In this essay, I am going to describe an episode of care for an individual which I was involved in whilst on placement at a local nursing home. I am going to choose an appropriate model and reflect on this episode and within this reflection examine my own values and beliefs relating to the individual receiving care. I will also explore the values and beliefs that will underpin my future practice as a nurse. Values are ideals, attitudes and beliefs held by individuals or groups to represent what they consider to be important. They are used to guide behaviour as are morals, which provide standards of behaviour where a decision about right and wrong is required (Chitty 2005). It is believed that professional values learned during training, together with individuals altruistic reasons for wanting to work in healthcare will provide a moral framework that lasts throughout their professional life (Tyreman 2011).
Most professions have an ethical code, such as The Code set out by the Nursing and Midwifery Council (NMC 2008). These codes give basic guidelines which individuals can apply to different situations when deciding which actions to take and set standards of conduct which nurses need to deliver consistently throughout their career (NMC 2008). There is also Guidance on Professional Conduct (NMC 2011) which is specifically for student nurses and midwives. A code of practice sets out behaviours and actions that are assumed to be correct in a given situation and a good code should reflect what the majority of professional would do in that situation anyway (Tyreman 2011). In 1970 the health care system began looking holistically at the patient and their rights, rather than just treating them medically. This is termed as bioethics, and focuses on situations individually, using ethical principles to determine the best course of action (Chitty 2005). During my nursing home placement, I was able to work with the nurses who came into the home each day to attend to patients. Before entering a resident’s room, the nurse would give me a brief description of what we were going to do.
In the case of one resident, who I shall call Mr Smith for the duration of this essay, she described him as being difficult and was not sure if he would even let us into the room to change the dressings on his ulcerated legs. She also warned that he often refused all personal care from the nursing home staff. On entering his room I was quite shocked at the sight of Mr Smith, he had a long beard, long hair and long, dirty fingernails. His room smelt strongly of urine and the bed he was laying in was soaking wet, as was the pyjama shirt he was wearing. Mr Smith did allow us in and the nurse changed the dressings on his legs. His lower legs, ankles and feet were severely ulcerated and Mr Smith was unable to stand so sat on the edge of the bed. Mr Smith complained of being cold and wet and I suggested that whilst he was sitting up I could change his bed for him. He refused to let me do this but did allow me to change his pyjama shirt for a clean one. I tried to persuade him that he would be much more comfortable in a clean dry bed but he was adamant that the bed not be changed. Once the nurse had finished dressing his legs, he got back into the wet bed and we left, informing the nursing home staff of the situation.
Reflective practice is one of the most important ways in which we learn from our experiences, by thinking about them in different way we can gain a greater understanding and identify which actions we can take as a result (Jasper 2003). To assist me with writing my reflection on this episode of care, I looked at a number of reflective models which were recommended to us on our values course. The first one I looked only had three stages and used the questions What, So What and Now What (Rolfe et al 2001), I found this too brief for this essay but I do think it would be useful to reflect on situations which could occur during your working day, as it is straight forward and a relatively quick reflection. Another model I looked at was by Chris Johns (2000) and I found this one a bit too lengthy for this particular episode of care, although it does have some good points and I may use it for future reflective work. The model I have chosen to use is Gibbs’s Reflective Cycle (Gibbs 1998). This reflective model appealed to me the most as it is laid out in an easy to follow diagram, there are six stages and each stage has s prompt, therefore giving you an idea of what you could include in your reflection.
It also includes an action plan and I think this is an important part of the reflection as it will confirm that you did something well, or help you to improve your actions for the future if necessary. Gibbs’s Reflective Cycle (Gibbs 1998) starts with a description of what happened. I have described the event already but I think it is also important to add that whilst talking to Mr Smith he did seem confused as to what day it was and how long he had been a resident at the nursing home but apart from that he seemed to be making good sense and his care plan showed no issues regarding dementia or mental health problems. The next stage in the reflective cycle is feelings, and what you were thinking at the time. Before entering the room I felt some apprehension as to how Mr Smith would react to us, due to the information I had just been given by the nurse. I think that the nurse was right to warn me of the possible reaction from Mr Smith, but I also think that by telling me that he was difficult caused me to from a negative opinion of Mr Smith before I had actually met him.
When I saw Mr Smith I did experience a certain degree of shock at his appearance and the odour in the room. I did feel quite disgusted at first, but I also wondered how someone could be in such an unkempt state when they were living in a nursing home and supposedly being cared for by others. Part of the pre-admission criteria for this nursing home is a mental capacity assessment (MCA), the results of which will determine the type of care given to the resident (Avante 2012). The Mental Capacity Act (2005) states that a person must be assumed to have capacity unless it is established that he or she lacks capacity, as Mr Smith clearly had capacity then he ultimately has a right to decide his own personal hygiene standards. I feel that if Mr Smith has always lived in this way then he should not have to change his habits at this stage in his life, as we must treat people as individuals (NMC 2008) and respect their dignity. When I spoke to Mr Smith I found him to be a pleasant, polite and intelligent man and I felt guilty for my earlier feelings of disgust.
