Bon Secours Memorial College of Nursing

NUR 4143 - Clinical Immersion

Tanner’s (2006) Clinical Judgment Model

Describe the most challenging moment or event you experienced recently. What actions did you
take and what would you have liked to do differently? What specific actions are you taking to
improve the outcome in future situations or to prevent recurrence of the situation? To answer this
question, use the guide for reflection using Tanner’s clinical judgment model (see below).
Background

While we have spent the last couple years learning how to handle tough situations that we may face in practice,
nothing can prepare you for having to deal with them once they actually happen. Since each circumstance is
different, each approach is unique. I had worked in the ED as a tech with a patient who came in with dehydration. A
cared for her for the day and since she had such a large, loving family, they were also very involved with her care.
Not only did I form a relationship with the patient but also with her family. About a week later I reported to the ICU
for immersion and noticed the same patient from the ED was assigned to me. What presented as dehydration turned
into an infection of her dialysis catheter and ultimately kidney failure.

Noticing

In all the time that I spent with this particular patient and her family, I noticed that she was so incredibly loved. I
told her that she was so blessed to have them because each time I was in the room there was someone from her
family by her side. Since she stayed on the unit for about two weeks, I worked with her a couple times. Whether I
was coming or going there was someone with her around the clock. I began to notice as interdisciplinary rounds
were being made that the severity of her condition was not well understood by her loved ones. They would ask me
questions about her condition but I found that I often was not quite sure how to respond. Every move I made as far
as her care needed explanation. This made me doubt my skills as a nurse.

Interpreting

Since the patient’s family was so involved in her care, I realized that their questions were not to criticize me as a
student nurse but to better understand her condition. I think that since they had spent so many days not realizing the
severity, they were simply trying to better understand the reasons for our interventions. I interpreted this as a lag in
communication between the healthcare providers and the family. Since I was the one in the room the most, many of
their questions were aimed towards me. There was a lot of, “Why are you doing this?” and “Is that safe?” I found
that many times I completely drew a blank as far as how to respond.

Responding

Sometimes I find myself going through the motions when providing care. A new order comes up, I implement it,
and move on to the next task. While I understand why I am doing it, others may not. I was providing mouth care on
the patient and her family stopped my to ask if the materials I was using were safe. As I mentioned, every move I
made was questioned. Since I have not yet mastered the art of therapeutic communication especially with family
members, I responded by giving my best answer and following it with, “but I was get the nurse to come by and
clarify before I go any further.” I think that seeing “student” on my badge made them doubt my abilities as a nurse. I
could have let this break me down or put myself in their shoes. I know that I would want to have someone more
experienced in the room so that is how I responded. I made sure to pay close attention to how she was speaking to
the family to clarify my interventions so that I can grow in that aspect.
Burns, P., & Poster, E. C. (2008). Competency development in new registered nurse graduates: Closing the gap
between education and practice. The journal of continuing education in nursing, 39(2), 67-73.

Reflection-on-Action and Clinical Learning

I have found very quickly that working as a student nurse with a preceptor really prepares me for the real deal.
While working in a group of students with one instructor was a good way to start out, I have found that working
with a receptor is more realistic and less stressful. The flow of care is much less chaotic in the sense that we don’t
have to wait to other students to give medications before we can. I found that working with the group of students,
care was sometimes held up because we were often waiting on someone else to finish their tasks. Working one-on-
one with a preceptor feels much more real. Also, working with the same nurse day to day is much easier than having
someone different each time you come to the unit.

Write your midpoint program outcome objectives and discuss you have met them. This section should address all 5
midpoint objectives.

1. Mid-point: Apply communication skills by successfully giving change of shift report to the oncoming
nurse using SBAR by midpoint.

I have met this goal by making sure to pay close attention to change of shift report each day. While I have
not yet mastered it, I am working hard to feel more confident in my SBAR report by the end of the
semester.

Final: Apply communication skills by successfully giving report on one patient during
interdisciplinary rounds.

I have met this goal by spending the semester being engaged in interdisciplinary rounds so that I was able
to give report on a patient on my own by the end of the semester.

2. Mid-point: Provide patients with non-judgmental nursing care while practicing empathetic care
within the framework of the Catholic health ministry.

I have met this goal by always providing non-judgmental care. This week we had two inmates on the unit.
While they would be easy to judge, I remember that they are people too and they are patients.

Final: Tailor individualized nursing care to meet the needs of culturally diverse patients including
consulting with pastoral care.

This goal was partially met since I did not have to tailor care to a culturally diverse patient but I made sure
to ask if there were any cultural beliefs that I needed to be aware of when providing care.
 3. Mid-point: Successfully process a difficult situation and react appropriately while providing patient
centered care with sensitivity and respect.

I met this goal early on as described in my reflection. The family of my patient made me doubt my skills as
a nurse but I reacted by thoroughly answering questions to the best of my ability or finding someone who
could.

Final: Meet the needs of patients through active listening, empathy, and encouragement.

This goal was met because I always met the needs of patients by actively listening, providing empathy, and
encouraging patients as well as their families when appropriate.

4. Mid-point: Recognize and report changes in patient status and critical results to appropriate
personnel using policies and procedures of healthcare agency.

I partially met this goal by recognizing a change in a patient’s heart rhythm and reporting to cardiology.
Additional interventions were ordered as a result.

Final: Participate in individualized plan of care based on patient values, novice level expertise and
evidence.

I met this goal by considering patient values when providing care as well as using my novice level of
expertise. When I was not sure of care based on my level of expertise, I made sure to find evidence of ask
for help.

5. Mid-point: Successfully identify strengths and personal learning needs and verbalizes these needs to
faculty by midpoint.

I meet this goal each day by reflecting on the care I have provided. I am my toughest critic. I make sure to
address my strength and weaknesses with my preceptor and set goals for each day as a result.

Final: Continue to seek out experiences to improve clinical skills in the hospital setting.

I met this goal by seeking out experiences to improve clinical skills throughout each shift. I helped with
procedures even when they were not for my own patients in order to gain exposure.

Nielsen, A., Stragnell, S., & Jester P (2007). Guide for reflection using the Clinical Judgment Model. Journal of Nursing Education, 46(11), p. 513-516.