Introduction

This essay focuses on a reflection on the development from novice, to competent beginner, to skilled practitioner in the light of my own development in clinical nursing practice. It is based on the signposts identified within my clinical learning portfolio and focuses on the notion of the helping role and caring skills within nursing practice. It utilises a reflective framework to better identify and reflect upon the journey from novice to practitioner.

The model for reflection I have chosen is Gibbs Reflective Cycle (see Appendix). Reflection has been described as as a process of internally examining and exploring an issue of concern, triggered by an experience which creates and clarifies meaning in terms of self, and which results in a changed conceptual perspective (Boyd and Fales, 1983). Therefore, the experiences of my three placements are explored under three rotations of Gibbs Cycle. Meretoja et al (2004) state that nurses’ self-recognition of own level of competence is essential in maintaining high standards of care. I have chosen the caring role based on my own recognition of the level of competence achieved in this area.

Cycle One

Novice to Advanced beginner

What Happened.

I had to assist a patient in with personal care; make them comfortable in bed and collaborate in pressure area management; assist with toileting, washing, mouthcare, and application of emollient cream. I also had to document care and any deviations from the norm.

Feelings

I was very aware of my inexperience and of the trust this patient placed in my and the nursing team. I was also aware of the intimate nature of the care I was providing, and the fact that it was basic care also highlighted the fundamental role such care has in supporting health promotion and patient wellbeing.

Evaluation

I was uncomfortable at first, and clumsy in the provision of the various aspects of care. However, my mentor was informative, supportive and helpful, which assisted me in doing the various tasks. However, I found it difficult to complete these as quickly as I should have. I did learn to communicate with the patient and provide a sensitive approach.

Analysis

This situation required fundamental aspects of the caring role. It also demonstrates the link between basic nursing care an every other aspect of nursing. The NMC (2004) requires nurses to provide individualised care for their patients. The care for this person was based on their own needs and adapted as those needs changed. I was able to identify those needs and develop competency in providing care at this level. The caring role was very rewarding but physically and emotionally taxing However, I was still in the process of identifying particular needs and responding to them, such as toileting, which required me working with others in a collaborative manner, which I did not find easy. I also realised how much I did not know about nursing.

Conclusion

In this situation, I could have developed more collaborative working skills and modelled myself on those around me more actively ie., copied the ways in which other nurses and healthcare assistants provided care. When I did do this, it was effective. But I found that despite my enthusiastic approach, my knowledge base meant that I did not always understand the rationale for what I was doing.

Action Plan

The action plan from this was to take the confidence and competence I had developed in the practical skills and incorporate them into all aspects of the caring role. It was also to identify areas where my knowledge base was lacking, and seek out this knowledge. Keeping knowledge up to date is a requirement of the NMC code of condut (NMC, 2004). Working collaboratively is another NMC requirement (NMC, 2004). Taking this knowledge forward into practice made this process of reflection a learning activity.

Cycle Two

Advanced Beginner

What Happened

As part of my role assisting with patient care, I had to monitor pain levels and assist with providing analgesia as prescribed, along with monitoring its effectiveness. This was a surgical placement, and I also discussed with elderly patient their coping and wellbeing after hospital discharge. I engaged in health education and support to enable clients to be self-caring.

I was also responsible for monitoring wellbeing through performing and recording clinical observations, recording fluid balance and reporting any abnormalities. I was also involved in providing personal care to patients in a safe manner, especially in the disposal of waste products.

Feelings

To begin with, I felt glad to be working at a more advanced level of competency, and felt confident in my basic nursing skills including performing clinical observations. However, the increased demand also meant increased pressure and I was aware of this. Again, I felt that I had developed a degree of competency but was very aware of my need to develop further knowledge and skills. The caring role involved supporting people and I had to access other professionals to ensure I gave the right information and that my care had been effective.

Evaluation

It was good to find that I had the clinical competence to effectively monitor clinical status. However, the complex nature of patient needs meant that I still didn’t always know the answers to their questions. Being involved in discharge planning was an enabling activity for myself and the patients. I developed competence in the administration of medications, under supervision, including controlled drugs, but felt I still needed more practice and skill in this area. Colleagues noted my competence and qualified staff were happy to delegate a range of appropriate tasks to me.

Analysis

It would appear that the caring role means the provision of patient centred, holistic care. This was achievable in this situation but required a lot of knowledge and the ability to provide focused attention and empathic care whilst carrying out complex clinical nursing tasks. This was harder to achieve, and I was made aware of my continued learning needs around medication and surgical care, for example. However, I must have developed some competence as qualified staff were happy to delegate to me and to act on my feedback.

