The introduction of clinical governance and high standards

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The impetus to achieve high standards of care was endorsed by the introduction of clinical governance and according to Upton and Upton (2005) combines the paired concepts of clinical effectiveness and evidence-based practice. Clinical governance accentuates the importance of providing first class care to patients by appropriate professionals, in a secure environment and in accordance with the needs of individual patients, which is central to quality improvement (Palfrey et al, 2004). It is a framework designed to assist nurses, by means of accountability and responsibility, consider the quality of the care they give and encourages a proactive approach to improve through best practice (Tait, 2004). This has contributed to the increasing value assigned to reflective practice. Matthews (2004) defined reflection as a process that encourages experiential learning which enhances knowledge to inform and improve nursing practice. A nurse has a responsibility to engage in reflection which encourages critical thinking and problem solving to advance and support their clinical competence and continued professional development (Wilding, 2008).

Schon (1987) identified two different types of reflection; reflection-in-action where the nurse reflects on the practice as it occurs; and reflection-on-action which occurs following the event and allows the nurse to explore and learn from practice. Reflection-on-action is frequently used as a foundation of formal assessment and transforms experience into knowledge (Jasper, 2006). According to Benner (1984) reflection is key to experiential learning leading to positive changes in practice and facilitates the progression from novice to expert. Nurses can utilise reflection as a means of continuous development and Gustafsson and Fagerberg (2004) suggests that there are many theoretical models available. Models of reflection including Gibbs (1988), Mezirow (1991) and Johns (2000) enable nurses to consider and reflect on their practice effectively and focus attention on relevant issues within their practice (Freshwater et al, 2008).

There are benefits and limitations to each of these models according to Duffy (2007) and nurses' can choose the one that is most appropriate for their needs. As Mezirow (1991) model lacks consideration of interpersonal aspects of learning and Gibbs (1988) model's descriptive design and lack of focus on practice they will not be used for this assignment. This assignment will provide an in-depth analysis of an experience in practice using John's model of structured reflection which has been adapted to suit the situation. Johns' (2000) model for structured reflection primarily adopts a humanistic approach which focuses on emotions and feelings, where the nurse and patient are considered as equal partners during the encounter; The model offers a systematic structure of simple questions that encourages a consideration of patient's individual needs and is appropriate when reflecting on the interpersonal relationship between the nurse and patient (Woods, 2003). Seminal work by Carper (1978) provides the foundation for John's (2000) model and focuses on aesthetics, personal knowing, ethics, empirics and reflexivity which encourages the nurse to adopt reflection as a means to examine and improve their practice. This reflective assignment will be presented in the first person and describes an experience in practice of administering an intramuscular injection which relates to the module 9 outcome of drug administration. To maintain confidentiality as identified by Nursing and Midwifery Council (2008), the patient will be identified as Jane.

Description of Event

Jane was admitted to the ward as an emergency admission following an episode of severe abdominal pain. She was evidently in pain and was very distressed on admission. Following Jane's thorough assessment and examination by the Senior House Officer a morphine based pain medication was prescribed, which was required to be administered via the intramuscular route. I introduced myself to Jane and proceeded to prepare the prescribed pain medication. I was given the opportunity to administer the injection by my placement mentor, as this was one of my competencies that I needed to achieve before the end of my placement. I was made aware that Jane was a nurse, and this forced me to express some concern to my mentor. I had previously had a negative experience in a previous placement whilst administering an intramuscular injection. This initiated a short discussion with my mentor and although she was able to empathise to some degree with my dilemma she encouraged me to proceed as I needed to combat my fear and also complete the competency in a positive and efficient manner. To allay my fears my mentor explained she would guide me and provide positive, constructive feedback following the event.

