As part of continued professional development reflection is a necessary part of the nursing profession, it is a useful tool to make sense of practice and to help integrate theory and practice. Reid (1993) states ‘Reflection is a process of reviewing an experience of practice in order to describe, analyse, evaluate and so inform learning about practice. Whilst Boyd and Fayles (1983) states:
‘Reflection encourages a deeper approach to learning. Reflective learning is the process of internally examining and exploring an issue of concern, triggered by an experience which creates and clarifies meaning in term of self, and which results changed conceptual perspective’.
By engaging in reflection it allows professionals to develop their way of thinking, it encourages individuals to make sense of situations and to promote best practice, thinking of alternative solutions if needed and to improve on existing knowledge.
Reflection can be divided into two types which were identified by Donald Schon (1983). These are reflection in action which involves reflecting whilst in practice, being able to consciously think and evaluate simultaneously and make changes while an incident occurs. Johns (1998) emphasises this view as he believes that reflection-in-action is a way of constantly monitoring the self in the situation. While Schon (1991) believes for nursing this means practice is enhanced as it is carried out. Reflection-on-action involves looking back at practice in order to uncover and analyse the knowledge used (Fitzgerald and Chapman, 2000). Reflection on action is turning information into knowledge and being able to reflect on how the situation be handled differently if needed. The nurse reflects due to either; knowing or feeling that something is ‘not right’ or experiencing positive emotions about a situation (Johns, 2006). Skills necessary for developing reflective practice according to Atkins and Murphy (1993) are self awareness, description, critical analysis, synthesis, judgement and evaluation. Bulman and Schutz (2004) state to be self aware is to be conscious of one’s character, including beliefs, values, qualities, strengths and limitations. Being self aware gives a better understanding of ourselves, it enables us to make changes and to build on our strengths and makes us aware of our weaknesses. Reflection’s outcome is that the nurse comes to a new point of view which influences the nurses thinking and possibly their practice (Atkins and Murphy, 1993).
On the use of reflection in nursing an article by Philip Burnard (1995) entailed ‘nurse educators' perceptions of reflection’ looks at findings from 12 nurse educators from different teaching institutions who were interviewed regarding how they perceive reflection. Burnard (1995) found the study to be ‘positive and reflection to be a useful and helpful way of improving the work they did as nurses’. The researcher also returned to the nurse educators on 3 separate occasions to interview them and to clarify answers to prevent research bias. LoBiondo-Wood & Haber (1994)
‘confirm that sample sizes in qualitative studies tend to be small, and suggest that interviewing should continue until 'data saturation' has occurred, that is, until no 'new' ideas or thoughts are identified by the respondents In this study, this occurred by the eighth interview, and the research continued until 12 interviews had been completed’.
The majority of the respondents expressed very positive feelings about use and application of reflection in nurse education and agreed it increases self awareness, enhances communication and encourages research. The disadvantages of the study were that it only used the perceptions from nurse educators, no practicing nurses’ perceptions were used to give an accurate view of reflection. It was a female based study and no ethical approaches were used, more research was needed to prove reflection enhances nursing practice.
It is necessary to consider when reflecting back on my critical incident the use of Gibbs model of reflection (1988). It allows us to go into depth throughout the 6 stages of the model to critically analyse thoughts and feelings and relate theory to practice where it allows. Carper (1978) identified that ‘individuals have different ways of thinking and knowledge differentiates it and is sometimes helpful to refer to a framework to assist reflection’. The Gibbs model was chosen as it provided sufficient guidance to help me through the reflective process. It helped evaluate the incident with its questions, to make sense of what happened and to consider options if the situation arose again. It takes into account feelings and emotions which many other models do not apart from Boud reflective model. John’s model of reflection appeared too complex for my critical incident with some of the questions not being relevant to the incident. I felt John’s model of reflection would be good for decision making and as a student did not find this helpful as do not have that kind of responsibility. The incident did not involve me making any decisions; it was my mentor making the decisions.
