Governing Nursing through Reflection - Personal Statement Example

Reflection on Practice Word Count 4967 Including References 4580 Excluding References Introduction Valuable learning can take place within clinicalnursing practice, often using reflection as the key strategy. Reflection offers an opportunity for practitioners to enlighten the essential nature of the care by delving into the less articulated structures of knowing how to journey with the patient with a terminal illness and his or her family (Fejes, 2008). Reflection offers a subjective and contextual view of the world through my views. In this assignment I will reflect on the care of a patient who I attended recently in my placement. I am a registered nurse who took RTP course, and I am ready to return to practice at the end of my course. This reflective account is about an incident on my placement in the gynaecology unit in an NHS Hospital, where my mentor, who is a senior nurse who directly supervised my work. For reasons of confidentiality and other ethical issues, the identity of the patient will remain undisclosed, but for the purpose of ease in description, I will use Paula as her name throughout this reflective account of her care. In this assignment, while reflecting, my focus will be on the nine NMC nursing prep learning outcomes (NMC, 2005). I will examine critically while delivering care to this patient, whether I had understood the importance of practice of nursing, midwifery, and community public health nursing within the framework of health and social policy. While reflecting, I understand that I would need to demonstrate an understanding of the requirements of legislation, guidelines in practice, codes of practice, and policies relevant to the nursing practice. Since this is an educative placement, an understanding of the current issues in nursing education and practice and the current structure and organisation of care in the local and national care settings must be learned. It would be evident from this assignment that I had used relevant literature and research to inform practice and derive learning while reflecting on the delivery of the care. As a nurse, I had also been able to demonstrate my ability to perform a need assessment and care plan leading to implementation of interventions. Only intervention is not sufficient, the outcomes also need to be evaluated, and these services would also involve emergency care. A care delivery by nursing is never complete without communication, and this would involve patient teaching and my ability to learn from the scenario. As a professional, there might be limitation on my part as far as competence if concerned, and the idea of reflection is to be able to identify my lapses quickly in order to be able to mend them as soon as possible. This reflective practice would also help me to identify my strength areas and weaknesses in competence, so I can understand better the importance of maintaining and developing professional competence. Description Paula is a 42-year-old lady with bilateral breast cancer with stage III disease. It was decided due to advanced stage of her disease that she will first undergo chemotherapy, which was initiated last year. She finished her last cycle of chemotherapy in the month of January 2009. She was instructed to come back for surgery once the chemotherapy was over, and accordingly, she presented for surgery. During surgery, the surgeons found that chemotherapy had had no response to arrest the progression of her disease, and the bilateral mastectomy specimens returned a far worse pathological state of cancer than was thought of. The surgeons were reserved about the prognosis. While I was assigned her care and was asked to follow her up during her stay in the unit, I had a chance to interact with her on several occasions, and family also met me quite a few times. While it was very sad that she had to undergo bilateral mastectomies and she has a grave prognosis due to metastatic cancer, she was really in need of palliative care while in the hospital or outside. The matter was further complicated by the fact that she is a single mother with a son. The family did not want to hurt her by telling the truth about her condition and her death and suffering, and hence they requested the nurse and the doctor not to tell Paula the truth about her condition. While there are some ethical issues involved in this, although the family's sentiments may be correct, their approach may not be in the best interests for her, and the care team including the doctor and the nurses must disclose the truth about her condition. This is necessary due to the competence criteria of the nurses and health professionals to observe ethical soundness in practice, since otherwise, the nurse loses her accountability and trustworthiness to the patients by violating her rights to information and autonomy. With this dilemma, Paula surprisingly was very positive, and she was beaming with hope that she is getting better and will be able to see her son growing up, which is any single mother's dream (Gonzlez, 2004). Reflection Reflection is a process of self-inquiry and transformation towards realising desirable practice as a lived reality. As such, reflection is both the research and developmental tool. By reflecting on my everyday practice, I have a chance to become increasingly mindful of myself within the practice, care delivery, and the way I do it. I may become more aware of the way I think, feel and respond to situations as they unfold. I may become more sensitive to the people within those situations, whether patients, their friends or relatives, or my colleagues. As a consequence, I can respond more in tune with my values and more skillfully with my patients and others, which is desirable from me as a person delivering care. The reflexive narrative is presented as an exemplar of researching self as a process of self-inquiry and transformation (Souter, 2003). At the end of this