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Assignment # Reflection on action as a Manager (Leader)

Submitted by: Yasmeen BiBi

Program: MScNrsing

Session: 20120-2022

Semester: 2nd

Submitted To: Madam Hajra Sarwar

Course Name: Advance Concept in Nursing Leadership and Management

Course registration: 70109655

Assigned Date: May 25th, 2021

Submission Date: May 25th, 2021

Acknowledgment

I would like to convey my special appreciation of thankfulness to my teacher Madam Hajra

Sarwar who gave me the golden prospect to do this wonderful project based assignment on the

topic, “reflection of my clinical days at University of Lahore”, which also helped me in reading a

lot of theoretical Research about criteria for incident report, how to write an incident reflection as

a student. I also came to know about the nursing role and responsibility during an incident as a

manager or leader.

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My Reflection on pain

Introduction

My reflection that is about a focus on my experiences and feelings on how I feel, experience

when I was on clinical at surgical ward in University of Lahore hospital, Lahore is related with a

patient who was complaining of severe pain. A nurse leader or manager oversees a team

of nurses, making decisions and directing patient care initiatives. They have advanced clinical

knowledge and are focused on improving patient health outcomes. Some of the

key responsibilities of a nurse leader include: communicating with staff and motivating them,

thinking creatively and critically, innovating new workflows, delegating tasks, showing

compassion for others, making decisions, mentoring and teaching others, solving problems and

overcoming difficult situations and also developing treatment plans to improve care and patient

outcomes.

Раin is what the раtient sаys it is. The point is about pain how patient felt and will nurse percept

it, and then nurses need to explore patient perception оf pain as well as their reроrt оf

experiences. These two are not quite the same, Раtient may reроrt her pain in а variety оf ways,

dependent on the nature and the intensity оf pain and the context in which it is felt (e.g. Whether

they are distracted from the pain).Their perception оf pain is а little more though and it includes

the meaning that patient feels and nurse would percept. Chronic low back pain (CLBP)

conditions are highly prevalent and constitute the leading cause of disability worldwide

(Markman et al, 2020).

I will use the Gibbs (1998) reflective cycle as a guide in this reflection. The Gibbs (1998)

Reflective Cycle is one of the most popular models of reflections consists of six steps are

following:
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1) Firstly, description is explaining the experiences during reflective situation which

describes as a matter of fact about the situation and what happen during the event. For

my case the management of this patient who was admitted and was being managed.

2) Secondly, feelings and thoughts about the experience of this clinical situation which is

the description or the analysis of what my thoughts and feelings were at the time of this

event.

3) Thirdly, the evaluation is of my experience which is about what is good or bad about my

experience during this event.

4) Fourthly the analysis of my experiences about what I can make out of the situation or it

makes a sense of situation that I feel.

5) Conclusion is the fifth step of this cycle and it is about what else I can do and what do

not, what I learn and what I do differently.

6) The final sixth step is the action plan suggestions or recommendations. For how I will

deal with similar situations in the future, or general changes I may find appropriate. This

plan will be about what I will do if this situation arises again or what I will do differently

bearing in intellect my experience from the steps above.

 Reflective practice which provides a self-analytical approach to appreciate and value one’s work is

viewed as self-recognition. Neither bigheaded nor arrogant, reflective self-recognition is part of

progression to professional development. It involves examining events at work continuously and

systematically to learn, appreciate, and to move to higher levels of contribution in the workplace

(Sherwood et al, 2021). Reflective writing is a way of phrasing, expressing and illuminating

one’s own and others stories crafting, determining to, understanding and developing, it will

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enable practice development because the outcomes of reflection are taken back into practice

improving and developing.

Description

During my clinical rotation at the surgical ward in UOL hospital, I came across a patient Mrs. X

suffering with severe pain due to slipped disc. Not using the name of my patient because of

confidentiality (NMC 2015).

