Bon Secours Memorial College of Nursing

NUR 4143 - Clinical Immersion

Mid-Point Guide for Reflection

Tanner’s (2006) Clinical Judgment Model

Describe the most challenging moment or event you experienced recently. What actions did you take and what
might you have done 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

The most challenging moment I have had during my experience on the unit as a nursing student was when I was confronted with a
male patient who was recently diagnosed with psychosis. He was going about the unit with his heart-shaped stress ball asking staff and
patients to “kiss the heart.” He was constantly pacing and unable to sit still. He kept touching the other patients and entering their
personal space. He was going about the hall with his water bottle and pouring water on the floor. It came to a point where he was so
confused that he began trying to enter other patients’ rooms—which made the female patients a bit anxious. He was repeatedly
reminded to keep his hands to himself and not to enter other patients’ rooms, however, he was not easily directable. When it was time
to medicate him, he placed his pills on the floor, refusing to take them and continuously paced up and down the hall, becoming
increasingly agitated. We ended up having to call up security to give him IM injections, however, when security showed up they
refused to hold him down to give him his injection because he was voluntarily committed.

Noticing

One of the first things I noticed about this patient when I started my shift was that he kept entering other patients’ personal space,
agitating other irritable patients, and increasing the acuity of the unit. Upon taking this patient’s vitals, I noticed that he had trouble
sitting still and was constantly tapping his feet on the ground. I politely asked if he could sit still for a minute for me to obtain a more
accurate reading of his blood pressure and pulse—as they were both initially high—and he got up, while still attached to the blood
pressure monitor, sitting on the adjacent seat and tangling me in the tubing. I noticed that the patient was going on about smelling
“sage”—which happened to be the name of one of the other patients of whom was ranting about how they were doing “witchcraft” as
he was pouring water on the floor.

Interpreting

Describe the clinical judgment or clinical reasoning that you performed. The example should include alternatives you considered, and
rationale for your decision.

The combination of both patients together and feeding into each other’s delusions, was escalating the situation and increasing the
acuity of the unit. With the acuity of several of the patients being rather high, patient safety was at risk and could be compromised. As
the other patient was encouraging this patient’s behavior, it was critical to separate these two. Fortunately, the other patient was easily
directable, so I asked that she remain in her room, and she complied. She did try to come out again, so I politely asked that go back to
her room.

Responding

What written evidence have you drawn upon for the care of your patient in this example? Provide cites/references.

There is a symbiotic relationship between the role of the patient and the role of the nurse providing care to the patient in question.
Most of the time the patient will approach the nurse and express agitation and ask for medication. Another way to assess a patient’s
level of agitation is pacing, restless, and raised voices (Tucker et al., 2020). The patient who we had to medicate was completely
preoccupied and was not asking for any intervention for his behavior. When I noticed his behavior, I approached him and asked if
there was anything I could help him with and how he was feeling. He was unresponsive to my questions and continued about his
behavior. I tried a method of distraction by talking about the things he was doing and he seemed a bit more receptive to that, however,
Nielsen, A., Stragnell, S., & Jester P (2007). Guide for reflection using the Clinical Judgment Model. Journal of Nursing Education, 46(11), p. 513-516. MSH 6/29/23
it ultimately was no help in the situation as other patients were becoming increasingly agitated with him. One patient even came close
to hitting him. I did my best to control the situation by asking patients to remain in their rooms once security came up to help us with
the situation.

Reflection-on-Action and Clinical Learning

Based on your experience as a student nurse on a unit with a preceptor, reflect on the differences of working one-on-one with a
preceptor versus a student nurse in a group of students and one instructor.

Working one-on-one with a preceptor is much more beneficial as a nursing student. I don’t feel as though I’m running around looking
for my preceptor when I have questions to ask, and I don’t have to wait while they’re helping with another student with education and
training. I am so grateful for the instructors at Bon Secours because I have learned so much from them, but I believe that working one-
on-one with my preceptor has allowed definitely furthered my personal growth as a future nurse.

Reflect on your midpoint practicum goals you set on your first day and discuss your progress toward meeting them. Please address all
3 goals.

I have successfully completed all of my midpoint practicum goals with the help of my preceptor. She has been such a great help in my
educational development and has encouraged me to become more confident and involved in patient care. I have been able to
accurately perform and chart on all of my patients’ mental status and perform a behavioral exam. As I am working night shift, most
patients are asleep during charting and there have been some who have been awake, but I was unable to assess due to the acuity and
agitation of the patient, but I was able to asses and chart on enough patients to get the hang of completing the chart. I always complete
hourly rounding and check on patients throughout the night. I have been able to perform and complete a patient admission without
assistance, however, due to the setup of Epic, there are some parts of the chart that I don’t have access to as a student nurse. I have
successfully performed the 5 rights and 3 checks during the medication administration of all patients with the supervision of my
nursing preceptor. I was also given the opportunity to educate my patients on their medication. My overall experience with my three
midpoint goals was a success.

Reference

Tucker, J. A., Whitehead, L., Palamara, P., Rosman, J. X., & Seaman, K. (2020). Recognition and management of agitation in acute

mental health services: a qualitative evaluation of staff perceptions. BMC Nursing, 19(1). https://doi.org/10.1186/s12912-

020-00495-x

Nielsen, A., Stragnell, S., & Jester P (2007). Guide for reflection using the Clinical Judgment Model. Journal of Nursing Education, 46(11), p. 513-516. MSH 6/29/23