Case Study Reflective Practice

Related Case of reflective practice
Related cases contain ideas very similar to the main concept, but they differ when examined carefully (Walker & Avant, 2005). Tori, a nurse in her first year of practice in the ER, received Betty, a 72-year-old female with diagnosis of high blood pressure. Betty’s medical history consists of hypertension and alcoholism. Betty, who lives alone, was found by her daughter after multiple attempts to reach her mom on the phone. Betty was semi-comatose and apparently intoxicated. Her daughter called 911 and Betty was transported to the ER via ambulance. Due to her hypertension and excessive alcoholism, Betty is frequently admitted to the hospital. Tori’s physical assessment revealed that Betty was alert and oriented

to person and place, her vital signs were stable. Her pupils were equal and reactive to light. However, Tori believed something was wrong with the patient. She was very talkative, but her speech was slurred. Tori did not think this was related to drinking. Tori continued to monitor her throughout her shift until she could be seen by the doctor, a resident. Due to Betty’s intoxication, the examining doctor believed the behavior was due to her alcohol consumption and determined the patient could be discharged. Tori disagreed with the doctor and discussed her concerns with regards to Betty’s slurred speech with the physician. The doctor could not see any reason for her concerns and insisted Betty be discharged. Because the resident initially saw Betty, Tori took her concerns to the attending physician. The attending ordered Betty to be monitored for one more day. The next morning’s assessment revealed Betty was stable, and she discharged home. The nurse indicated considerable experience had been gained working in the ER but was under the impression that better collaboration among physicians and nurses would lead to better patient outcomes. The nurse experienced what she believed to be a poor decision-making process and lack of attention to critical details that typically lead to questioning clinical practice and potentially could result in poor patient outcomes.
Borderline case of reflective practice
A borderline case is an example that contains most of the defining attributes of the concept being examined but not all of them (Walker & Avant, 2005).

Tom, a critical care step-down nurse, was assigned to take care of Mr. Jones. Tom knew Mr. Jones, whom he had previously transferred to the regular medical-surgical unit. Mr. Jones was being treated for an acute exacerbation of COPD (Chronic Obstructive Pulmonary Disease). He was glad to see a familiar face and was able to build good rapport with Tom, even though he was wearing a BiPap. Mr. Jones suffered from shortness of breath in the BiPap had to be removed for him to eat. His color would become dusky if the BiPap remained off for too long. According to Tom, this was not a new experience for the patient, and he always improved after taking deep breaths. During this episode, Tom felt that Mr. Jones was not looking good, but a check of his vital signs revealed differently, they were within normal limits. Tom felt better about Mr. Jones’s condition. Near the end of the shift, however, Mr. Jones became restless and was complaining of shortness of breath. Tom recalled that when taking care of Mr. Jones previously, he frequently had episodes of anxiety with increased shortness of breath and hypoxia. Tom, using knowledge gained when working in a specialized unit, interpreted the patient’s behavior to be consistent with the theory that patients with chronic lung disease often need a hypoxic drive to sustain respiration. Following

