The use of Critical Reflection in Nursing Practice

Nursing practice is a complicated phenomenon, and usually something which has many dimensions. Nurses can develop better understanding of the ways in which they practice, the influences on their practice, and of their responses to challenging situations, through reflection on that practice, and, specifically, reflection on critical incidents. The use of reflection in nursing practice has been established as an important learning and development tool. Not only has it been described as an effective means of engaging in professional and personal development through self-assessment and self-evaluation (Gustafsson and Fagerberg, 2004 p 271), it is also known to be a way of looking at the quality of practice, and questioning how things are done (Bowden, 2003 p 28; Coutts- Jarman, 1993 p 77). Nurses usually use reflective models to guide their practice, as placing a structure on this process makes it more purposeful (Gibbs, 1988, online; Rolfe, 2005 p 78; Jones, 1995 p 783). Price (2004 p 46) also argues that reflection is a patient-centered activity, and one that is linked to the development of critical thinking.

The NMC (2004 b), the professional body that governs nursing practice and sets the standards for nurses, states that nurses should: ‘ Act to ensure the rights of individuals and groups are not compromised; manage risk to provide care which best meet the needs and interests of patients, clients and the public; review and evaluate care with members of the health and social care team, and others; share experiences with colleagues and patients and clients in order to identify the additional knowledge and skills needed to manage unfamiliar or professionally challenging situations; contribute to the learning experiences and development of others by facilitating the mutual sharing of knowledge and experience.’ This assignment shows how the author has attempted to adhere to these guidelines through this process of reflection.

WHAT

The author witnessed a member of staff putting medication in the food of a confused and sometimes aggressive patient who regularly refuses their medication. The member of staff was crushing tablets and putting them into the patient’s food. This patient, an elderly and confused person, is someone dependent upon nursing staff for support with all of their activities of daily living (Farley et al, 2006 p 46). They are difficult to communicate with and it is not possible to get informed consent or true compliance from them. However, the medications were necessary to maintain their state of health, address their mental condition and prevent exacerbations of chronic conditions (such as hypertension). The author was moved to question this practice, and asked the nurse about this, but the reply was rather defensive. It seemed that they believed this was the only way to administer the medications and that it was for the patient’s own good.

SO WHAT

To begin with, the author felt that it was important to question this occurrence, because they found it ethically challenging. While the author understood the need to ensure the patient had had their medication, this occurrence challenged previously acquired understanding of informed consent and respecting the rights and dignity of the patient (NMC, 2004a, online). Acting in the best interests of the patient, however, is another requirement of nurses, and in this case, it was easy to see that they did need the medication and that it would help their subjective feelings of wellness to some extent. However, the author would also question how far this would improve their state of being, because with their cognitive impairment, they might not be able to recognize the difference between subjective measures of sense of wellbeing.

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The main issues in this scenario revolve around the ‘competence’ of the patient and their ability to give consent (Hedgecoe 2008). The issue of consent is central to nursing practice, particularly in relation to ensuring the patient care is client-centred (DoH, 2001, online; NMC, 2004a, online). The autonomy and dignity of the client is at stake when one considers providing or enforcing care without consent (DoH, 2001, online). Veitch (2002) offers an authoritative overview of the practical issues involved in consent and advises that it ‘is the dividing line between treatment and assault’. (Veitch 2002 Pg 11). This is a very important issue to consider, because, as already discussed, the NMC (2008, online) requires nurses to only act in the best interests of their patients. That means being proactive, providing information to the patient, and communicating with them as best they can, even when there are communication difficulties. Veitch (2002) also goes on to comment that ‘Consent’ is not just the signing of a document prior to undergoing a procedure, it is a hugely complex area with legal, ethical and practical components and all of these are brought into sharp focus when they are compounded by degrees of reduction in cognitive function (Veitch 2002 Pg 22). The problem here is that the patient, who is suffering from vascular dementia, cannot really be considered fully competent to make decisions about their care. They are cognitively impaired, and in need of significant care, surveillance, assistance and input in order to maintain basic levels of health and functioning. As such, this issue highlights the plight of such individuals, because they are occupying a cognitive world which is disconnected from reality, and within which they are unable to reason or understand what is being asked of them (Bowler, 2007).