course I will be a registered teacher in nursing, and I will have to guide them to write their own reflective accounts on their care delivery. Therefore, it would be good enough for me to guide others to construct a reflexive narrative if I would take it earlier. From the scenario, it is clear that the narrative that I am going to present will reveal facets of suffering of Paula and my responses to that. There is a need to research suffering from a number of research perspectives, examine suffering within the clinical context, and evaluate nurse-patient interactions with patients who are suffering (Mantzoukas, 2008). The sensitive nurse, able to fathom the complexity of suffering, will appreciate and respond to the person's suffering in its unique pattern manifestation. Therefore, this reflective account will provide insight into various dimensions of my practice including systemic observations of what I learned as a nurse clinician from my practice. Reflection is a process in practice, meaningful reflection indeed influences and informs practitioners to critically analyse practice situations so the practitioners can respond to and approach situations in a professional manner where standards of practice are maintained. This also provides the practitioner a framework where actions can be planned (Nicholl and Higgins, 2004). Reflection is clearly related to critical thinking, but I did not explore this directly at that time. I did, however, feel and came to understand how reflection might be an inherent element in the engaged and interested learning of the phenomena in practice when a deep approach to learning is the goal. I suspect that I did not consider the relationship with critical thinking in greater detail because, at the time, I had not considered the dimensions of depth of reflective learning. The exploration of reflective learning also stimulated me to pull together my ideas of what we do when we engage in the immensely complex process of learning something. To begin with, however, it was difficult to discern where to begin. It has been suggested that using a framework would be better (Chabeli and Muller, 2004), so it makes the reflective process structured and guided. I personally feel those who are very experienced would not need a framework for reflection. For me as a nurse as a means of reflective practice, I have and would always prefer to have a framework, and I choose the Gibbs (1988) reflective cycle in my reflections on my practice. From my experience and previous reflective episodes, I have seen that reflection is a dynamic and cyclic process. Therefore, a framework with overt cyclical approach would be most suitable. Gibbs formulated his reflective cycle while attempting to explain experiential learning, and in each step of the cycle, the reflective practitioner is faced with a series of questions that both guide and provide structure to the reflective process on practice. This process starts with a phenomenon and description of the event, and in each step, there are questions that lead to further critical analysis leading to a plan of action and then re-reflection on the changes. Reflections needs to take place at a conscious level that allows a nurse to make decisions about her learning, and critical analysis of such will also consider thoughts and ideas, evaluation of them, and making conscious informed choices about the future course of action in a given scenario. Most of the student life nursing placements lead to experiences which are based on observations in the clinical scenario of actions or practice of other people. This definitely helps the nurses to gain experience and technical skills. However, reflection is a process to review those experiences, so a closer and critical examination leads to further learning leading to more skills and expertise (Jasper, 2003). Moreover, this can be a great way to look back at personal experiences to assess learning, categorize the knowledge, and areas of gaps in learning. Gibbs model was chosen since it was easy to use in a repetitive manner during subsequent reflections. Therefore, this assignment would comprise of reflections on my experience on this patient according to the following cycle. These are description, feelings, evaluation, analysis, conclusion, and action, which next may lead to another description, so on and so forth (Jasper, 2003). Reflection The incidence in this scenario comprises of mainly two elements. One, the care of the patient and the other the ethical issues involved in her care. When the patient is pretty hopeful that she will get through her current condition without much event, and she is motivated to pull through such that she can see her son grow. At the same time, I felt concerned about her, since it raises a question, whether she understands her condition appropriately and correctly. Obviously, she has advanced disease, where her cancer was unresponsive to the treatment. In this situation, my experience says, she will be advancing towards death as days will go by, and most of the therapeutic options available in her case have complications of their own, which she will suffer. On the other hand, her family does not want her to know her actual condition, which would be ethically inappropriate from professional nursing point of view. Telling the truth is necessary so the patient can take her own decisions about her life, but it seems humanly impossible to declare the truth on the face of her zeal and motivation (Tuckett, 2004). I felt really awkward since I did not know what to do. I was feeling extremely sorry for her and sorry for me too, about how to break the bad news. How she will feel when she hears the bad news I was not able to make a decision as to what to do and what my competence requirements dictate Howell and Pelton (2001) in their study highlight the use of reflective practice in cancer nursing. I am sure it will be demonstrated in this reflective account how I was enabled to examine