In the era of evidence based practice and knowledge-driven healthcare, nurses are constantly challenged to discover new and better ways of delivering care. Thus, journaling and reflective practice becomes an important tool in Nursing Practice. Reflective writing through keeping a journal allows nurses to become more sensitive observers and encourages enquiry which focuses on the roles as well as direction of nursing (Holly, 1987). Through this professional journal writing, I discovered the value of the reflective process.

This process has changed my feelings, belief and assumption in enhancing holistic care to my patients, peers and even for my family. Atkins (1995, pp. 32) supports this by saying that “reflective writing is the process of internally examining and exploring an issue of concern triggered by an experience which created and clarifies, meaning in forms of self”. I used four methods of seeing to demonstrate my level of understanding namely, literal, lateral, critical and speculative. By critically analyzing the nursing articles, I have developed a greater understanding about nursing, especially about my own practice within the nursing discipline.

Reflecting on the practice based description in the professional journal which I maintained over my career, I have discovered a number of emergent themes relevant to ways of knowing and the empirical, interpretive and critical paradigms. In order to comprehensively explain and analyze my ideas, I have used headings entitled Describing, Informing, Challenging and Reconstructing. DESCRIBING I have used the tenants of Benner (1984, 2000, and 2001) to form the eclectic conceptual framework. Specifically, Benner’s work on Novice to Expert (1984) provides me useful descriptions to describe my four practice descriptions.

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It explained well the events, interaction, thinking, concern and feelings which I have been experience in my practice descriptions. The following practice description is extracted from my professional journal which serves as a sensible point to the many issues discussed in these articles. PRACTICE DESCRIPTION 1 Mr. Alan was a Chronic Myeloid Leukemia patient at relapsed stage. He was our regular client who always came for blood transfusion under the care of Doctor Y. Nurse M received this case. Mr Alan’s platelet count was only 600U/L. Therefore, Doctor Y requested me to insert IV (Intravenous) line for him since nurse M was a novice.

I went to see Mr. Alan who knew me very well due to his frequent hospital visits. Previous experience in setting IV lines had made him confident of my work. I had successfully inserted the IV line and started infusion Normal Saline while waiting for the blood product. Upon receiving the blood product, Nurse M called me to check it. Mr. Alan was to be transfused with 4 units of platelet concentrate and 2 units of Fresh Frozen Plasma. While checking, we noticed that 2 units of platelet concentrate had expired one day prior to Mr. Alan’s admission. I immediately informed the Lab Technologist on duty about this. He told me that Mr.

Alan was supposed to be admitted on the previous day for transfusion but he refused to do so. Private hospitals like ours depend on the General Hospital to obtain blood product for all in patients. The General Hospital could only supply us with two units platelet concentrate on the previous day and with an additional two units on the following days. Next, I discussed this problem with doctor Y. I strongly insisted that the act of transfusing expired platelet to patients is against medical laws. Since the cells in the platelet die after the expiry date, this does not benefit the patient and may cause other complications.

Doctor Y firmly and furiously told me to proceed with the blood transfusion without any guilty conscience. Since the doctor, ordered to give. We have no choice rather than to start Yogeswary Arumugam the blood transfusion. I feel sorry for Mr. Alan. Although I am a Critical Care Nurse, I had no authority to speak on behalf of the patient’s safety and he was not informed about expired platelet. Since the incident happened after office hours, I did not have opportunity to inform higher authorities about this. Transfusion was completed without any ill effect and Mr. Alan was discharged late in this evening .

My colleague and I wrote this event in the patient’s report. The next day, I reported this incident to my Unit Manager and higher authorities so that no such incident will happen in the future. Immediate meeting was held that morning by the Blood Transfusion Committee. The General Manager circulated a memorandum stating that no expired blood product is to be released by laboratory staff and that the doctor was totally responsible for any adverse event to the patients. ( Yoges 2008 entry 2/5/2008) PRACTICE DESCRIPTION 2 Mr. Kris was in ICU (Intensive Care Unit) for five days already.

