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Introduction In this essay I will be reflecting on an episode of care in which I was involved in during clinical placement. I will be using the Gibbs (1988) reflective cycle, which consists of six stages; 1. Description – What happened? 2. Feelings – What was I thinking and feeling? 3. Evaluation – What was good and bad about the experience? 4. Analysis – What sense was made of the situation? 5. Conclusion – What else could I have done? . Action Plan – If the situation arose again, what would I do? Reflection is used to look back at situations and to be able to notice what could be improved or done in a different way for better practice and also for the patients benefit. Atkins and Murphy (1995) states ‘Reflection relates to a complex and deliberate process of thinking about and interpreting experience, either demanding or rewarding, in order to learn from it.
Siviter (2004) states that reflecting on situations benefits by gaining confidence, the ability to recognise where improvement is required, learning by own or others mistakes and behaviours, looking at situations from other peoples perspectives and having the ability to improve the future by learning from the past. Reflective practice is widely used by all professionals as and when they face new and different situations and challenges (Jarvis, 1992). In order to maintain patient confidentiality and to abide by the Nursing and Midwifery Council (NMC) code of professional conduct, I will hereby be calling my patient ‘Jane’ (NMC, 2008).
Description It was my first ever night shift. I was based on delivery suite. I had worked two previous day shifts so knew the basics of what needs to be done and how events need to be documented. Myself and my mentor were allocated a patient. We went into her room and introduced ourselves to Jane. Jane had no objections to me being present and assisting in her care. Jane was a primigravida, full term, low risk pregnant young lady. She had support from her boyfriend and her best friend.
Jane was contracting two – three in ten minutes and was coping well with the pain. Jane was examined by my mentor and appeared to be four centimetres dilated which meant she was in established labour (NICE, 2007). I was given the responsibility of listening into the fetal heart every fifteen minutes, timing and documenting contractions half hourly, monitoring maternal pulse every hour, monitoring fluid input and output and keeping records up to date with all my findings including keeping the partogram up to date as per the NICE guidelines (2007).
Later on that evening my mentor was called out of the room and did not return for over an hour. When she finally returned, she checked on the progress of my observations and explained to myself and Jane that there were two other patients that had delivered their babies in the waiting room due to being full on the ward and to top it all up they both had retained placentas and needed to have manual removals in theatre! She reassured me and Jane that what I was doing was correct and for me to push the buzzer if I needed help with anything at any time and left again.
About half an hour later Jane started complaining that she was feeling pressure and started to push! I pressed the buzzer and a midwife (not my mentor) entered the room. I explained the situation and also made her aware that Jane was due a vaginal examination to check on dilatation progress as her last one was over four hours ago (NICE, 2007). The midwife carried out the examination and Jane now appeared to be seven centimetres dilated. The midwife explained to Jane that she is not ready to push and asked if she would like to consider any pain relief, Jane agreed to entonox.
The midwife advised me to carry on and to press the buzzer again if needed but also advised me that Jane will not be fully dilated for at least another two – three hours and that my mentor would be back by then. Jane managed to nap in between contractions while I kept the observations and documenting up to date. About half an hour later she started pushing again. I kept on telling her she must stop involuntarily pushing as she could cause herself harm. “If pushing is commenced before the cervix is fully dilated, it can cause all sorts of problems.
The cervix itself is likely to swell up and may be pushed out of the vaginal canal, with serious risk of damage to it, and bleeding. The efforts themselves will not hasten delivery; instead, this will help to exhaust the mother, running the risk of her being unable to push when the appropriate moment arrives. This may mean an instrumental (forceps or ventouse) delivery which may have been otherwise unnecessary” (Pregnancy-Bliss 2007 – 2010). Jane listened to me for a while but then started pushing again.