Conclusion

It is hard to see what else I could have done, except perhaps done more reading around surgical care, discharge planning and the nurse-patient relationship.

Action Plan

It was possible to identify future learning needs, and so my action plan included building on my current competence by engaging in more advanced practice, under supervision. Having the confidence to engage in more complex nursing tasks will help me to achieve more competence in advanced practice in the future. Recognising the demands of the caring role means that I will view future practice as based upon this role.

Cycle Three

Competent Level

What Happened.

I monitored patients with chronic pain and helped with analgesia. I also supported patients with freedom of choice for their own care (NMC, 2004) and provided personal and palliative care in sensitive manner. I mastered more advanced practical nursing skills including aseptic technique and safe disposal of sharps. I fully documented all care given, and recorded medication given, and communicated to staff at shift change during the nursing handover.

Feelings

During this experience, I felt that my knowledge and experience in the caring role was finally coming together. I was confident and happy in engaging with patients and providing empathy and a supportive manner, whilst also carrying out more complex clinical tasks appropriately and effectively. It was very nerve-wracking giving handover, but I became more confident as I had more practice.

Evaluation

I was able to provide care of a high standard, and recognise my sphere of competence and seek help when needed. I was able to engage in effective caring relationships with clients, meet their individual needs, but also value my own input into their wellbeing.

Analysis

It was obvious that I had moved on to a level of nursing competence which allowed me some autonomy. I was able to act with less direct supervision, but still access the support of the whole care team. The caring role extended to the provision of all care, including end of life care, and I was able to utilise my knowledge and experience and also identify my learning in action, and my future learning needs, which have changed since the first reflection.

Conclusion

The change from novice to competent practitioner in the caring role has demonstrated not only the acquisition of skill but the incorporation of clinical abilities into what is really a way of being with patients.

Action Plan

Signposting future learning needs is important following this reflection. I was able to identify the need to still learn advanced clinical skills and perhaps know more about the range of other professionals who could enhance care in individual situations.

Conclusion

This reflection has signposted my development towards competent nursing practice. The caring role encompasses provision of basic care, advanced techniques, medication and pain relief, health promotion, end of life care and collaborative care. It seems to be the fundamental and most important part of nursing practice.

Collaboration and coordination, as well as the holistic management of the situation, are highly recognized as meaningful characteristics of competent nursing practice (Meretoja et al, 2002).

References

Boyd E, Fales A. (1983) Reflecting learning: key to learning from experience.

Humanist Psychol

23 (2) 99–117.

Gibbs, G. (1988) Learning by Doing. A Guide to Teaching and Learning Methods Further Education Unit, Oxford Polytechnic, Oxford

Meretoja, R., Leino-Kilpi, H. & Kair, A. (2004) Comparison of nurse competence in different hospital work environments Journal of NursingManagement.12(5) 329–336

Meretoja, R., Eriksson, E. & Leino-Kilpi, H. (2002) Indicators for competent nursing practice

Journal of Nursing Management

10(2) 95-102

Nursing and Midwifery Council (2004) Code of Conduct Available from

www.nmc-uk.org

Accessed 30-4-07.

Introduction

Oelofsen (2012) defines reflective practice as the process in which an individual makes sense of situations, events and actions that occur in the workplace (Natius, 2012). In the light of nursing practice, the concept of reflection plays a critical role by enabling practitioners (nurses) to, competently manage the impactful and precarious nature of care giving (Natius, 2012). According to Keeling and Somerville (2004), reflective practice facilitates the understanding and development of self-awareness, inter-personal skills and also the ability to influence positive change in others (David & June, 2004). These skills are key to nurses in mapping out the most appropriate action plans to take in any given situation.