I organised the equipment onto a trolley and the medication was prepared allowing consideration for Jane's age, physical build and her pre-existing conditions. A full explanation of the procedure and outcomes was given to Jane at the bedside. Following this informed consent was obtained. Jane expressed her approval that I administered the injection as she appreciated the need for student nurses to learn through practice. Prior to the drug administration Jane's name, address, date of birth, medication chart and any known allergies were checked. I commenced the injection and whilst administering I reassured Jane throughout to comfort and reduce any anxiety that might have consequentially increased her pain. Once the procedure was completed I disposed of the sharps safely and ensured that Jane was comfortable. During the private conversation with my mentor I was given positive feedback about my management and administration and then my mentor provided me with the opportunity to discuss my thoughts and feelings, and in particular, my initial reticence to give the injection.


The definitive aim of performing the intervention was to achieve one of my competency outcomes for the management placement. Competence assessment according to Gustafsson and Fagerberg (2004) is characteristic of nurse training in the UK and accounts for 50% of the Fitness for Practice (National Assembly for Wales, 2002), allowing mentors to judge the students capabilities. It was important that I accomplished this learning outcome as in previous placements there had been limited opportunities to administer intramuscular injections. Whilst it is important to perform the intervention safely and competently Mantzoukas and Jasper (2004) believe that it is also essential that the invasive impact of such an activity on a patient's anxiety and discomfort is recognised. Although the practice of giving intramuscular injections is routine for nurses, it is one of the few invasive practices which has the potential to inflict pain in an attempt to provide relief to patients (Wynaden et al, 2006).

In addition to achieving a competence outcome the administration of the injection would also relieve Jane from her pain and anxiety. Nurses have a considerable part to play in pain management and according to Duke (2006) effective communication between the patient and the nurse, together with successful utilisation of analgesia improves patient outcomes. Jane expressed verbally her distress and need for pain relief however I also identified non-verbal cues of facial grimacing and restlessness, which often reveals more about how a patient is feeling and what they are thinking (Kozier et al, 2008). This was reinforced in a study by Manias et al (2005) which revealed that an inadequate awareness of non-verbal communication resulted in poor pain management. Jane received an explanation of the procedure and had constant assurance and reassurance during the consultation in order to demonstrate learned communication skills, which helped to ensure the successful and professional nurse-patient relationship.

The reluctance to administer the intramuscular injection originated from a negative experience during the first year of training. I was asked to give an intramuscular injection to a patient prior to a surgical procedure. The nurse explained the procedure to me and asked the patient for their consent prior to the administration of the injection. The patient was quite emaciated and I believed that the green needle which was normally used for the procedure was too long. I expressed my concerns to the nurse but was told that it would be acceptable to proceed with the green needle. During the administration of the injection contact was made with the patient's thigh bone. I rebounded with repulsion as I believed that I had harmed and hurt the patient. I was too naïve to express my concerns to the nurse and on reflection following the incident I questioned my own competence and ability.

This negative experience had a significant impact on my confidence and initiated feelings of fear, anger and insecurity. Nursing according to Higginson (2006) is a very complex career and the training presents unique situations that stimulate feelings of fear and anxieties. The negative experience, together with the fact that Jane was a nurse, made me question my capabilities as a nurse. Although Jane seemed unaware of my anxieties I assumed that she and my mentor would doubt my ability. The reluctance to perform the intervention made me feel incompetent and negligent of my duties however support and encouragement from my mentor helped to allay my fears. The Royal College of Nursing (2005) highlights the importance that students are adequately supported and given opportunities to learn during their practice placements. By encouraging me to administer the injection the mentor adopted an ethos of learning rather than teaching which promotes independence and active contribution to care (Ireland, 2008). Following the injection Jane expressed her gratitude at being relieved from her pain which increased my confidence and instilled a belief in my competence and abilities as a student nurse.


This situation generated many emotions within me of which frustration, fear, disappointment and then relief were the dominant feelings. When my mentor initiated that I was to give the injection my initial feeling was that of fear. Although I attempted to convince myself that I had the confidence to perform the task, the recollection of the previous negative experience emerged and caused increased anxiety. Moscaritolo (2009) believes that high levels of anxiety can affect students' clinical performance. However guidance from a placement mentor can facilitate learning, empower students' and ensures they are competent in safe and effective practice (Gopee, 2008). Although I was worried about appearing incompetent due to my lack of confidence, especially in front of Jane who was a nurse, my mentor encouraged and supported me throughout the experience. With this encouragement I believed I behaved professionally and competently, ensuring that Jane would be unaware of my anxieties. This increased my confidence in my clinical abilities and developed a trusting relationship with my mentor.

