Reflective  Journal    Regan Preston – 20825201 Bethesda Hospital Palliative Care Unit: NURS8820 Prac Scholar: Professor Karen Tambree 17 August 2012    

   

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Table of Contents      

Clinical Placement Reflection  ..............................................................................................................  3  

Reflection  ............................................................................................................................................  3  

References  .............................................................................................................................................  6  

 

   

 

 

 

 

 

 

 

 

 

   

 

 

 

 

 

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Clinical Placement Reflection  

This journal is to reflect on a situation that took place during my clinical placement at Bethesda

Hospital, palliative care ward. This reflection is based on the Gibbs Reflective Cycle (1988)

model.1 The Gibbs reflection model consists of six stages to complete one cycle, which

facilitates in my ability to improve my nursing practice continuously and learning from the

experiences for better practices in the future.1 The cycle starts with a description of the situation,

analysis of my feelings towards the event, an evaluation of the experience, an analysis to make

sense of the experience, a conclusion of what else could have been done and the final stage is

an action plan to prepare if the situation arose again. Reflection is used to generate practice

knowledge, assist an ability to adapt new situations, develop self-esteem, adding value and

professionalizing practice.1 However, O’Connor (2007) explained that reflection is about gaining

self-confidence, identifying when we need to improve our practice, learning from our own

mistakes, looking at other perspectives, and improving the future by learning from the past

experiences.1 Using a model of reflection enables me to explore and evaluate all previous

clinical experiences. The model allows me to develop the skills to evaluate and navigate myself

through the reflection process and identify areas of weakness or vulnerability as well as to, and

a platform to upgrade skills to overcome these deficiencies. The cornerstone to the reflective

process is the understanding of the Australian Nursing & Midwifery Council (AMNC) national

competency standards for registered nurses. These are core competency standards by which a

nurse’s performance is accessed in obtaining and retaining a license to practice.2,3 Linked

together with evidence based theory and practice, reflection will assist me in my professional

development towards becoming a more competent nurse.4

Reflection  

On an evening shift, a fellow student and I were advised by our preceptor to perform an

observation round for all our allocated patients in our care, in order to prepare them for up

coming five o’ clock dinner meal service. This process involved ensuring patients were

comfortable, and in an upright position, and that dining trays were placed in the appropriate

positions to eat and drink off. On approaching room number ten, I advised my colleague that the

patient presenting was an eighty two year old male with terminal lung cancer. I had been

monitoring him throughout my shift, as we were advised during the afternoon shift handover,

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that the patient’s health had deteriorated gradually throughout the morning shift. On entering the

patient’s room, greeting out his name, there was no patient reply. On further observation of the

patient, my colleague and I both came to the realization that he was unconscious. I approached

the patient, called out his name again, and gently tried to arouse him. It became evident

immediately that he was not breathing and I began to palpate his radial artery, only to find no

pulse. We looked at each other in dismay, confirmed with each other that the patient was

deceased. I immediately took action and responded by alerted nursing staff, by depressing

emergency room button. Within a few seconds a range of staff entered the room, in which we

advised them on our findings. This was my first experience of a death of a patient, in palliative

care.

On analysis of the event, I felt feelings of anger and frustration towards the nursing staff that

entered and assisted us at time of patient’s death. On initial entry into the room, the attending

nursing staff told me that that the action of depressing the emergency button was totally

unnecessary and an inconvenience as all nursing staff were pulled away from there activities to

attend to this emergency call. I was advised in future only to depress the patient room call

button. I stood there in disbelief and immediately felt feelings of anger. I was under the

impression and understanding, that in any clinical situation that involves a patient’s death,

palliative or acute, required immediate emergency attention. As nursing students, and as part of

ANMC standards professional code of conduct that we practice under, I believed my actions

were responsible and accurate. My anger was also focused on the fact that at the moment of

patient’s death, all communications around bedside by attending staff were focused on the

emergency call button protocol, which I personally found very inappropriate, and showing very

little respect to the deceased patient. As competent nursing students, we are bound by the

ANMC competency standards, and it is our responsibility to provide nursing care that advocates

for our patients rights in life and death, showing respect and dignity towards the patient. (ANMC

