Nursing

How nursing students can be empowered by reflective practice Dolphin, Sarah . Mental Health Practice (through 2013) ; London  Vol. 16, Iss. 9,  (Jun 2013): 20-23.

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Reflection is not just another chore to complete on the way to qualifying, says Sarah Dolphin. She provides a

detailed description of how this skill helped her to learn from one particular incident during her training

Abstract

Reflective practice is seen as an important skill to develop because it enables a nurse to become self-aware and

provide the best possible patient care.

This article describes how an incident during the administration of an injection caused the author to examine

critically the events that occurred and their effect on patient and practitioner, and to learn from them. It is argued

that reflecting on practice in this way enables nurses to develop professionally and personally and, ultimately,

results in a higher standard of care.

Keywords

Reflective practice, self-awareness, communication, personal development, nursing student

AT UNIVERSITY we are told that reflective practice is crucial to being a good nurse. It allows the practitioner to

understand what occurred and to use the experience to improve care (Jindal-Snape and Holmes 2009, Mann et al

2009). But in my experience many nursing students and practitioners dismiss reflective practice as irrelevant,

perhaps because we are only required to think about it and do not need to evaluate it further.

For my part, as this issue was assessed in a second-year module, I considered it to be something simply to tick

offto pass the course. The critical incident I chose to reflect on leftme feeling terrible. At the time of the incident I

wanted to bury my head in the sand and pretend that it had not happened. If it had not been for someone pushing

me to write a reflective account I would never have realised that the incident was not a disaster but a situation to

learn from.

Here, I examine the incident and reflect on it to try to illustrate how useful the skill of reflection is.

Reflection does not simply mean thinking about a situation: it is the systematic appraisal of events that occurred

and examination of their individual components to learn from the experience and influence future practice. It

requires a high level of self-awareness and conscious efforts. This effort can develop into reflexivity, which can

challenge beliefs and assumptions (Brechin 2000).

Ichheiser (1970) highlighted that 'the psychologically naïve, unreflective person lives and acts under the silent

assumption that he perceives other people in a factual, objective way'. Reflective practice is crucial to

acknowledge that objectivity is impossible without first understanding that practitioners will have an effect on

patient care, whether directly or through others, via their body language and other non-verbal and verbal

communication, and their thoughts and emotions.

The incident

I have chosen to use Gibbs's model of reflection (Gibbs 1988), however I have adapted it by combining the

evaluation and analysis steps into a single section. The event I reflect on was the administration of a depot

injection that took place in a patient's home. The injection was not given as it should have been: the vial shattered

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when I tried to open it and I cut myself. My mentor, who I will call Alison, gave me first aid. I then failed to give the

injection at the next attempt and had to repeat the procedure to give the prescribed dosage.

Description

There were three of us in the house at the time of the incident: the patient, myself and Alison. The purpose of our

visit was to deliver a long-acting antipsychotic injection, which I was going to administer under Alison's

supervision and with the patient's consent. We had explained why the medication had been prescribed and had

asked the patient whether there had been any reactions to, or problems since, the previous injection was given.

This was the second time I had given injection - my first was to a different patient the previous day and the

procedure had gone smoothly. The only feedback was that I should try to talk to the patient while giving the

injection because this would help her feel more at ease. It was acknowledged that this would become easier as my

confidence grew.

On the second occasion, I carried out the injection using the Z-track technique at the dorsogluteal site (Dougherty

and Lister 2011). When I met resistance from the muscle I stopped depressing the plunger and withdrew the

needle, but Alison informed me that I had not administered the entire dose. I replaced the needle with a new one to

reduce the risk of infection and gave the remainder of the dose with no problem. I had discussed the re-

administration with the patient, apologised for having to re-administer and obtained consent.

Feelings and thoughts

Throughout the process I was nervous. Despite having given one injection already with no problems, I was still

inexperienced and did not have confidence in my ability to give medication in that form. At each stage of the

process I had conflicting emotions, thoughts and feelings - for example, pride at not having 'wimped' out, while also

being apprehensive about being able to continue. I thought I might feel overwhelmed by the process, make a

mistake or have to hand over to Alison. The thought of being overwhelmed was much stronger than the pride I was

feeling. It almost took over my focus on the intervention I was carrying out, and other emotions and thoughts also

distracted me.

When the needle was withdrawn and Alison told me that the patient had not received the full dose I could feel

myself getting flushed and hot. I did not want others to be aware of my stress and embarrassment and think that I

was not competent to administer the injection. However, I found Alison's presence reassuring in that she could

assist me should I need it, and she was helpful in guiding me through the process. Alison gave me positive

feedback to boost my confidence and put me at ease. This created a good feeling that I was acting and carrying

out the required actions in the appropriate way, and it helped because she would not have given me such feedback

if she thought I was not capable.