The first stage of Gibbs model of reflection is description in which I will describe my critical incident. I nursed an elderly lady called Mrs M, who had been admitted with a urinary tract infection (UTI). Mrs M. had a past medical history of dementia, general confusion, hypertension, heart failure and recurrent UTI’s. During Mrs M’s admission there had been an outbreak of gastro-enteritis which she had contracted. Mrs M soon started to refuse her medications as felt the vomiting was associated with taking her medications. The only tablet Mrs M would take was an anti-sickness tablet but as her symptoms from the gastroenteritis subsided Mrs M continued to refuse her medications as was anxious the vomiting would return. Mrs M was on medications for her hypertension and heart failure and as she had not taken her tablets, her observations were starting to show a raised blood pressure and heart rate. During a drug round, once again Mrs M declined her medications and requested her anti sickness tablet. After several moments thought, my mentor then decided to give either her hypertensive tablet or digoxin tablet, relying to Mrs M it was her anti-sickness tablet. Mrs M was unaware of what had been done and swallowed the tablet. Further drug rounds after that were spent alternating between her digoxin tablet and hypertensive tablet making sure she had her recommended prescribed daily dose. Mrs M eventually started taking her medications with reassurance from her consultant and feel as her confusion lessened due to her UTI clearing, felt this contributed to Mrs M making the decision to take her medications.
The second stage of Gibbs’ model is to discuss thoughts and feelings: At the time I did not feel this was a wrong thing to do. I believed it was best for Mrs M to be taking her tablets for her health problems. I trusted my mentor completely and knew she had Mrs M’s best interests at heart. Due to my inexperience this makes me feel gullible and easily led and feel this is now a weakness that I need to be aware of.
Evaluation is the third stage of Gibbs’ model. This stage requires the reflector to think about what was positive and negative about the event. The positive part of the situation was that Mrs M was taking her tablets which would eventually alleviate her side effects. A bad point of the incident is that we were deceiving an already vulnerable adult and overall it would not solve the problem, it would not be a suitable solution to the problem.
Analysis is the 4th stage of Gibbs’ model. This stage requires the reflector to analyse the event and to make sense of the situation. The first issue to be discussed is consent. The Department of Health (DoH) (2009) provides detailed guidelines regarding consent to treatment and states:
‘Seeking consent to treatment must be about enabling patients to make healthcare choices which are right for them, and recognising that different patients will make different choices in apparently similar situations’.
The NMC (2008) informs registrants that they must make the care of people their first concern and ensure they gain consent before they begin any treatment or care. Before any care or treatment takes place, consent must be given by a competent person. This consent is agreeing for healthcare professionals to provide the care that is needed for individuals and allows the patient to determine what happens to their body. Lord Donaldson pointed out in Re W (A Minor)(Medical Treatment: Court’s Jurisdiction) [1993], consent has two purposes. The first is a legal defence to an allegation of trespass to the person. The second is a more pragmatic clinical reason that acknowledges that care and treatment requires the cooperation of the patient if it is to be carried out successfully. Therefore, it is clear that consent provides protection to healthcare professionals against trespass to the person and it allows a patient to express their autonomous wishes.
Patients who have capacity have the autonomy to take an active role with their healthcare. Autonomy can be defined as ‘the capacity to think, decide and act on the basis of such thought and decision freely and independently and without let or hindrance’ (Gillon, 1986). Whilst Downie and Calman (1994) state that:
‘To be an autonomous person is to have the ability to formulate and carry out one’s own plans or policies. A second feature is the ability to govern one’s conduct by rules or values’.
Each definition implies that every person has control over their life and what happens to their body. They are able to absorb information about their required treatment and able to make a decision without the influence of others and achieve the best possible outcome. Mrs M lacked autonomy as she had made a decision not to take her medications even though it was important for her health, each time consent was required she would continue to refuse her medication regardless of the implications of not taking them. She did not have the capacity to make the right decision and continued to believe her vomiting was associated with her medications and could not encourage her otherwise. Mrs. M had been taking these tablets for some time before coming into hospital due to her condition and with this in mind a best interest decision was made on Mrs M’s behalf to avoid deterioration with her health.