He was totally dependent on mechanical ventilator support. He was diagnosed with positive Malaria type Falciparum. Since the virus spread to brain, he became comatose. My duty started at 8. 30 a. m. My Unit Manager assigned me to supervise and observe all junior nurses including novices in the ICU, As usual before attending to a patient, I read through the patient’s report to know their progress. After gathered information about Mr. Kris, I went to this bed to assess his condition. While assessing, I noticed fresh blood oozing from the patient’s head. I called upon Nurse N who was in charge of Mr.

Kris on that day. As far as I , Nurse N is very efficient and caring nurse. I asked her if she checked patient’s observation prior passing report about this. She told me that she busy preparing drugs and forgot to check the patient’s general assessment after receiving report. Both of us lifted the patient’s head and found that there was quite a large pressure ulcer on the occipital region. The quality objective of my unit to ensure 100% of patients admitted to ICU do not develop bedsore. This showed negligence in nursing care to Mr. Kris. I could not blame Nurse N because she just returned from a long holiday.

Both of us cleaned the ulcer and applied mild dressing. His family members were very sad when they heard about this. However, they understood the risk of critically ill patient to develop pressure sore with proper explanation from myself. This issue was discussed during passing over report. The importance of Nursing Care Plan was stressed to the nurses. Upon observation, I noticed that nurses were scared to turn the patient as he was not hemodynamically stable. I ordered regular turning and dressing to be changed whenever necessary. His head was supported with an air ring.

As a result of regular checking and good care , the ulcer healed after 6 days. Unfortunately, Mr. Kris died after 12 days in the ICU due to Malaria,(Yoges, 2008 entry 24/05/08). PRACTICE DESCRIPTION 3 Nurse S called me to insert peripheral lines for Madam Jane who admitted at 1. 00a. am. She was diagnosed with APO (Acute Pulmonary Oedema) secondary to CCF(Congestive Cardiac Failure) IV line was removed due to swelling. Consequently, all injections were delayed due to no IV access since 6 a. m. According to Nurse S, a few nurses had tried to insert the IV line but to no avail.

I approached Madam Jane and introduced myself. She was in a frightened state when she saw me. I held her hand and massaged it gently. Her whole body was grossly edematous. She was breathless, tachypnoeic and indicated a fluid overload. I found a seven puncture marks on her hands. I was very annoyed with my colleagues who had punctured her hand and called me after they had traumatized her veins. I can imagine how was the pain did Madam Jane undergone. Yogeswary Arumugam However, Madam Jane agreed to the insertion of IV lines with gentle touch and proper explanation.

I inserted the IV line and injection frusemide were given. She was satisfied with the way I approached her and my technique of giving injection. She began to compare me with other nurses and complained that they rushed into giving the injection. Moreover, they were not concern about patient’s pain. I promised her that junior staff will not be allowed to insert IV lines without supervision. She thanked me but I felt sorry for her. I was always present and talked to her and gave her some encouragement during her three days stay in my unit.

She was so thankful to me and interrelationship has grown since then. This issue was brought forward during a ward meeting and my Unit Manager mentioned that junior nurses were no longer allowed to insert IV lines except under the guidance of senior nurses. Alternatively, they were supposed to call an available Medical Officer. (Yoges 2008, entry 6/6/2008). PRACTICE DESCRIPTION 4 On 2nd June 2008, I received a call from the OT (Operation Theatre) saying that Mr. Chin, a patient, needed to be monitored in the ICU as he had developed Tension Pneumothorax post operatively.

He had undergone Decompression and Instrumentation on his spine. A Chest Tube was inserted by Doctor T in the OT. Nurse A was assigned to look after Mr. Chin. Doctor T requested continuous suction at 15cmH2o. Nurse A had 7 years of experience in the ICU. I expected that she knew about Gomco Suction which was used in my unit to create pressure for patient. While Nurse A prepared “Gomco Suction”, I went about doing some other chores. As a result, I did not have the opportunity to supervise her work. She did not approach me with any question either. I forgot to see Mr. Chin in the evening.

