The patient, an 81 year old widower, was presented to accident and

emergency (A and E) department with a severe head injury. For anonymity as

per the NMC (2004) the patient will be referred to as Mark Evans. He arrived
by way of ambulance with paramedics who informed the A and E staff of the
estimated arrival time, a brief patient history and the injuries he had incurred.
Mark was diagnosed with dementia over 15 years ago and lives in a nursing
home that provide him with 24 hour care. He is a 6 foot 4 inches tall
gentleman who fell from height, backwards, hitting his head on a skirting
board. On impact this created a 3 inch, c-shaped laceration to the right side of
his head.

Going into hospital offers people the opportunity to receive the care they need
in crisis situations and for acute illness to be treated. But, when individuals are
in pain or have experienced an accident or a fall, noisy environments, fast
pace of work, new faces and intense questioning, this can be traumatic and
confusing. A and E departments are geared towards fast and effective
responses, assessment, diagnosis, intervention and discharge (Cunningham
and Archibald 2006).

A critical incident is something that can be positive or negative situation, and

are described by Rich and Parker (2001) as a snapshot of something that has
happened to a nurse, patient or their family. For nurses and student nurses
alike, reflective practice is regarded as a valuable learning tool for reviewing
critical incidents. In order to do so, I will explore my feelings and actions from
the critical incident described above and examine evidence based literature to
build the gap between theory and practice (Bailey 2005). Reflective practice is
thought to aid your way of thinking when applying knowledge to practice.
When I reflect on incidents I learn valuable lessons from what works in
practice and what does not. From this I will be able to develop my self
awareness involving my limitations, capabilities, critical thinking skills and
problem solving abilities. A wide range of literature will be used to reflect how
this particular incident correlates to the NMC code of conduct and best
practice.

In order to critically evaluate the incident I encountered whilst on placement in

Accident and Emergency, I will use the Christopher Johns Model of reflection.
His model uses 5 cue questions and in order to acquire a more in depth
description the model will be applied to this incident to facilitate critical
thought.

Johns (2000) model for structured reflection can be used as a guide for
analysis of a critical incident or general reflection on experience. The model
asks you to look at the situation which would include focusing on yourself and
paying attention to your thoughts and emotions. He then advises you to look
out of the situation and write a description of your thoughts and feelings, what
you are trying to achieve, why you responded in the way that you did, how
others were feeling, did you act in the best way and ethical concepts. He also
considers the use if internal factors, such as the expectations from others,
time factors, normal practice and anxiety of the situation. All of which will be
explored throughout.
The first cue question from the Johns (2000) model requires a full description
of the critical incident and asks you, as the reflector, to consider the essential
factors that contribute to this experience and the key processes for reflection
in this incident. As the occurrence was unfolding I tried to recall the advice
and practical training I have learned since learning the role of a nurse and
their responsibilities within a clinical setting. A description, in detail, of the
account can be found in the appendices for reference through out this essay.
Here is a brief overview of the incident, highlighting the key parts to the event
that I feel are significant to reflection and learning. On admission the patient
was extremely agitated as he was strapped to a paramedic’s spinal board,
with a neck collar and head blocks. This is the usual procedure for a patient
with a head injury. All of the equipment used where to restrict his movement
as much as possible, to preserve the cervical division of his spine. However
all of these preventative measures put in place began to heighten the
symptoms a sufferer of dementia would experience. From this an incident
began to unfold. The consultant in charge of this patient advised a team of
staff involving 2 senior staff nurses, 2 nursing students and 1 medical student
to remove the neck collar, head blocks and spinal board. He proceeded to
prompt staff to hold his head in a neutral position by holding either side of the
head to prevent it from moving. All of which was previous to any scans or x-
rays being taken. The anaesthetists refused to anaesthetise the patient as his
age, condition etc. were all conflicting factors when giving sedation. To
prevent any injury to the neck or spine, we were all advised to restrain the
patient, in an environment unfamiliar to him

The area of the incident I want to focus on is the way in which clinical
judgement and management skills used to manage a head injury of this
patient. There are both positive and negative aspects present in this situation
and I hope, in the future that this experience will provide me with the
knowledge and experience to build on similar scenarios, both as a student
and qualified staff nurse.

