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Create a reflective piece using the Gibbs Reflective Model which identifies an incident in the workplace where there was a lack of leadership.
Use critical analysis of a reflective cycle to explore how this incident has increased your knowledge and understanding of professional practice with respect to the values and behaviour s in the field of nursing, and how future your behaviours will change.
Definition of Gibbs Reflective Cycle
Gibbs' reflective cycle (1988) is a tool used by numerous professionals, including (but not limited to) health professionals, education workers and those in leadership positions: its purpose is to assist practitioners in reflection, which contributes to continuous personal development (CPD) and helps to ensure that a person is continually learning and improving in their role. The idea is to systematically reflect on a particular situation to ensure that all aspects have been considered and evaluated, as this will assist the reflector in understanding what to do next time they are in a similar situation. The process consists of the following steps: Click to Expand
- Description: What happened?
- Feelings: What were you thinking/feeling?
- Evaluation: What was good about the experience? What was bad about it?
- Analysis: What sense can be made of the situation? What was really going on, as opposed to what you may have perceived?
- Conclusion: What was the end result – how well did you think you managed the situation overall? What else could you have done in the situation?
- Action plan: If the situation occurred again, what would you do? Would you act differently? Is there a skill you can develop or something you can learn to help you to be better equipped next time?
The incident I will be reflecting on occurred whilst I was placed with the vascular team. We had received a request for a duplex carotid scan for a patient on ITU who had been admitted due to a large stroke. Upon arrival we read her notes which highlighted significant aphasia and difficulties with communication. The nurse also informed us that the patient had a long standing memory problem and as a result of this, she did not remember why she had been admitted and would become very distressed when her stroke was discussed. When we approached her to perform the scan we found that she was under minimal sedation and was having assistance from a ventilator. The scan was completed without difficulty and we began to document our findings in the notes.
A nurse came onto the ward with two members of the public in order to show them around ITU before the man's surgery. This has been a long-standing protocol which strives to decrease worry before a planned stay in ITU. The members of the public were brought to the bedside where the nurse began to explain what the equipment was and what it was used for. The nurse made no effort to introduce the members of the public or herself to the patient. She also glanced at the patient's notes and then informed the members of the public that she had been admitted to ITU because of a stroke. Upon hearing this, the patient became overtly distressed and had to be more heavily sedated after the nurse in charge of her care could not calm her by talking in a soothing manner. This event clearly caused undue anxiety to both the patient and members of the public, in addition to the members of staff who bore witness to the incident. The incident was reported using an in-house critical incident report by both myself and staff from ITU as this was a breach of patient confidentiality and poor practice.
Interpretation of the incident
Before the incident, I was aware that the nurse was showing the members of the public around the ITU in order to familiarise them with the ward. I was very surprised when the nurse did not check the patient's notes beforehand, and the distress caused to both the patient and the members of the public was entirely unnecessary. To critically reflect upon this incident I shall use a well-known reflective cycle from Gibbs (1988). This model is cyclical and is unique because it includes emotions, knowledge, and actions and believes that experiences are repeated, which moves away from the model proposed by Kolb (1984). Some scholars, such as Zeichner and Liston (1996), believe that a wider and more flexible approach is needed by examining values in a critical light and how the practice of this can lead to changes in quality.
The most important factor in this incident was the lack of intervention from myself or the other healthcare professionals. The nurse should have been made aware that this was not a suitable area to bring the members of the public to. I also assumed that there would not be disclosure of specific patient details as this would be a breach of patient confidentiality policies which are covered in numerous guidelines from the Healthcare Professions Council (HCPC, 2012) and the Nursing and Midwifery Council (NMC 2015).
The main emotion that I felt in this situation was anxiety. I had been to ITU many times before and it is an environment in which I feel comfortable. I had not been to ITU to perform a carotid ultrasound before and I felt nervous as I wanted to perform the test well. I believe that, as a result of this, I moved some accountability to my senior colleague. I found the incident upsetting to witness as the distress was caused by a member of staff and their actions were avoidable.