However I am glad to say that these feelings were kept private and did not affect my treatment of Mr Smith. This is an important requirement for being a good nurse as you must not discriminate against those in your care in any way (Royal College of Nursing 2012) and must always treat people with kindness and consideration (NMC 2008). Personally I also thought that Mr Smith should have a good bath, haircut and manicure and get out of his bedroom and do something social, for his own benefit. Social groups, such as family and friendships, help us to gain a sense of belonging and acceptance, humans need to be love and be loved (Maslow 1943) and I feel this is an area lacking in Mr Smith’s life. However I do not know the patient well enough to judge the reasons for this though I assume that it is his choice and therefore this right to live this way and perhaps nursing home staff have tried their best to involve him in activities to no avail. The next stage is to evaluate what was good and bad about the experience.
I felt that the nurse did a good job and that she treated Mr Smith well. As he was unable to get out of bed and into a chair she was forced to work at an uncomfortable angle. He resisted at first but she gently talked him into it and allowed him some control in the situation. I felt disappointed that I did not succeed in changing the bed but I also acknowledge that I worked within my guidelines as you must not begin any treatment or care without first gaining consent (NMC 2008). Also I realise that in this particular situation I was only there to observe the nurse and changing the bed at that time was not the top priority although it would have improved the patient’s comfort. The fourth stage in the Gibbs cycle is analysis, in other words, what else can you make of the situation. I am still wondering how Mr Smith has become how he is today, I almost feel that he has given up on himself and I am curious about his previous life. To find this out I would need time, and cooperation from Mr Smith that he may not be willing to give.
This experience has shown me that one of the barriers to giving care to someone is their own resistance and it has made me consider ways of overcoming these barriers. It has taught me that there will be situations where you do not succeed in helping someone in the way that you wanted and each person has the right to accept or decline treatment and as a nurse you must respect and support that right (NMC 2008). The conclusion stage of this cycle asks what else you could have done. In this situation I do not think there was much more that we could have done. Our task was to go in the room and change the leg dressings, which we did. We tried to change the bedding but failed to do so and we informed the nursing home staff that this needed doing. We treated Mr Smith with respect and maintained his dignity. We gained his consent to change his leg dressings and we recognised that consent was not given for changing his bed. In this case I was inexperienced, as I had not met anyone like Mr Smith before, if I was to carry on caring for Mr Smith I would consider it to be in his best interests that I made a referral to another practitioner (NMC 2008) or called on others for advice.
Teamwork is essential when considering the holistic needs of a patient and we need to be aware of the roles and responsibilities of others involved (NMC 2011). The final stage of the Gibbs Reflective Cycle is an action plan so I thought about what I would do if a situation similar to this one arose again. The most important thing for me would be to not allow myself to prejudge anyone and practice in an anti-discriminatory way. Thompson (2006) describes discrimination as the process of identifying a difference and giving unfair treatment on that basis. I will remember that each person I treat is an individual and sometimes you have to accept that individuals have the right to refuse services and often exercise that right (Thompson 1995). I have found this to be a really useful exercise and can see the value of reflection. Without reflection on all the different aspects in given situations, it could be easy to blame yourself when things go wrong. It is important to acknowledge that constraints in the workplace can prevent you from achieving a positive outcome every time (Taylor 2000). At the same time a reflection on an episode where you did everything right and had a good outcome can build confidence.
An inability to reflect could cause an inability to consider that you were wrong and therefore you are unable to learn from your mistakes. Life offers us lessons, we just need to be open to learning them (Taylor 2000). Having carried out this reflective exercise I can now see that actually I have used reflection before, in everyday life we reflect on all kinds of situations without even realising it. Reflection is essential for growth and development, and the skills learned during your professional training will stay with you (Jasper 2003). Values are often seen as a good thing to have and beneficial to the holder, with the suggestion that the stronger your values are the better, but this is not always the case and we can use the example of Adolf Hitler to emphasise this point (Pattison & Pill 2004). In fact aside from the basic moral virtues it is judged essential for any professional to possess, named as courage, honesty and justice, I feel it is important to keep your own values and beliefs to one side when considering situations and not let them influence your decisions.
Problems will arise if an individual’s strongly held personal belief conflicts with the professional values they have been taught and are expected to follow (Pattison & Pill 2004). Nurses will often encounter situations which challenge their own personal values and morals (Chitty 2005) and ethical dilemmas are common. The ability to respond to such dilemmas depends on the nurse’s own personal attributes, such as honesty and integrity (Gallagher and Wainwright 2005). Good character is a prerequisite for nursing, this is judged on behaviour, conduct and attitude and trust and honesty are essential (NMC 2011). With these existing values we can develop our professional values through training, reflection and experience to be the best nurses we can be.
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