On the next day(3rd June 2008) my Unit Manager called me to her office to investigate the Under Water Seal Drainage(UWSD). She informed me that the Thoracic bottle was not filled with water. I was shocked and furious about the incident. My Unit Manager said that Doctor T was not aware of it. She said all nurses in the shift were not competence in observing the UWSD. None of them noticed about the incompleteness of UWSD. After 2 hours, continuous suction was removed and patient was put on free flow. When enquiry Nurse A about this, she told us that she forgot to fill water. She asked for forgiveness from my Unit Manager.

Asking forgiveness was not important to us at the moment. I was very worried about Mr. Chin when the chest X-ray was repeated. I sincerely hoped and prayed that nothing happened to his lung. Report of the finding was same as intra-op. Dr. T then requested to put back the patient on 15 cmH2O pressure again. This time , I prepared myself, as the primary nurse who looked after Mr. Chin was a novice. My daily entires in my professional journal made me to visit and monitor his progress. On the 4th June 2008, another CXR was done . It was reported that tension pneumothorax was almost resolved.

Doctor T ordered to off continuous suction and UWSD were removed on the next day. Mr. Chin was transferred to the general ward. He was discharged after one week. I contacted him one week later, to find out his condition. He was advised by doctor to rest at home. (Yoges 2008 entry 5/6/08). INFORMING Knowledge is personnel ability and involves an intrinsic part of the human being. Nursing knowledge and its development is governed by philosophical view points or paradigms; which describe the nature of human beings and their relationships with the environment (Fawcett, 1990).

The essential purpose of exploring the paradigms in my practice description was to identify hidden nursing knowledge from my professional journal. Harper and Hartman (1997) mentioned that Nursing Knowledge has traditionally been influenced by the paradigms of positivism, interpretive and critical social theory. In this writing these paradigms were also referred to as empirical (scientific or technical), interpretive (practical) and emancipatory (critical). Empirical (Scientific. positivism or technical) Yogeswary Arumugam

Empirical (Scientific, positivism or technical) paradigm is usually defined as ‘the thesis that all knowledge of matters of fact and based on experienced’ (Flew 1979 cited in Smith & Grech, 2008 pp27). Knowledge generated from this paradigm is observable, personal, subjective, analytical and generated through scientific means. In practice description one, the senior nurse was knowledgeable. She knew the fact of giving expired blood products. Empirical paradigms are not implemented in this situation because nurses do not have any authority to voice their opinion.

All doctors in my hospital are specialist. They did not like to hear any commenced or inquiries from nurses. Most of the time, we as a nurse became as silence knower. Positivism maintains that there is an objective reality that exists independent of the observer, where phenomena are driven by natural laws accessible to observation and measurement (Harper and Hartman 1997). In description three, nurses lacked of knowledge as well as experiences. Besides they were not aware of the importance giving anti-diuretic to Madam Jane.

They were careless and did not bother to take action in such scenarios. Delay in treatment can threaten a patient’s life. My present in that situation had facilitated to solve the problem. The knowledge generated by the empirical paradigm is observed in a nurse’s competency in handling the daily nursing care. As a professional, a nurse must be more responsive and vigilant in order to perform duties well. Munhall (1993 pp126) stated that “the empirical or positivist paradigm was not accurate in reflecting but nursing is more holistic philosophy based, especially in area of caring”.

Interpretive paradigm “Personal and experiences are important in the world of nursing”, this fact was supported by Smith & Grech (2008 pp28). The theories behind this interpretive paradigm are concerned with personal meaning, feelings and acceptance of subjective information as relevant. Thompson (1990) said that knowledge from interpretive paradigms are constructed and recognized in a social and historical context. I support Harper and Hartman (1997) that understanding of meaning is important in nursing practice. My engagement with Madam Jane in practice description 3, describes nursing as a unique healing work.