Competency elements 1.1-3, 2.3 3.1-4, 4.2-4, 7.1-4, 8.1-3, 3.5, 9.1-3, 10.4)2,5

On evaluation, themes and feelings of dread and terror, anxiety, feeling scared, helplessness,

guilt, sadness, frustration and emotional breakdown are all part of providing care to patients in

the dying period.6-9 Caring and treating dying patients is a major stressor in nursing practice.10,11

Nurses experience and are confronted with death in every day work, and hence are exposed to

many emotional aspects of grief.7,11 Death and dying are an integral part of a palliative care

environment. During research studies conducted by Kelly (1998) with female nursing students

facing patient death for the first time, four major themes were evidenced.12 These were namely

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the uniqueness of the new experience of patient death, overwhelming sense of awe at moment

of death, sadness due to patient death and reflection and evaluation of own personal beliefs

with regards to death.12,13 Loftus (2004) evidenced that many people that grow up in a western

society, are not exposed frequently to death, and in most cases are protected or shielded as

children from experiencing death.11 Hospitals are viewed as institutions were patients only

recover from illness, disregarding the reality that more patients die in hospitals than at home.11

This concept in itself makes for very little preparation or insight of young students facing realities

of patient death.11,13 Within clinical practice; nurses spend more time with patients than any

other medical profession. Part of a nurses role is to provide compassionate care, and dignity to

patients. As nurses we need to be adequately prepared for patient death, and training to deal

with death is vital element in student preparation for death.13 A solid base of training in this

regard enables students to cope better and have a more positive outlook on dealing with dying

patients.6,14 Personal development, continued education, promoting ethical care and patient

advocacy are practices, as nurses, we are bound by, as stipulated by the ANMC professional

code of conduct umbrella we practice under. (ANMC Competency elements 1.1-3, 2.3 3.1-4,

4.2-4, 3.5, 9.3, 10.4).2 Nurses repeated exposure to death and grief also leads to increased

work stressors, and nursing burn out. Furthermore, this can lead to emotional care

disengagement from dying patients, which has a serious impact of level and quality of care

given to dying patients.7,13 As nursing students we are bound by the ANMC professional code of

conduct, to provide to our patients the highest level of care, and source help and assistance in

coping with stressors faced in the workplace, and not letting these affect patient healthcare

outcomes. (ANMC Competency elements 1.1-3, 2.3 3.1-4, 4.2-4, 7-1-4, 3.5, 8.1-2,9.1-5, 10.1-

4).2 Cooper and Barrett (2005) highlight the importance of nurse education in dealing with

patient death.15 Education facilitates critical thinking and deeper reflection.14 Experiments

preformed have shown that nursing students anxiety scores decreased significantly following

patient death education.8,9 Reflection is a key element in nursing practice, Freshwater et all

(2005) evidenced how reflective practice is a successful method used in nursing practice, and

successfully can be integrated with nursing education.9,14-17 Student nurses need to reflect of

their personal experiences throughout their practice, and this reflection process will enable

student to earn from past experiences.11,18 Processes like storyboarding facilitate for deeper

reflection and critical thinking.11,15 Storyboarding is the process that encourages clinicians to use

the right side of the brain to formulate ideas, expressed in a group, and critical analysis of these

thoughts and reflections.11,15,17

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In future, my action plan will reflect that I have come to the realization and understanding that

patient death is an integral part of nursing practice in palliative care settings.18 I will also

recognize that strong preceptor, mentors, and support from all members of the multidisciplinary

team have positive implications for nursing students coping with stressors associated with

patient death.12,14,16,17 On this placement I was fortunate to receive an extremely high level of

support and education from my practitioner scholar, who assisted me throughout my clinical

placement. Qualified nurses and experienced clinicians in a palliative care setting are able to

offer support to inexperienced nursing students, using their life experiences with death, and

transferring this experience and support to less experienced students.10,14,16 Beck (2002)

evidenced that one of the most successful models of learning for nursing students is observing

and emulating expert role models, who ultimately act as mentors and instructors to student

nurses.8 Part of our professional practice is to embark on gaining further and additional

education in palliative care, resource education that raises awareness to factors that affect

terminally ill patients, developing appropriate skills to assist with the spiritual as well as physical

needs of dying patients, adequately preparing me as a student nurse for entry into practice as a

registered nurse.9,12 It is also important for me to take responsibility and make myself aware of

hospital guidelines and procedures regarding patient death, especially in palliative care settings.