• What I want to achieve was outlined in my action plans and aim to

achieve them in practice.
Reflection on a clinical Skill

This essay will discuss a clinical skill in which I have become competent in
practicing. I will use a reflective model to discuss how I have achieved the necessary
level of competence in my nurse training programme. The reflective model I have
chosen to use is Gibbs model (Gibbs 1988). Gibbs model of reflection incorporates
the following: description, feelings, evaluation, analysis, conclusion and an action
plan (Gibbs 1988). The model will be applied to the essay to facilitate critical thought,
relating theory to practice where the model allows. Discussion will include the
knowledge underpinning practice and the evidence base for the clinical skill. A
conclusion to the essay will then be given which will discuss my reflection skills,
acknowledge my competence and show my personal and professional development.

The clinical skill I have chosen to reflect on within this essay is the administration of
Intramuscular (IM) injections. I have chosen this as within my first clinical placement
this was a widely used method of drug administration and I became involved in the
process of IM injections. I therefore researched the topic of IM injections and my
knowledge within this area developed.

The first stage of Gibbs (1988) model of reflection requires a description of events. I
was asked to administer a drug to a patient via IM injection. I had observed this
clinical skill on a variety of occasions and had previously administered an IM
injection under supervision. On this occasion I was being observed by two qualified
nurses, one of which was my mentor. The drug had been drawn up and was ready to
be administered and the patient consented to have a student administer the injection.
My mentor was talking me through the procedure step by step and informed me that I
should use an alcohol wipe to cleanse the injection site, when the other nurse
interrupted and said that this was not necessary. This was in front of the patient, who
then requested that the alcohol wipe was omitted as on previous occasions this had
caused a stinging sensation. My mentor said that this was acceptable and I continued
to administer the injection, omitting the use of the alcohol wipe. On the previous
occasions when I had administered IM injections I had not cleansed the site and had
never been instructed to adopt this practice.

I am now going to enter into the second stage of Gibbs (1988) model of reflection,
which is a discussion about my thoughts and feelings. I was aware of being under the
supervision of two qualified nurses and this made me feel very nervous and self
conscious. Once my mentor questioned my practice, concerning skin cleansing, I
became even more aware of feeling nervous and under pressure. The patient was
present and I did not want the patient to feel that I did not know what I was doing. I
thought that as I had been observed carrying out this clinical procedure on many other
occasions then my practice must have been seen to be correct. I was now feeling very
confused about the use of alcohol wipes in the administration of IM injection. I was
also concerned that the practice of the qualified nurses was so inconsistent, which led
me to evaluate the whole process.

Evaluation is the third stage of Gibbs (1988) model of reflection and requires the
reflector to with state what was good and bad about the event. I was aware that
research by Workman (1999) suggests that the use of skin cleansing wipes is
inconsistent and not necessary in IM injections if the patient appears to be physically
clean and an aseptic technique is adopted, along with stringent hand washing by the
nurse. It has also been noted that the use of cleansing with an alcohol wipe can cause
skin hardening (Mallet & Dougherty 2000). The trust policy was to follow guidelines
published by the Royal Marsden Hospital (Mallet & Dougherty 2000). The Royal
Marsden (Mallet & Dougherty 2000) advocate the use of skin cleansing wipes,
however it is stated within their guidelines that they adopt this because their patients
are often immunocompromised, and give evidence of previous studies which indicate
that skin cleansing is not normally necessary. Therefore my practice was within the
trust protocol. This experience made me think about my attitude towards literature
and how it is applied in practice. Burnard (2002) suggests that a learner is a passive
recipient of received knowledge, and that learning through activity engages all of our
senses.

The site used in the IM injection was the gluteus maximus, this the most commonly
used site for the administration of IM injections (Greenway 2004, Workman 1999).
The gluteus maximus area is both thick and fleshy with a good blood supply (Watson
2000). It is located in the hip area and forms the buttock (Watson 2000). It has been
noted by Watson (2000) that the gluteus maximus is near the sciatic nerve and
Greenway (2004) suggests that this presents a risk of threat of injury in the
administration of IM injections. When I administered the IM injection to the patient, I
injected into the gluteus maximus muscle, as the evidence stipulates this is best
practice.

Stage four of Gibbs (1988) is an analysis of the event, where Gibbs encourages the
reflector to make sense of the situation. I will do this by exploring the skill and
looking at the evidence underpinning it. An IM injection is the administration of
medication into the muscle; there are many reasons why drugs are given via the IM
route (Workman 1999). These include a rapid absorption rate, the conscious state of
the patient, and the drug effect being altered by ingestion (Mallet & Dougherty 2000,
Workman 1999). Workman (1999) suggests there are four considerations in giving an
injection, the site of injection, the technique, the equipment and the route. On my
clinical placement, an orthopaedic outpatient centre, IM injections were administered
on an almost daily basis. However Hemsworth (2000) comments that IM injections
are rarely used in certain specialities and suggests that, in this case, nurses current
practice in IM injections may not be up to date with recent research findings.