Comparative examination of four

models of reflection

as applied in the context of nursing

Model of reflection	Key features
Gibbs model of reflection 1988	It is fairly straightforward (Marshall et al., 2006) gives a clear description of the situation, analysis of feelings, evaluation of the experience and subsequent analysis of the experience to make sense of it (Marshall et al., 2006) Repeats the same loop of action several times (Marshall et al., 2006) creates room for an alternative course of action It reflects on the current experience with the view to developing appropriate action plans should a similar situation arises again.
Johns model of reflection 1994	A structured model with steps that have questions, prompts and activities that aid in reflection (Davey, 2011). The concern of questions lies in describing the experience and its main issues, reflection on what the practitioner was trying to achieve and why he acted in a certain way. It also looks at the consequences of the action to the self (practitioner) and to the client (patient), the feelings that the action evoked and academic sources of knowledge that possibly influenced the decisions made. This model explores the different angles to how the situation could be handled differently and also what would be done in the future should the situation recur
Kolb’s model of reflection 1980	Based on experiential learning cycle and covers four phases. The stages are: Concrete Experience (CE)-Learning by experiencing. In this phase, the learner (Nursing student) learns from specific experience, relates to people (patients) and becomes sensitive to their feelings (Martin, 2006). Reflective Observation (RO)-Learning by reflecting. This stage entails making careful observation before judging, viewing issues and situations in different perspectives and looking for meaning in the situations. Abstract Conceptualization (AC)- Learning by thinking. It is a critical stage where a learner logically analyses ideas, plans systematically and acts on the situation from an intellectual understanding. Active Experimentation (AE)- Learning by applying / doing. This is the last phase where the learner shows the ability to get things done, takes risks and influences people and events through action.
Goodman model of reflection 1984	This approach is premised on three levels of reflection: Level 1: Reflection to attain given objectives. In this level, the criteria for reflection are limited to technocratic issues of effectiveness, efficiency and accountability. Students, for example, are expected to give an account of an occurrence and demonstrate some degree of learning (Robotham & Frost, 2006). Level 2: Reflection is on the basis of the relationship between principles and practice. Assessment of the consequences and implications of beliefs and actions, as well as the rationale employed in practice, is done. At this level, students begin to link theoretical perspectives to practice and also apply their experiences in similar circumstances. Level 3: reflection that integrates ethical and political concerns. At this level, there is deliberation of emancipation and justice over the value of professional objectives and practice. The practitioner links the everyday practice to the broader social structure and forces such as economics, health, and resources.

Gibbs model of reflection is commonly employed in the Health profession because of its clarity and precision (Brock, 2014). It allows for easy description, analysis and evaluation of experiences and thus helps the reflective practitioner (nurse) to, clearly make sense of her experiences as well as examine her nursing practice (Holland & Roberts, 2013).

Unlike the Gibbs model, the other models, for example, Kolb’s model 1980 and Goodman model 1984 are relatively complex. These models require, to a greater extent, some degree of experience (McKee & Eraut, 2012). The Kolb’s reflective model, for instance, is basically hinged on experiential learning that covers four stages (McKee & Eraut, 2012). And since experienced nurses have enough experience, they can easily relate to the model and apply it in practice.

Model that is best suited for nursing practice

John’s model of reflection 1994 is best suited as a tool for the nursing profession. Its structured nature serves as a good platform for a complete assessment of the nursing practice (Rideout, 2001). The questions are excellent cues in prompting particular actions (Driscoll, 2007). This approach is also wholesome in the sense that it explores all the areas of the nursing practice. It examines the practitioner’s experiences, her reflection on the experiences, actions taken by the practitioner and impact of the actions on self (practitioner) and the patient (Mohanna et al., 2011). It also looks at the aspect of the academic sources that may have influenced the decisions made as well as the possible angles to how the situation could have been dealt with differently and how it can be handled in the future (Moon, 2013).

Importance of the choice of framework of reflection in encouraging and supporting reflection

A desirable framework of reflection is helpful to nurses as it provides a structured process that guides the act of reflecting (Jasper, 2003). The choice of a particular framework of reflection is important because students face different experiences, and so is the need for an appropriate framework to offer the necessary support and encouragement throughout their learning process (Schon, 2008).

Critical analysis of all the four models with respect to what is good and bad about them

The four models of reflection examined above, all have their strengths and weakness in their application. Below is a table summarizing their strengths and weaknesses.

Model of reflection	Strength(s)	Weakness(es)
Gibbs model 1988	Challenges assumptions (Devinder Rana, 2013). This attribute is important in validating data and drawing appropriate conclusions. Explores different approaches to thinking and acting and as such encourages creativity. Links practice and theory. It helps a learner to apply knowledge gained in practice.	It is not necessarily introspective (Watson & West, 2006). Reflection requires both introspective and retrospective perspectives.
Johns model of reflection 1994	Its structured nature allows for wholesome analysis of learning. Simple in nature thus easy to apply	Its simplicity may not necessarily capture all the critical components of reflection
Kolb’s model 1980	Its four stages of experiential learning i.e. Concrete experience, Reflective observation, Abstract conceptualization and Active experimentation provide a favourable framework for in-depth learning and application.	Mostly applies to experienced practitioners hence cut off less experienced ones.
Goodman model 1984	This model is crucial in developing professional skills in learners as well as empowering them to be economically, socially and politically competent individuals.	Significantly cuts off young learners. Such learners are yet to fully understand the applicability of the tenets of this model.