the doctor’s orders, Tom treated Mr. Jones with 5mg of morphine to relieve his discomfort. The medication order indicated the patient could receive 2-5mg every 4 hours as needed for pain; no attempt was made to administer the lowest dose ordered. Tom was sure the extra sedation would ease Mr. Jones’s anxiety, therefore improving his breathing pattern. Unfortunately, when the nurses were completing bedside shift report, they discovered Mr. Jones not breathing well and called the rapid intervention team. Mr. Jones transferred to the ICU.
This borderline case has some defining attributes of the concept but not all required for reflective practice. Unfortunately, the nurse did not take the time to view the situation from all possible angles.
Contrary case of reflective practice
A contrary case consists of a real-world situation that does not fulfill the requirements of the concept of reflective practice. It meets none of the defining attributes (Walker & Avant, 2005). Mr. Smith, age 69, had a history of CHF (congestive heart failure) and frequent arrhythmia. He was admitted to the recovery room after placement of a pacemaker with an automatic internal cardiac defibrillator. Mr. Smith transferred to the observation unit once he fully recovered from his procedure. When weighed the next morning, the nurse found he had gained 4lbs. in the previous 24 hours. Because the patient’s weight gain indicated a possible acute exacerbation of his CHF, the nurse should have done more than make a note in the progress notes. Mr. Smith discharged home but was readmitted within 24 hours with severe shortness of breath. This unusual finding shows an obvious antecedent to engaging in critical thinking and reflective practice. At minimum, the nurse should have contacted the doctor to report the significant weight gain. With appropriate intervention, Mr. Smith’s readmission could have been prevented.
Antecedents and Consequences
Antecedents
Antecedents are events or incidents that must occur before the occurrence of the concept. In reflective practice, antecedents are initiating factors of phenomena or precursors that trigger reflective/critical thinking. Both a positive or negative event can trigger reflective practice and cause the individual to question his or her knowledge, assumptions, ideas, and beliefs. Antecedents create a situation that requires a solution using a holistic perspective while engaging the full self. Antecedents for nurses related to the concept include analysis, engagement, reflection, assessment, knowledge, communication, relationship, advocacy, accountability, judgement, evaluation, criticism, and environment. Antecedents of patients are a need, illness, disharmony, caring environment, and relationship.
Consequences
Consequences are those events or incidents that occur as a result of the occurrence of the concept otherwise known as the outcomes of the theory. The consequences are a decision made to benefit the overall well-being of the individual. There is the assumption that engaging in critical thinking will yield some results; these results are the consequences of the concept of reflective practice. The positive implications for nurses are self-satisfaction, trust in personal judgement, inner peace, increased job satisfaction, and increased personal and professional development. The positive consequences for patients have improved quality of care, safe passage, and healing.
Empirical Referents
The final step in this concept analysis of reflective practice as it applies to critical thinking is to identify the empirical referents that demonstrate how the concept is measured or determined to exist in the real world.

Empirical referents are classes or categories of actual phenomena that, by their existence or presence, demonstrate the occurrence of the concept itself (Walker & Avant, 2005). Several standardized tests are used to measure critical thinking skills of persons in health care and curriculum development. The most common are the Watson-Glaser Critical Thinking Appraisal, California Critical Thinking Skills Test, Ennis-Weir Critical Thinking Essay Test, and the Cornell Critical Thinking Test. In an integrative review of progress in the teaching of critical thinking to students in accredited nursing programs, 20 assessment studies were reported from 1997 to

1995.
Implications for nursing
A clear definition of what it means to think critically using reflective practice is warranted across the spectrum from nursing education, practice, and research. This ability will allow for consistency among all areas. It is important for our nursing professors to possess the capacity to critically think so they, in turn can educate us as student nurses on how to appropriately critically think. This ability gives way for preparation of dedicated nurses who can promote a safe passage to patients.
Reflective thinking as a practicing nurse is crucial in the development of skill and knowledge acquisition. Nurses engaged in reflective practice must be able to utilize holistic patient characteristics including family, environment, social, and political implications to arrive at an optimal solution. Raterink (2008) conducted nurse focus groups to explore various enhancers and barriers to critical thinking as it applies to reflective practice. Findings indicated nurses believe critical thinking strategies build confidence, provide flexibility, allow for better organization, and develop their ability to better handle stressful situations. Enhancing factors included teamwork, staff and administrative support, variety, and acuity of patients. The main barriers were too much charting, lack of collaboration, complex patient assignments, overtime, criticism from coworkers, patients, and their families.
Although Dr. Benner attempted to define reflective practice as an essential part of knowledge and skill acquisition, there has been little research related to an accurate definition of what it takes to think critically. Another major challenge is the lack of discipline-specific assessment and evaluation tools related to the reflective practice concept. Gaps found in literature include lack of descriptive research on patients’ and family members’ perception of the importance of their nurses critical thinking ability in preventing medical errors and promoting safety. Research to date has shown inconsistencies in multidisciplinary critical thinking definitions, assessments, and evaluation tools. These areas of quality patient care need to be explored further using research.