Experiences can often lead to being rich sources of learning. Samuel and Betts (2007). Through this Reflective Practice I intend to use Gibbs (1998) Model of Reflection to explore my feelings, thoughts, intentions and actions based on the event I will describe. Gibbs talks about reflection being a six stage process that not only includes a description but also allows the learner to explore their feelings, evaluate what they have learnt, assess this through analysis and consideration of other theories, conclude with what has shown to be important out of all this and finally consider an action plan of how the learner would manage the situation should it arise again.
I also looked at Kolb (1976) Reflective cycle and although it is generally similar to Gibbs I felt it had vital elements absent. It is a simple four step approach that included DO->THINK->CONCLUDE-> ADAPT->DO.
Miller (2017) discusses a model often used in education with the acronymn DEAL for Describe, Examine, Articulate Learning. It is a model that would be suited to a nursing student as they begin to use the tools of self relflection and journalling. However as a senior nurse I think to evaluate what I learnt and being able to summarise this to present an action plan is vital in my clinical leadership role as an RN.
I was Duty Lead, managing the Hospice In-Patient Unit (IPU) as well as managing community calls over a long weekend. There had been a phone call from a distressed relative, Jill, who had a family member in a local Aged Residential Care (ARC) facility. The phone was answered by Jackie, a Registered Nurse (RN) working in the IPU who immediately went to speak to our on call Community Nurse, Maree, before speaking with me. The normal process is to pass all calls onto the Duty Lead who will then triage them. Maree said she could not help with the issue that Jill had described and Jackie then felt torn and was upset for the family and patient who was well known to us.
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My initial thought was around Jackie who took the call and who had not passed it to me. She took the issue to Maree who happened to be in the building at the time. This could have escalated the issue unnecessarily and made my job more difficult. Jackie also works in the community so I could see where she had confused her two roles. Having known her and worked with her I knew she meant no harm or disrespect to me.
Having dealt with another patient and his family only days beforehand who had had an unfortunate experience in the same facility, I felt very concerned for the current patient. I tried to not let this influence my assessment but I do think it may have influenced some of the questions I asked.
My next step was to call Jill and hear directly from her what her concerns were. She was able to describe what was happening and because I knew the patient, as well as having his past medical notes in front of me, I was able to listen and understand her concerns. I was also able to empathise with her and provide insights into what was occurring. It was clear that he was activley dying. He had a symptomatic disease that at end of life can be very distressing for family members to observe and hear. After some discussion I felt able to empower her to talk to the RN at the facility and invite them to call me if they would like some support in managing the patients symptoms.
This approach gave the family some control and did not minimise what was happening or undermine anyone involved. Although I felt positive about this approach, I was also anxious that I had said enough and that I had asked the right questions and had an accurate summary of events. I was conscious to not alienate the family from the facility RN.
The relief I felt when the RN called me was palpable. I felt proud of them as it became obvious that he was an inexperienced RN with a very difficult situation he had to deal with and little clinical experience in Palliative Care. Wald (2015) believes that we need to cultivate an environment where expertise and values are shared so we can all grow and develop our professional identity.
I questioned the facilty RN and established that his knowledge of managing a symptomatic dying person was limited. The hospice ARC nurse had visited the facilty four days prior and set up a syringe driver (SD). The RN thought because they were on a SD the patient would not require any extra medications. I explained the dying process as best I could over the phone and discussed the factors that may be contributing to increased need for analgesia and sedation. I was frustrated that this RN had no support and the transition for our patient from IPU to ARC has not been smooth. These thoughts began to fester and escalate. The thoughts became bigger than the initial concern. The Ministry of Health, Palliative Care review (2017) highlights a priority: improve quality across all settings. This was not being achieved in this instance and I was frustrated.
As I began to write about the event, I deconstructed it and saw many factors that made it as it was. By deconstructing it I could then reconstruct it and see it differently to assist me in establishing what the key issues were and how I could plan for future events such as these (Samuels and Betts, 2007). Initially the issue was the phone call and how it was handled from the IPU team. It became clear to me that in fact my biggest concern was for the patient and his family and for his death to be well managed.
I often use ‘informal debriefiing’ with colleaugues or someone in a more senior position to me as a means to reflect, however, I have, through this reflection, seen the power of journalling (Raterink 2016) and using an established reflective tool such as Gibbs.
Gibbs challenges us to plan and make future improvements. I have identified the key underlying issues for me and the root of my frustration. Number one factor is to ensure a smooth transition from IPU to ARC and for this to happen more education and follow up needs to be provided. I have spent time with the hospice liaison ARC nurses to better understand their scope and together we are working on how we can improve patient outcomes by educating a wider range of nurses. The transition and resourcing remains a work in progress, however this reflection has provided me an opportunity to build a more collaborative environment (Chacko and Sreerenjini, 2012).
CLINICAL LEADERSHIP AND RESILIENCE
Mannix, Wilkes and Daly (2013) attempted to find a definition of what clinical leadership is and in doing so found a number of attributes of effective clinical leadership rather than a clear definition. They included either a personal qualities focus or a team focus. Analysing this they could then explore the attributes that provide supportive work environments and build resilience with the teams.