Through evaluation of the event in question I have become more aware of different
practices concerning the use of alcohol wipes in skin cleansing. I am aware that both
practices have been researched, but as I develop professionally I am developing my
own skills and will not cleanse the skin in future unless the trust policy dictates so or
the patient requests me to do so. There is no clear evidence in this area but I will use
the literature which is available to justify my actions, and therefore give evidence
based care. The reason my mentor suggested using the alcohol wipe could be that she
has been qualified for a long time, and practices have changed. In this scenario I have
learnt from experience and through experience (Burnard 2002). Following this
incident in practice I will now be more prepared to challenge the views of others in
relation to my clinical practice.

In conclusion, stage five of the Gibbs (1988) model, I am aware that all nurses do not
use evidence in the same way and may use different methods but as long as my
practice is safe and evidence based then I can practice safely. My future practice will
depend on the area in which I am working and I aim to find out the trust protocol
concerning clinical procedures before I commence any procedure

Within my action plan my aim is to research further into the theory of using alcohol
wipes in the administration of IM injections. I am also planning to have a discussion
with the qualified nurses on the subject of skin cleansing.

In conclusion my reflection skills have developed through the production of this

essay. Using a model of reflection has helped me to structure my thoughts and
feelings appropriately. My level of awareness concerning evidence based practice,
and its importance, has been enhanced with the use of critical reflection. My
competence, within this clinical skill, has been further developed and I now feel that
my personal and professional development is progressing. Using this reflective model
has helped me to realise that my learning is something which I must be proactive in.
Furthermore as a student nurse I have recognised that reflection is an important
learning tool in practice

Student Essay 2003 - The Learning

Experience of a student nurse, a critical
analysis.
— filed under: Student Essay, Nursing, Award, Student Learning

Author: Emma-Louise Greenwood, Student Essay Award 2nd Prize, 2003, University
of Stirling.

Introduction

My learning throughout the first year has been helped by an unerring optimism in the
value of nursing, and an appreciation that each and every daily interaction augments
my experience (Spouse 2003:200, Marris 1986 cited by Johns 2000:65). This
enthusiasm, however, has caused an inhibitory effect on my self-directed researching,
and created conflict in some placement areas. Whilst developing my role as a nurse,
my activities as a person at home and beyond have diminished, as I attempt to adjust
to the demands of both domains (Spouse 2003:109). I resent distracting influences,
and frequently domestic pressures restrain my desired pace to accumulate factual
knowledge. As described by Palmer et al. (1994:40), my learning can oscillate
between two extremes, “all or nothing”. Spouse (2003:42) depicts the student nurses’
need to develop multi-tasking skills emotionally, mentally and physically as they are
caught between the cultures of clinical areas, peer driven University life and home.
The conflicts arising from these settings creates a disharmony, which I believe for
some, may undermine nursing as a career choice. The developmental educative
process in nursing is a sophisticated and complex combination of scientific, logical,
humanitarian, communicative experiences and psychomotor skills, designed to
consolidate abilities and produce “knowledgeable doers” (Sajiwandani 2000:51,
Slevin 1992:36, Cheung 1992:159). Level one students are progressively introduced
to models of self-assessment, for example Johns’ Model of Structured Reflection
(1993:11), patient assessment models, for example Roper et al. Activities of Living
(1999). They are also exposed to many intellectual academic and practical concepts
simultaneously within the multi-various placements. The learning experience is an
attempt to focus the mind, and is defined by Kolb (1986, cited by Earnshaw and Dale
1994:16), as part of the perpetual cycle of reflection, generalisation and application of
any event. This process is a vital and fundamental principle in the creation of a sound,
and intellectually processed evidence-base of knowledge required by Nursing and
Midwifery Council (NMC) (2002 6:8) to underpin professional nursing practice.
Eligibility to practice requires completion of the nursing curriculum and qualification,
and registration with the NMC. Throughout training, student nurses are obliged to
meet educational standards, demonstrating they are: ‘competent, health-orientated,
thinking, reflective, change-receptive and accountable practitioners’ (Slevin 1992:31).
Proof of competence comes from a documented evidence-base, tutors, mentors,
assignment and examination results, and is based on continuum of regular
assessments. It is ultimately mentors in clinical practice and tutors in academic
practice who determine level of attainment and discriminate between satisfactory and
unsatisfactory student performance (Walton and Reeves 1999:44).