The care that I rendered to Madam Jane by performing gentle touch, massaging and tender loving care with inter-personal relationship and proper explanation promote a comfortable environment to Madam Jane. Three important qualities of interpersonal relationship are presencing, concern and authenticity. This healing process, I learned by reading article wrote by Taylor (1995). These qualities which were identified in me developed a good rapport with Madam Jane. The nurse- patient relationship has variously described as a lived dialogue (Paterson and Zderad1976).

Actively engage in communication provide us a rich source of meanings and interpretations for the development of practical knowledge. As stated by Harper & Hartman (1997) that subjectively allow nurses to learn about their experiences and share them with other person. This enable nurses to be emphatic, sensitive to patient’s needs and the ability to constantly evaluate the effectiveness of nursing intervention. Critical paradigm When using critical paradigm, there is an attempt to achieve an optimal outcome with a balance between the technical and interpretive approaches (Barwick. 1998).

Important concern in this paradigm is an intention to achieve social equity and empowerment. I was immersed by critical paradigm in the second and third incident. Luckily I was called in the third incident. I managed to act quickly to prevent necessary problem that may happen to Madam Jane. As stated by Taylor (1995, pp 104) “The healing work of nursing can be found in split seconds, even in the midst of chaos, if the people relate to one another-from the heart to heart”. Yogeswary Arumugam According to Greenwood (1993),all nurses’ actions are reflective ideas, models or theories of purposes and intention.

The mean to their execution are termed as theories of action or action theories. Ways of knowing Nursing has strong tradition of focusing on various ways of knowing how to provide excellent care. Carper (1978) identified four pattern of knowing in nursing : Empiric, Ethic, Personal and Aesthetic. In 1995, White introduced another pattern of knowing in nursing named as ‘sociopolitical knowing’. I will use this pattern of knowing to demonstrate my understanding in my practice description Empirical knowing (The Science of Nursing) relates to facts, descriptions, explanations and predictions.

This pattern of knowing is based on the ideas of science and is similar to the view as espoused by empirical paradigm. We empirics have a very limited scope as far as the development of nursing knowledge or theory is concerned. I agree with Chin & Kramer (1995) that nursing cannot be formulated but it is based on people lived experience and the insight that evolve from the art of nursing. I believe insight and experience cannot be reduced and measurable which are what empiric demands. Ethics (Moral Knowledge in Nursing) refer to moral obligation, values and esired ends. Ethics focus on issues of duty and responsibility. This is not just the knowing of ethical codes of conduct, but the ability to discriminate and make moral judgments. This knowing requires the understanding and ability to apply a variety of moral and ethical framework to complex situation requiring moral insight and judgment. Chinn & Kramer (1995) support this by stating that it involves making moment to moment judgments about what should be done, what is good, what is right and what is responsible?

In practice description one, I faced the dilemma of being either the patient’s or the nurse’s advocate and the resultant decision which I made was dependent on my ethical knowledge. I had knowledge about my profession and society of which patient was a participant. Whereas in practice description one and four, Mr. Chin and Mr. Alan was not informed about the actual occurrences during their stay in hospital. This could create conflict to doctor, nurse and patient. At certain times, incident should be concealed in order to maintain the hospital’s prestige.

Aesthetic knowing (Art of Nursing) in nursing is made visible through the action, bearing, conduct, attitudes and interactions of the nurse in response to others. Perception of meaning in an immediate encounter is what creates an artful nursing action and the nurse’s perception of meaning in reflected in the action taken (Carper,1978). This approach is similar to interpretive paradigm. Listening and comforting the patient in all situations is example of aesthetic nursing that I have learned through my practice description. Personal knowing (self knowing) in nursing is about aware of self.