Reflective practice and its use to medical education

The ability to reflect plays a critical role in medical education. Reflective practice enables learners in the medical field to clearly understand and develop self-awareness, interpersonal skills and analytical skills (Jack Mezirow, 2011). These skills will come in handy in practice as medical students will be able to handle people (patients) in frontline settings such as a hospital scenario.

The importance of students developing a habit of assessing their own learning needs

Through self-assessment with regard to learning needs, students are able to constantly identify areas of weakness and improve on them (Earl, 2004). The fact that students are actively engaged in the process serves as a motivation for them and subsequently translates to better outcomes (Bonnie Beyer, 2014).

References

Reflective Writing on Critical Incident in the Clinical Experience with Integration of Leadership Theories in Analysis.

This write up aims at exploring a conflict that occurred in an urban private hospital concerning a patient, relatives and medical team. Its purpose is to reflect and critically study and understand a clinical incident and use it as a learning episode by use of reflective model. To identify the measures put in place to manage the conflict and the type of leadership skills and leadership theories used to resolve the conflict. Gibbs reflective cycle will be used to expound on the scenario as it unfolded. This is because Gibbs is clear and thus allows description, analysis and evaluation of the experience helping me to make sense of experiences and examines my practice (Gibbs, 1988).

Conflict can be defined as disagreement in which the people involved feels that their needs, interests and concerns are threatened. Health care related conflicts are complicated because the care process is ongoing and involving a lot of emotional effort and professional relationships therefore tends to occur frequently and thus interpersonal conflicts, (Johansen, 2012)

Incident description

I once worked in private urban hospital and while there on my practice I encountered a scenario that left me thinking on how well our patients are informed and involved in their care. On this particular day I reported to work as usual and received the report in a high dependency unit, about the unit and the patients admitted. Special report given was that there were some pending investigative procedures on two patients to be facilitated by one consultant. This investigation were requested on the previous day therefore follow up was to be done during this shift to ensure they are done.

After receiving the report we went for quick unit round and assessed the patient status and then the unit manager embarked on contacting the consultant to come and do the tests, efforts to trace him were futile since his phone was not going through. The unit manager contacted the second on call for the same and said that he was out of town thus not in a position of performing the test the same day. In this particular organization the patient and relatives are appraised on daily basis of everything that it’s to be done therefore the relatives were eagerly waiting for the test result when they came back during the visiting. When the relatives came back they wanted to know the test results unfortunately they were not available because the test had not been done, the manager and the doctor covering the unit tried to explain to them in vain.

They became very furious and agitated and started using abusive language. Efforts to make them understand were futile. They walked out of the unit to have a discussion among themselves and in 30minutes they were back demanding that their patient be discharged against medical advice so that they can outsource the service elsewhere saying “you people do not care about our patient but we care about him and we are ready do anything possible to facilitate this test been done”. They signed the form for leaving against medical advice and left.

From this episode a crisis meeting was convened to include the medical director, director of nursing the unit in-charge and the doctor who was covering the unit then and a critical analysis and evaluation of the scenario was done and it was resolved that this particular consultant always have an issue with his patient whenever he is on call and therefore it was agreed that the director of medical services and nursing service will meet with the doctor and have a one on one discussion in order to prevent a recurrence.

It was also agreed that we follow up on this particular patient and find out what was their progress and whether they went for the test and to even apologize to them and let them understand that we care and patients interest come first and only that there was a problem on that day, the patient was traced and found to be doing well and they never went for the test on that particular day they had to wait until the next since they could not get the service where they went because it’s the same consultant who doing the procedure in that facility and therefore opted to come back to our facility for readmission and they very apologetic and remorseful for the actions “we regret our action and we want to apologize for unnecessary attention that we demanded for while your efforts was to ensure for better outcome of patient. We are sincerely sorry for the disturbance and our shameful acts” we reassured the relatives and readmitted the patient for continued care.

Feelings

This experience made me feel like we failed no matter how we tried explaining to the client and his relatives it never seemed to be working. I also felt that we failed to meet our goal of ensuring that patients are satisfied with the services they receive, though the unit manager was very composed throughout this situation and handled the relatives with a lot of care and caution she never seemed to be worked up by their demand.

This leader portrayed very good qualities that I really admired and felt that I should emulate, she had a good charisma. Felt that she was a transformational leader because she displayed charisma and we as her juniors followed her way of instituting measures in place. She was able to reason with the relatives and explain on the events as they were unfolding even though they never paid any attention or reasoned with her, she explained of the challenge we were facing in the situation. She engaged the relative by stimulating them to understand through use of logical questions and exploring on their assumptions (Hendel, Fish & Galon, 2005).