Whilst the previous negative experience in practice established a fear within of administering intramuscular injections, the fact that Jane was a nurse also generated a preconception that she would review my practice and have an opinion on my abilities as a student nurse. However, on reflection Jane would have been more concerned and preoccupied with her pain and impending diagnosis rather than being focused on the fact that I was a student nurse. As Craven and Himle (2008) believes that appreciating and understanding that patients are individuals is a fundamental part of nursing practice I believed that Jane deserved compassion regardless of my own fears. Her pain and distress would have persisted if immediate treatment was not given therefore it was a moral and professional duty to provide the pain relief (Tan, 2009).

I hoped that by giving Jane the medication safely and competently to relieve pain it would establish a trusting relationship between us, which according to Rushton et al (2007) is imperative. Displaying clinical competence ensures that patients' are cared for and their needs identified (Iacono, 2007). Sellman (2006) maintains that trust is an essential component of nursing practice and highlights the fragility of it under conditions of immense vulnerability, such as chronic pain or acute illness. I was aware of Jane's distress and wanted to provide care based on best evidence and in her best interests which is a prerequisite of good practice. It is crucial that nurses demonstrate clinical competence, display benevolent qualities towards the patient and appreciate the risk involved for the patient, as the equilibrium of power in the nurse-patient relationship is uneven which places the patient in a vulnerable position (Bell & Duffy, 2009).


My motivation to pursue a career in nursing was driven by the desire to care for patients whilst appreciating their needs, individuality and autonomous right to excellent care. In pain management, the duty to prevent or relieve suffering is fundamental and as advocates for patients, it is the nurse's responsibility to address the current issues (Vaartio et al, 2008). Nurses are committed to the ethical principles of beneficence and nonmaleficence according to Tuckett (2004) and have the best interests of the patients at the centre of their practice which includes achieving optimal pain assessment and management. My action advocated the need for adequate pain relief, ensured that the administration of the injection was safe and I believe that Jane was cared for in a caring and empathetic manner which matched my beliefs of doing what is right and good in a clinical situation, which Carper (1978) described as ethical knowing.

The importance of reflecting on previous negative experiences is highlighted by Bulman and Schutz (2004) who encourages nurses to explore their actions, identify problems and develop their future practice. My previous negative experience when administering an intramuscular injection was a traumatic experience however was a powerful catalyst for learning. In health care there is an accepted and elemental predilection for learning from failure which then is used to inform improved practice. The establishment of the National Patient Safety Agency (NPSA) in July 2001 in the UK aimed to improve the safety and quality of care through reporting, scrutinising and learning from adverse incidents in the NHS. I have learned from my negative experience and believe that this demonstrates an ethical consideration to a situation which improves the safety of my patients (Ghaye, 2005).


Carper (1978) describes empirics as scientific knowledge that provides factual evidence that explains, informs and underpins nursing practice. Kozier et al (2008) believes that it is imperative that nurses understand the physiology of pain and have a duty to relieve their patients from this pain where possible. Jane was admitted to the ward for investigations and pain relief however when I observed that Jane was emaciated the feelings that I sensed with my previous experience came flooding back. The situation was a replica of the negative experience and the anxiety, fear and apprehension clouded my judgement. I perceived myself as too inexperienced to administer the injection. Hemsworth (2000) believes that limited opportunities for students to perform injections in practice are associated with restricted knowledge and skills. However this experience helped to inform my practice and provided me with the confidence to choose the needle and the site of administration appropriate for Jane.

