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Introduction
The best way to describe critical reflection is through a passage delivered by Aldous Huxley in which he said, “Experience is not what happens to a man; it is what a man does with what happened to him” (University of Texas, 2012). In the healthcare profession, a health professional is confronted by situations that that requires critical understanding. Some encounters are challenging and perplexing. And because there is a level of urgency in the practice of medicine and healthcare, majority of the time healthcare practitioners does not have the luxury of time to contemplate on their actions. This is unless the incident has passed, and they are confronted with a consequence. Most often than not, the consequences are rather undesirable when health professionals find it compulsive to assess their past actions. As a result, it creates a powerful impact to the professional that allows him or her to contemplate on the situation as per the health practitioner’s response and its possible impact to the other person. The nursing profession is no less different than any other branch of the healthcare. Nurse Practitioners are not exempted from this circumstance. The goal of this submission is to provide for the critical reflection of a particular case experienced in the healthcare profession utilizing Hesook Suzie Kim’s principles. This paper would evaluate the case based on the merits and shortcomings of the nurse practitioner under the given situation along with the implications of the nurse practitioner’s action in the light of Kim’s model. Specifically, the three distinct phases of (a) descriptive phase, (b) reflective and the (c) critical/emancipatory phase will be employed during the analysis. In addition, the situation will be processed through the framework of Dunphy’s Circle of Care Model.
As mentioned earlier, the nursing profession is not exempted from complaints of malpractice and negligence. In fact, in 2003 the National Practitioner Databank reported that 16,339 nurses and nurse practitioners had been a malpractice report filed against them (Right Diagnosis, 2014). In 2012, the nursing profession ranked 3rd with 476 reports of malpractice. In the same report, Pharmacist ranked first with 1,039 and Physicians ranked second with 776 in the number of complaints filed against a profession (U.S. Department of Health and Human Services, 2012). This is the reason nursing schools inject into its curriculum a class that allows nursing students to understand the importance of critical reflective inquiry. Hence, reflective journaling has been utilized to assess educational courses in graduate nursing programs (Kim, Lauzon Clabo, Burbank, Leveillee, & Martins, 2010). In a classroom exercise, the Nurse Practitioner is asked to reflect on a case from the clinical practice. The cases examined are usually emotionally exhausting thereby causing the student-nurse to feel guilty of not performing to the level of what is expected of their profession. Through critical reflective inquiry, the student-nurse is able to “identify the nature of distortions, inconsistencies and disharmony emerging from reflection, and work towards correcting such disparities through various emancipatory processes” (Kim, Lauzon Clabo, Burbank, Leveillee, & Martins, 2010).
Statement of Purpose
Critical reflection was developed by Hesook Suzie Kim in 1999 for the purpose of improving one’s practice through the discovery of insights rooted from the training of a medical practitioner (pp. 2-3). In addition, it is also the unique function of the nurse to aid individuals towards a healthy and disease-free lifestyle, thus it is required that every nurse maintains a certain degree of professionalism and integrity in the conduct of the roles. Thus, critical reflective inquiry could assist nurses and nurse practitioners in performing their role and securing the integrity and sense of professionalism in nursing.
Kim (1999) proposed that clinical experiences should be evaluated using three distinct phases. The following sequence are as follow: (a) descriptive phase, (b) reflective and the (c) critical/emancipatory phase. By applying this into the process of evaluation of clinical experiences, nurses and other healthcare professions will be able to process the situation and dissect the situation in details and eventually process the appropriate response should it occur again in the future.
In this case, a critical reflective inquiry is being conducted to shed some light to a case personally experienced by a student-nurse practitioner during the exercise of the nursing roles and responsibilities. In this case, the student-nurse practitioner would like to assess how her personal reaction and response could have compromised the integrity of her profession and the welfare of the patient involved in the scenario. It should be remembered that the primary role of a nurse and nurse practitioner is to ensure the welfare of their patient without necessarily overriding the patient’s rights and privileges . Hence, Dunphy’s Circle of Caring Model would be utilized to serve as a theoretical foundation of critical reflective inquiry.
Theoretical Framework
Critical Reflective Inquiry are done to improve one’s approach through a process of deep analysis and introspection. This approach has been developed most especially in the field of medicine and healthcare. This is in accordance to the nature of the profession being dynamic and accountable to not only to the patients, but the same accountability also extends to the community. Hence, the principle behind the approach of critical reflective inquiry adapts Dunphy’s Model of Circle of Caring: A Transformative Model. According to this model, the practice of healthcare requires the need to “incorporate the strengths of medicine and nursing in transforming way” (Bryant-Lukosius, DiCenso, Browne, & Pinelli, 2004). The model uses a feedback loop to help caregivers, like graduate student-nursed, as they learn to use their nursing knowledge combined with their education to provide meaningful care to their patients. It is an assessment-planning-intervention evaluation process that uses contextual and environmental information about the patient to develop the medical diagnosis and how the patient will respond to the illness. The Advance Practice Nurse integrates nursing interventions and complementary therapies to improve outcomes.