decision making in patient situations. Also I believe from my previous experiences of reflection that this would be able to uncover the knowledge and the artistry that are embedded in practice (Howell and Pelton, 2001). The quality of care giving is advanced through reflection. I am not a qualified oncology nurse; however, in my area of practice placement, Gynecology, there were chances that I undertook care of patients affected with cancer. I knew that it would offer me challenges regardless of my expertise and setting of care. The first problem was that there is a body of knowledge in cancer nursing that had been built through experience and research, and I in my current position was just more than a naive in it. Her clinical problems would be unique, and this could lead to challenging opportunities for clinical problem solving. Family is an important part of the care process, and it would be my role to help the patient and the family along her care continuum. Whatever may be the fact, I could understand when I was assigned to her care that there would invariably be a range of patient care concerns that needed to be taken care of through skilled interventions. I was feeling afraid and was extremely doubtful about my abilities to care and to communicate with her. My lack of experience was my weakness, but my strengths were zeal to do something for her and my academic learning. Although the complexity of her disease is frightening given my academic learning and skills, when I talked to my mentor about the potential problems that I might face in her care, my mentor assured me that, she will guide me closely throughout, and in the wake of her care, I would come to understand that it is her complexity of disease and other family situations, which would provide me both the opportunity and the challenge to make a tangible difference in patients' and families' lives. She reminded me that care apart, I must convey the message of hope to her through caring, provision of comfort, quality of life, and execution of effective treatment of symptoms (Kirklin, 2007). The first challenge was to develop a care plan for this patient. Care plan of this patient would depend on the assessment of her clinical, psychological, social, and spiritual status. It was decided by the medical team that she will put on chemotherapy again, and hence my job was to provide care during chemotherapy. It is to be recognised that my experience in conduct of chemotherapy was nominal, and my standards were below at par. I raised this concern to my mentor stating that I must be accountable for my work, and given my skills and training, I do not conform to the NMC standards (NMC, 2005). My mentor ensured that she will supervise and guide me throughout so I need not worry. I only knew from others that all chemotherapy situations lead to adverse effects of nausea and vomiting. My mentor said that nausea and vomiting are two of the most common and dreaded side effects of chemotherapy in breast cancer (Correa and Ahles, 2007). She also told me not to be anxious about that since the present protocols based on newer insight into the pathophysiology and standardisation of antiemetics would clearly indicate a protocol for antiemetic administration. However, she also stressed on the fact that while delivering care I must be aware that there is considerable interindividual variations in emetogenic response (Dibble et al,, 2004) meaning no two patients are same, so constant and consistent monitoring is necessary. Consideration of the ethical issues is of paramount importance in such cases. Looking back, I can see that the care of this patient had many ethical issues. As per NMC standards (2004), a nurse must be aware of the ethical standards of practice. For chemotherapy to begin, it needs patient's consent, and my problems began when I contemplated about explaining the patient's condition to her. This would be an absolute necessity to get consent from her, but the family does not want to disclose the truth about her condition to her. Informed consent is the usual way in which patient preferences are expressed. Informed consent is the practical application of respect for the patient's autonomy (Aveyard, 2005). The policy of patient-centered nursing care highlights the needs for shared decision making through active participation of the patient. As an ethical basis of patient-nurse, informed consent constitutes a central feature of an encounter characterized by mutual participation, good communication, mutual respect, and shared decision making (Breier-Mackie, 2001). Communication is the most important aspect of healthcare practice including nursing (Williams and Gossett, 2001). This indicates communication will have to find out ways to tell truth. If the facts are uncertain they should be acknowledged and represented as they really are. The patient herself is very hopeful about her treatment outcomes. My question was did the patient really need to know the truth. Given her clinical condition, she is going to die eventually despite the best form of care, and the natural history of breast cancer suggests so (Schairer et al., 2004). I expressed my doubts to my mentor, and she told me about importance of nursing communication skills and the ways the truth should be told, where the extent of motivation can be very acceptable and it can also ensure hope. Current recommendations do not advise deception, and the ethical doctrines of autonomy and truthfulness suggests telling the truth at any given situation (Royak-Schaler et al., 2006). This would become more important when the patient will eventually understand the course of her treatment and future life. Despite that I was feeling shaky to tell her the truth, may be because I did not want to be a messenger with a bad mouth. For a patient with advanced disease in bilateral breast cancer, the policy and guidelines for palliative care suggest palliative chemotherapy, and since palliation is the goal, the