Reflection Has Become An Important Concept In Nursing Nursing Essay
Reflection has undoubtedly become an important concept in nursing in recent years, stimulating debate and influencing nursing practice and education all over the world. Much has been written about reflection theory, the majority of which has been applied to educational settings (Price 2004). The process of reflecting, on the other hand, has been described as a transferable skill that can be incorporated into clinical practice, allowing practitioners to better understand themselves and others and solve problems (Mantzoukas & Jasper 2004). Indeed, the ability to consciously reflect on one’s professional practice is widely regarded as important for the advancement of education and, by extension, clinical expertise (Mamede & Schmidt 2004).
Reid (1993) defines reflection as “the process of reviewing a practice experience in order to describe, analyze, and evaluate it in order to inform learning about practice” (Reid 1993, p. 305). The nursing profession appears to advocate for nurses to be educated and practice in ways that foster critical thinking, autonomy, and empathy for others (Reed & Ground 1997). Reflective practice, according to Bulman (2004), may be one way to accomplish this. Some evidence suggests a strong relationship between lived experience and learning in an intensive care setting, with most critical care practitioners learning from previous experience (Hendricks et al 1996). Reflection has recently been linked to the concepts of critical thinking and deconstruction. It is argued that combining these principles creates a retrospective and prospective dimension, allowing the practitioner to deconstruct events, reason the origins of situations, and consider what has happened and what may happen in the future (Rolfe 2005).
In order to be effective in practice, one must be purposeful and goal-oriented. It is thus suggested that reflection should be concerned not only with understanding, but also with situating practice within its social structures and with changing practice (Bolton 2001). This suggests that the practitioner would benefit from a structured approach to reflection. Indeed, the use of a reflection model or framework is advocated as a tool that can aid and facilitate the practitioner in reflection, thereby promoting a process of continuous development (Bulman 2004).
Reflection is viewed as a dynamic process rather than a static one (Duke 2004), so using a framework that takes a cyclic approach to reflective practice seems appropriate. Gibbs’ (1988) Reflective Cycle is one such framework, which is adapted from an experiential learning framework and uses a series of questions to guide and structure the practitioner when reflecting on an experience. Gibbs (1988) identifies six critical areas to consider when reflecting on a specific situation, encouraging practitioners to consider what occurred, why it occurred, and what could be done differently in the future. The following are the six components of the Reflective Cycle:
What happened, exactly?
Emotions – What were your thoughts and feelings?
What were the positive and negative aspects of the situation?
Observation – What do you make of the situation?
Finally, what else could you have done?
Action Plan – What would you do if the situation arose again?
It is clear that the concept of reflective practice has had a significant impact on the nursing profession. This paper will focus on 2 clinical scenarios occurring within an intensive care setting. Gibbs’ (1988) Reflective Cycle will be used to discuss the issues raised. The goal is to highlight the benefits of a structured reflective process and to identify ways to improve clinical practice in the future.
Description of Scenario 1
The first scenario involves the care of an elderly, critically ill patient in a surgical intensive care unit. The patient had been in intensive care for nearly 3 weeks at the time of this scenario, having been admitted with respiratory failure requiring intubation and clinical symptoms consistent with sepsis. The patient had numerous other underlying medical issues, was morbidly obese, and required high levels of inotropic and ventilatory support despite antibiotic therapy. Despite the patients’ symptoms, no definitive source of sepsis was found.
The author was caring for the above patient on a 12-hour day shift, and during the morning ward round, it was noted that the patient’s condition had deteriorated significantly over the previous two days, with increased inotrope dependence and worsening renal function. With few treatment options left, the consultant anaesthetist recommended that the patient undergo a CT scan to identify or rule out an abdominal problem as the source of the sepsis. A consultant surgeon reviewed the patient and determined that, given the patient’s co-morbidities, surgery of any kind would be inappropriate, despite potential positive CT findings.
Knowing that a CT scan had been performed 1 week prior with no significant findings, the author expressed doubts about the utility of such a procedure and suggested that the patient’s family be informed or consulted about the planned investigation. The patient’s son had been contacted the day before and informed that the prognosis was bleak. Withdrawal of treatment was mentioned as a possibility if the patient’s condition did not improve. The son, on the other hand, was not informed about the scan, which took place the same day.
The patient’s transfer to the radiology department for a scan proved difficult. The patient was sedated for transfer, which necessitated the administration of additional inotropes due to the sedation-induced hypotension. The patients’ large size also made it difficult to find a transfer trolley that could handle their weight. Again, the author expressed concern, stating that transfer might be inadvisable due to the patients’ unstable cardiovascular status. The anaesthetist decided that we should proceed with the scan.
Throughout the transfer, the patient remained unstable, necessitating an increase in inotropes upon arrival at the scan. The patient became dangerously hypotensive and bradycardic while on the CT table, and cardiac arrest appeared to be imminent. Adrenaline boluses were given, as well as large fluid boluses of gelofusine. As a result, the CT scan was aborted midway and the patient was quickly transferred back to the ICU. During the transfer, additional adrenaline boluses were required.