In addition to providing comfort and support through effective communication it was important that I also performed the procedure safely and competently. Student nurses should repeatedly utilise opportunities to participate in learning activities to progress and maintain clinical competence and practice (Wilding, 2008). Following my assessment of Jane I believed that the injection should be administered into the ventrogluteal site using the shorter blue needle. The fact that the ventrogluteal site is the safest and the least painful site for delivering injections and that a shorter needle is advisable for patients who are emaciated provided with me with the rationale for my decisions (Craven & Himle, 2008). The administration of intramuscular injections according to Hunter (2008) requires the nurse to possess the knowledge and rationale of the guiding principles that underpin the clinical skill. Bandolier (2003) believes that educating student nurses on injection techniques can lead to improved and safer practice as the National Patient Safety Agency (2007) states that poor practice can create adverse risks for patients and nurses.


During the negative incident I had identified that the patient involved was emaciated and raised my concerns with the choice of needle with the nurse. However as a first year student I lacked confidence to assert my choice to refuse to perform the procedure. This experience damaged my confidence in my abilities and had a negative effect on my future involvement with intramuscular injections. Retrospectively I should have asserted myself further and examined both my actions and the nurse's immediately following the incident to address the issues. Nurses according to Baxter and Rideout (2006) have a powerful influence in the development of the students' perceptions of themselves and their abilities.

I approached this recent experience with an open mind and minimal reference to my previous experience nevertheless my mentor should have been informed at the beginning of the placement of my apprehension of intramuscular injections. Allison-Jones and Hirt (2004) believe that a good communicative relationship between a mentor and a student is an important part of learning with the mentor's expertise, competency, approach and communication skills playing a central role (Stuart, 2007). Accepting that every situation is different and adopting an approach of clarity and transparency would improve my outlook and confidence for future practice.

Saveman et al (2005) maintains that a good interpersonal and communicative relationship,

professional approach, and a caring manner are all essential to build a successful nurse-patient relationship. With the refusal to administer the injection the prospect of building a caring and trusting nurse-patient relationship with Jane would have been unattainable. I am disturbed and frustrated that a negative experience influenced my confidence and could have been avoided if it had been addressed at the time by means of reflection and clinical supervision. Reflection according to Ashby (2006) can encourage nurses examine their practice, increase their self-awareness and uncover implicit knowledge. I am pleased however that I was now able to adopt a spirited and willing approach to combat my fears and carried out the procedure in a considerate and professional manner. The administration of pain medication to Jane demonstrated effective pain and distress management which according to Hall-Lord and Larsson (2006) is central to the prerequisite of first class delivery of nursing care.


Johns and Freshwater (2005) define reflection as a process that encourages nurses to examine their actions and learn from experience which enhances and informs their practice. Whether the reflection occurs prior, during or following clinical practice it is a process that nurses can apply to understand and appreciate positive or negative experiences (Schon, 1987). The use of John's (2000) model supports the need for the student to work with the mentor and has enabled me to explore and make sense of this reflective experience. The model offered a systematic structure of simple questions that encouraged a consideration of Jane's individual needs and was appropriate when reflecting on the interpersonal relationship between my mentor, myself, and Jane. It has allowed me to understand how the negative experience in the first year had an effect on my confidence when faced with a similar situation. As Jasper (2006) suggested it has helped explain and resolve my original feelings of incompetence and failure. By reflecting on my previous negative experience it proved a catalyst for learning and it informed my knowledge and rationale for deciding on the site of administration and needle size for this practice experience.

This experience has highlighted the implications of not reflecting adequately and addressing any issues arising from a negative experience in practice. Stein-Parbury (2005) believes that clinical supervision is an ideal opportunity for nurses to share their knowledge and experiences, improving competence in a supportive environment. I believe that this experience has facilitated the appreciation of the significance of aesthetic, ethical, and personal ways of knowing and has developed empirical knowledge (Carper, 1978). Although I administered the injection competently the initial reservations that I had would not have existed if I had had more confidence in my own abilities and addressed past issues. My mentor empathised with my fear and lack of confidence but imparted her knowledge to guide and support me. Johns (1995) believes that the combination of diverse sources of knowledge and personal knowledge is needed to inform a clinical intervention. Following guidance from my mentor and personal experience from clinical placements I am now more aware of the improvements that I need to make to become a competent student nurse.