The good and the not always so good: the experience in clinical
placement – working alongside the mentor

MacLeod (1994:46-48) develops the argument that there is real value in the everyday
ward experience. There is a complex interface between the lecture-based, group
learning, intertwining with the noticing, understanding, responding in practice-based
experiences. Here, the students take the initiative to interpret, participate and immerse
themselves with practical care issues under the guidance of an assessing mentor. The
NMC (2002: 6.4:8) states that as a registered practitioner, a nurse has a duty to
facilitate students of nursing, to develop their competence, that is, they have a
responsibility to assist in their training. This however, makes an assumption based on
point 6.1, that the mentor has, to the best of their abilities, kept-up in learning skills
and competencies required to develop their own performance. In all forms of
mentored “supervision”, the personalities and experiences of each staff member and
student will provide for different qualities of transfer of learning (Hilgard et al. 1971,
cited by Sajiwandani 2000:69). That is, for a student to recognise the relevance of a
situation, requires they have a prior knowledge or familiarity with that experience
(Spouse 2003:200). Initially, the mentor will be obliged to direct the student’s
attention to relevant experiences and initiate the reflective process. Therefore, one of
the major influences of a student’s learning experience is the quality and nature of
mentorship (Spouse 2003:214). Where mentors befriend students and provide good
support, they legitimise student’s work, who in turn readily seek opportunities to
participate to achieve learning outcomes. Where this relationship is lacking, students
are unable to gain access to professional practical knowledge (Spouse 2003:210). In
this respect, where worst case situations manifest and structured assistance is missing,
the most helpful card in a student nurse’s hand, is their supernumerary status. It is the
student’s responsibility to foster better relations or to be reassigned to a different
member of staff, explore relationships with patients, colleagues as well as literature,
thereby stimulating their understanding. Communication with fellow students at this
time, may also improve their commitment to study and reduces a potential sense of
isolation created by the lack of attention from qualified staff (Spouse 2003:211).
Through this reflective discussion it is commonly noticeable that some mentors either
misunderstood their role or were too preoccupied by their own responsibilities to
engage with the students on their anticipated agenda. The reflective process on the
other hand also enables the student to gain a sense of proportion. Whilst researched
academic study underpins practice, there are frequently qualifications made by
nursing staff about ward performed procedures, stating that ‘real-life’ situations
employ differing methods to those taught in the class-room. These instances challenge
student’s assumptions and provide the impetus for further clinical reflective
investigation (Spouse 2003:205). They also serve to demonstrate the existence of
multiple methods of care delivery, attuning them to motives and perspectives of other
practitioners in the health care team, indicating that other’s, have legitimate reasoning
(Palmer et al. 1994:69). The traditional apprenticeship model does not fit well in
today’s nurse training. Instead, mentoring uses a form of ‘scaffolding’ practice,
whereby students work alongside, are provoked to think aloud, and, where they not
likely to become overwhelmed, stretched in their abilities to undertake tasks in a safe
environment. (Glen and Leiba 2002:120). The mentor, monitoring a student’s
readiness to learn and capacity to perform, is guided by this framework. Students are
not encouraged to be ‘task-orientated’ automatons (Slevin 1992:116, Hunt 1992:101).
The taught nursing process ‘puts the patients first’, centrally and viewed holistically
(Roper et al. 1999:13), that is appreciating that the patient exists as a member of a
social culture, who has (amongst others), a role, status, relationships and spiritual
needs (Roper et al. 1999:27). In many instances, however, students will meet mentors
who have ‘burnt-out’, as a result of lack of satisfactory working environments, long
hours, diminished professional respect, and inability to cope with levels of anxiety in
a constructive manner. The burnt-out qualified staff may have experienced, over
prolonged periods, reinforced subordination from other members of the health-care
team, effectively disempowering them. Consequently, through a lack of ability to
articulate, the professionals attitude alters in negative ways. These negative responses
manifest themselves in the mentor’s loss of concern and tendancy to resort to task-
allocation or respond in detatched and mechanical fashion (Glen and Leiba 2002:133,
Johns 2000:197). When students are faced with such situations in clinical settings, it
is very easy to adopt a similar approach. The student should attempt to engage staff in
reflective discussion, as a means to remind them of their own reflection, whilst
acknowledging their situation, because as mentioned by Moll (1990) cited by Spouse
(2003:199), there is an inextricable link between practice and theory. Their influence
on each other is mutual, and without good practice, theory has no meaning.
Theoretical understanding therefore is difficult to explore when faced with poor
practice. The benefits to the student of the continuously asessed nature of their
competence, monitored throughout the nursing curriculum, is that it is not superficial.
It is not dependent on the mood of the mentor in a busy clinical environment, or the
particular relationship between a student and a lecturer (Walton and Reeves 1999:80).
It is an up-dated measurement of progress and achievement. It encompasses real
world situations, adult-orientated problem-solving, close, (but unthreatening),
supervision and is graded to the student’s expected ability (Walton and Reeves
1999:83). Snapshots of, and overall performance gradings, interpreted reflectively,
will begin to acclimitise students to the reality of critical ambience they can expect to
find working on a ward. Students of nursing show a great flexibility of thought, but
they are not always able to articulate their anxieties, either about study or clinical
placements (Palmer et al. 1994:77). Reassurance about their work from mentors and
tutors, may serve to reinforce, an otherwise dwindling, confidence and self-awareness.
The evidence-base requiring development by all student nurses differs for each
individual (Ewles and Simnett 1999:121). It is driven by experience and a need to
achieve specified learning outcomes in clinical placement. Without reflection, and the
tutor’s corroboration, students may remain unfocused and disillusioned by the lack of
strict guidelines to assist in creating this document. Consistent nurturing by tutors
helps to convey the complexity of the concept of underpinning knowledge. Nursing
cannot happen in social isolation and students require comprehensive
acknowledgement to prevent both physical and mental exhaustion (Palmer et al.
1994:90). Support and guided reflection provided by mentors during placement and
by tutors, preceeding, during and following placements, serve to reaffirm the validity
of the student’s work, and to justify that they are not being used as another pair of
hands. These vital discussionary times allow the past experiences of the student to be
positively, selectively filtered and thus help in generating new strategies. As Dewey
(1933 cited by Palmer et al.1994:89), expressed, the notion of reflective learning is
primarily a willingness to learn, but further to this is a responsibility to search for
meaning within situations.

