Scenario 2 is reflection in the light of Gibbs reflation cycle.

Using Gibbs: Example of reflective writing in a healthcare assignment

 Description
In a placement during my second year when I was working on a surgical ward, I was working under the supervision of
my mentor, caring for a seventy-two year old gentleman, Mr Khan (pseudonym), who had undergone abdominal surgery.
I had been asked to remove his wound dressing so that the doctor could assess it on the ward round.
I removed the dressing under my mentor's supervision, using a non-touch procedure, and cleaned the wound, as requested by the
doctor. My mentor was called to another patient at this point, so at her request I stayed with Mr Khan while we waited for the doctor to
come to see him.

The doctor had been with another patient, examining their wound, and I noticed that she came straight to Mr Khan to examine his
wound, without either washing her hands or using alcohol gel first. I also noticed that she was wearing a long-sleeved shirt, and I was
concerned that the cuffs could be contaminated. I thought for a moment about what to do or say, but by the time I had summoned
enough courage to say something, I thought it was too late as she was already examining Mr Khan.

Feelings
I was alarmed by this, as I had expected the doctor to wash her hands or use alcohol gel before examining Mr Khan. However, I felt
intimidated because I felt that the doctor was more experienced than me as a second year nursing student; and I didn't want to
embarrass her. Also, I didn't want to make Mr Khan concerned by confronting the doctor in front of him.

Later, I spoke to my mentor about the incident. She suggested that we speak to the doctor together about it. My mentor took the doctor
aside, and asked her whether she had washed her hands before examining Mr Khan. She looked quite shocked. She said that she had
been very busy and hadn't thought about it. My mentor discussed the importance of hand hygiene with her, and the doctor assured her
that she would wash her hands before examining every patient in the future.

Evaluation
The incident was extremely challenging for me. I regret that I did not act to challenge the doctor's practice before she examined Mr
Khan. However, I am pleased that the doctor responded so positively to the feedback of my mentor, and I have observed that she has
now changed her practice as a result of this incident. I too have learned from the incident, as it has taught me the importance of acting
assertively with colleagues, in a sensitive manner, in order to safeguard patients' well-being.

Analysis
The Royal College of Nursing (2005) states that hand hygiene is the single most important activity for reducing cross-infection, and
points out that many health care professionals do not decontaminate their hands as often
as they should. Recent guidance published by the Department of Health (2007) highlights the possibility of staff transmitting infections
via uniforms, and the need to review policies on staff dress. The Nursing and Midwifery Council Code of Professional Conduct (2004,
section 8) states that as a nurse 'you must act to identify and minimise the risk to patients and clients'. As the student nurse caring for
Mr Khan under my mentor's supervision, this also applies to my own practice as a student nurse.

Conclusion
Looking back on this incident, I can see that I should have acted sooner, and that I should have ensured that the doctor washed her
hands before examining Mr Khan. I can now see that my inaction in this incident put Mr Khan's well-being at risk. After discussion with
my mentor, I recognise that I need to develop the confidence to challenge the practice of colleagues, putting the well-being of clients at
the forefront of my mind. I realise that I need to be supportive to colleagues, understanding the pressures that they may be under, but
ensuring that their practice does not put clients at risk.

Action Plan
In future, I will aim to develop my assertive skills when working with colleagues, in order to ensure that the well-being of clients is
maintained. In my next placement, I will make this a goal for my learning, and will discuss this with my mentor to work out strategies for
how I can achieve this.
*******************
THE END
... or is it? This may be the conclusion of a single learning experience, but it is the beginning of your development as a professional, in
which your confidence and assertiveness could have a direct impact on a patient’s wellbeing. Next time... you start with your action
plan. How does it work out? What happens next time you are in a similar situation? You can continue to use Gibbs’ reflective cycle to
chart your ongoing learning and development.

Scenario 3
Introduction
The incident I will be reflecting on occurred whilst I was placed with the vascular team. We had received a request for a duplex carotid scan
for a patient on ITU who had been admitted due to a large stroke. Upon arrival we read her notes which highlighted significant aphasia and
difficulties with communication. The nurse also informed us that the patient had a long standing memory problem and as a result of this, she
did not remember why she had been admitted and would become very distressed when her stroke was discussed. When we approached her
to perform the scan we found that she was under minimal sedation and was having assistance from a ventilator. The scan was completed
without difficulty and we began to document our findings in the notes.
A nurse came onto the ward with two members of the public in order to show them around ITU before the man's surgery. This has been a
long-standing protocol which strives to decrease worry before a planned stay in ITU. The members of the public were brought to the bedside
where the nurse began to explain what the equipment was and what it was used for. The nurse made no effort to introduce the members of
the public or herself to the patient. She also glanced at the patient's notes and then informed the members of the public that she had been
admitted to ITU because of a stroke. Upon hearing this, the patient became overtly distressed and had to be more heavily sedated after the
nurse in charge of her care could not calm her by talking in a soothing manner. This event clearly caused undue anxiety to both the patient
and members of the public, in addition to the members of staff who bore witness to the incident. The incident was reported using an in-house
critical incident report by both myself and staff from ITU as this was a breach of patient confidentiality and poor practice.

Interpretation of the incident

Before the incident, I was aware that the nurse was showing the members of the public around the ITU in order to familiarise them with the
ward. I was very surprised when the nurse did not check the patient's notes beforehand, and the distress caused to both the patient and the
members of the public was entirely unnecessary. To critically reflect upon this incident I shall use a well-known reflective cycle from Gibbs
(1988). This model is cyclical and is unique because it includes emotions, knowledge, and actions and believes that experiences are
repeated, which moves away from the model proposed by Kolb (1984). Some scholars, such as Zeichner and Liston (1996), believe that a
wider and more flexible approach is needed by examining values in a critical light and how the practice of this can lead to changes in quality.