On 2021-03-22 I reached at surgical ward in University of Lahore(UOL) hospital when I got

orientation toward and patients and was known about Mrs. X was diagnosed with slipped disc a

year earlier and had initially had her illness treated by painkiller i.e. morphine. It was at this

stage that the doctors explained that her care would now be directed towards her comfort rather

than a cure to which she had replied, ‘you mean palliative care’. She was care of by her husband

at home. She was prescribed oral morphine and could decide within stated limits how many

tablets she could take in any one 24 hour period.

As she spoke she held her husband’s hand tightly, looking across to him as she described her

experiences and feelings about the matter. Yes, there had been some bad nights when the pain

had woken her and she had to sit up and watch television to try and distract her. Yes, sometimes

the pain made her feel nauseous, but she was alarmed at how frequently she was taking the ‘pain

tablets’ and how this made her feel about herself. However well meant the medication was it

didn’t feel dignified to be so reliant on drugs, or quite so sleepy and unresponsive for such a high

percentage of the day. Whilst the analgesia was working well when she took the tablets, the

quality of life wasn’t what she wanted.

Her husband told that once her doctor explains that it was normal to have panic moments about

such medication. Morphine has a reputation, one that people connected with misuse of drugs,

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rather than their therapeutic use. Used on a regular basis, the drug will not cause addiction and it

will provide a great deal of reassurance to Mrs. X as well.

At this point she shake her husband’s hand, and said, ‘tell her…tell her what we have talked

about it!’ he then explains that his wife was used to dealing with pain, she suffered recurrent pain

in her neck and shoulder after a road traffic accident some years before. The pain had sometimes

been severe, but he had massaged her shoulders and used heat packs that she found soothing.

They had decided that they wished to use this technique now, keeping the morphine for absolute

emergencies, when she was losing sleep and cannot eat as a result of the discomfort.

The duty nurse assured them that they were in charge of the analgesia and be allowed to make

their own decisions. She started to make notes though, and announced that she was making a

referral to the palliative pain clinic, something that would help them to take stock of the

situation. There was very good reason to suppose that this might be a problem connected with

choosing the right dosage of the morphine, rather than using supplemental pain relief measures.

Mrs. X responded sharply, ‘You’re not listening to me though, I want to use heat packs instead

of morphine, at least during the day. I want to be more alive with my husband.’ Duty doctor

assured Mrs. X that she heard what she said and respected her point of view. There would though

be nothing lost by using the clinic to gain a further check on this matter. With that she excuses

her, explaining that has a further appointment that morning and left, having checked that Mrs. X

has a sufficient supply of her different medicines.

As I walk from the patient’s bed the duty nurse empathizes with Mrs. X plight, saying that if she

has slipped disc she should probably grasp at straws too. She would reach out for things that

seems more normal, and then observe, ‘but this isn’t normal is it, the pain she has isn’t normal.

It’s not just a whip lash injury and old age.’

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Feelings

I remember that during this episode feeling a mixture of confusion, surprise, anger and

impotence. Mrs. X had surprised me by the way she spoken; using what seems to be a planned

announcement. All care providers during that round waited for and perhaps rehearsed this

moment. Nothing in my experience to date prepared me for such an encounter, at least in such

circumstances, where all as nurses were so obviously working to support the patient. It was only

later that I called the episode a confrontation. Mr. and Mrs. X had confronted the nurse and I had

been the largely silent witness to the event. As the discussion proceeded I remember making

supportive noises, remarking how useful heat packs sometimes were and glancing across at her,

who seems to be signaling with her expression that I should leave this debate to her. I was trying

to read her reactions to the points and concluded that if I cannot support her arguments to the

patient, then I should remain silent. There were issues here that I perhaps not enough practice

like this situation and not an enough experience like managers to deal with, at least, whilst

‘thinking on my feet’.