However, in this case, the scenario is taken to be in a residential care home. This means that one could reasonably assume therefore that the patient is not severely cognitively impaired and may suffer from fluctuating degrees of impairment (Bowler 2007). To this extent, the situation may be helped by considering whether they were happy to take the medication when they were less confused. If the patient is normally happy to take their medication when they were cognitively aware, the legal considerations become easier as Lord Donaldson has stated, in legal statute, that if a patient is judged not to be competent then ‘the healthcare professionals who are responsible for their care are also responsible for making a decision that they believe is in the patient’s best interests and in line with a decision that they believe the patient would have made if they were competent to make it at the time.’ (Donaldson 1993).

It would appear, therefore, that perhaps the actions of the nurse in placing the medication covertly in the patient’s food is excessive, and may be motivated by expedience and convenience rather than the best interest of the patient. It might be that, as may be the case in many circumstances, preconceptions about patients, and even stereotyping and prejudice, could be affecting actions here, because despite the egalitarian nature of the nursing profession, there appears to be ongoing ageism in clinical practice (DoH, 2001, online). According to the Department of Health in the National Service Framework for Older People (DoH, online), older people are often subject to preconceptions and prejudice because of ageism, and this ageism can be quite subtle, and pervasive in our modern society. Even those who deal extensively in the elderly may be prejudiced towards them, or have some degree of innate ageism (Gunderson et al, 2005 p 167). With the ongoing focus on patient-centeredness (DoH, 2001, online) and on ensuring patient safety through the highest standards of care (DoH, 2004, online), this author would argue that actions which occur as a result of prejudicial preconceptions are quite likely to place patients at more risk. In this situation, the nurse may possess such preconceptions but be unaware of them, but this action could place the patient at risk. If someone else came along and asked the patient if they had had their medication (obviously in a more lucid moment), the patient would say no, because they would be unaware that this had occurred. Therefore, the patient could be overdosed because a second dose might be given.

The ethical considerations that arise from this particular scenario are not the same as the legal ones, although there are large areas of both overlap and concordance of views (Lo, 2005). Hippocrates has been cited as stating that one should ‘first do no harm’. (viz Carrick 2000). This is the basis of the Hippocratic Oath which is taken by all doctors in the UK, and also the basis of fundamental principles of healthcare and professional practice. This is effectively translated into the Principle of Non-maleficence which means that the healthcare professionals must ensure that the patient is not harmed. An aggressive and confused patient may well be in danger of harming themselves and suitable treatment can be considered as justified in this context (van Uffelen, Chinapaw, van Mechelen et al. 2008), but it is questionable how much harm would occur due to this refusal to take the medication. The author would question whether it would not be more appropriate to allow the patient time to return to a more lucid state and then give consent for the medication, complying with their care themselves. This would respect their autonomy, and would also mean that the care given was not entirely bound by routines within the residential home, and would mean a patient-centred approach (DoH, 2001, online).

The Principle of Beneficence can also be considered here, and it should be noted that this Principle is coloured by the circumstances of the event being considered. One could argue that the use of medication to ease the patient’s apparent distress is ‘doing good’ under the terms of this Principle. If the overall aim of nursing practice is to act in the best interests of the patient, then it may be necessary to take such action, and to take responsibility for making such a decision, if it can be fully established that these actions are only done because it is better for the patient. This author would argue that in this situation, if the decision to put the medication in the food is just about expedience, about it being more convenient and manageable for the staff, then this would not be acting within the principle of beneficence. It is important to not just continue with standard or routine practice just because ‘everyone does it’. The balance in this situation is between beneficence and maleficence, and is therefore relating to the motivation of the individual. Is the nurse doing this to avoid having to spend time and energy persuading the patient to take their medication? Or is this simply the best solution because otherwise the patient will not take the medication and will become ill as a result? More details about this would be required to fully understand the ethical challenge here.