Review of Literature
Before one could provide for an extensively discussed application of critical reflective inquiry, it is necessary to first identify and enumerate the distinct profession under review. In this case, it refer to the nurse practitioner (NP) as well as is an advanced practice registered nurse (APRN) who have completed advanced coursework and clinical education beyond that requirements demanded from the general registered nurse (RN) role. According to the International Council of Nursing, an NP/advanced practice registered nurse is "a certified nurse who has earned the knowledge base, decision-making skills, and clinical competencies for extended practice beyond that of an RN, the features of which would be decided by the context in which he or she is credentialed to practice" (International Council of Nursing, 2014). Nurse Practitioners manage acute and chronic medical ailments through thorough history taking, physical exam, and the ordering of diagnostic tests and medical treatments. They are fitted to diagnose medical problems, order treatments, prescribe medications and endorse referrals for a wide range of acute and chronic medical infirmities within their scope of practice (International Council of Nursing, 2014).
Given this understanding of the distinction between a nurse practitioner, advanced nurse practitioner and registered nurse, it would be easy to separate the roles and responsibilities of each in accordance to responding to the needs of a patient. It should be established that not all the time, a healthcare professional is expected to respond to the request and calls of the patient expressly if it is beyond the scope of their responsibility. It is easy to commit a blunder if one does not have the full knowledge of the situation.
The Circle of Care Model
According to Dunphy, risk is inevitably experienced in one’s pursuit of providing quality care to patients. Hence, the Circle of Care Model was created as it aims to foster a transformational framework to advance the crucial aspects of the nursing practice in an effort to address the standards of risk assessment (McKnight, 2011). The model takes root from a problem-solving methodology utilized in the primary and acute care facilities. The Circle of Care Model features the following attributes: (1) a broadened and contextualized database, (2) concern labeling that actively incorporates patient responses to the meaning of illness in day to day life (3) a holistic therapeutic approach that includes nursing based interventions and complementary therapies (4) view of outcomes based on patient’s perspective of improvement (Dunphy & Winland-Brown, 1998). Dunphy’s model aims to conduct a comprehensive assessment of the important objective and subjective information concerning the situation and conduct collaborative planning to arrive at a uniquely-designed nursing interventions particularly suited to a given situation.
The model of Circle of Care adapts Boykin and Schoenhofer’s theory called Nursing as Caring Theory. Boykin and Schoenhofer proposed that the nursing profession has a philosophical framework of being transformational as implied in the practical implications of its discipline (Boykin & Schoenhofer, 2001). The authors formulated the theory having believed in two fundamental assumptions that, (1) humans are natural caring individuals, and (2) the nursing profession as a disciple and vocation is in pursuit of caring and nurturing people as part of a greater purpose of propagating the principle of “caring” (Alligood, 2013, p.370). In lieu with this, Dunphy formulated the attributed of caring in the nursing profession. These attributes include collaborating six elements namely authentic presence, courage, knowing, advocacy, patience, and commitment (Dunphy & Winland-Brown, 1998).
Authentic Presence. This attribute operates according to the principle of self-knowledge and self-awareness. Dumphy emphasized that nursing requires the individual’s personal intention to be with another person or to render service to another person (Dunphy & Winland-Brown, 1998). In addition, authentic presence requires a degree of attention to be mindful of establishing interpersonal relationship.
Courage. In the nursing profession, nurses are confronted with the situation that requires them to make deliberate choices. This actions and decisions necessarily require courage. In the Circle of caring model, Dunphy said that nurses have to act on obligation and must have to decipher which situation requires care.
Knowing. The nursing profession requires to know a great deal of information, both subjective and objective. However, knowing requires humility because not everything can be learned nor does it always presents itself in the most obvious manner. Dunphy noted that on such instances when the act of knowing would necessarily requires probing, nurses and nurse practitioners must humble themselves into admission that this matters are not clear to them rather than assume and impose something with uncertainty.
Advocacy. The term advocacy refers to the act of pleading or arguing in favor of something. Similar to the nursing practice where there are instances that nurses and nurse practitioners would necessarily have to voice out and verbalize an idea or opinion because it is in the best interest of the people concerned. Dunphy said that in certain occasions, as in most cases, people will have differing views and opinions. Thus, there is a need to be open to presenting one’s self if only for the purpose of just offering an alternative explanation.