Conclusion

A qualified nursing practitioner is a professionally trained integrated member of the

health-care team. This professional education should be life-long, beginning with
three years pre-registration factual knowledge and skill acquisition. As previously
described there is a symbiotic relationship between nursing’s craft and nursing
wisdom, and they are required in practice simultaneously. Despite the apparent
impression given by traditional methods of education that these categories exist
seperately, for nursing they are fluidly cohesive, one informing the other, through
reflective analysis (Watts 1992:171). The elements experienced by nursing students
during their training are bonded internally together to authenticate their practice, by
unleashing possibilities inherent in the situation between patient and the therapeutic
self (Kirby and Slevin 1992:70). The following guidelines are intended to promote
improvements in the student’s learning experience. Qualified staff who direct pace
and direction of study need to encourage students in imaginative and innovative ways
to prepare them for adoption of new concepts and the flood of changes and that they
will need to make in all aspects of their life. Support such as this will guide them
through the vulnerable initial stages of their steep learning curve of level one, as
echoed by the dissonance described in the first paragraph of the essay.

Guidelines

I would like to see better preparation of mentors by lecturer-practitioners within

clinical placements, in order to foster environments of positive, constructively
planned activities. From this, students can gain insight to challenge their assumptions
and lay-view of nursing. In this respect, I would like those in the clinical settings to be
encouraging students rather than attempting to degrade their efforts by dismissing
their academic research based interest in the subject of nursing. I would like access to
professional teaching staff in-college at all times, especially immediately prior to and
post placement. I hope for tutor liaison with mentors more regularly within the
clinical settings, serving to remind mentoring nurses that their duty to support
students is real, and linked with Higher Education Establishments. I would like to see
in-college tutors giving better, basic and consistent guidance whilst initially
developing the concepts of critical reflective consciousness and the production of an
evidence-base of knowledge thus strengthening the intellectual and practical growth
of students.

http://www.practicebasedlearning.org/resources/materials/docs/reflectiononpr
actice.pdf
References

Johns, C. (2000) Becoming a reflective practitioner: A reflective and

Hollistic approach to clinical nursing. Practice, Development and
Clinical Supervision. Oxford Balckwell Science: 2000

www.contemporary nurse.com/archive/vol/24/issue1/article/2218: Accessed

November 17th 2010

Cunningham, C and Archibald, C. (2006) Supporting people with dementia

in acute hospital settings. Nursing Standard. Vol. 20, No. 43, pp, 51-55