This reflective essay will adopt

Rolfe’s model of reflection

, (Rolfe, G et al. 2001) which was derived from Borton’s developmental model. (Boyd E et al. 1983)

The scenario is presented as Appendix 1 and the patient has been anonymised as ‘Lee’ in accordance with the NMC guidelines (NMC 2008)

What?

When analysed in overview, one can note that the main issues contained in this scenario are that a schizophrenic patient, who may therefore be psychotic, who is certainly confused due to his metabolic disturbances (hyponatraemia) and possibly idiopathic confusion, has made an allegation of physical assault against another staff member. The patient is also forgetful and the event happened three days ago. Clearly the incident cannot be confidently verified at this stage and there is a question as to whether the patient is reliable in making this allegation. Analysis revolves around my reflection on the actions that I took and whether they could be considered appropriate or capable of improvement.

My role in the situation was that I was the recipient of the allegation. Having heard the allegation, I tried to make sense of it. On the one hand I was aware of the seriousness of the allegation if it were true, and therefore I was also aware of the potential harm that an untrue allegation could cause to the professional integrity of the ‘Special‘ who was involved. I was obviously aware of Lee’s potential for confusion and psychosis, but I was also impressed by the apparent veracity of his recollection and also by the fact that he started to cry when he was recounting it. (Nicol M N et al. 2004)

On balance, I did believe his account of the situation. I therefore felt that I had a moral and professional duty to escalate the complaint to the Senior Ward Sister. After a period of discussion with the Ward Sister, I filled in an Incident Report Form (IR1), which was then forwarded to the hospital management.

After the event, I experienced a period of prolonged self-examination. I was concerned in case I had inadvertently been party to a false allegation and considered further the consequences for the ‘Special’ involved. After a period of intense reflection, I concluded that I was right to take the action that I did, both because of my professional duty to ‘do my best for the patient’ but also because I was acting as the patient’s advocate in these circumstances, which seemed entirely appropriate. (Brooke C et al. 2007)

The response of the Ward Sister seemed entirely appropriate. I believe that she went and spoke to Lee herself and determined that there was sufficient evidence to make the reporting of the incident (IR1) appropriate. This reassured me greatly. The Ward Sister also discussed the ethics and implications of the situation with me, which was both professionally helpful and considerate, as she could see that I was unclear about what I should do in these circumstances.

In any reflective process, one also has to consider the feelings of the patient. In this case Lee did appear to be pleased that he was being taken seriously, but his fluctuating lucidity meant that further questioning did not clarify the situation any further. He certainly appeared to be pleased when he was told that the ‘special’ would not be assigned to him again.

So what?

The theoretical elements of the analysis of this situation are straightforward. Jasper, in his erudite series of analyses (Jasper M 2007), acknowledges that part of the responsibility of being a professional practitioner is to ensure that you give the best care possible to your patients or clients. In an analysis of a similar situation, the author is unequivocal in his assessment that the professional duty of the nurse is to share such reports of possible patient abuse with their immediate superior. Even if the patient is ‘of reduced capacity’ or ‘of questionable reliability’ (Jasper M 2007 Pg 36), they should therefore considered ‘vulnerable’ in the professional sense, and offered greater, not less, protection.

An ethical analysis would suggest that the nurse should invoke the Principle of Non-Malificence, which was derived from the often quoted dictum of Hippocrates, which stated that one should “first do no harm”. (Carrick P 2000). This Principle stated that healthcare professionals must ensure that their patients are not harmed, nor will come to harm. (van Uffelen J G Z et al. 2008).

I did consider the possibility of speaking to the ‘Special’ in an unofficial capacity, but came to the conclusion, that there was nothing that they could say which would change the proper course of action. This concurs with the opinion of Tschudin who analyses a number of similar situations. (Tschudin, V 2003).

This level of analysis gave me a deeper insight into the situation and reinforced my initial conclusions relating to the proper and appropriate course of action.

Now what?