Patience. Same with the discussion under advocacy, patience is required whenever there are differing views and opinions. However, the nurse and nurse practitioner should remain engaged into the discussion and remember to honor their freedom of choice and individual preferences.
Commitment. This attribute is necessary for directing one’s obligation towards the process of informing the patient of the situation along with the other facets. The responses made should be in accordance to what is right, fair, conscious and caring.
Kim’s Critical Reflective Inquiry
Hesook Suzie Kim believes that to prepare nurses into the actual demands of the profession it is necessary that they are able to practice critical thinking effectively and efficiently (Kim, Lauzon Clabo, Burbank, Leveillee, & Martins, 2010). This is the reason Kim proposed the need of incorporating into the nursing program a curriculum that would teach student nurses how to process situations and arrive at a sound response and decision according to the process. Kim knew that theoretical thinking is necessary in order to decipher which among the situations require attention. Also, there is a need to know which among the responses are most suited for the situation (Kim, The Nature of Theoretical Thinking in Nursing, 2010). In addition, Kim noted that in conducting critical reflective inquiry three phases are necessarily completed. These phases include the (a) descriptive phase, (b) reflective phase and the (c) critical/emancipatory phase.
Descriptive Phase. This phase necessarily include the need to gather the information—facts and other details affecting the situation. This includes identifying the agents in the scenario, the event and the circumstances that might directly or indirectly impact the response of every agent. The descriptive phase should also incorporate details relating to the emotions of the agent under the situation. This will aid in the reflective phase that will follow. During the descriptive phase, the narrator must detached one’s self towards the scenario and assume the role of an observer whose intention is simple to narrate the situation because this is the only way that the narrator or the person conducting the critical reflection is able to pursue with the next phase (Shaun, 2012, Abstract).
Reflective Phase. During the reflective phase, the nurse or nurse practitioner would have to evaluate the actions and the responses along with the implications that it brought. The results or consequences of the action should be reviewed to generate insights. During this phase, interpretation of the scenario is initiated (Shaun, 2012, Abstract). At this point of the critical reflection process, the student nurse and nurse practitioner provide interpretation to how the response could have impacted the doer and the receiver of the action. However, the interpretation is not a single interpretation but collective. This means that there can be multiple interpretations that the narrator could provide for one single situation and one single response.
Critical or Emancipatory Phase. Under the emancipatory phase, the narrator would have to harmonize all the insights drawn from the reflective process. There should be mutual understanding of the situation, the response and the result as supported by the theory utilized to evaluate the action (Shaun, 2012, Abstract).
During my rotation at Thundermist in Woonsocket, I met a young lady in her late teens who was battling clinical manifestations of sexually transmitted disease, but above all she was experiencing emotional and psychological problems. Utilizing Kim’s principle of critical reflection, the first step is the descriptive phase. I described the situation I had during my rotation at Thundermist as one in which I experienced battling a choice between medical beneficence, maleficence and allowing my patient to exercise her autonomy. To expound more about this statement, Kim emphasized the need to state the facts, both subjective and objective.
During the history taking, the patient confided her situation. It was revealed that the patient was living with an older man who introduced the patient to drugs and was, in fact, the reason she had gonorrhea. She also said that she had been prostituting just to have money to buy drugs. She admitted that her involvement with the man she was living with, her source of livelihood and her addiction that led her grandmother to take her children away from her. As a response and being a member of the healthcare profession, I was compelled to refer the patient to a gynecologist to have her condition checked. Then I contact Behavioral Health to refer her to a counsellor who would assist her with her addiction and other emotional and psychological problems. During the following encounter, I had with the patient she reported some minor improvements but noted that she felt uneasy and had not connected with the counsellor who was assigned to her. So I suggested that she see another counsellor. However, during the last meeting I had with the patient it was highly noticeable how she seemed to have gotten worst from her previous condition. She admitted that she had gone back to prostituting and had been using the drug more. However, this time she refused help. She was also ready to give and surrendered her children to the custody of her grandmother noting that they were better off with her than they would be with her. I tried to coax her otherwise, but she walked out and said she has her mind made up.
The facts in this case were that it involved a young Hispanic girl who was in her late teens, involved in drug use, prostitution and had kids who were taken from her because of her vices. On top of these details, was the emotion of the patient during the three encounters and her verbal response to counselling, i.e. “no connection with the counsellor.” As for the response of the health professional, there was a personal decision to contact the Behavioral Health department for the patient’s counselling session. There was also the recommendation of rehabilitation. All these were not recommendations that were open for discussion. Instead, the health professional insisted this to the patient, without knowing the patient’s decision or plans.