patient may undergo the therapy in the community setting. A community setting nursing care would involve a closer assessment of the patient and more efficient communication. I decided to tell the patient the truth, and exercised care to choose my words since telling the truth meant enabling her take a decision on her own. Considerable communication skills would be necessary here. This would avoid paternalism, and I was aware that empathy and care have tendencies to turn into a paternalistic approach to the patient (Woodward, 1998). This would not mean also that I was creating a situation where the patient would feel hopeless. I told her the real clinical scenario that contrary to her belief her disease has advanced, and this is very common in any cancer, and she will have to make a decision. In this situation, although medical management has advanced a lot, the doctors do not expect much, and if she agrees they will put her into palliative chemotherapy which she can access from her home. I also told her that traditional understandings of illnesses like cancer being a 'death sentence' are continually challenged as contemporary health care confronts new frontiers of treatment and cure. She is expected to have morbidities, and the aim of our care would be to improve the quality of her as much as possible (Ryan-Woolley et al., 2007). She was initially shocked, and even today I cannot forget the look she wore in her face. It was pale and anxious, as of somebody has slapped her. She was not in a position to believe this. I allowed the time to pass and then held her hand. I said worry is natural, but she should prepare herself to face the reality with strength. I now understand why they say empathic communication is so important for nurses, and now I understand how nurses should devote time and energy to develop a culture-competent communication skill. I slowly explained to her that as per NHS guidelines and legislations on palliative management of advanced cancer, chemotherapy can be used as adjuvant, curative, or palliative treatment, depending on the type and stage of malignancy. The effects of such chemotherapy are usually expressed in terms of response rate. In her case, the cancer has metastasized, and response rate would primarily refer to objective measurements of changes in cancer size, sites of metastatic disease, and measurable serologic or other markers of tumor activity. Chemotherapy would lead to some toxic adverse effects, and in her case, the toxic chemotherapy agents would be attempted to be avoided. Evidence (Jansen et al., 2006) suggests that many patients desire to go for adjuvant chemotherapy despite its potential toxic effects and very low-grade benefits for a prolonged duration since they think that something is being done to decrease the recurrence of cancer. In her case curative chemotherapy is not possible. She seemed to have understood. I also said that perhaps in her case the doctors have chosen chemotherapy as single-modality therapy due to the fact they do not expect cure of the cancer in her current state of affairs. I ensured that this treatment is necessary for her with the goal being symptom control, prolongation of life, or the combination of the two. Her emotional response to this noncurative therapy was not encouraging. Since I was a trainee without much experience, I felt shaky, and I asked myself the questions, what price in side effects she must pay for life prolongation, and how much life prolongation is she likely to get for this price All the more so, when the therapeutic goal is the more modest one of symptom reduction without life prolongation, the patient asks if the same symptom control might be achieved with less toxic therapy (Rhodes and McDaniel, 2001). I had hardly any answers. I told clearly to them that I had to tell the truth to the patient. Since our goal was to involve the patient in decision making, she has to know the truth and she has a need to know the truth in order to make a rational decision about the actions and plans for her life. In her case, I needed to have a very strong and supportive relationship with her which can be made based on trust only. I told the family about the need to be ethical and a care that is based on evidence. Studies (Lo et al., 1999) have shown that most patients with diagnoses of serious illness wish to know the diagnosis. Similarly, recent studies (DePalma, 2006) are unable to document harmful effects of full disclosure (DePalma, 2006). The family entrusted me to break the news. I was also getting mentally stronger due to this ethical issue and the growing need to display ethical soundness in my practice. Communication skills based on understanding of her disease became suddenly important. I felt that speaking truthfully means relating the facts of the situation. This does not preclude relating the facts in a manner measured to perceptions of the hearer's emotional resilience and intellectual comprehension. The truth may be "brutal," but the telling of it should not be (Tuckett, 2004). A measured and sensitive disclosure is demanded by respect for the patient's autonomy and sensitivities. It reinforces the patient's ability to deliberate and choose; it does not overwhelm this ability. My mentor and I opened the conversation with her with a straight question about how much the patient wished to know and whether she wanted someone else to be involved (Chauhan and Long, 2000). Her illness experience included a longer period of living with illness and its effects, and thus needed a longitudinal understanding of illness that incorporated the whole of her illness journey. Current cancer survival rates indicate a longer lifespan of people suffering from cancer in the UK. Researchers (Mathew et al., 2003) in this area have suggested that falling death rates, together with more public health attention to particular illness risk factors, have led to an emphasis on health promotion strategies and surveillance or 