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When the author returned to the ICU, he was greeted by the patient’s son, who was unaware that the patient was being scanned. He was made aware of the patients’ precarious state. Back in the ICU, it was determined that further resuscitation was not necessary. When the patient died a few minutes later, his son was present.
The author’s predominant thoughts and feelings on the day these events occurred were ones of guilt and inadequacy. Having considered the multiple health problems faced by the patient at this time, the author felt that the process of transferring the patient to CT scan and carrying out the scan itself may cause the patient stress, discomfort and potential danger, and ultimately be of little or no benefit.
Throughout the transfer and scanning process, the author became increasingly concerned about the patient’s immediate safety and the possibility of deterioration in the patient’s condition. When the patient became dangerously bradycardic and hypotensive, the authors focused their efforts on preventing cardiac arrest.
When I returned to the ICU and met the patients’ son, it appeared that neither the patient’s dignity nor the family’s concerns had been respected. The author felt inadequate and that the patient’s interests had not been properly advocated. The patient died in a distressing and inhumane manner, and the son had no opportunity to spend personal time with the patient prior to his death. The author felt guilty because it appeared that the CT scan should not have occurred and that the unsavory circumstances surrounding the patients’ death should not have occurred.
Looking back on the events of scenario 1, it appears that the experience had both positive and negative aspects. During transfer to CT scan and the emergency situation which followed, the author felt that there was good teamwork between the different professionals involved in the care of the patient. As a result, immediate action was taken, preventing cardiac arrest.
However, it appears that this situation could have been avoided, which raises a number of concerns about the patient’s care. Ethically, one must question how appropriate it was to scan a severely septic, unstable patient, especially when corrective treatments would have been inappropriate in the event of an abnormality being discovered. Should the author have fought harder for the patient’s and family’s interests? Was there a breakdown in communication and consensus among the critical care team members? This incident resulted in a clinical emergency situation, which resulted in the patients’ deaths. Thus, the author believes that the clinical condition of the patients, as well as the ethical issues and dilemmas surrounding their care, must be examined and discussed in the hope that lessons can be learned through the reflective process.
The majority of illness and death in intensive care patients are the result of sepsis and systemic inflammation. Indeed, sepsis affects 18 million people worldwide each year (Slade et al 2003), with severe sepsis remaining the leading cause of death in non-coronary intensive care units (Edbrooke et al 1999). Sepsis is a complex condition caused by an infectious process and represents the body’s response to infection. It is characterized by systemic inflammatory and cellular events that cause altered circulation and coagulation, endothelial dysfunction, and impaired tissue perfusion (Kleinpell 2004).
Dellinger et al (2004) define sepsis as the systemic response to infection manifested by 2 or more of the following:
Temperatures above or below 38°C (36°C)
Heart rate greater than 90 beats per minute
Respiratory rate greater than 20 breaths per minute or PaCO2 greater than 4.3kPa
High or low white blood cell count (more than 12,000 or less than 4,000)
In severe sepsis, impaired tissue perfusion and microvascular coagulation can result in multiple organ system dysfunction, which is a leading cause of sepsis-related mortality (Robson & Newell 2005). While all organs are vulnerable to failure in sepsis, the most common are pulmonary, cardiovascular, and renal dysfunction (Hotchkiss & Karl 2003). Dolan (2003) advocates evidence-based sepsis treatment in which patients receive targeted organ support when multiple organ systems fail. To maximize perfusion and oxygenation, this includes mechanical ventilation, renal replacement therapy, fluids, vasopressor or inotropic administration, and blood product administration.
In recent years, new therapies have emerged that have been shown to improve the chances of survival from severe sepsis in some cases. Human activated protein C recombinant has been shown to have anti-inflammatory, anti-thrombotic, and pro-fibrinolytic properties (Dolan 2003). Bernard et al (2001) discovered a significant reduction in the mortality of septic patients treated with activated protein C in a randomized controlled trial. The National Institute for Clinical Excellence (2004) now recommends this treatment for adult patients with severe sepsis and multiple organ failure who are receiving optimal ICU care. Steroids, whose use in the ICU has long been debated, have also been shown in low doses to reduce the risk of death in some septic shock patients (Annane 2000).
Despite the development of specific treatments to interrupt or control the inflammatory and procoagulant processes associated with sepsis, its management continues to be a significant challenge in healthcare (Kleinpell 2004). The patient in Scenario 1 was clearly in a state of severe sepsis, with respiratory, cardiac, and renal failure, and was receiving some of the above-mentioned supportive treatments. Indeed, the severity of this condition appears to have been underestimated. Given this, the ethical issues surrounding the decision to send this patient for a CT scan must now be addressed.
Ethical Issues and Agreement
In recent years, ethical concerns have emerged as a major component of critical care health care (Friedman 2001). As a result, caring for these patients in an intensive care unit necessitates confronting and resolving difficult ethical issues (Fisher 2004). Much of the literature in biomedical ethics has traditionally come from theoretical perspectives such as principled ethics, caring ethics, and virtue ethics (Bunch 2002). Although these perspectives can help with ethical awareness, they do not necessarily provide much direction for clinical practice. Melia (2001) agrees, claiming that many discussions of ethical issues in health care are presented from a moral philosophical standpoint, leaving out the clinical and social context in which decisions are made and implemented.