My role was to complete the scan and establish the presence or absence of carotid disease, which I did. The results of the scan would have been used to determine the best course of management for this patient. It is important to note that acting in the patient's best interests was also part of my role, and I feel that I did not fulfil this completely. The duty to protect patients and patient confidentiality at all times lies with all staff, including myself, my vascular colleague, and the ITU staff. Our failure to act as a team could be explained by Rutkowski's (1983) theory of group cohesiveness. This theory proposes that altruistic behaviour is dependent upon the social norm, and is defined as people helping those in need, and who are dependent upon them for help. Rutkowski's (1983) showed that the group is more likely to act in accordance with the perceived social norm if there is a high level of group cohesiveness. In the situation that I have described, neither my colleague nor I were familiar with the healthcare professionals on ITU and there may have been a low level of group cohesiveness as a result of this.
Further work (Koocher & Keith-Spiegel 2010) has demonstrated that irresponsible professional behaviour can be averted by informal interventions. People were found to be more likely to take action if they were the senior person in a situation, and most felt that a positive outcome was as a result of their intervention (Koocher & Keith-Spiegel 2010). It is important to note that the way in which this outcome was measured (taken from data described as 'feelings after intervention'), may have introduced bias as it is likely that participants felt pleased with their courage in acting in an appropriate manner, regardless of the outcome of the intervention. It is possible that their intervention garnered no difference in professional behaviour. It is important to note that cases of major misconduct, such as those which could result in harm to patients or damage to the reputation of the Trust, should be dealt with by more formal routes. We completed an internal incident report which automatically flags the incident to senior clinicians and managers which would ensure that this incident was not unheeded. If this incident had not been reported, it would be an indicator of declining professionalism and acceptance of inferior standards of care. Tolerance of poor standards was highlighted by the Francis report (2013) as a consequence of poor staffing, policies, recruitment and training, and leadership.
The patient had a jugular line in place, which I had anticipated would make the scan more difficult and therefore probably contributed to my increased level of anxiety. I feel that if I had not been as anxious I would have been more likely to intervene; however it is clear that both my colleagues and I should have intervened more quickly. I believe that an informal intervention as described by Koocher and Keith-Spiegel (2010) would have been appropriate in this situation.
Having witnessed the distress caused to both the patient and members of the public, I am now aware of the important of being more assertive if similar situations were to arise in future. Although I believe I should have intervened at the time, the experience I have gained from this has made me more aware of the important of always acting in the best interests of the patient even when this may take courage. I believe that having greater confidence in my ability to scan would have reduced my diffusion of responsibility and allowed me to act in a more autonomous fashion. There should also be a greater emphasis to establish strong working relationships between healthcare professionals to in turn increase levels of group cohesiveness (Rutkowski et al 1983).
My future practice will involve becoming more proactive when I believe that there is a risk to patient confidentiality, and I will not assume that other members of staff will act in a professional manner at all times. I will continue to undertake reflective practice by using the model proposed by Gibbs (1988), and will aim to become confident when protecting patient confidentiality, particularly in situations where I am applying clinical skills which are new to me or that I do not feel completely confident with. As a trainee healthcare scientist, I aim to consistently implement the values and principles as set forth by the HCPC (2012) of a clinical scientist, and although this experience was difficult, I now feel that I have a greater understanding of these principles and values.
Changes in norms and behaviours
Due to the incident, I have formed a new set of behaviours. The first of these is that I will no longer assume that all members of staff will act in accordance with guidelines about patient confidentiality. Tied to this is a conscious effort on my part to refrain from assuming that I can predict the actions of other healthcare workers and I will always prioritise the welfare of patients in my care. Gibb's (1988) model has allowed me to critically reflect on my behaviours and has allowed me to identify aspects of my behaviour which may be detrimental. Critical reflection of this incident has made it clear that there is a deference to those I deem more senior than myself, perhaps due to a subconscious desire to maintain good working relationships.
It is possible that the major obstacles which prevented me from speaking out in this incident were my perception of an authority gradient between myself and my colleague and low group cohesiveness. To prevent future events like this occurring I will express any concerns about my clinical skills before beginning any procedures in order to both reduce any authority gradient and to also reduce the diffusion of responsibility as much as possible. I now feel more confident in protecting patient confidentiality and will aim to always embody the values and principles of a healthcare scientist.
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