I asked for consent as per the NICE guidelines (2007) to have a look under the covers to check if there were any visible changes to her genitalia, she consented. I was shocked to see that there was a head crowning! I pressed the buzzer again and my mentor rushed in looking all hot and bothered. There was a sudden rush to get consent for syntometrine and intra-muscular vitamin K while gloves were going on me and my mentor’s hands. Within five minutes we delivered a healthy baby girl. Syntometrine was injected for the third stage of labour and baby was injected vitamin K.
Feelings While my mentor or any other midwife was present in the room, I felt more confident and secure that if something was to go wrong, there was an experienced professional there. All the while I was left alone with Jane I was putting myself in her position and thinking that I probably would not have liked to be left alone with a year one student. The whole time I was thinking of ‘what if’s’ and working myself up which probably meant that I was not able to concentrate 100%. Evaluation I was left alone with a labouring patient.
In order to provide high standards of care and practice at all times as mentioned in the NMC guidance on professional conduct for students (2009), a student should work under appropriate supervision and support at all times (NMC, 2009). Jane lacked continuity of care from her midwife. Although I was in attendance at all times, she did not have continued support from her allocated midwife. There was other midwives entering the room to check up on me and Jane but they were not recognised by Jane.
NICE (2007) states that a woman in established labour should receive one-to-one care by her dedicated midwife and should not be left alone for a prolonged amount of time NICE, 2007). Although the NMC guidelines for students (2009) states that we should be open and honest to our patients at all times, I feel that is was not appropriate for my mentor to explain the problems that were going on outside of the room we was involved with especially informing her that the staff shortages lead to deliveries in the waiting room and retained placentas NMC, 2009).
The NICE guidelines (2007) state that the length of established labour varies between women (NICE, 2007). It is not professional to predict how everyone will progress in labour as everyone is an individual and everyone’s physiology is different. Because Jane was a primigravida it was assumed that she would labour for longer. Women should have the opportunity to make informed decisions about their care and any other treatment required (NICE, 2007).
In this case Jane was asked for consent for the administration of a drug to speed up the process of the delivery of her placenta and consent to administer vitamin K in an injection form for the baby at the peak of Jane’s contractions which I believe is not best practice as people in pain are unable to think straight and to make important decisions like that should be made while calm and to have the opportunity to raise questions and concerns if needed. Analysis Although we had a good outcome, things could have gone terribly wrong, which could have led to complaints being raised and accumulated.
Jane was stereotyped as a ‘primigravida’ which meant that she was in for a long labour. The other ladies which my mentor had gone in to care for were multiparous women, which meant they would deliver quickly. They had delivered quickly, but was faced with problems and ended up going to theatre. This could have happened because my mentor was split between patients which prove this was not good practice. Jane deserved full autonomy. My mentor should have backed up her autonomy and refused to care for others while our patient needed her.
I had tried my very best and used my self initiative to make Jane comfortable, care for her as I would like to be cared for and for her not to notice the absence of my mentor. I was not supposed to be in charge there, but I had no choice. I had a self awareness of myself and my responsibilities as a student but I had no choice she was in my sole care so I had a responsibility over her. I was the only professional face Jane recognised after my mentor. I had to look after her in the best possible way and make her feel comfortable. After all a midwife dedicates herself to be ‘with woman’.
This whole situation boils down to the fact that the trust was short staffed. If there were enough staff then my mentor would not have needed to leave the room and would have provided the vital one-to-one care and everything else that accompanies good practice. It is not for me to say anything or to complain to the trust involved, but feel that my mentor or her supervisors should raise concerns over what had happened and should facilitate additional staff to prevent situations like this from arising again as the next one may not turn out into a good one like Jane’s did.
We were very lucky that Jane had a positive attitude and trusted to be left alone with me. I believe there is an issue of power over gaining consent in this episode of care and would like to use power and consent as my theory. Midwives are known to have power (NMC, 2008). By having power midwives are able to get their patients to agree to certain things. Patients become vulnerable in a hospital setting.