For an autonomous person this also gives the right to refuse treatment, even if life saving treatment was essential. The NMC the code (2008) states “respect and support people’s rights to accept or decline treatment and care”. Aveyard (2002) states ‘If a patient refuses care, care cannot be given. To do so would be to infringe patient autonomy and to contravene the principles of consent’. A competent person has the right to refuse treatment even if initial consent was granted. If the individual does not feel it is in their best interests or changes their mind then consent is no longer valid. To continue with treatment would be grounds for trespass to that individual. However, Mrs M. was not competent and as such her refusal was taken into consideration but her health was the main issue and what was best for Mrs M. The decision to covert her medication was made to alleviate her symptoms from not taking her medication and to prevent any further deterioration with her health.
To return to the issue of best interest decision making Griffith et al (2009) states that where a patient lacks decision making capacity, the (Mental Capacity Act 2005) and its guiding principles ensure that their rights and interests are at the centre of the decision making process’. The Mental Capacity Act was brought in to protect people who were unable to make decisions for themselves or lack the mental capacity to do so. When it is referred to as ‘a person who lacks capacity’ it means a person who lacks capacity to make a particular decision or take a particular action for themselves at the time the decision or action needs to be taken. (Mental Capacity Act 2005). Here Savulescu et al (2001) states that:
‘It is important to determine capacity because competent adults have the right to refuse treatment, but failure to treat an adult who lacks capacity may constitute negligence. Decision making about capacity involves assessing and determining whether a patient is capable of making adequate decisions. Illness and medications can impair a person’s ability to make decisions about their health’.
Re C (1994) established the test for capacity and subsequently was added to the Mental Capacity Act. It lays out guidelines that informs that a patient has capacity if they can; understand what will be done to them; understand the likely consequences of leaving the condition untreated and understanding the risks and side effects. If a patient’s capacity is in doubt then a test to decipher their mental capacity should be assessed as all adults are deemed competent unless proved otherwise. Griffith et al (2009) states ‘the need to assess capacity only arises where the behaviour or circumstances of the person triggers a doubt in your mind about their ability to make a decision’. Degenerative brain disorders such as dementia can cause deterioration in mental capacity. Mrs M has dementia and general confusion which hindered her from making a competent decision, the implications of not taking her medications were explained to Mary but she was adamant they would make her vomit. Mrs M’s reasoning for not taking her medications was understandable but could not be convinced that this was not the cause, this put doubts in my mentors mind about Mrs M’s capacity and her ability to make decisions about her health.
The refusal of treatment can be difficult for health-care professionals as their duty to respect autonomy conflicts with their desire to act in a beneficent manner (Dunbar, 2003). Generally, the principle of beneficence is the nurse’s responsibility to benefit others (Beauchamp and Childress, 2009). Beneficence is a major element of a nurse’s professional duty and generates a moral obligation to undertake positive actions aimed at safeguarding the health and welfare of patients (Hendrick, 2000). Mrs M. had dementia and refused to take her medications, she failed the capacity test as was unable to comprehend the consequences of not taking her medications. She could not retain the information that was relayed to her about the reason why she had been vomiting which resulted in repeated conversations persuading Mrs M. she needed to take her medications. As Mrs M.’s side effects of not taking her medications were worsening, it was then decided as Mrs M. would only take an anti sickness tablet to replace this with her hypertensive tablet or Digoxin tablet on alternative drug rounds. This decision was made with the best interests of Mrs M. as she lacked the comprehension and importance of taking her medications.
The NMC (2007) guidelines state ‘The responsibility of the nurse must always be to put the patient’s best interests first. The concept of best interest is a guiding principle for decision making in health care and is defined as acting in a way that most optimally promotes the good of the individual (Buchanan et al, 2006). The principle of best interests is the basis of the ethical principle of non-maleficence, which is the principle to do patients no harm (Beauchamp and Childress 1989). Non-maleficence is considered to be less morally demanding than beneficence; it generates fewer obligations simply requiring nursing staff not to harm patients, rather than imposing an obligation to act positively to help (Hendrick, 2000). The Law Commission (1991) states ‘the treatment will be in the best interests of such patients if, but only if, it is carried out in order either to save their lives or to ensure improvement or prevent deterioration in their physical or mental health’. Determining the patient’s quality of life, to assess whether the quality of life of a patient would be better or worse than to have no life at all is fundamental to best interest decision making. Mrs M. was suffering with heart failure and high blood pressure each of which had risen to high levels. Her heart rate had increased which indicated she needed to take her tablets before any lasting damage was done. As Mrs M. was not competent to refuse her medications, a best interest decision was made to administer the medications covertly. When considering a best interest decision, there are factors that need to be taken into account, the first would be to find the best course of action for the patient and to give the best outcome. The Mental Capacity Act provides a checklist to follow which will take into consideration the patient’s quality of life, physical condition, previously expressed wishes, risks and benefits. All these factors need to be taken into consideration to ensure that the patient is at the forefront of any best interest decision made and not what is best for the nurse or other health professionals.