Evaluation and analysis

When I was told that I had not administered the medication fully I suddenly became aware of my position in

relation to the patient and Alison's proximity to me. I became mindful that I was within their intimate space, which

made me feel uncomfortable. The patient was still and quiet, which could be interpreted in different ways: they

were unaware of the situation and of how I was feeling; they were concerned that I might need to administer again;

or they were not concerned and were waiting for me to inform them of what was going on - which I did as I

progressed through the next steps.

At this point, my mind went blank. I froze even though I should have been finding a plaster to put on the injection

site before continuing and was unable to speak. Then I heard Alison move from the sofa, which was about five feet

behind me, and stand next to me. Although I felt reassured by this, I was still anxious, and could feel my heartbeat

quicken.

Communication among professionals, or in this case a nursing student and mentor, is essential to maintain good

patient care and safe practice; a lack of communication can lead to problems in the patientprofessional

relationship (Shah 1993, Washer 2009).

Alison told me that I had not administered the full dose and I responded by becoming physically rigid. I turned my

head to look at her with an expression of apprehension, anxiety and fear. I felt my face flush red, my eyes widened

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and I opened my mouth slightly to help take a deep breath as I realised I had been holding my breath. Although I

perceived this reaction as a negative communication at the time, I took solace in the notion that many emotions

are 'expressed best by non-verbal language' (Hosley and Molle-Matthews 2006).

When Alison knelt beside me, she was square on to me so I could see without having to turn my body that her

posture was open. She was leaning in towards me as she guided me, making eye contact whenever it was

appropriate, and appeared to be relaxed and confident. Although at the time I did not notice this, because I was

focused on the task in hand, I was reassured that she was close by to help me through the next steps. Her

movement from the sofa was also a method of communication. The message I received was that she was there for

me. I communicated my relief by looking at her and acknowledging her presence.

She made gestures to indicate what I needed to do while talking to me in a low, quiet tone that conveyed she was

calm. I could hear her clearly but the patient would not have been able to do so. She talked me through what I

needed to do next, using unambiguous language - for example: 'Right, so what you need to do now is attach a new

needle to the syringe. Good. Next you need to...' This allowed me to go through her instructions one step at a time.

Doing so prevented me from becoming more confused and anxious, and forgetting what she had said and having

to ask her to repeat it. I acknowledged what she said by paraphrasing, summarising, reflecting and clarifying

(Stickley and Stacey 2009). Although I did not recognise this at the time, I was practising active listening skills.

After the patient had consented to me administering the injection again and I carried out Alison's instructions, I

was upset that I needed her help in the first place. I felt like a failure for not being able to administer the injection

when I had done so before without any problems. I was also nervous about what else might go wrong, which added

to my anxiety. However, as I completed each step of her instructions I noticed I was not feeling any particularly

strong emotions because I was concentrating so much on the task.

I then became aware that the patient had not been spoken to for a while. It seemed like minutes but had in fact

only been a few seconds. I broke the silence by telling them that we were nearly done and Alison then turned to

look at me, nodded and gave me a smile. This reassured me that I had done the right thing and I felt less tense.

As I finished the final step of putting the plaster on the injection site, I felt a wave of relief, I wanted to show that I

was calm and that nothing remarkable had happened. However, this could not have been reflected in my body

language because the patient informed me that I had not hurt them and that I had done well. This revealed that I

was not as in control of my body language as I had thought and that I needed to find a way of being more aware of

myself. I took comfort in Hosley and Molle-Matthews's assertion (2006) that many emotions are 'expressed best by

non-verbal language'. But I was still embarrassed and upset.

During this experience, I had a certain degree of power over the patient. I was aware of this to an extent, in that if

the patient refused to have the injection then this would be reported, and if it continued it could result in them

being recalled to hospital. However, when the incident took place, there was a noticeable shiftin power from me to

the patient. The patient could have insisted that I stop administering the medication and that it was given by the

qualified nurse. The patient could also have refused to let me return for any future visits. Alison had power over me

at this point, too, and I could feel myself submitting to this in my body language, slouching slightly as she moved

towards me even though I had stiffened my muscles. At that point she also had power over me in terms of holding

the knowledge about what steps I should take to continue with the administration. I was also aware that I now felt

vulnerable, when before I had perceived the patient to be the vulnerable one.

But as I continued with the drug administration, I felt empowered. By being given instructions about what I should

be doing, I was able to take greater control (Norman and Ryrie 2009) of what was happening, and not simply give

up. I gained a greater understanding of why it is important to empower patients; being empowered myself showed

me how much it can help increase confidence.

