Case study: Reflection on practice and knowing one’s self

From reading Chapter 43 and working through the Critical Stop Points within the chapter, it should be very clear that the student nurse in transition from student to staff nurse may encounter many personal and environmental issues. These may cause personal or professional difficulties and possibly work-based challenges in terms of personal coping with and/or responding or adapting to such challenging issues.

It is thus essential that from the outset that the practitioner begins to utilise the skills of reflection in and on your role in accordance with the Nursing and Midwifery Council (NMC) Code (2015) and this will enable and facilitate a deeper understanding of one’s self. As practitioners reflect on their practice in a more meaningful and structured manner this will help the practitioner to practice safely and effectively and most importantly to demonstrate that such practice concurs with the standards set out within the Code. The four themes within the Code will require all registrants to Prioritise people – Practise effectively – Preserve safety – Promote professionalism and trust. The NMC (2015) have stated that the Code should be seen as a way of reinforcing professionalism. Further, through professional revalidation all NMC registrants will be required to provide fuller, richer evidence of continuing ability to practise safely and effectively as a requirement for registration renewal. The NMC (2015) have clearly stated that the Code will be central in the revalidation process as a focus for professional reflection. Figure 1 provides the NMC template for written reflective accounts. The authors advocate that all new registrants pay particular attention to the application of the NMC template and how the themes have been operationalised therein.

Many authors have published on the nature and process of reflection, (Kolb, 1984; Gibbs, 1988; Johns, 2000; Taylor, 2006; Oelofsen, 2012) and highlight the important advantages to reflection in one’s practice. Dewey (1933) suggested that we do not learn by doing rather we learn by doing and realising what came of what we did. Schon (2013) defined reflective practice as a process, which can influence and inform practitioners about how to approach and respond to situations. This definition implies that with reflection comes enlightenment, which can then be used to inform future actions and decision making. There is also an inherent suggestion that reflective practitioners are forearmed for future clinical encounters by engaging in reflective practice (Johns, 2000).

Oelofsen (2012) suggested that reflective practice helps the practitioner to make sense of events, situations or actions within the work place, and suggested that whilst many pre-registration programmes leading to registration included a focus on reflective practice that organised reflection within practice was rare due to the pressurised world of frontline practice. This invariably will present the nurse in transition with further challenges. However, if the process of reflection is actively engaged with, by the new staff nurse, from the outset, this will have demonstrable benefits for the new registrant and will be an effective enabler to their practice within all themes as outlined within the Code.

Figure 1 NMC Template for written reflective accounts

The authors have advocated and outlined a brief synopsis of the literature, which highlights the importance of reflection. They further suggest, based on their own experiences, that The Gibbs’ (1988) reflective cycle is a popular model that may be used to underpin reflections. It has been cited within the literature as enabling the process of reflection involving six distinct stages within the reflective process. This is presented in Figure 2. This presents a systematic guide for reflection that all registrants can follow quite easily. These may also be kept as part of one’s own professional development portfolio.

Figure 2 Gibbs’ (1988) Reflective Cycle

To enable the nurse in transition to practice their skills of reflection related to the themes within the Code, and to apply both the NMC template (Figure 1) and operationalise the Gibb’s Reflective Cycle (Figure 2), we now present an update on the case history of the service user Rosie (as presented within Chapter 43). This is presented below with some questions for you to consider, if you were the mental health nurse attempting to assist the service user Rosie.

Rosie was a client who had re-presented at the Community Mental Health Team (CMHT), following referral by her GP, for assessment of her mental health status due to an escalation of her depressive symptoms related to an ongoing court case. Many emotional and stressful issues presented for Rosie during the court case and she subsequently required increasing levels of mental health support and counselling from the CMHT. She was prescribed antidepressant medication and is concordant with this regime. However, she refused a voluntary admission to an acute psychiatric hospital, as was the recommendation from the CMHT. 

Service User Rosie

When I wrote the original short piece on my life and the issues that I was facing at the time for the main chapter in this book, I very much came to realise that I have many ongoing issues in my life. I also realised that I presented only a small insight into my life. I still feel very sad and lonely throughout the day, even though my home is never empty of family. I often cry uncontrollably during the day and feel that I want to be alone. My mood is constantly low and I feel that my senses are dulled a lot. I awaken often during the night and my mind starts racing immediately about all that is going on and how I have no control. It is all deeply upsetting to me and I have lost all interest in the things that I would normally do. I have lost a lot of weight, and funny enough this should make me feel happy, but it does not. I love my husband, but we don’t have sex anymore, as I am not really interested and he finds all of this confusing and struggles to know how best to help me. I am unable to tell him, as I do not really know myself. I do know that I need him around me, as I do my family but I just wish that they understood how I am really feeling at this time.

As I was preparing and dealing with complex issues surrounding the sexual abuse that I had experienced, it was necessary for me to talk about these things that I had locked away deep in the corridors of my mind. Giving statements to my solicitor and the police, and being made to feel that I was a liar at times by the defendant’s solicitors only makes me feel that I have lost my entire sense of self. I feel very inadequate, despondent and hopeless and can’t seem to see how all this torment will end. Having to recall horrible experiences that happened to me as a child, now today, as a fully-grown adult, is one of the most difficult things I think that I will ever have to face. I feel tormented, anxious, restless and I have had thoughts that my life was not worth living many times. But, my family and grandchildren are my backbone, they help to bring me back to reality and keep me grounded and I can chase these horrible thoughts away. I think that talking about these issues might help me on the road to survival from being a victim of childhood sexual abuse, but the court case is as equally hurtful and devastating to me, and I can’t turn back now. The fact that he has now pled guilty helps me to move on, but I know it is going to be a long time and another long journey ahead of me. I do feel a bit stronger now.

1. What do you feel is the most appropriate course of action to follow with Rosie at this time? Will Rosie concur with your professional judgement?
2. How can you ensure that you are practising safely and effectively cognisant of potential risk, and supportive factors in Rosie’s life?
3. In terms of promoting professionalism and trust, can you consider other courses of action to assist Rosie and her family at this time, which does not appear to be currently part of her mental health care package?
4. How can mental health nurses provide a therapeutic presence and support for Rosie that promotes her self-esteem and self-worth during her court ordeal?

Note: Reflect on how you might approach these situations. If you’re not sure, discuss with your tutor or placement mentor