In my future practice I will utilize continual reflection, trying to discover new ways of thinking

about dying, focusing more on providing highest quality of patient comfort and care in their end

of life journey. This will enable me to become a more professional and holistic nurse, delivering

the highest level of quality care to my patients.

 

References 1. O' Connor E. Foundations in Nursing and Health Care: Beginning Reflective Practice.

Association of Operating Room Nurses. AORN Journal. 2007 Feb 1;85(2): 429. In: Health

Module [database on internet]. Available from:

http://www.proquest.com.ezproxy.library.uwa.edu.au/; Document ID: 1214516671.; 2007.

2. ANMC. In: Australian Nursing & Midwifery Council. National Competency Standards for

registered nurse. 2011

3. Crisp. Potter and Perry's fundamentals of nursing. Chatswood, N.S.W. : Elsevier Australia

2009.

4. Hoffmann J. Evidence-based practice across the health professions,Tammy Hoffmann Sally

Bennett; Chris Del Mar c2010, Chatswood, N.S.W. : Churchill Livingstone, c2010.; 2010.

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5. Robinson A, A. "Student nurses' experiences of the body in aged care." Contemporary Nurse

19.1-2 (2005): 41-51.

6. Huang X, Chang J, Sun F, Ma W. Nursing students' experiences of their first encounter with

death during clinical practice in Taiwan. Journal of Clinical Nursing. 2010;19(15-16):2280-2290.

Available from: jlh

7. Shorter M, Stayt LC. Critical care nurses’ experiences of grief in an adult intensive care unit.

Journal of Advanced Nursing [Article]. 2010;66(1):159-167. Available from: a2h

8. Beck CT. Nursing students' experiences caring for dying patients. Journal of Nursing

Education. 1997;36(9):408-415. Available from: jlh

9. Thompson GT. Effects of end-of-life education on baccalaureate nursing students. AORN

Journal. 2005;82(3):434. Available from: jlh

10. Hopkinson JB, Hallett CE, Luker KA. Everyday death: how do nurses cope with caring for

dying people in hospital? International Journal of Nursing Studies. 2005;42(2):125-133.

11. Loftus LA. Student nurses’ lived experience of the sudden death of their patients. Journal of

Advanced Nursing [Article]. 1998;27(3):641-648. Available from: a2h

12. Kelly CT. The lived experience of female student nurses when encountering patient death

for the first time: Adelphi University; 1998. Available from:

http://search.ebscohost.com/login.aspx?direct=true&db=jlh&AN=2004134043&site=ehost-live

13. Supiano KP, Vaughn-Cole B. The impact of personal loss on the experience of health

professions: graduate students in end-of-life and bereavement care. Death Studies.

2011;35(1):73-89. Available from: jlh

14. Karkada S, Nayak BS, Malathi. Awareness of Palliative Care Among Diploma Nursing

Students. Indian Journal of Palliative Care. 2011;17(1):20-23. Available from: jlh

15. Lillyman S, Gutteridge R, Berridge P. Using a storyboarding technique in the classroom to

address end of life experiences in practice and engage student nurses in deeper reflection.

Nurse Education in Practice. 2011;11(3):179-185. Available from: jlh

16. Parry M. Student nurses' experience of their first death in clinical practice. International

Journal of Palliative Nursing. 2011;17(9):448-453. Available from: jlh

17. Miyashita, M. "Nursing autonomy plays an important role in nurses' attitudes toward caring

for dying patients." The American journal of hospice & palliative care 24.3 (2007) .

18. Phillips M, Breakwell S, Kim M, Faut-Callahan M. Clinical observation reflections from

students in an interdisciplinary palliative care course. Journal of Hospice & Palliative Nursing.

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