reflective practice

Pushpa Nepal, HSNS 566 Reflective practice

Reflective writing is a useful approach for nurses to learn from experience. In nursing, self-

reflection is essential to acknowledge own strength and limitation and to initiate necessary

changes in future to improve the situation and for professional development (Ushe, Foster &

Stewart, 2012). I have selected Gibbs' reflective cycle to reflect the incident as it helps to express

both events and feelings generated by experience (Andre & Heartfield, 2011, pp. 62-63).

Description

On placement, I was assigned to take complete care of 4 patients in a surgical ward of the tertiary

hospital under the supervision of my mentor/clinical nurse specialist (CNS). The night shift new

graduate registered nurse (RN) handed over to us that one of our post-operative patients had an

indwelling catheter (IDC) which was taken out a night before and patient voided after removal of

IDC. The RN reported that the patient's incontinent aid was moderately wet at night, however,

the patient was still complaining of not being able to void which made RN think that the patient

was confused.

Upon receiving a handover, I went to check my patients and I found that particular patient was

restless and when asked she stated she had a lot of pain in her lower abdomen. A quick physical

examination revealed distended lower abdomen. After reviewing her clinical notes I noticed

patient received PRN (as needed) analgesia for abdominal pain early that morning however no

further investigation and intervention were done for pain. Furthermore, I assessed the patient and

found she was well orientated to time, place and person as there was no significant history of

confusion or delirium in her clinical notes.

Feelings

At that time, I felt the situation wasn't correct and I reported immediately to my mentor. She

appreciated my initiation and instructed me to perform an ultrasound bladder scan.

Evaluation

Bladder scan revealed a residual volume of 998mls of urine in bladder. I immediately notified

my mentor and the junior medical officer (JMO) working on the floor who reviewed the patient

and ordered for immediate insertion of IDC. While I was inserting IDC under supervision of my

mentor I delegated the assistant in nursing (AIN) staff working on the floor to keep on close eye


on my rest of the patients and answer their needs. Upon insertion of IDC a urine output was

1650mls within a couple of minutes and patient stated she felt much more comfortable. Patient

thanked us for not ignoring her complaint of pain and not considering her as confused and

undertaking prompt action to make her comfortable.

In my opinion, the night shift RN changed her incontinent aid which was fairly wet thought the

patient was confused when patient stated she can't void. The patient might have incomplete

bladder emptying or overflow incontinence which the night RN might have assumed as patient

voiding normally. Later, my mentor spoke to the night duty RN about the incident and asked her

either she attended bladder scan or informed any of the senior nurses or treating team about the

situation. The RN said she was really busy and she didn't think about it. My mentor explained to

her how important is to attend comprehensive and accurate assessment of patient rather than

making an own judgment. My mentor discussed about legal requirement of nurses to fulfill the

duty of care and how negligence can lead to harm to the patient. The night shift RN assured my

mentor that she will never ignore patient's needs and always fulfill her duty of care in future.

Analysis

Australian Nursing and Midwifery Council (ANMC) have outlined the competencies for nurses

to provide safe and competent nursing practice adhering to the legal and ethical framework

(Davidson & Everett, 2012). ANMC competency for registered nurse requires nurses to perform

a comprehensive and accurate assessment of the patient before performing any interventions

(NMBA, 2006). In this scenario, the night duty RN should have performed comprehensive

assessment (physical examination and bladder scanning) when the patient was complaining of

abdominal pain and discomfort. It is the responsibility of nurses to fulfill the duty of care for

their patients. Based on ANMC competency standards, reflecting on this incidence has enhanced

my understanding of the importance of duty of care, nurses role to advocate for their patient,

critical thinking and analysis, comprehensive and systematic nursing assessment to identify

actual and potential health problem and need of effective communication and care coordination

with multidisciplinary team to achieve optimal level of health. Furthermore, with this incidence I

have also learned that whilst providing care to the patient nurses must understand their own

personal value and attitudes should never impose the care they provide to their patients (NMBA,

2006).