My initial feelings (with Mrs. X for not acknowledging all that all were trying to do) quickly

became displaced towards my duty nurse. During the event I couldn’t explain why that was, but

afterwards, when I made notes, I realizes that it is because she seems to have set the agenda in

her own mind and to be requiring the patient to comply with concerns of her own. Put rather

crudely, she seem to be saying, listen I know about these things, this is a phase, an anxiety; you

can work through all this. I believe at this point that she missed the significance of the event, the

way in which the she arranged the conversation. For them, this is not a phase at all, but a well

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thought-out and very important decision, one that they want the nurses to accept emphasize the

importance of negotiated care planning (Radcliff et al, 2020).

My feelings of powerlessness if I say as a nurse leader were associated strongly with my lack of

as much as my clinical experience as I have like an MScN student like a mentor managers etc. I

have met this before. No matter how many placements I do, no matter how well the mentoring I

receive, I keep meeting situations where I am unsure about how to respond next. If I say as a

nurse leader must have some charismatic abilities for juniors to follow me.

I feel younger, less knowledgeable than I should be at this stage in my training. I want to

reassure patients, to support colleagues and to give good advice, but there is not enough authority

and confidence as a student to do that. If I felt unsettled and uncertain about her response, right

then I couldn’t easily explain that. I couldn’t offer a second opinion, couldn’t suggest an idea

that might help support the patient.

Evaluation

Afterwards, this short episode prompted doubts and debates about several important aspects of

nursing for me. Setting aside the etiquette of learning in clinical practice, not challenging a

qualified nurse in front of a patient, there were problems here associated with supporting patient

self-respect and self esteem, with my assumptions relating to analgesia and pain control

strategies, and I realized, with my assumptions about types of pain and who had the expertise to

define these.

Dignity is more than simply using the appropriate terms of address, protecting the privacy of

patients and attending to their expressed concerns (Sailian et al, (2021).It is about illuminating

the ways in which they live and accommodate illness or treatment. It is about verdict out what

benchmarks they use to say that ‘yes, I am doing well here; this makes me feel good about

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myself’. Upon reflection, I sense that on this occasion had not worked hard enough to discover

how Mr. and Mrs. X define quality of life, or being in charge of their situation. I was more

concerned with providing resources, sharing research or theory about medication and questioning

the familiar misconceptions associated with morphine. To put it simply, all were ‘missing a

trick’, reading the encounter as something that had happened many times before, the report of

problems or anxieties, a request for help, rather than a decision that the patient and her career had

already come to occur and manage. Reading situations well seem, with the benefit of

retrospection, to be the first basis for dignified care. ‘What is happening in this situation, what

will help the patient mostly?’ were questions that all health professionals especially nurse

perhaps assumed that all already knew the answer too.

I realized that in my clinical experience, I already accept the argument that patients would wish

to remain pain free come what may and that the tackling of fears about prospective pain, was

something that nurses engaged in. I tacit that because chronic pain of vertebra represented such a

major threat, because it was greater and more all encompassing, that there was little or no doubt

that it should be removed. What was so unsettling, and took so much time to examine, was that

Mrs. X acknowledged the possible severity of pain, but that she still preferred to respond to it

using measures that had worked for her whiplash neck injury. Mrs. X was willing to trade off a

pain free of state for something that gave her a greater sense of control and which perhaps

enabled her husband to express his support for her in a very tangible way (preparing heat packs,

massaging her, rather than simply giving her the tablets). Mr. and Mrs. X questioned all my

assumptions about best analgesia practice, and seemed to write a large question mark on the

textbooks I had read about chasing rather than controlling pain in palliative care situations

(Behar et al, 2020).

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Reflections (learning opportunities) analysis

The episode with Mrs. X left me uncomfortable because my past approach to pain management

was theoretical and having experience less than like a mentor or supervisor to manage this

situation at the spot. I regularly made use of science to decide what could be done as regards pain

relief and to assume that patients would wish to achieve all of those benefits. This wasn’t about

local applications of heat versus morphine, Mrs. X could use both, it was about choice and how

patients made choices, why they reached the decisions that they did. It was for me, about

accepting very personally, that providing that patients are given all the relevant facts, alerted to

the options, that they really are able to make choices that work for them. The very fact that Mrs.

