Some Hints and Tips and Examples

It might help to think of reflective writing as like you’re writing a blog.  Of course if your instructor has a particular ‘model’ be sure to follow his/her format.  Mostly your instructor is looking to get a feel for the way you think about your nursing practice.

More specifically:

  • you think about the way you practice, critical thinking, use what your see or assess and combine that with what you know
  • you can learn from experience
  • you are not afraid to acknowledge when things could have gone better
  • your focus is the patient or client and their interests
  • your aim is always to improve care and outcomes for patients and clients

Reflective writing should not be:

  • a test of your writing skills
  • a showcase for a particular project or piece of work you are particularly proud of
  • essays requiring references and evidence

Rather, they should describe some specific experiences in your day to day work, how you thought about those experiences, what you learned, and what you do differently as a result.
Please remember to choose experiences that are personal (the narrative should say ‘I’, not ‘we’), recent, relevant to your work and provide anonymity with respect to patient details. Each of the three reflection pieces should focus on a different experience – this is an opportunity to demonstrate the breadth of your experience.
You can use the guide below for your writing – they help by offering questions to answer in each piece such as ‘What happened?’ ‘What did you do?’ ‘How did you feel about this?’
You might find it useful to think about the process of reflection using the ‘4Rs’ model devised by The Queens Nursing Institute Director Rosemary Cook (Cook, 1998). This describes the difference between:

‘Recollection’-

just recounting what happened, without any real thinking about it, and no attempt to learn or improve practice e.g. ‘the mother got very angry about her child’s response to vaccination, shouted at me and stormed out of the surgery’. The danger with recollection is that you may not remember the incident accurately, and you may recall only the negative aspects.

‘Reaction’ –

recalling what you did in response e.g. ‘I told the receptionist to book her in with someone else in future’. First reactions may have been instinctive and inappropriate.

‘Reflection’ –

thinking more about the situation, from both your own and the parent’s point of view, to try to analyze, evaluate and learn from it e.g. ‘I wondered if the mother was frightened by the child’s slight temperature after the vaccine … had I explained that this might happen? Maybe she thought the baby was becoming seriously ill. Perhaps we should give parents some written information about what to expect, and where they can get advice …’

‘Response’ –

doing something constructive to improve the situation, and to improve care in the future e.g. telephoning the mother to explain about the vaccines, and reassure her before her child’s next appointment; talking to other members of the practice team about improving the way parents are given information, and the support available after vaccination.
[Cook R (1998) Reflect on the past and plan your future. Practice Nurse 17:98-102]

You might find the following example useful: however, don’t feel you have to copy the style or type of incident exactly. The reflective practice pieces are YOUR way of showing how you think about your practice.

Example of reflective writing:

re Sydney, 86 years old – COPD, heart failure, NIDDM, neuropathy and dementia.

Recollection

Sydney lives in a ground floor council flat with his wife. His wife is his main carer, yet she is unwell with asthma. Sydney and his wife have refused all social services help, day center care and carers support groups.

Sydney had been in hospital two months prior for heart failure and respiratory disease and was awaiting his outpatient appointments. He was referred by the GP due to frequent hospital attendances. The GP stated that Sydney was difficult and refused all input and services offered and that his wife did not appear to be coping well.

I had been visiting Sydney for approx four months and had built up a good relationship with him and his wife. During this visit Sydney looked unwell, had decreasing oxygen saturations (they were 66% on air at the time of assessment) and appeared to be increasingly chesty but not symptomatic of a chest infection. I contacted the consultant expressing my concerns, the consultant agreed to see Sydney the following week. The day following the appointment the consultant contacted me to say that she was concerned that Sydney was in respiratory failure and needed to be admitted but had refused. I contacted Sydney’s wife who asked me if I could visit as she was concerned.

