Reflection on the nursing process, using Gibbs 1988 model
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This is a reflective essay based on a situation encountered during my first six-week placement on an ear, nose and throat ward at a local hospital. In order that I could use this situation for my reflection the patient will be referred to as “Mr H”. This is in order that his real name is protected and that confidentially maintained in line with the NMC Code of Professional Conduct to
“Treat information about patients and clients as confidential and use it only for the purpose for which it was given.”
In order to help me with my reflection I have chosen Gibbs (1988), as the model to help with my reflective process. This model comprises of a process that helps the individual look at a situation and think about their thoughts and feelings. The experience gained in this can then be used to deal with other situations in a professional manner.
The Nursing process is a framework used by the health care professionals. The framework is made up of four components. Assessment of the patient on admittance to hospital, considering all of the patients individual needs in order to identify any problems. Planning: at this stage the nurse and if necessary carers, relatives and the patient discuss achievable goals and how these can be met. Implementing: This is the direct care needed for the patient, what is to be done for the patient, when and by whom. This gives the patient a clear understanding of what is going to happen to them throughout their stay in hospital. Evaluating: This step of the process informs the carer and the patient whether the goals set have actually been achieved (Kenworthy, et al 2002).
Whilst working on a morning shift I was asked if I would assist a team of nursing professionals and nursing assistants with washing and making a patient comfortable.
Mr H was a 68-year-old patient who had previously undergone cranial facial surgery to remove a tumour, which was invading his left eye. This was a very rare form of cancer. After a recent CT scan it was found that the tumour had reoccurred and this time was inoperable. It was shortly after this diagnosis that he was transferred to our ward for palliative care.
The World of Health Organisation (WHO) defines palliative care as:
“The active total care of patients whose disease no longer responds to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families”
(Lugton, Kindlen 2000)
On admission to the ward the patients care plan was completed with an initial patient assessment, relating to the “Activities of daily living,”(Logan et al 2001). The aim of this care plan was to allow the patient to die with well-controlled symptoms and to help the patient and family receive psychological, spiritual and emotional care during the last days of the patient’s life.
It was only through his body language that the nursing staff could tell if the level of medication was correct and whether he was in any pain or discomfort. Mr H was given diamorphine for his pain, cyclizine an anti-emetic drug to prevent sickness and hyoscine to help with his secretions. A syringe driver was used to give a continuous subcutaneous infusion, as at this stage Mr H was unable to swallow.
The patients family were with Mr H and so were asked to wait outside whilst the patient was washed and made comfortable. Mr H had strong wishes not to be catheterised, this was respected and a conveen was put in place. He was given a bed bath, a shave and a clean change of clothes. Throughout the procedures the nursing staff helped protect his dignity by keeping the cubicle door closed and by keeping the patient covered as much as possible.
The nursing staff continually spoke to him and reassured him, whilst I held his hand. Day to day deterioration was occurring, so it was essential that his family were informed of any changes in his condition and that everything was done to ensure he was comfortable and free from pain. Mr H died a few days later with dignity and respect and peacefully with his son and daughter at his side.
I felt extremely self-conscious when standing by the bedside. I did not know how conscious the patient was of the situation around him, so it was obviously important to talk to him. I found it difficult to know what to say and was really conscious of others listening to me and wondered if I was saying or doing the right things. The atmosphere in the room was very quiet, my mentor and other staff present were very concerned he may die whilst we were washing him, so we were all doing our best to ensure the family were allowed back into the room as quickly as possible. The family were obviously anxious and upset at being away from him for any length of time.
The good that came out of the situation was that the care plan for the last days of life had been met. The patients and the family’s psychological, social and spiritual needs had been addressed, and the patient was comfortable and free from pain (Kemp 1999). The care that was carried out protected the patients’ dignity and respected him as a human being, with his family being involved as much as possible with his care.
The bad thing about the situation was that medically there was nothing more that could be done for this patient. All the family could do was to sit by his bedside and wait for their loved one take his last breath, and to be at peace.
I chose this incident to reflect upon because I found it very rewarding to be part of the team that helped this patient, in his last days of life, die with the dignity and respect he deserved. Everything that could be done for the patient and his family was done in a very professional, but also a very caring manner.
The NMC guides us to:
“Promote and protect the interests and dignity of patients, clients, irrespective of gender, age, race, ability, sexuality, economic status, lifestyle, culture and religious or political beliefs” (NMC 2002:4).
I feel that we had achieved this for the patient and his family. I do not believe a person dying to be, part of the routine and ritual of the hospital staff caring for them (Field & James 1993, Walsh & Ford 1989 cited in Lugton, Kindlen 2000).
I have realised while reflecting that dying is unique and highly personal to the person experiencing it and also to those close to them (Lugton, Kindlen 2000).
On looking back on the incident I do not feel that my attitude towards death has changed, however, being involved with the care of this patient did make me think. It gave me better awareness on how to approach and communicate with patients and families of patients dealing with end of life situations.
In conclusion I can now see that whilst giving palliative care to a patient it can be easier to focus on the care to be implemented than the feelings of the patient and the family. I was nervous about giving care to Mr H., as I had never been in this type of situation before, I found I concentrated more on my own personal emotions than that of the patient and his family. When implementing palliative care it is important to observe the non-verbal and verbal communication of both the patient and the family, especially that of touch, which in itself can convey empathy. As a student I need to be more aware of this.
If I find myself in this situation again I would ensure I was confident enough to implement palliative care in a professional caring manner, which hopefully will mature with personal experience and by observing my mentor and other members of staff. I would fully discuss the care to be implemented before approaching the patients’ bedside and ensure I have a better understanding of the patients needs. I would talk to the patient whether or not they were conscious and also aim to provide support for the family.
Kemp, C. (1999) Terminal Illness, A guide to Nursing Care, 2nd ed. USA: Lippincott.
Kenworthy, N. Snowley, G. Gilling, C. (2002) Common Foundation Studies in Nursing, 3rd ed. Edinburgh: Churchill Livingstone
Jones, I. (1999) The UKCC Code of Conduct, A critical Guide. London: Drogher Press.
Lugton, J. Kindlen, M. (2000) Palliative Care, The Nursing Role. Edinburgh: Churchill Livingstone.
Palmer, A. Burns, S. Bulman, C. (1994) Reflective Practice in Nursing. Oxford: Blackwell.
Roper, N. Logan, W. Tierney, A. (2001) The Elements of Nursing. 4th ed. London: Churchill Livingstone.