Knowing of one’s self makes possible therapeutic use of self and this enhances the experiences of transpersonal healing. My engagement with Madam Jane will be an example to my peers to improve skill and to be more concerned in identified patient’s needed. Without this component of knowing, the notion of the “therapeutic use of self” in nursing would just be an illusion (Carper, 1978). Personal and aesthetic knowing is similarly espoused by interpretive paradigms. Sociopolitical knowing locates knowledge within the sociopolitical environment of the persons and their interaction.

White (1995) said this way knowing was concerned with the “who”, “how” and “what” of nursing practice and the sociopolitical would deal with the “wherein”. This aspect of knowing would encompass the contexts not only of the nurse-patient relationship but also of nursing as practice profession. It also included political, historical, economic and other key factors in consideration of theoretical, practical focused and research related Yogeswary Arumugam knowledge and action. The example of presence that resulted in a closer relationship between Madam Jane, Mr.

Chin and Mr. Alan was through empathy and empowering environment. Critical Reflection Nursing practice has been traditionally influenced by technical, practice and emancipatory reflection, however , most nursing academics have approached reflective practice from critical perspective(Taylor,2000). I was feeling very uncomfortable to discuss issue pertaining Mr. Alan to higher authority. Street (1991) believed the paradigm of nursing is shifting towards practice and documenting the reality of nursing enabling nurses to change of the critical analysis and decision making.

My issue was discussed without delay by management since it dealt with patient’s safety and hospital prestige. I feel that all professional nurses should follow the principle of accountability in our practice to enhanced good practice. Espoused theories are learned consciously from nursing college and literates as nursing theory whereby the theoriesin-use is largely unconsciously from repeated everyday experience in clinical practice area (Greenwood, 1993). Theories-in-use are tacit wheels espoused theories are explicit.

Critically reflecting on practice description four, show how Nurse A failure in effecting a proper and safe procedure to Mr. Chin. It is quite common for theories supposedly dispensed to provide nurses with appropriate tools and knowledge failing to achieve practical outcomes. The apparent failure of putting into practice what is being preached at medical schools lead to the classification of theories of action into espoused theories and theories-in-use (Agris &Schon, 1974). This reflective have given more insight into the way, I think about nursing practice. It has emphasized my awareness of professional judgement.

CHALLENGING “Reflection is an integral part of the action research process, which begins with an idea that some kind of improvement or change is needed” (Kemmis and Mac Taggert, 1982 cited in Mackey 1998 p. 19). Nursing practice is challenging career nowadays. We encounters all sort of humans in the healthcare setting and their expectations are often beyond the target. Related to incidence 3, Madam Jane expected wonderful and loving care from nurses. She paid for her nursing care in the private sector. In this view, nurses should rise to the challenge of satisfying patients’ needs and expectations.

The action research approach involves the nurses working closely with to monitor systematically the issue and problems relates to changing practice. Reflect to description 2, although nurses understand their nursing practice and care to Mr. Kris. They were not aware of the other consequences that can happen when nurse critical ill patient. To nurse a critical ill patient is not an easy job. Recommended alteration is required in an intervention included update the nursing documentation especially ‘Nursing Care Plan’. In this incident, novice should be brave and challenge their self for better outcome.

RECONSTRUCTING According Taylor (2000), constructing is a method where the situation of the incident is to put together again with the transformative strategies for managing change in the light of a new insight. Nurses are requisite to implement and construct changes to the method they structure their time and bear out their nursing practice. Through professional journal writing, I have gained valuable insight, personal feeling and knowledge. New nursing knowledge such as ways of knowing and intervention of paradigms in practice description has a great impact on my future as critical care nurse. Yogeswary Arumugam

I now become cognizant and acknowledge the relationship of espoused theories in use in stripe of my duty. This insight advances my career in different illumination and utilizes my experience and knowledge to try to find possible tenacity. I enthusiastically attach in action research in teamwork with my peers. I identified my weakness and lack of courage to speak for the right. CONCLUSION After going through the process of learning and application of theory, I have value the importance of keeping professional journal. I have explored the value of reflective practice in nursing by using of various patterns of knowing and paradigms.