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Clinical leadership can be confused with management, however clinical leaders do not have to possess all attributes of a manager according to Watson (2008). Leadership skills include being able to motivate and influence others, set goals and see these achieved, being a pioneer, a role model, advocate and change agent (Giltinane, 2013). Leaders need to have effective communication skills, be able to empower a team and lead change. They need to challenge the status quo. Florence Nightingale had a servant-leader model of care where she saw power if acquired, should always be for the benefit of others (Wright, 2012). Being resilient is also a component of leadership.
All registered nurses have a responsibilty for education however not all registered nurses are clinical leaders. Rolf (2014) believes that advanced nurse practitioners should display strong leadership skills. In order to develop good clinical reasoning skills and improve outcomes in complex healthcare systems (Ailey, Lamb, Friese & Christopher 2015) we need to teach clinical leadership skills to nursing students (Koen & Koen, 2016)
Clinical leaders shoud be passing the baton, setting examples and inspiring furture leaders. Dyes, Sherman and Chiang-Hanisko (2016) believe that it is a vital obligation for current leaders to develop future ones. Our goal is to improve patient outcomes and the environments we work in. For any business to grow it must have a succession plan. We start developing new leaders from students (Kim, 2012). In my role within the IPU at an urban hospice I often preceptor student nurses as well as orientate new RNs. I start with teaching the values of the hospice and cite examples as to how we portray these. The most successful people and organisations possess strong value systems. They are like the scaffolding. Strategy and mission may change however values do not.
As a NZRN I am accountable to Nursing Council of NZ and am required to be on the Professional Development and Recognition Pogramme (PDRP). In domain 2.8 it calls us to be reflective in our practice and to assist less experienced nurses with reflection. As a component of clinical leadership we must understand and be able to explain this succinctly. Nicol & Dosser (2016) provide clear guidance and understanding of what an effective reflection framework consists of in relation to professional development in nursing. NZNO have published a document that clearly defines what this looks like. They provide various frameworks and a set of questions that are most helpful as a tool.
In clinical practice we are faced with a raft of situations that are often complex and challenging. We can not anticipate from day to day what will happen or how we will manage. However, by having a set of values that includes personal, professional and cultural as well as effective tools such as reflection we can navigate our way through these situations. Resilience and self care are also key components of healthy nurses.
Resilience has been a field of work I have had an enormous interest in and having read many papers and dissertations I have come to a similar conclusion that Diane Coutu describes in an article published in Harvard Business Review 2002. She identified three characteristics of resilient people. Having looked at survivors of concentration camps, military veterans, and people who have lost everything in stock market crashes, she was able to identify these. The survivors demonstrated an innovative survival, they found meaningfulness in life and had an acceptance of reality.
Resilient people and companies face reality with staunchness, make meaning of hardship and instead of crying out in despair they improvise solutions from thin air. Being resilient is about the capacity to be robust under conditions of enormous stress and change. I think many nurses are inherently creative problem solvers with a ‘can do ‘ attitude. They cover the 24/7 shifts, they adapt their role to meet the needs of their patients, families and colleauges. We must look after others while at the same time look after ourselves so we do not burn out.
Building resilience has many facets. Back, Steinhauser, Kamal and Jackson (2016) believe that workplace factors such as recognising values are vital in this. Individual skills are important too and it is crucial to understand how this is done to ensure resilience becomes a relfex or a way of facing and understanding the world. It becomes deeply etched into a person’s mind and soul. It is often something you realise you have after the fact. Resilience is often referred to as “bouncing back”. For something to bounce back it must hit a hard surface first. Mroz (2015) suggests that how we cope with stress depends on some predispositions in our personalities such as self efficacy, optimism and resilience.
“There is good evidence that when people are put under pressure they regress to their most habituated ways of responding” Karl. E. Weick, Professor at Michigan Business School.
Search Institute discovered that resilient children had an uncanny ability to get adults to help them. Maurice Vanderpol also identified characteristics of survivors of concentration camps and believes they had a ‘plastic shield’ made up of; a sense of humour, an ability to form attachments to others and they possessed their own inner space that protected them from intrusion or abuse.
Norman Garmezy (1918-2009) was a Developmental Psychologist and Clinician who amongst many other things identified children who overcame obstacles in life had a personal sense of autonomy, and understanding of the ability to act independently rather than react to their environment and thay had an ability to control emotions and impulses.
Maintaining a good work life balance is important in any job, although I think in Palliative Care nursing it is crucial. Kim and Windsor (2015) concluded high levels of resilience were conducve to lower levels of stress. Sutton, Williams and Allison (2015) found self-awareness positively affected job satisfaction. Along with this they saw people developed a greater understanding and acceptance of others and an appreciation of the diversity of views. Reflective practice was paramount in this growth.
There are many forms of self care and for them to be effective they need to be personal to the recipient. For me, personally, I can sum up what builds my resilience, reduces my stress and gives me life, quite easily in four words – faith, family, friends and fun.
A constant challenge when working with people is to stay healthy emotionally as well as physically. Over my years of life, I have journalled at times, however these have been primarily on a personal level. I have seen through this exercise of reflective practice how beneficial it is in my professional life as well. It allows me to consolidate my thoughts and make sense of them. It prompts me to focus on my personal values as well as those of the organisation, to look at the bigger picture and not be so concerned about the less significant event. Being in a healthier, stronger place personally has the added advantage of being more uesful to those I work with. There will always be stressors in our working lives but we need to find a good work-life balance and identify what builds our resilience. I am fortunate to have supportive peers who share a sense of humour, care deeply and are skilled in their roles.
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