It would seem that the major problem with hiding medication in food is deception. Although it may be considered a practical expedient, It would not be an appropriate course of action if the patient was rational and competent, so consideration is required as to why it would be considered appropriate just because they are not competent and rational at this time (Wong, Poon, Hui 2007). Therefore, it is appropriate for the author to have questioned this practice, at this time, and to explore the parameters and dimensions of this action (Hargreaves, 2004 p 196).

This area of intervention is fraught with difficulty and should not be entered into lightly. If a decision is made by the healthcare professionals to give the medication, it should be recorded in the notes together with the reasons for that decision and it should be given. If the patient will not take tablets then alternative routes of administration should be considered (Welsh and Deah 2007). It is not appropriate to overtly deceive or mislead the patient as doing so contravenes any concept of personal autonomy and dignity (NMC, 2004a, online; NMC, 2008, online). ). However, it may be that this course of action has been agreed with relatives or next of kin who have responsibility for the patient, which clouds the debate somewhat.

There appears to be a fine line here between ethical and unethical practice, and therefore, it is important to clearly understand and justify why this course of action was taken. It would also help if nurses could address their own prejudices and potential bias about certain patients, through critical self examination and reflection (Daly, 1998 p 323). This would also help develop critical thinking skills (Daly, 1998 p 323). Nurses could then reflect critically on these kinds of actions to explore if there are not perhaps alternative approaches which could be used, such as providing the medication in a different form, one that is more palatable to the patient. It is not possible to easily define what the right course of action is in these circumstances, but if the nurse adheres to the principles of client centred practice (DoH, 2001, online), it should be easier to evaluate the motivations for these actions and therefore understand the ethical impact of this situation. However, it would also be important to consider the theoretical basis for this, and for nurses in this particular care environment to discuss this practice and come to some consensus relating to the ethical issues and the ethical principles which arise from this kind of situation.

NOW WHAT

As part of this reflection the author will now try to draw together conclusions about the scenario described and discussed above, evaluating it as a whole. Having reflected on this scenario, it is apparent to the author that there is a lot to be learned from the situation. To begin with, it highlights how complex even simple nursing actions can be, particularly when they address ethical issues. The primary ethical issue in this scenario relates to the autonomy and capacity of the patient, and the motivation for the actions of the nurse involved. Autonomy is a key ethical principle, and respecting the rights and the individuality of the patient is central to professional nursing practice. Patient-centered practice is an ideal, but it should be a fundamental principle and in such a scenario, using patient-centeredness as a benchmark for evaluating care could be a useful way of analyzing whether nursing actions are ethical or not.

In this scenario, the author would argue that the nurse should have taken more time with this particular patient, and should perhaps have considered how to provide the medication safely without challenging her autonomy quite so much. It is obvious that deception is a concept and practice that is incompatible with the fundamental principles of nursing and health care. This author has learned from this that covert actions are inacceptable, and if this situation were to arise again, they would feel empowered to challenge it, and to take action, to turn the focus back onto the rights of the patient. It is also important to consider the balance between the factors surrounding what constitutes the best interests of the patient. There will always be an ongoing negotiation, in situations when the patient is not fully competent, but if the nurse adheres to ethical principles, they will provide patient-centered care and this must, ultimately, meet the individual needs of the patient.

This process of reflection has been a significant learning journey for the author, because it has broadened and deepened their understanding and insight into ethical challenges they face in their daily work and practice. Reflection, guided by a constructive model, has helped the author to analyze and evaluate this situation, and to explore the parameters of the ethics and philosophies which apply to it. The author has found that carrying out this reflection has not only enhanced their understanding of this situation, and of the complexities of the ethical questions raised by it, but also enhanced their critical thinking skills.

Ethical decision making in nursing appears to be something that is hard to pin down, as ethical questions often leave a degree of confusion about the right and the wrong thing to do. Such is the case here, but the author has learned that there is literature to inform the nurse about the rights and wrongs of the more ambiguous ethical dilemmas, and that using such information can aid understanding and improve future practice.