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Following Johns Model of Structured Reflection Argumentative

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I was asked to complete a pre-operative assessment on an elderly lady for cataract extraction, using an I.C.P. for intra ocular surgery under LA. During the assessment process she expressed several times that she was extremely sensitive to things going near to her eyes, also during the assessment I observed from her body language and tone that she was very nervous and anxious about the whole being in hospital experience. Throughout the assessment I tried calm her down and gain her trust by being friendly and humorous but at the same time explaining every step of the procedure and what she was to expect by the end of my part of the assessment she had relaxed considerably.

As I am not qualified to complete the assessment I had to get one of the senior-nurses to come and complete the assessment by taking all the measurements and readings from the eye all of which are vital before the commencing of the operation at a later date. The first test is to measure the eye using a slit lamp. I had explained the test to the patient and said there was nothing to worry about, as it was a simple routine procedure. The lady felt quite confident about completing the examination without to much fuss.

I then left her in the examination room whilst I went to find a staff-nurse. When I returned the senior-nurse walked in and introduced herself to the patient and proceeded to start the examination, which initials the patient to sit forward in a headrest and to stay very still and not blink or move the eye. This the patient found very difficult to do and kept blinking. In response to this the senior-nurse asked her to sit still and stair straight ahead repeatedly, the patient did not respond well to this and became more agitated and started to blink and squint making the test impossible. Then without warning the senior-nurse lent forward and pulled the eyelids apart to gain a better view of the eye, as the patient was not expecting this she withdrew from the machine ‘this seemed to annoy the senior-nurse further’.

After several attempts to take the readings and the involvement of two other nurses ‘during which time the patient had become very upset’, the senior-nurse sat back and with a big sigh addressed one of the other nurses “This woman is being very difficult so she cant have it done (the surgery), she will have to come back at a later date”. She then made a note in the I.C.P. and left. Throughout the procedure I stood in the background and kept quiet once the senior-nurse had left I had to explain to the patient why she couldn’t have her surgery done until she completed her measurements and I suggested it would be best if she came back at a later date. Once I had arranged a new date for her to come back she left with her husband still quite upset.

2.Explore the experience using the reflective cues:

*Aesthetic: Ask yourself:

a)-‘What was I trying to achieve?’

b)-‘Why did I respond as I did?’

c)-‘What were the consequences of that for:

*The patient?



d)-‘How was the person(s) feeling?’

e)-‘How do I know this?’

a) During the examination we were trying to complete an accurate measurement of the eye (which is essential for the lenses selection in cataract surgery) with minimum pain and distress to the patient.

b) During the procedure I kept silent and in the background leaving the more experienced senior-nurse to deal with the patient, I did this as I assumed that the senior-nurse must have dealt with this type of patient before and know what would be the best way to deal with this type of situation and I thought that as I am inexperienced the more experienced nurse must know best.

c) The consequences of my actions for the patient was that she got a rough treatment from the nurse with no emotional support form either me or the examining nurse to make her feel more relaxed as a result she became more agitated and stressed. As for the nurse at the time I felt that if I intervened it would be like saying I thought her actions were wrong, also having me not say anything would be best as not to undermine her authority. Myself I felt if anything to be in the way

d) After the first section of the assessment I observed the patient to be much more relaxed and happy. As soon as the senior-nurse came into the examination room the patient appeared to tense up in anticipation to the examination and as the senior-nurse got more annoyed she became more and more upset, I can assess this as during the examination the patient started to cry and appeared very upset, she only stopped crying when her husband came to comfort her.


*Personal: ask your self:

-‘How did I feel in this situation?’

-‘What internal factors were influencing me?’

Throughout the entire procedure I felt inadequate, helpless and annoyed, I felt as though I wanted to intervene to try to calm the patient and reassure her that if she just relaxed it would all be over in just a moment. But as the senior-nurse has been practising for some time I felt like who am I to interrupt her examination and comment upon her assessment techniques I felt as though she would resent the interruption. The factors influencing me were that she is experience and I am not.

*Ethics: ask yourself:

-‘Did my actions match with my beliefs?’

-‘What factors made me act in incongruent ways?’

My actions did not match my beliefs as I believe in my opinion that the sister should not have treated the patient so roughly and she should have been more patient and forgiving and I now believe I should have intervened to reduce the patients suffering, but I just stood there and did nothing. The factors influencing most of all as I mentioned before were lack of confidence and lack of experience.

*Reflexivity: ask yourself:

-‘What would I change if faced with a similar situation?’

-‘Has this changed my ways of behaving?’

If I were to face this salutation again in the future, their would be several things I would do differently first of all I would not leave the patient alone in the examination room surrounded by the ophthalmic equipment as this gave the patient time to reflect and some of the instrumentation could have been intimidating instead I would ask them to sit back in the waiting room until a trained nurse was available to see them. Secondly when handing over the patient to the senior-nurse I would spend more time passing on important information about the patients worries and fears so the senior-nurse would then know to be more patient with particularly anxious patients or repeat all the procedure to patents that maybe haven’t understood all I have told them. Also throughout the examination I could have worked with the examining nurse to provide a comfortable none threatening environment for the patient and if they are still difficult to gain a reading from them give them a rest and try a different approach.

As a direct result form this experience I took it upon myself to improve my handling of patients during the second faze of pre-operative easements by making my self much more active and involved in he actual examinations of the eyes also by transferring information to other nurses more accurately and always express my feelings about the patients state of mind.

Although I cant say whether making these changes would have resulted in the patient in question being able to complete the examinations I could have handled the entire situation better.


Johns. C., Freshwater. D. (1998) Transforming nursing through reflective practice. Bailliere’s Study Skills for Nurses Vol 2 Bailliere Tindal pp 201-226

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