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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.
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