They are in a unfamiliar setting, they wear night clothes or hospital gowns day and night and their conversations with the midwife are generally while they are sitting down or lying in the bed while the midwife looks over them (Rumbold, 1999). A typical primigravida hands herself over to the midwife and believes the midwife knows best so she has no choice but to agree to the professional (Thompson, 2004). Clients and patients assume they need to give their consent to health professionals and have no choice. This is not true consent and they are entitled to choice whether it is consent or refusal (Jones, 2000).
Although Jane had the power of making her own decisions on her labour and birth, I believe the power of the midwife (my mentor) explaining to Jane that she had a while to go yet and she was in the safe hands of myself while the midwife attended to someone else’s emergency made Jane agree to it. After all Jane came to the hospital to deliver her baby because she believed that hospitals are the safest place to deliver babies and midwives know how to do this best, so she trusted and conformed to the midwifes judgement on the length of time on her labour.
Reflective Conclusion In conclusion to this reflective cycle I would like to emphasise that I believe that the midwife in charge of Jane should not have been judgemental as stated by Jones (2000) ‘Healthcare professionals are expected to be non-judgemental in their care’ and should have not agreed to leave a person in which she is in charge of her care to a student while attending other clients. Action Plan
If I ever come across with this type of situation again in the future, I will try everything within my power to encourage the midwife to be in attendance at all times apart from short periods of time for a break. Failing this I will make sure I follow the woman’s instincts and follow her up by observing and questioning in order to be prepared and to be able to get help quicker if need be. I believe I did the best I could do, with the amount of knowledge and education I had sustained by being a student for a mere six months.
I would also like to add that this situation has been a great learning experience for me and will be more knowledgeable in the future and will be more calm and aware of the situation. Assignment Conclusion In conclusion to this essay, I have reflected on an episode of care in which I was involved in by using the Gibbs (1998) reflective cycle and have divided the cycle into the six stages which are involved. I have also mentioned the relevance of power in this episode of care and how clients conform to the midwife.
Using a reflective cycle is a new experience to me. By dividing the episode of care into the six sub-headings, it was easier to manage while studying each section at a time. I found it difficult to criticise a professional as we all believe that they are there to care for us and to protect us but unfortunately staff shortages and tight budgets do not always permit this. I have now gained the ability to reflect on situations and also to reflect on situations to determine the good things, the bad things, the rights and the wrongs.
Before I did this essay, I had not thought about this episode of care in depth as I have by using this reflective cycle therefore did not realise what went wrong at the time, but now I am aware of what went wrong and am able to act on it to prevent it from occurring again in the future. I will be using reflections more frequently to be more competent in doing it and also to expand my knowledge and ability to care for people in my care and around me. Reference List Atkins, S. Murphy, K. (1995) Reflective Practice Nursing Standard 9; 45:31-35 Gibbs, G. 1998) Learning by doing: A Guide to teaching and learning methods Oxford F. E. Unit: Oxford Jarvis, P. (1992) Reflective Practice and Nursing. Nurse Education Today, 12:174-181 Jones, S. R. (2000) Ethics in Midwifery, Mosby National Institute for Health and Clinical Excellence (2007), Intrapartum Care: Care of healthy women and their babies during childbirth (online) accessed 13/12/10 at http://www. nice. org. uk/nicemedia/live/11837/36280/36280. pdf Nursing and Midwifery Council (2008), The code: Standards of conduct, performance and ethics for nurses and midwives, Nursing and Midwifery Council
Nursing and Midwifery Council (2009), Guidance on professional conduct. For nursing and midwifery students, Nursing and Midwifery Council Pregnancy Bliss (2007 – 2010), Pushing in labour (online) accessed 17/12/10 at http://www. pregnancy-bliss. co. uk/pushing. html Rumbold, R. (1999), Ethics in Nursing Practice, Baillere Tindall Siviter, B. (2004), The Student Nurse Handbook, Baillere Tindall Thompson, F. E. (2004), Mothers and Midwives; The Ethical Journey, Elsevier