Sydney explained that he did not want to go to hospital as if he was dying he would rather die at home. He had some loose ends to tie up. I explained to Sydney and his wife what was happening to his body and what in-patient treatment he would receive. Sydney was reassured he was not in the terminal phase of his disease. I allowed him time to ask questions. Sydney’s wife was given time to express her concerns. I took his oxygen saturations and explained why they were low and what was needed to increase them. I offered Sydney alternative places of treatment such as the local rehabilitation hospital that I knew he liked but he continued to refuse.

Sydney was due to see the consultant as an out-patient in a week’s time, after much discussion Sydney agreed to be admitted following that appointment if his condition had not improved which would also give him time to put his affairs in order. I asked the wife if she felt she needed any support but she refused. I suggested that the district nurses call over the weekend to check he was okay but his wife refused saying she could cope. I talked through with his wife what to do in an emergency and that I would call again first thing Monday morning.

When I left his home I consulted Sydney’s GP who confirmed that as Sydney had capacity we had to respect his decision and there was no further action to take. I contacted the district nursing team leader who was working that weekend so she was aware of the situation should his wife call. I sent a fax to the consultant to let her know of the outcome of my visit. I contacted Sydney’s daughter with his permission to inform her of the outcome of my consultation. I
documented the consultation in his notes.

Reaction

As a nurse I did not feel comfortable with Sydney refusing treatment when not in the terminal phase of his life limiting condition. As a nurse, I feel I have a responsibility to improve my patients health and well being. This may be a very simplistic view but I felt that I hadn’t carried out my job effectively if Sydney was not getting all the treatment he required.

Reflection

Patients’ choice is an ethical issue that many nurses struggle to deal with. For example, I could have felt that what was in the best interests for Sydney was to be treated immediately even though he didn’t want to be hospitalised, removing his autonomy temporarily so his health could be restored to how it was previous to this episode. Sydney would be forced to take up a hospital bed that he doesn’t want that could have been given to another patient that wants treatment. As a health care professional, I have to take these areas in to consideration when deciding what is in the best interests of my patients and making a clinical decision. I have always been taught as a nurse that I need to be able to justify my decision with confidence should I ever be asked to. This is not always possible as there will always be times in a nurse’s career when you question the decision you make. However, what is important is to assess risk whilst providing the patient with all the information without prejudice and agree with them on an outcome that is in their best interests whilst respecting their autonomy and acting where necessary as their advocate.

I felt that the consultation went well. I felt able to communicate effectively with Sydney as we had a good relationship prior to this incident. However, nurses need to be aware of over involvement which can cloud nurse’s objectivity in the patients care. A part of developing a relationship with patients and their families, nurses develop a greater respect for their autonomy and choice over their own care.

As a district nurse I had experience with similar situations, and had previously reflected on these and therefore felt more comfortable dealing with this incident. I felt confident that Sydney had capacity as I was familiar with the mental capacity act. However, I have since attended a training update on the mental capacity act so that I can make evidence based decisions. I felt that Sydney had been given all the information he required to make an informed decision. He was given the potential outcome of not going to hospital and he was prepared for that. Sydney and his wife were offered all available community services but refused.

I did, however, feel that I would have benefited from some counseling skills. I was aware that Sydney was frightened and I felt like a novice in counseling him. I felt that the way I communicated with Sydney may not have been effective in him opening up about his fears. We had some limited training by a psychologist on behavior change a couple of months prior but I did not feel comfortable using the tools learnt as I hadn’t done any further reading.

Response

I feel that attending further sessions on behaviour change and counselling skills would be helpful and to do some reading around these areas. I also feel that doing some joint visits with the psychologist would be helpful in gaining experience. I would make sure that the consultations were documented so that I could prove that Sydney was given all the relevant and necessary information and to uphold my professional code of conduct and accountability. I had also offered to attend any further hospital out-patient appointments in the future so that Sydney feels supported, so that I had the relevant information and options could be discussed jointly as a team. I also feel that I would benefit from looking at some tools of decision making to help me in the future and continue to reflect on my experiences.

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