Covert administration refers to medication that is concealed, usually in food or drink, so that it is being provided to the patient unknowingly Griffith (2007). Although Mrs M’s medication was not hidden from her in food, she was unknowingly taking the medications she had refused, with us informing Mrs M. she had been given her anti sickness tablet. Treloar et al (2000) suggests that the use of covert means to administer medication is widespread, particularly in areas where patients lack capacity because of dementia or severe learning disability.
The NMC states ‘The decision to administer medication covertly must only arise through conclusive evidence of the patient’s inability to comprehend the significance of refusal and in addition it must only be considered in order to save life or to prevent deterioration of health and it must be in the patient’s best interests’ (NMC 2007). In certain exceptional circumstances the NMC recognise that covert medication may be considered to help prevent a patient from missing out on essential treatment and in the absence of informed consent, considerations must be taken into account. The NMC (2007) recommends that ‘the best interests of the patient/client must be considered at all times and that medication must be considered essential for the patients/ client’s health and well being, or for the safety of others’. These guidelines are in place to ensure that the best interests of the patient are considered at all times and all aspects are looked at before giving covert medication. It is also important to make sure that covert medication is not regularly given as it is only a short term solution until further measures can be put into place. The NMC (2007) state “the decision to administer a medication covertly should not be considered routine, and should be a contingency measure. Any decision to do so must be reached after assessing the care needs of the patient/client individually. It should be patient/client-specific, in order to avoid the ritualised administration of medication in this way”. Mrs M’s medications were given to her covertly as she refused to take them, her lack of capacity prompted us to make a decision for Mrs M which was done in this way as it seemed the best possible option for her and this ensured she received her medications to control her symptoms. Lamnari (2001) states ‘In practice the benefits of ensuring the patient receives the appropriate treatment by administering medication covertly need to be balanced against the non-maleficent act of omitting important medications and the disrespect of patient autonomy’.
Conclusion is stage five of the Gibbs model, at this stage we look at the key aspects made through the reflective process. Reflecting back on the incident I feel that covert medication for Mrs M was made in her best interests. Covert medication should only be used as a last resort making sure that other options were considered or used, taking into considerations the capacity of the patient and their current situation. Making sure best interest decisions are not taken likely and have been given full thought before following through with any decision.
Principles and theories are there to help back up decisions, making sure the right conclusion can be made and understanding how a decision was made. Understanding that sometimes ethical principles may clash, but to ensure the best interests of your patient are at the forefront of any decision. The important principle is respect for Mrs M’s autonomy as consent is the key principle but as Mrs M lacked consent as she failed to comprehend the importance of taking her medication a best interest decision was made.
Action Plan is the final stage of the Gibbs Model. This stage looks at what you would do if the situation arose again. If the situation were to arise again, I would make sure the consultant or other health professionals were informed of the situation, telemetry could have been connected to Mrs M to monitor her heart rate or we could have waited until she was ready to take her medications again as Mrs M may have needed more time to get over her UTI. A liquid or injection form of the tablet could have been offered.
In conclusion nurses come across many legal and ethical dilemmas in their career. The NMC are there to guide nurses with everyday decisions being aware of limitations and patients rights. It is important that these dilemmas are dealt with appropriately making sure the right choices are made for patients with the four principles supporting nurses with their ethical decision making. With the useful tool of Reflection, reflecting back on situations can play a part in improving nursing practice by learning from past experiences. By engaging in reflection it can change your way of thinking by becoming more self aware and by using a model of reflection has helped me through the incident and analyse the situation in more detail. This assignment helped raise awareness of the laws in place and ethical issues that may arise and the guidelines that are there to help guide through the decision making process.
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