Description
The most important factor in this incident was the lack of intervention from myself or the other healthcare professionals. The nurse should
have been made aware that this was not a suitable area to bring the members of the public to. I also assumed that there would not be
disclosure of specific patient details as this would be a breach of patient confidentiality policies which are covered in numerous guidelines
from the Healthcare Professions Council (HCPC, 2012) and the Nursing and Midwifery Council (NMC 2015).

Feelings
The main emotion that I felt in this situation was anxiety. I had been to ITU many times before and it is an environment in which I feel
comfortable. I had not been to ITU to perform a carotid ultrasound before and I felt nervous as I wanted to perform the test well. I believe that,
as a result of this, I moved some accountability to my senior colleague. I found the incident upsetting to witness as the distress was caused
by a member of staff and their actions were avoidable.

Evaluation
My role was to complete the scan and establish the presence or absence of carotid disease, which I did. The results of the scan would have
been used to determine the best course of management for this patient. It is important to note that acting in the patient's best interests was
also part of my role, and I feel that I did not fulfil this completely. The duty to protect patients and patient confidentiality at all times lies with all
staff, including myself, my vascular colleague, and the ITU staff. Our failure to act as a team could be explained by Rutkowski's (1983) theory
of group cohesiveness. This theory proposes that altruistic behaviour is dependent upon the social norm, and is defined as people helping
those in need, and who are dependent upon them for help. Rutkowski's (1983) showed that the group is more likely to act in accordance with
the perceived social norm if there is a high level of group cohesiveness. In the situation that I have described, neither my colleague nor I were
familiar with the healthcare professionals on ITU and there may have been a low level of group cohesiveness as a result of this.
Further work (Koocher & Keith-Spiegel 2010) has demonstrated that irresponsible professional behaviour can be averted by informal
interventions. People were found to be more likely to take action if they were the senior person in a situation, and most felt that a positive
outcome was as a result of their intervention (Koocher & Keith-Spiegel 2010). It is important to note that the way in which this outcome was
measured (taken from data described as 'feelings after intervention'), may have introduced bias as it is likely that participants felt pleased with
their courage in acting in an appropriate manner, regardless of the outcome of the intervention. It is possible that their intervention garnered
no difference in professional behaviour. It is important to note that cases of major misconduct, such as those which could result in harm to
patients or damage to the reputation of the Trust, should be dealt with by more formal routes. We completed an internal incident report which
automatically flags the incident to senior clinicians and managers which would ensure that this incident was not unheeded. If this incident had
not been reported, it would be an indicator of declining professionalism and acceptance of inferior standards of care. Tolerance of poor
standards was highlighted by the Francis report (2013) as a consequence of poor staffing, policies, recruitment and training, and leadership.

Analysis
The patient had a jugular line in place, which I had anticipated would make the scan more difficult and therefore probably contributed to my
increased level of anxiety. I feel that if I had not been as anxious I would have been more likely to intervene; however it is clear that both my
colleagues and I should have intervened more quickly. I believe that an informal intervention as described by Koocher and Keith-Spiegel
(2010) would have been appropriate in this situation.

Conclusion
Having witnessed the distress caused to both the patient and members of the public, I am now aware of the important of being more assertive
if similar situations were to arise in future. Although I believe I should have intervened at the time, the experience I have gained from this has
made me more aware of the important of always acting in the best interests of the patient even when this may take courage. I believe that
having greater confidence in my ability to scan would have reduced my diffusion of responsibility and allowed me to act in a more
autonomous fashion. There should also be a greater emphasis to establish strong working relationships between healthcare professionals to
in turn increase levels of group cohesiveness (Rutkowski et al 1983).

Action plan
My future practice will involve becoming more proactive when I believe that there is a risk to patient confidentiality, and I will not assume that
other members of staff will act in a professional manner at all times. I will continue to undertake reflective practice by using the model
proposed by Gibbs (1988), and will aim to become confident when protecting patient confidentiality, particularly in situations where I am
applying clinical skills which are new to me or that I do not feel completely confident with. As a trainee healthcare scientist, I aim to
consistently implement the values and principles as set forth by the HCPC (2012) of a clinical scientist, and although this experience was
difficult, I now feel that I have a greater understanding of these principles and values.

Changes in norms and behaviours

Due to the incident, I have formed a new set of behaviours. The first of these is that I will no longer assume that all members of staff will act in
accordance with guidelines about patient confidentiality. Tied to this is a conscious effort on my part to refrain from assuming that I can
predict the actions of other healthcare workers and I will always prioritise the welfare of patients in my care. Gibb's (1988) model has allowed
me to critically reflect on my behaviours and has allowed me to identify aspects of my behaviour which may be detrimental. Critical reflection
of this incident has made it clear that there is a deference to those I deem more senior than myself, perhaps due to a subconscious desire to
maintain good working relationships.
It is possible that the major obstacles which prevented me from speaking out in this incident were my perception of an authority gradient
between myself and my colleague and low group cohesiveness. To prevent future events like this occurring I will express any concerns about
my clinical skills before beginning any procedures in order to both reduce any authority gradient and to also reduce the diffusion of
responsibility as much as possible. I now feel more confident in protecting patient confidentiality and will aim to always embody the values
and principles of a healthcare scientist.