Success and failure

I believe the incident as a whole was a success and a failure. It was a success because the medication was

administered as prescribed. On the other hand, breaking the vial, withdrawing the needle too soon, the lack of

communication and my nervousness, were all negative aspects of the process. On reflection, though, it did not go

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as badly as I thought it had, and I am embarrassed about my reactions to the events. The communication that

occurred during this incident was positive. It was effective in that it conveyed to me what I needed to do next and

that the situation could be rectified through communication, co-operation and collaboration between the three of

us. Although the main focus of the communication was between two individuals, there were three of us involved,

and all of us were communicating in some way.

There were many aspects of the situation described that I believe I could have carried out in a more positive way.

When I realised that I had not given the full dose, I should have placed the syringe back onto the tray following

removal of the needle and communicated verbally with Alison about what the next action should be. This would

have helped me to relax and I could have turned to face her. This would also have shown that I was listening

intently. I would then have demonstrated this through my communication with her. Although I believe I did this

during the incident, I could have done it more effectively if I had been making eye contact.

I could also have been more assertive by asking Alison to move closer to me when carrying out the injection. Her

physical presence would have reassured me. But when the procedure was being undertaken, I was aware that she

was in the room and was happy for her to stay on the sofa as she could observe well from there. This is because I

was feeling confident following the success of my previous injection I had administered.

I should also have checked visually to see that all of the medication had been administered, if I had done so the

incident that followed would not have taken place. Paradoxically, I would then not have had the experience of

having to re-administer the medication and would not have become aware of how much my body language

conveys my emotions and the importance of using active listening skills to enhance communication among

practitioners.

Action plan

In future, if I think that the process of administering medication is not being carried out perfectly, I will try to

remain calm. I will take a deep breath and speak to the nurse who is supervising me. I must also practise trying to

maintain a professional demeanor and remain in control of my body language. If I become injured and I am unsure

of how to act, I will ask a member of staffimmediately or as soon after the event as is possible to receive any

necessary treatment or first aid. I will then complete any relevant paperwork. Furthermore, I must ensure that I

acknowledge the patient who is being given the injection because throughout the process described here, my

focus was on the task in hand and not on the patient.

Discussion

The reflection I undertook required me to identify the individual components of this incident, explore my feelings

and my selfawareness surrounding those components, and critically examine them to improve my practice. This

highlighted all aspects of the incident and helped me to develop professionally. It also helped me develop my

personal way of carrying out some aspects of my practice, such as administrating intramuscular injections while

adhering to best practice guidelines.

Since carrying out this reflection, I have administered many injections successfully. Using reflective practice has

been beneficial because I have been able to tell my supervisor whether I wanted him or her to move next to me or if

I needed help. This feeling of empowerment and the confidence it gave me took me by surprise and made me want

to reflect thoroughly in the future.

Conclusion

Initially, I thought reflection was irrelevant, but through experience I have learned that this is not the case.

Reflection allowed me to examine an incident and turn what I had believed to be a negative experience into a more

positive one. It has had a positive effect on my self-awareness and communication, and has strengthened my

practice. It has also given me pride in the skills I have developed. Nursing students should regard reflection as a

valuable tool.

Sidebar

Alison made gestures to indicate what I needed to do while talking to me in a low, quiet tone that conveyed that

she was calm

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Online archive

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Conflict of interest

None declared

References

References

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Social Care. Sage, London.

Dougherty L, Lister S (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Student edition.

Wiley-Blackwell, Chichester.

Gibbs G (1988) Learning by Doing: A Guide to Teaching and Learning Methods. Oxford Further Education Unit,

Oxford.

Hosley J, Molle-Matthews E (2006) A Practical Guide to Therapeutic Communication for Health Professionals.

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Ichheiser G (1970) Appearances and Realities: Misunderstanding in Human Relations. Jossey-Bass, San Francisco

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227-230.

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AuthorAffiliation

Correspondence

sarah.dolphin@humber.nhs.uk

Sarah Dolphin is a staffnurse, Westlands Inpatient Assessment and Treatment Unit, Humber NHS Foundation

Trust, Hull

Date of submission

August 1 2012

Date of acceptance

October 18 2012

Peer review

This article has been subject to double-blind review and has been checked using antiplagiarism software

Author guidelines

www.mentalhealthpractice.co.uk DETAILS

Publication title: Mental Health Practice (through 2013); London

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Volume: 16

Issue: 9

Pages: 20-23

Number of pages: 4

Publication year: 2013

Publication date: Jun 2013

Section: Art &science | self-awareness

Publisher: BMJ Publishing Group LTD

Place of publication: London

Country of publication: United Kingdom, London

Publication subject: Medical Sciences--Nurses And Nursing, Medical Sciences--Psychiatry And Neurology

ISSN: 146 58720

Source type: Scholarly Journals

Language of publication: English

Document type: General Information

ProQuest document ID: 1370335479

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Copyright: Copyright RCN Publishing Company Jun 2013

Last updated: 2016-04-09

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