X's illness was now incurable, that she and her husband usually tackled pain together, meant that

her solution to the challenge was different to those that many other patients arrived at. Having

dealt with this pain for some time, knowing that it could and probably would get worse, meant

that she was better equipped than other less experienced patients to make a decision here.

This took nothing away from the benefits of sharing further discussion with pain clinic experts. I

thought, Mrs. X will stand her ground, she will insist on doing things her way if her husband is

strong too. What it did highlight though was the importance of listening to patients, hearing how

they perceive pain, how they narrate not only the pain but what they did about it. In this instance

the narration was all about dignity, and coping, and finding ways to help one another and how

this enables us to feel in the face of such a terrible illness. So, in telling us about her pain, what

she did about it, using morphine when it was ‘absolutely required’, Mrs. X was not reporting her

ignorance of what could be achieved if the medication was used differently, but what she

preferred to do as it enabled her to achieve different goals. Mrs. X goals were about liveliness,

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alertness and stoicism, showing that she could bear at least a measure of pain a holistic care in

chronic pain.

I wondered why I hadn’t listened carefully enough to such a story. Was it because of time

pressure, or perhaps smugness, that Mrs. X and I felt that nurse on duty already knew what

account would be shared? Did a duty nurse think that the patient would ask for help, more help,

as the pain continued? If so, then guesses had prompted the nurses to behave as experts, and

problem solvers, on the patient’s behalf. Perhaps hearing a patient narrative is about discovering

what sort of role duty nurses would like to fulfill. If so, then it might be a difficult role. I thought

hard about how hard this was for patient. She was going to be asked to witness Mrs. X’s future

pain, one that was now less perfectly controlled. She was going to be asked to reassure, to

suggest measures that might help, without reminding the patient that she ‘already knew that you

couldn’t manage pain that way!’ When I think about it now, that is very stressful for a nurse. It is

about caring and allowing patient’s to make choices that mostly nurses personally might not

make.

Conclusions

First, that being patient centered is never easy and requires real listening and interpretation skills.

My criticism of what she chooses to do, to try and dissuade Mrs. X from a course of action,

recommending further appraisal of the situation, is an easy one to make. Nurses confront

situations such as this relatively unprepared and react as considerately as possible. It is easy in

hindsight to recommend other responses, a further exploration of what motivated Mrs. X pain

management preferences.

Second, that experience can be a valuable teacher, the equal of textbooks. If nurses are interested

in care, then they should be concerned with the sense that patients make of their own illness, the

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treatment or support that they receive. Nurses need to understand what patients have to teach us

and have to acknowledge that this means that a nurse won’t always seem in control self, expert

and knowledgeable. Nurse’s expertise might be elsewhere, helping patients to reach their own

decisions.

Third, that one way to understand patient perspectives on illness or treatment, on pain

management in this example, is to hear how they talk about the situation. How do they describe

the pain, how do they refer to what they did about it? The way, in which the story is shared, how

nurses coped, how this made them feel is as important as the facts related. Sometimes a patient

needs to feel strong even heroic in the face of illness.

Recommendation

My action plan should a situation such as this arose again will be significantly different. I will

continue to reflect and study how acute and chronic pain is managed and the role of the nurse in

such management and most especially to ensure I look at documentation for patients. Effective

pain management is fundamental to quality care, good pain control speeds recovery. To increase

the effectiveness of nursing interventions and to improve the management of pain, the use of

pain assessment tools for acute pain has to be followed such as verbal description scales(VDS)

which are based on numerically ranked words such as none mild, moderate severe and very

severe for assessing both pain intensity and response to analgesia. Numerical Rating Scales

(NRS) this is easily used as a verbal scale of 0-10 indicating no pain on one extremity of the line

and 10 indicating severe pain at the other extremity (Hammer and Davies 1998). Uncontrolled

pain can lead to increased anxiety, fear, sleeplessness and muscle tension which further

exacerbate pain (Angeletti et al, 2021).

