REFLECTION ON A NIGHT DUTY IN EMERGENCY AND TRAUMA , HOSPITAL KUDAT

1)Definition Reflection

Reflection is a generic term with many definitions. Boyd and Fales (1983) define it as the
process of examining an experience that raises an issue of concern, as an internal process
that individuals use to help refine their understanding of an experience, which may lead to
changes in their perspectives. Boud D. (1985) define reflection as the cognitive and affective
behaviors in which individuals engage that result in new insights and deeper understandings
of their experiences.

Atkins and Murphy (1993) performed a meta-analysis of the many definitions of reflection
present in the literature and noted that there are three common elements essential to this
process. First is a trigger event, which is typically an awareness of some uncomfortable
feelings or thoughts either positive or negative. Second is a critical analysis of these feelings
and thoughts and the experience itself. Third is the development of new perspectives as a
result of this analysis. For trainees, this analysis could mean the development of new
perspectives on their lived experiences, which may result in more informed clinical decisions.

Hogston and Simpson ( 1999) define reflection is different from simply recalling an event, or
even discussing a day at work with a colleague. The benefits of reflective practice are many
and varied. It can lead to an analysis of (nursing) actions in such a way that it can become
evident how things might have been done differently, or equally the recognition that things
are done well and should be repeated.
2) Sources of reflection

2.1) Positive things (decision- making)

Reflection often requires the individual to question why a particular problem exists.
For example, when a nurse begins to question why a particular the patient is not entitled to
certain medical treatment or why certain differences exist in health care, the pediatrician is
using premise reflection. For trainees to begin to recognize their own assumptions and
biases and how they might impact their clinical decision-making process, as well as their role
in social advocacy, significant skill in premise reflection in required.
Atkins and Murphy (1993) performed a meta-analysis of the many definitions of reflection
present in the literature and noted that there are three common elements essential to this
process. First is a trigger event, which is typically an awareness of some uncomfortable
feelings or thoughts either positive or negative. Second is a critical analysis of these feelings
and thoughts and the experience itself. Third is the development of new perspectives as a
result of this analysis. For trainees, this analysis could mean the development of new
perspectives on their lived experiences, which may result in more informed clinical decisions.

2.2) Reflective for learning and providing the best care to patients

As professionals, we are accountable for our ongoing learning and self development,
providing the best care to our patients. To ensure this, we need to focus on our actions and
skills to be able to meet the demands of patients, colleagues and professional bodies. In
order to be reflective practitioners, we need to be reflective thinkers. "Reflective thinking is
thinking that is aware of its own assumptions and implications as well as being conscious of
the reasons and evidence that support the conclusion" ( Lipman, 2003, p.26 ). John Dewey
defined reflective thinking as "an active, persistent and careful consideration of any belief or
supposed form of knowledge in the light of the grounds that support it and the further
conclusion to which it tends" (cited in Martin, 1995, p.167). Reflective thinking leads one to
be more self-aware so he can develop new knowledge about professional practice.
2.3) Reflective important for professional development

Reflective practice has been recognised to be an important tool for professional

development. Rowls and Swick (2000) agree and observed that practitioners who regularly
reflected enabled them to develop their skills and the way they deal with patients. Schunk
and Zimmerman (1998) describe how a self- reflective practice allows us to monitor,
evaluate and adjust our performance during learning. Adjusting strategies based on
assessment on our learning helps to achieve the goal of learning and identifying the
activities well suited to our situations (Schunk & Zimmerman, 1998). However, practitioners
often found the process quite time consuming and there was a greater fear of becoming
introspective or being critical of oneself too much in practice. It is likely that one can be too
engrossed in his reflection that he gets to neglect the delivery of a great work performance.

However ,Fry, Ketteridge and Marshall (2003) seem to take a balanced view and
define reflection to be an integration of existing knowledge and new knowledge. This implies
that as a reflective practitioner, I should always evaluate if my current knowledge is still
applicable, and in updating myself, should be able to incorporate my new learning with what
I already know.

3) Skill / attitude for reflection

Striving to become better at what one does entails reflecting on both the positive
things that one has achieved and the mistakes committed in the process of performing one's
duties and responsibilities. Reflective practice focuses on the learning that has evolved and
correcting what has been done wrong. This essay assesses my professional, clinical
development through an analytical reflection from a patient seen in the Emergency
Department , as part of the holistic health assessment module. The assessment model used
in the consultation will be examined, together with theoretical and evidence based practice,
and how this has helped developed my approach, linking decision-making and best practice
outcomes.
4) Reflection Writing

This essay will discuss the reflecting on both the positive things that one has
achieved and the mistakes committed in the process of performing one's duties and
responsibilities . This essay assesses my professional, clinical development through an
analytical reflection from a patient seen in the Emergency Department , as part of the holistic
health assessment module. The assessment model used in the consultation will be
examined, together with theoretical and evidence based practice, and how this has helped
developed my approach, linking decision-making and best practice outcomes.