I have learnt to bridge the gap between theory and practice through reflection. Page & Meerabeau (2000) who said reflective journal summary help nurses ‘gain critical insights into nursing’. Thus, critical reflection is important tool to advance our profession as a nurse. The knowledge and theories that I gained through reflective journal writing, definitely has changed my perspective and ways of thinking. REFERENCES Argyris and Schon (1974). Theory in practice : increasing professional effectiveness. San Francisco : Jossey Base. Atkins S. & Murphy,K. (1995).

Reflection Practice, Nursing Standard, August 2,vol . 9,No. 45 pp. 32. Barwick, J. (199)Presencing’ The Australian Journal of Holistic Nursing, Vol. 5, No. 2,pp. 19. Benner, P. (1984). From novice to expert : excellent and power in clinical nursing, in Grech, C. (2006). Nursing Practice –Reflection Analysis and Innovation-Study Guide,University of South Australia. Benner, P. (2000). Shaping the future of nursing. Nursing Management,7(1)31-5. Benner, P. (2000). The wisdom of caring practice. Nursing Management,6(10),32-37. Benner, P. (2001). Taking a stand on experiental learning and good practice.

American Journal of Critical Care, 10(1). 60-62. Carper,B. A(1978)Fundamental patterns of knowing in nursing. Advances in Nursing Science,1(1),13-23. Chinn, P and Kramer, M (1995). Nursing pattern of knowing, in Theory and nursing : a systematic approach. Mosby, St Louis, pp:1-17. Fawcett, J. (1990). Conceptual models and rules for nursing practice, in Johns,C(1995). ‘Framing learning through reflection within Carper’s fundamental ways of knowing of in nursing’. Journal of Advanced Nursing, vol. 22,no. 2,pp:226-234. Flew.

A, editor(1979). A dictionary o philosophy,London:Pan Books Greenwood,J. 1993)Reflective practice, a critique of the work of Agris and Schon’, Journal of Advanced Nursing ,Vol. 18,pp. 1183-1187. Harper, M and Hartman, N . (1997). Research paradigms,in Research mindedness for practice: on interactive approach for nursing and health care. Smith,P. (Ed)Churchill Livingstone, New York,pp. 19-52 Holley, M (1987)the journal. In keeping a professional. 2nd edition,Deakin UniversityPress,Malven,Victoria:pp. 5-10. Mackey,S(1998). Massaging as a nurse intervention. Using Reflectionto achieve change I practice,Contemporary Nurse,Vol. 7,No. 1,pp. 18-23. Yogeswary Arumugam

Munhall P. (1993). Unknowing’ :towards another pattern of knowing in nursing. Nursing Outlook 41(3),125-128. Page,S & Meerabeau,L. (2000). The role of nurse educators in development reflective practitioners. Nurse Educations Today. Vol. 20. No. 5,pp365-372. Paterson, J. & Zderad, L. (1976)Humanistic nursing. Wiley, New York. Smith, C & Grech ,C. (2008). Nursing Practice Reflection Analysis & Innovation Study Guide, University of South Australia. Street, A. (1991). Form Image St. Leonard,Australia,pp. 1-21 to Action : Reflection in Nursing Practice , Allen & Unwin , Street, A. (1995).

Journalling. in Nursing replay , Churchill Livingstone , Melbourne,pp. 147-171. Taylor,B. (1995)Nursing as healing work. Contemporary NurseVol. 4, No. 3, Pearson Professional, Australia:pp100106. Taylor, B. (2000). The nature of reflection’ in Reflective Practice, Allen & Unwin St. Leonards, Australia. Thompson,J. (1990). Hermenetic inquiry. In: Moody L. E. 9(ed)Advances in nursing science through research Sage. london, vol 2. White,J (1995). ”Patterns of knowing :review,critique and update”,Advances in Nursing Science. Vol. 17,No,4,pp:7386. Yogeswary, A. (2008)Pofessional Journal (Unpublished)


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