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This essay will discuss my experience of having undertaken the Objective Structured Clinical Examination (OSCE) where I was asked to write and carry out particular clinical skills testing my competence and knowledge. I will use a reflective model to discuss my experience of having undertaken the OSCE and my thoughts about the feedback I received. The reflective model I have chosen to use is Gibbs model (Gibbs 1988). Gibbs model of reflection includes: description, feelings, evaluation, analysis, conclusion and an action plan (Gibbs 1988). The model will be applied to the essay to help me access what happened, make sense of it, and learn through my own experience by relating theory to practice and backing it up with evidence.
The clinical skill of which I was tested on within the OSCE I have chosen to reflect on within this essay is the mechanism of labour. I have chosen this because midwives use the theory of the mechanism of labour to assess progress during labour, and to explain events during labour. Understanding the mechanism of labour has direct implications for midwifery practice (midwifery.org, 2001), so therefore is very important for me to understand and implement in my own practice.
The first stage of Gibbs (1988) model of reflection requires a description of events. I was given a scenario which stated that I was looking after a patient called Jane who had been admitted to labour ward in labour. I was asked to demonstrate the mechanism of labour with the doll and pelvis provided and asked to describe my actions and speak clearly while carrying out the process. Once I had read the scenario I grabbed the doll and pelvis and sat down on the chair provided and placed the dolls head in the pelvis in the transverse position. Then stated that fetal axis pressure and cervical dilatation increases causing the fetus to enter the pelvic cavity and head rotates 1/8 of a circle to lie in the oblique of the pelvis putting the doll in a right occipitoposterior position. With maternal effort in the second stage the baby descends along the curve of carus and is born by extension. When the head is born it restitutes to be in line with the shoulders. The dolls head was born face to symphisis pubis. Then the shoulders descend and turn with the next contraction to lie in the anterior posterior diameter of the outlet. The head rotates externally and with this there is internal rotation of the shoulders. The baby is then delivered by lateral flexion with the next contraction. Once I had completed my explanation, I was given a second attempt to go through it again. So I did and unknowingly corrected a few mistakes I had made.
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. Even though this assessment was formative, I was aware that it would show my lecturers as well as myself the level of my competence I had in understanding the mechanism of labour. I knew I would find explaining the mechanism of labour difficult as it contains a lot of information which needs to be explained in an orderly way. I was being examined by Swi Ong a senior lecturer at Middlesex University who is also my link lecturer at chase farm hospital. Being watched made me feel very nervous and under pressure to get it correct. Once I finished my explanation, I was asked to have a second attempt, my first thought was to focus my thoughts as I could hear myself muddle my explanations of events on my first run. After my second attempt I was pleased with myself as I focussed more and corrected some mistakes I had made in my initial attempt. Once I had completed this section of the OSCE, I was not down hearted about my performance but took it as a learning experience which would help me access my own ability and help show areas which I need to improve on.
Evaluation is the third stage of Gibbs (1988) model of reflection and requires the reflector to state what was good and bad about the event. Once I had received my feedback from
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.
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