'control' activities. A total view of illness needs to encompass understandings of the chronic characteristics of illness; balancing the simultaneous treatments aimed at cure and symptom management; the day-to-day management of unstable symptoms; redefining the individual's view of themselves; exerting control; and the ongoing social and psychological adjustments that may be required (Mathew et al., 2003). The care would be in a shared decision making manner. In order for shared decision making to occur, patient was informed of her diagnosis, prognosis, and treatment options. I feel I worked by according respect for patient autonomy, and this played a central role in medical decision making, the paternalistic paradigm of the relationship needed to be exchanged for a shared decision making paradigm. When her initial shock subsided, she appeared to be quite willing to accept the side effects of chemotherapy one more time; her hopes were prolongation of life and symptom relief despite very small probability of cure (Charalambous et al., 2008). I established a communication and therapeutic relationship eventually with the patient throughout my days of close contact with her. She was afraid of becoming a burden to her family, and she was a little upset that she would not be able to observe her son grow, at least would not be able to be a part of it. I did not resist her while she was expressing such an agony, I accepted rather she can indeed become a burden to her family. But at the same time, I reminded her that many we have loved most in our lives, such as children and parents, have been burdens to us from time to time. Every person, at one time or another in his life is useless. But no person is ever worthless (Wyatt, 2007). The family needs the opportunity to show its love by bearing this burden, and the patient wrongs them not to allow this opportunity. I also reassured her that we will continue to care for the patient and family, even if chemotherapy is no longer used. This optimistic approach after a realistic discussion is appropriate and of great psychological benefit to the patient and the family, as well as the physician and other members of the health care team including the nurses (Wyatt, 2007). As I recalled from my reading, chills and rigors can be a complications which needs to be urgently attended to. This had nothing to do with chemotherapy, but was more probable to be associated with pyrogens in the intravenous fluid which quickly responds to antihistaminic agents and steroids. Fortunately, there was no associated vomiting, and it seemed the prophylactic medications worked well for alleviation of her vomiting complaints. Conclusion This reflective account, I must say that this had been a very important experience pre-reregistration nursing placement. I came to understand the role the mentors can play in educating the trainee nurses, and how learning, education, and skill accomplishment happen in the practice setting. I nave skills got reinforced while working in the NHS placement where the policy guidelines were followed in the management, and this experience would count a lot when I would start functioning as a teacher in my posting. Regarding the patient care, I must say that I have followed all ethical standards, and my nursing care did follow the requirements of NMC although I needed to seek help from the members of the oncology care team and my mentor. Regarding my mentor I can say that she turned this placement a learning experience for me, and through this reflection, I am finally able to understand the areas of my lacks. I lacked in the area of academic learning of cancer and cancer treatment, which I feel I will make up in my next opportunity to care such a person. I will study the regimen and find out the pitfalls in management. Empathic communication a specific skill that a nurse must be able to acquire, and it can be attained only through practice and knowledge. I lacked severely in that area, although I somehow managed in this care. Some more knowledge about current standards of palliative cancer nursing care would have been very much desired, but I could not manage to know some of them before being entrusted in this patient's care. If practicing as a community level specialist nurse, I would have to have it, since much of the care in the community level needs to be managed by the nurse alone, and I promised to myself next occasion, my patient will experience a standard nursing care with difference. Cancer care in the UK is governed by policies and guidelines widely followed across NHS, and it is in a pretty advanced state. In her care, in every step, there was necessity for clinical decision making, which I was able to perform based on prior experience and academic knowledge. The care plan would be decided through assessment and planning under guidance of my mentor and with advice from the other members of the multidisciplinary care team. On this issue, she has rights to exercise her choices, and despite the family encroaching her rights as a patient, I felt, nothing should create an ethical dilemma out of this issue, and my standpoint was clear from the beginning. I felt terrified to break the news, but professional competence, ethical guidelines, and evidence suggested me to be true, but it demanded a lot of communication skills that I might have been lacking. The care issues evolved round her chemotherapy regimen and associated adverse effects and pain relief. These were not issues, since the chemotherapy regimen adequately covered the adverse effects issues. I had to be her advocate while I felt the pain medication was inadequate, and I raised this issue to the medical team, who ultimately sought pain medicine help to start her on a regimen based on the available guidelines. References Aveyard, H., (2005). Informed Consent Prior to Nursing Care Procedures. Nursing Ethics; 12: 19 - 29 Breier-Mackie, S., (2001). 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