Given all the facts about the case, Kim proposed the second phase which is the reflective phase. During this phase, there is a necessity to incorporate the fact into the process of interpreting the events and the response of both the nurse and the patient. According to the facts, the patient did not directly requested any help. She did confide her situation with the attending health professional. However, there was no hint that the patient was requesting help aside from the obvious reason of consultation that was frequent urination and burning sensation during the process of voiding. Patients usually feel secure in the presence of health professionals. Hence, patients find it easy to confide their personal feelings and experiences with anyone from the profession because of the role that patients perceived to be held by every member of the medical profession (Hunt & Wainwright, 1994). Nevertheless, there was nothing more. However, the patient responded differently when the topic of pregnancy was mentioned. Stimulus facilitates different responses. In this particular case with the word “pregnancy” the patient became too sensitive because it touched a sensitive topic of motherhood. Being a mother whose children were deprived of her because of her status, the patient felt a sense of longing for her children. It is a mother’s natural instinct to desire and long to be with their children, but if this is deprived of the mother it would create an unhealthy emotional and psychological impact (Mercer, 2004). The nurse’s response was a natural reaction. There was the earnest desire to take the patient under her care especially since the nurse can relate to the patient being a mother herself. As Dunphy mentioned in her Circle of Care Model, every human being has an innate capacity for caring. Thus, when the situation presents itself that requires an individual to render the necessary care and attention, it without hesitation that they will be compelled to help. In this case, the nurse was the knowledge of how to solve the patient’s problem, and that was through counselling and drug rehabilitation. According to Dunphy’s model, the nurse could have also considered herself and her presence “authentic” and she was there to extend her help, and she could do something for the patient—requested or otherwise. However, in this case, the nurse failed to recognize that two other component was missing from Dunphy’s model to that particular situation. The first was courage. On this case, the nurse failed to act with the obligation to offer the patient with the options she could take. Instead, the nurse jumped in neglect an important principle under this attribute. The nurse neglect to decipher whether the situation needs care. Of course, the patient came into the hospital and naturally you would assume that they are in need of care. However, according to the fact, the care needed by the patient was only on the issue of frequent urination and burning sensation during voiding. Other than that, there was no verbal request from the patient to attend to her emotional and psychological problems. The second attribute that the nurse failed to address as indicated in Dunphy’s Circle of Care model was the nurse’s patience. The Circle of Care Model asserts that nurse and nurse practitioner should practice patience in allowing the patient to take her course towards the process of recovery (Dunphy & Winland-Brown, 1998). In the case of the patient, the nurse did not give that opportunity for the patient when she insisted that the patient sees a counsellor and undergo rehabilitation. As a result, the patient got overwhelm. Drug addiction is not cured overnight. It necessarily has to take a long process, and the progress are often slow and gradual. When the nurse became too persistent, the patient could have felt that she was being pressured. Either that or the patient felt that aside from her children and her family, she was also failing the nurse’s expectation who was persistent at trying to help her.
For the final phase—emancipatory, Kim expressed the need to harmonize the insights drawn from the first and the second phase (Shaun, 2012). In this case, the nurse’s response can be viewed as an abuse of her therapeutic privilege. While she might be knowledgeable of what is appropriate and necessary, she failed to allow the patient to exercise her right to autonomy. Patients should always be allowed to make the final decision. Nurses and members of the healthcare profession can only present the patient with all the probable options and their consequence and benefits. However, the patients will still be the one to decide. In similar cases like this, the nurse should always take into consideration that patients have the right to refuse treatment.
Conclusion
The concept of critical reflective inquiry allows every member of the health care professional to re-evaluate their action and decisions and find merits in what they done. At the same time, it enables them to contemplate on the things that they have not done. Through critical reflection, a healthcare worker can see them from the point of view of an observer. Every action that every person does have an equivalent reaction. Therefore, everything that a nurse practitioner does should be reviewed and evaluated based on the insights taught to them. In addition, every healthcare worker has a responsibility to review their decisions according to the theoretical models of behavior. It is not all the time that one’s action is plausible. In fact, due to the demands and the pressure of working in the healthcare, they are not given the luxury of time to contemplate and meditate on what they have to do. Instead, the reaction and responses of the majority of the healthcare professionals are highly spontaneous and are based on what they deemed the most appropriate at the time. Other times, the reaction are insinuated and a reflection of their instinct. Through critical reflective thinking, the healthcare worker can review their actions and scrutinize their decisions and response whether it was the most appropriate or not.
As far as Kim’s model is concerned, to facilitate for critical reflection there is a need to know the facts and detach one’s self from the situation that one is critically reflecting. This is to provide for a more objective approach to evaluating and analyzing the situation. In addition, the process of critical reflection should also consider all the facts and offer multiple interpretations to a single situation to arrive at the best possible emancipatory reaction.
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