Conclusion

Reflecting on this incident I feel I performed fairly well however, I should have acted much

sooner to alleviate my patient suffering. I now realize if I would have ignored the incident

thinking the patient is confused I would have put my patient's well being at risk. Retention of

more than 800mls of urine in bladder increases the risk of bladder overdistention injury (Nguyen

et al., 2016). Similarly, there are many other complications associated with acute or chronic

retention of urine which may include infection, flaccid bladder, renal damage due to reflux and

development of bladder diverticulum or pouching (Casey, 2011). Hence, if the relevant action

wasn't initiated in time the situation might have been worst. Looking back on this incident, apart

from fulfilling duty of care I realize nurses are legally obligated to recognize and respond

promptly to unsafe and compromised care. Therefore, keeping patient wellbeing at the forefront I

also learnt to challenge the practice of colleagues if their practice put patient's health at risk

(NMBA, 2006). Furthermore, this incident helped me to understand the importance of

comprehensive patient assessment in identifying actual and potential health issue. By conducting

thorough patient assessment the exact cause of the problem was able to notify and with the

involvement of multidisciplinary team the issue was easily resolved. This incident provided me

an insight of the importance of patient-centered holistic care, effective communication and

teamwork skills for smoother transition as a beginning level RN (Walker et al., 2013).

Action plan

Nurses are accountable to provide safe and competent nursing care (NMBA, 2008). The national

competency standards for registered nurse require registered nurses to fulfill duty of care and

recognize and respond to unprofessional and unsafe practice (NMBA, 2006). With this incidence

I have learned to fulfill the duty of care carefully and to significantly improve the assertive skills.

Similarly, effective communication is an essential attribute a new graduate nurse should have.

Taking time to listen to the patient, recognize their unique need and involving them in their own

care promotes patient-centered care (Stein-Parbury, 2012). Relating back to the incident, due to

lack of effective communication a client needs was neglected therefore, in order to successfully

transit into beginning level RN I should develop competent communication skill.


The transition from a student into the professional graduate is often confronting and requires a

wide range of knowledge and professional skills (Williams, Richard & Al Sayah, 2015).In order

to successfully adopt into the professional role, a new graduate nurses are expected to prioritize

care, manage workloads, make an appropriate clinical decision, exert leadership skills and work

within the interdisciplinary team (Williams et al., 2015). The other key competencies required

for a new graduate nurse are practicing within the evidence-based framework, mentoring,

regularly monitoring patient progress, care coordinating and advocating for patient (Davidson &

Everett, 2012). Apart from other skills, a novice practitioner is also expected to have skills like

leading, mentoring and delegating the task to other staffs based on their competence and scope of

practice (NMBA, 2006).

Leadership skill is one the essential skill in the nursing profession. Upon completion of

graduation, a new graduate nurse is also expected to lead a team depending upon the

organization policy and protocols. The new graduate nurse can demonstrate and built leadership

capability by working within a small group of staff who has different competencies and skills

such as enrolled nurse and assistants in nursing in order to achieve a common goal (Thoms &

Duffield, 2012). Leadership skill requires a nurse to clearly delegate tasks to others, provide

recurrent feedback, communicate effectively within a team and involve in the professional

development of self and others (Thoms & Duffield, 2012). Delegating a task to others is often a

challenging job for a new graduate nurse. Before delegating a task to others it is essential to have

a sound knowledge of skills and capabilities of other team members (Thoms & Duffield, 2012).

In addition, consistent supervision, support and mentoring are essential to ensure delegated task

has been performed safely and accurately (NMBA, 2006). Meantime, as a leader providing

appropriate feedback is also important to motivate team members.

Hence, reflecting on this incident has helped me to get insight into my clinical practice,

understand the importance of comprehensive assessment, assertiveness, holistic patient-centered

care, interdisciplinary teamwork, leading, mentoring and delegating within the team for a

successful transition into the role of registered nurse.

reflective practice

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