I also felt the manager had some qualities of transactional leader because she was able to monitor the performance and step in to correct the situations as they arose and also utilized passive management since the problem arose unexpectedly and therefore rushed in to handle the situations (Hendel, Fish & Galon, 2005). Utilization of these skills gave the manager an upper hand in handling the furious relatives and creating their understanding even though they decided to leave the hospital.

Convening a crisis meeting by the management was a very important step as this created an opportunity to address the issue as it happened and come up with solutions to prevent recurrence and provide steps in handling the situation in case it recurs. The affected consultant was also give an opportunity to explain what transpired and he had a genuine reason because he was in theater doing a procedure and he called back to the facility after he was done to inquire why we were calling him them.

I felt that the relatives also have role to play during care of their loved by been supportive and establishing a trusting professional relationship with the health professional to establish a common working ground. Decision to withdraw the patient from the hospital was solely made by the relative and the patient felt vulnerable and tossed around since he could not make sound decision there compromising on the patient care in the name of seeking for a service.

Evaluation

This episode provided a learning situation for me as I experience how difficult it might be in handling clients that you have already established a professional relationship with, and with all efforts to try and let the clients understand the situation by providing them with information. What was good about this incident is that the manager was very calm and composed all through and understood the feelings of the relatives concerning their loved one. She was able to utilize her skills optimally to handle the situation. What was bad about the situation is that the investigation was not carried out and the clients felt ignored or left out and thus opted to leave the hospital and seek services elsewhere as fate would have its way they never accessed the services on the material day because most of them are outsourced and the same consultant does the procedure in the facility they went too. They were embarrassed by their behavior and even come back to apologize on the same and we reassured them. Eventually they brought the patient for readmission.

Study done in an Israel hospital on conflict resolution on nursing managers indicated that they mostly utilized transformational leadership style because it allows for creativity and flexibility in problem solving and scrutinizing all protocols and policies set to manage situation through critical analysis (Hendel, Fish & Galon, 2005).

Actions to withdraw the patient and interrupt care compromised on the patient health status and even the expected outcome.

Analysis

From this situation the patient’s relatives were right in demanding for action because they had been explained about the test, its importance and why the result may be needed to make decision on the way forward in patient’s management. On the same case having not done the test on the same day would not have worsened patient’s condition and still medical management would still be ongoing as we awaited the test to be done. The crisis meeting organized ensured the lasting solution is availed in order to improve on patient care and therefore a ensure quality care leading to better patient outcome.

To effectively resolve a conflict a better understanding should be ensured through clear communication and understanding the crisis leading to disagreement. Therefore conflict resolution becomes an important aspect in prevention of errors occurring (Sportsman & Hamilton, 2007).

The unit manager utilized the transformational theory and understood that followers are an important aspect to facilitate leadership and that the follower is always accountable and with skills to critiques scenarios and issues as they unfold just like the leader does. Similar to the incident the manger took control of the situation vividly which was a learning opportunity for in the unit that day as potential leaders (Daft, 2008).

Conclusion

From this incident it can be concluded that the health team played their part well though an element of ineffective communication is evident since the relatives were aware that the test needed to be done in order to make decision on the management therefore emphasis had been put across thus explains their fury when it was not done.

Leadership experience plays an important role in ensuring or equipping the leader with skills to handle situation in future thus creating an understanding of the theories used in leadership. For one to be effective leader one must learn whom they are what are the strengths and weaknesses establish a personal philosophy and be strong to stand firm and represent what we believe in terms of patients care and skills of conflict resolution (Daft, 2008).

Action plan

To work as a team is an important aspect of nursing and that effective communication is paramount in ensuring that the patient and relatives are well informed on the care provided to their loved ones. This experience has been an eye opener in me and it has made me realize that I can never be ready to solve a conflict this because each occurrence is always unique and present in a different manner, therefore utilization of leaderships skills become important. This will change the current practice because more emphasis will be on passing information to the relevant bodies.

References.

Daft, R.L. (2008).

The Leadership experience.

Mason, OH: SouthWestern.

Gibbs, G., (1988) Learning by doing: a guide to teaching and learning methods, Oxford Polytechnic Further Education unit.

Hendel T., Fish M & Galon V. (2005) Leadership style and choice of strategy in conflict management among Israeli nurse managers in general hospitals;

Journal of Nursing Management

13, 137–146

Mary L. Johansen (2012 ) Keeping the peace: Conflict management strategies for nurse managers Nursing Management:


43 ( 2)


doi: 10.1097/01.NUMA.0000410920.90831.96

Sportsman S, Hamilton P(2007;). Conflict management styles in the health professions. J Prof Nurs. 23(3):157–166.