Following Gibbs' (1988) model of reflection, I shall establish the integration between
theory and practice. This model identified six stages involved in reflective practice where at
each stage the I would ask myself a number of questions leading to the final stage of an
action plan. It begins with selecting a critical incident to reflect upon followed by keen
observing and describing of the incident, then analyzing my experience. This is followed by
interpreting the experience and exploring alternatives leading up to an action plan. This is is
a cyclical process which enables continual retrospective reflection. Baird and Winter (2005,
p.156) give some reasons why reflection is require in the reflective practice. They state that
a reflect is to generate the practice knowledge, assist an ability to adapt new situations,
develop self-esteem and satisfaction as well as to value, develop and professionalizing
practice. However, Siviter (2004, p.165) explain that reflection is about gaining self-
confidence, identify when to improve, learning from own mistakes and behaviour, looking at
other people perspectives, being self-aware and improving the future by learning the past.

Gibbs' model of reflection (1988)

1) ( Description)

I am a registered nurse and have been working night duty in an Emergency and Trauma
Department at Hospital Kudat. Currently, I am undertaking a Bachelor of Nursing course and
during my studies I have come to consider past experiences through critical reflection. The
following incident is shared in the hope of encouraging nurses to reaffirm belief in their
abilities and in themselves as effective professionals.

One particular night I was about four hours into my shift when a man presented with chest
pain. As was customary for me, I helped the man to undress and in the course of recording
various observations, I chatted with him to ascertain what had brought him to Emergency
and Trauma Department in the middle of the night.

2) ( Feeling )

He told me that he had awoken that night with central chest pain which radiated to the neck
and left arm. He went on to tell me that whilst walking to work (a couple of kilometres) he
would experience chest pain which subsided at rest. Previous investigations had revealed
nothing. The ECG I performed showed no acute changes, and the pain had subsided.

The man was a smoker and was slightly overweight; however, the most telling factor of all
was the stressful occupation he held. He was a judge. The intern on duty at the time came
over to allocate herself a patient and when I told her what I knew of this patient's history and
background her response was 'so what?' I immediately became concerned at the intern's
attitude and proceeded to speak with the duty medical registrar.

3) ( Evaluation )

While the intern examined the patient, I discussed the patient's history with the registrar and
was interested to determine the criteria for admission to hospital for a person with chest
pain. By this time, a colleague had entered the discussion and the registrar felt the history I
had related to her was not significant. The patient had a normal ECG and the pain had
subsided. The registrar had not examined the patient at this time; however, with the history I
related she would more than likely discharge the patient home. My colleague and I
discussed with her different aspects of the case and pointed out that, in our experience, it
was most unusual for a man of his status to come to a public hospital emergency
department in the middle of the night unless there was a signify cant reason for concern.

He could quite probably have contacted any of his influential medical friends but he had
instead presented to Accident and Emergency at a major public hospital.

4) ( Analysis )

Finally, after discussing the patient with the intern, the registrar rationalized that she had
admitted a previous patient without a true cardiac history. She then admitted this patient to a
male medical ward in an unmonitored bed and said he could be reviewed by his own
cardiologist in the morning.

The following night I came to work and was not at all surprised to hear that the judge had
suffered a cardiac arrest that morning as a consequence of an acute inferior myocardial
infarction. I spoke with the Medical Officer Oncall that night and discovered that the judge
had experienced a form of crescendo angina which would ultimately result in a myocardial
infarction. He underwent bypass surgery three weeks later.

The Medical Officer on call agreed wholeheartedly with my original thoughts-that it was
unusual for a judge to attend a public hospital Emergency and Trauma Department without
significant reason. His pain had been severe enough to warrant a nocturnal visit. This alone
should have been a sufficient indication of a more sinister problem.

5) ( Conclusion )

After studying critical theory, reflection and critical thinking this semester, this critical incident
came to mind. It is a poignant example of the need to look beyond the technical data and
symptomology of a patient. As far as the medical staff were concerned, the patient had a
normal ECG and was pain free. This was enough for him to be sent back home. Hopefully
the intern has learnt a valuable lesson.

6) ( Action Plan )

Nursing diagnosis is a valuable form of knowledge development, and our 'gut feelings' which
come from years of nursing experience, should be recognized as significant precursors to
diagnostic reasoning.

The patient should be treated as a whole person and not just as a 'chest pain'. Patients must
be considered within the whole context of their life, role in society, profession, class, social
history, gender, lifestyle and so on. Nurses must advocate for all patients within the context
of their individualism and affirm their right to equality in health care. This is a significant part
of the challenge of professionalism.