Given the fact that Lee had reported a possible episode of abuse, it seems entirely appropriate that it would be properly investigated. The action of the Sister in removing the ‘Special’ from caring for Lee also seemed appropriate and proportionate. It may have been considered more appropriate to suspend the ‘Special’ from work, but in circumstances when one is dealing with a confused and psychotic patient and there is a significant element of uncertainty about the veracity of the allegations, this might be considered inappropriate and unduly prejudicial to the ‘Special’. (McMillan J 2005)

At the time of the reporting of the incident, I apologised to Lee myself and reassured him that such a situation would not be allowed to occur again. I feel that this was also a professionally appropriate course of action, as it not only communicated a professional sense of responsibility to Lee, but also it demonstrated the fact that I was taking his complaint seriously and was sorry that it had happened. (Kozier, B et al. 2008)

When analysed in overview, I effectively had two possible potential outcomes of the situation. Either I believed that Lee‘s story was probably true, or I didn’t. This gives rise to a deeper analysis and, in the words of Cruess & Cruess, the evolution of a student into an ‘expert practitioner’ is judged by the ability to operate from a deep and holistic understanding of the total situation, a concept that is often referred to as ‘professional intuition’. (Baillie L 2005). Cruess et al. suggest that this ‘professional intuition’ is better considered as ‘professional expertise’, which is generally built up and gained over years of experience and which, when tested in the clinical environment, can become an altogether more robust concept. (Cruess S R et al. 2007). Reflection on this situation, together with the guidance received from the Ward Sister, has helped me to fully understand the main elements of this situation. If I were to encounter such a situation again I would feel more confident in dealing with the situation rather than having to reflect at length after the event. Such analysis has helped me to realise that, to cite Schon, it is one of the ways professionals evolve and move beyond rule-bound behaviour and which enables them to function in a world of uncertainty and see problems in a holistic way and act appropriately. (Schön, D A (1987)

Appendix

Scenario:

A 78 year old gentleman called Lee was admitted to my Ward with

schizophrenia

and other medical conditions, one of which includes confusion and hyponatremia. It has been explained to the patient and his next of kin that due to the dangerously low sodium level Lee is on a fluid restriction of 750 mls per day, however due to the patient’s mental statue, he constantly demands fluids and if not given he will start screaming and disturb other patient and can be very aggressive a time. For this reason the Senior Sister requested a special in order to provide a one to one care for Lee.

I supported the patient with personal hygiene care one morning, Lee began to cry, when I asked ‘what is the matter Lee?’ he said, ‘three days ago a special slapped my arm and pinched me. And he said ‘I was waiting for her to finish her shift to inform a staff nurse, by then I had forgotten’. I hope when my son will visit me, I will remember to tell him what has happened.

I reassured him that this will not happen again and I also apologised on her behalf and told Lee that particular specialist will not be caring for him any more.

I reported the incident to the Ward Senior Sister and together we filled in an Incident Report Form (IR1).

References

Boyd E & Fales A (1983) reflective learning: the key to learning from experience. Journal of Humanistic Psychology, 23 (2): 99-117

Brooke C; Waugh A Eds (2007) Foundations of Nursing Practice, Fundamentals of Holistic Care. Lond Mosby Elsevier.

Carrick P (2000) Medical Ethics in the Ancient World. Georgetown University press : Philadelphia

Jasper M. (2007) Professional Development, Reflection and Decision – Making. Blackwell Publishing, Singapore.

Kozier, B, et al. (2008) Fundamentals of Nursing: Concepts, Process and Practice. Harlow: Pearson Education.

Nicol M N, Bavin B C, Bedford-Turner S B, Cronin P C Rawlings-Anderson K R (2004) “Essential Nursing Skills” 2nd ed. Churchill Livingstone, Mosby

NMC (2008) Nurse Midwifery Council: Code of professional conduct: Standards for conduct, performance and Ethics (2008) London : Chatto & Windus 2008

Rolfe, G., Freshwater, D., Jasper, M. (2001). Critical Reflection in Nursing and the Helping Professions: a User’s Guide. Basingstoke: Palgrave Macmillan.

Schön, D A: (1987), Educating the Reflective Practitioner: Toward a New Design for Teaching and Learning in the Professions, Jossey-Bass Publishers, San Francisco.

Tschudin, V (2003). Ethics in Nursing: the caring relationship (3rd ed.). Edinburgh: Butterworth-Heinemann.

van Uffelen J G Z, Chinapaw M J M, van Mechelen W, Hopman-Rock M (2008) Walking or vitamin B for cognition in older adults with mild cognitive impairment? A randomised controlled trial. British Journal of Sports Medicine 2008; 42 : 344 – 351