Nurses and Midwives Reflection Process

Nurses and Midwives in the UK are formally required to record 5 pieces of reflection on either continuing professional development (CPD) or practice related feedback to improve their nursing practice.

Here I start with the theory of reflection (see Framework image) and then give an example from my own nursing history of an awful incident – one I will never forget.

If you don’t want the theory (and let’s face it who does?); scroll down to my real-life example and see how I have applied the Gibbs theory model to a terrible incident which almost made me give up nursing.

Let’s Get Started

To see if Gibbs reflective cycle can help you reflect on aspects of your practice, recall a nursing situation that didn’t turn out as you expected or go to plan.

Look at the Gibbs Model flow chart above –

Stage 1 – Description (Pure Facts)

The first step is to describe what you know. Ask yourself the following questions:

• What are the brief facts of the situation?
• What occurred? Who was involved?
• What did you do? What did others do?

Stage 2 – Description – (Feelings)

• How were you feeling at the time?
• Were there influences affecting others actions/behaviour?
• Were there any known or perceived difficulties with the activity, timing, location, information or resources etc.?

Stage 3 – Evaluation

• What was good and bad about the experience
• How might the facts and feelings (from stage 1 and 2 above) have affected your actions/behaviour
• What other circumstances may have affected your actions or thoughts?
• How issues might influence the activity or practice related feedback?

Stage 4 – Analysis

• Why you picked this incident to reflect on?
• What sense can you make of it? Does it make sense given the preceding 3 stages?
• What is the main area of concern or focus on the future?

Stage 5 – Conclusions

• What have you discovered?
• What have you learned from this incident and circumstances?
• What questions remain?

Stage 6 – Now What? (Action)

You have analysed the incident and want to make sure you improve your practice for next time, so need to move into the action planning stage:

• What will I do differently from now on or the next time this arises?
• What resources/help will you need?

Reference

Gibbs, (1988) Learning by Doing: A Guide to Teaching and Learning Methods Further Education Unit, Oxford Brookes University, Oxford.

Example Reflection –  Sadly, a real story!

Night Duty Drug Round

Stage 1 – Description (Pure Facts)

I am a third-year student nurse ‘in charge’ on night duty, in a London hospital, with a junior nurse to deal with 23 pretty sick people in this medical ward.  A doctor asked me to give a patient (Mrs X,) 0.1 mg of Digoxin (a heart stimulant – steady, slows and strengthens the heartbeat) to relieve symptoms of severe congestive cardiac failure and difficulty breathing.  I had never given such a high dose of Digoxin before and measured 4 tabs from the 0.25 mg bottle.  I checked the script and the tablets with both the doctor, who nodded, and my junior nurse. We were all in agreement. I checked Mrs X’s pulse rate (standard practice for Digoxin), which was in the OK range, before giving the tablets. I kept Mrs X on hourly observations after.

At about 2 am I suddenly realised I had given 10 times the amount of Digoxin as stated on the Doctors script.  In horror, I called the night sister who agreed with me.  We filled in an incident form, informed the doctor and Mrs X’s relatives of what happened. Petrified, I was told to go see the hospital matron in the morning.

Mrs X did not seem to suffer any ill effects from the Digoxin during the night and went on to make a full recovery.

Stage 2 – Description – (Feelings)

I had been on nights for a long stretch.  It was a very busy ward with only two-night staff and I was “in charge”.  Mrs X was very ill and needed constant monitoring.

I had only ever seen 0.25mgs of Digoxin tablets and did not know there was a paediatric blue table of 0.1 mg made.  I was very reluctant to give such a big dose which is why I checked the four tablets of .25 with the doctor who looked at the tablets and said OK.  I was nervous about the dosage being so high and took Mrs X’s pulse for much longer than the customary 15 seconds.

The doctor too was under tremendous strain, his beeper kept going off and he was rushing about all over the place.  I had never met him before.  He had recently come from a paediatric ward.

Stage 3 – Evaluation

Nobody ever blamed me for the incident, neither did they reassure me.  Mrs X went on to make a full recovery and the relatives were very understanding about the situation which was a relief.  Matron was kind to me and impressed I had owned up to the error – nobody would have ever known, she said.

I felt absolutely terrified about the error though and watched Mrs X all night for signs of overdose.  I didn’t sleep all the next day and returned to my next night shift to find Mrs X better.

Stage 4 – Analysis

This incident really frightened me because I had done everything right – I had checked the dosage with both the Doctor and the junior nurse.  I had not known that you could get a 0.1 mg of Digoxin or it was blue.  I have no idea what prompted me to think about the overdose later on that night except that I had been very reluctant to give it.  The Doctor agreed I had shown him 4 white tablets who said “I thought you knew what you were doing” Which isn’t any sort of answer really.  Yet he didn’t get in trouble (like me) at all for overseeing and agreeing my mistake.

I also realised how dependant patients are on the care and insights of the medical profession and the trust they put in us; I’d let Mrs X down.

I believe that this incident was down to a series of incidents linked to overwork, tiredness and misunderstandings. Plus if I’d known the Doctor better I might have had a conversation about the dose.

Stage 5 – Conclusions

I was so relieved that Mrs X survived the overdose and the relatives were understanding but, if she had a serious reaction or even died, I’m not sure I could have carried on nursing.

Stage 6 – Now What? (Action)

I have learnt to be more careful with drugs and to really understand the dosage.  If necessary now I will look up the drug in the reference books before I give them because it is my responsibility if I do it wrong.

I will always be ultra-careful with new drug scripts in the future and if I am nervous, then to go with my gut feeling and check and check again. Although, as I said to Matron, at the time I’d felt as if I done as much as I could have.

Also, if nurses in my team are involved in incidents where they have made a clinical mistake, I am always on hand to offer support and give them an opportunity to talk to me.

I never want another nurse to go through what I went through alone and I definitely do not want to harm anyone in my care.

Linked to NMC Code of Practice 14 – “Preserving Safety”

Further Information

• British National Formulary (BNF) the drugs’ bible in the UK, available online with a subscription

Other of my real stories here:

• For a second applied reflection example, see my blog about My Infographic Mistake
• For a third reflection see Dog Walking

I have also published a workbook for nurses where you can see the model and have space to add your own private stories. Available on Amazon With over 400 great reviews.

Thanks for reading and good luck in your career. J