reflected on this incident over and over again, I still feel I did the right thing. My action conforms to European (EU)/WHO human right law and code of professional conduct for each nurse and midwifes (ABA 2000, Lavikainen & Lahtinens 2001 &WHO 2001, Mills 2002). The principle of non-

maleficence/beneficence is concerned with the obligation of protecting and preventing client from harming him/herself; and to remove whatever could cause harm and promote good (Beauchamp & Childress 2009). It would be professional misconduct and therapeutic failure if I failed to report the incident. This may have profound effect/impact on the nurses on duty at the time (Nightingale 1969). The loss of a client by suicide can be psychologically traumatic, and result in careerending for nurses that were on duty at the time. Failure to take accurate professional/ethical decision can lead to legal action against me and the hospital (Collins 2003). My sense of professional judgement prevented and saved her from committing suicide (Rush et al. 2000). Furthermore, my response and action saved me from self-blame, fear of damage to my reputations and litigation/lawsuit.

Action plans Reflection is a tool for learning from experience which contributes to know how and/or practical knowledge (Teekman 2000). If it happens again, I will use the knowledge and experience gained in this incident which I termed a storeroom to analyse, evaluate and plan for situation at hand. I will review literature on misuse of drugs and suicidal intent/attempt, because I have discovered that this type of incident places patient at high-risk of committing suicide (Collins 2003, Jin et al. 2008, Pedgett et al. 2008). The knowledge gained in this incident will help me to take appropriate action in similar situation in future. I will also encourage and reassure patients of their safety/confidentiality in order to sustain trust and relationship between us (McCabe & Timmins 2006). As part of personal and
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professional development, I will abreast my colleagues and nursing students with the knowledge and experience acquired in this incident. This will further consolidate theory-practice gap in nursing. My judgement/action in this scenario has improved my competence and interpersonal relationship with patients and makes me conscious of professional and ethical practice (Titchen 2003). Reflective sessions helped me a lot to tackle most of the difficulties I encountered during my rostered year. I used knowledge gained from group reflective session to solve a lot of clinical practice incident such as in the case of Mrs. Y in this scenario. I started my internship year under supervision with much tension and anxiety of making mistakes. But now with the help of structured group reflective sessions and personal reflection on clinical practice, I can confidently and competently work independently, perform nursing duties as outlined in the scope of nursing and midwifery practice framework (An Bord Altranais 2000). I will continue to update my knowledge by attending seminars, conferences and research into area of interest in nursing.

Supporting Evidence

References
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