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Poorly controlled acute pain may lead to the development of chronic pain. I also learnt that there

is a psychological aspect to pain. My nurse-patient relationship really helped in this area.

According to Holland et al (2008) each patient should be regarded as unique in a nurse-patient

relationship and that individuality should be taken into account when undertaking nursing care

(Holland et al 2008 p11). Another aspect of nursing care that helped was effective

communication which is an essential prerequisite for effective nurse-patient relationship. By

talking to patient in an open, honest way about their pain made them feel more relaxed and in

control which help them to cope better. I hope to increase my nurse-patient relationship and how

to deal with acute cases as well as chronic cases. This will be a goal I will be aiming at in my

next placement though discussion with my mentor and further research. It would be foolish and

unprofessional to recommend to other patients that they might not wish to remove pain, or that

overcoming pain doesn’t always mean don’t continue to experience it. For every Mrs. X there

may be many other patients who would welcome the complete removal of pain or minimize pain

and maximize their comfort, so that they can live calmly, quietly, with their own version of

dignity. But it does seem to me, that it will be worth thinking about the diversity of patients and

how they prefer to cope when I assess pain and help manage this problem in the future. I won’t

be able to walk away from the responsibility of debating whether I have explained all that I

could, detailed the strengths and limitations of different ways of coping. I will need to find

further reflection time to contemplate what patients have said. As we all know that Self-

reflection and action in leadership is an important key to developing as a leader. Select the best

way to reflect, for you as a nurse leader or manager is to supercharge your leadership. Be aware

of the impact one have on other people through his/her interaction with them and understand

how their own behavior and actions can drive effective outcomes forward. And, if one needs

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some guidance or someone to lead you through the process ask for help! Yeah I will definitely

follow will take help from seniors and existing literature. InshaaAllah

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References

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(2021). Assessment of Pain and Associated Comorbidities: A Survey of Real Life

Experiences Among Nurses in Italy. Journal of Pain Research, 14, 107.

Bell, E. H. Mentorship: The Role of the Nurse Leader. GNF PRESIDENT’S MESSAGE, 81(1),

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Becker, K. L. (2020). Tell me your dreams and goals: Structuring communication exchanges to

improve patient-centered care with chronic pain patients. Applied Nursing Research, 53,

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Behar, E., Bagnulo, R., Knight, K., Santos, G. M., & Coffin, P. O. (2020). “Chasing the pain

relief, not the high”: Experiences managing pain after opioid reductions among patients

with HIV and a history of substance use. PloS one, 15(3), e0230408.

Gibbs G (1988) Learning by doing: a guide to teaching and learning methods, Oxford, Oxford

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Leontiou, I., Merkouris, A., Papastavrou, E., & Middletton, N. Self‐Efficacy, empowerment and

power of middle nurse managers in A correlational study. Journal of Nursing

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Markman, J. D., Czerniecka-Foxx, K., Khalsa, P. S., Hayek, S. M., Asher, A. L., Loeser, J. D., &

Chou, R. (2020). AAPT diagnostic criteria for chronic low back pain. The Journal of

Pain, 21(11-12), 1138-1148.

Radcliff, T. A., Horney, J. A., Dobalian, A., Macareno, B. O., Kabir, U. Y., Price, C., &

Strickland, C. J. (2020). Long-Term Care Planning, Preparedness, and Response Among

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Rural Long-Term Care Providers. Disaster Medicine and Public Health Preparedness, 1-

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Sailian, S. D., Salifu, Y., Saad, R., & Preston, N. (2021). How is Dignity Understood and

Preserved in Patients with Palliative Needs in the Middle East? An Integrative Review.

Sherwood, G., Cherian, U. K., Horton-Deutsch, S., Kitzmiller, R., & Smith-Miller, C. (2021).

Reflective practices: meaningful recognition for healthy work environments. Nursing

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