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Who Will Be There? Ethics, the law, and a nurse’s duty to respond in a disaster

When disaster strikes, nurses are needed Registered nurses have consistently shown to be reliable responders, and their compassionate nature typically compels them to respond to those in need, even when it puts their own safety or well-being at risk. There is a strong relationship between the nurse and the public who expects that nurses and other health care providers will respond to their needs in an infectious disease emergency or in other types of disaster resulting in mass injury or illness. Society, as such, sanctions professions to be self-regulating on the understanding that such a response would occur. But do registered nurses have a contractual “duty” to answer a call to help in disaster situations? Do they have an ethical obligation to respond? Can the law require them to respond?

A nurse’s duty to care is an ethical component of the nurse-patient relationship that can be inferred from Provision 2 of the ANA Code of Ethics for Nurses with Interpretive Statements which states that “the nurse’s primary commitment is to the patient.” However, nurses not only have an ethical obligation to care for others but also to care for themselves. Provision 5 of the Code states that the nurse owes the same duty to self as to others. This conflict of obligation is especially prominent during times of disaster when nurses are put in the position to provide care to critically ill or wounded patients for extended periods of time. During these times of pandemics or natural catastrophes, nurses and other health care providers must decide how much high quality care they can provide to others while also taking care of themselves.

Registered nurses, especially those in non-emergency response functions, may find themselves in a difficult predicament. They are called upon to respond in times of mass casualty—such as a catastrophic weather event (hurricanes/floods) — or when the nature of their work puts them at risk for exposure—such as influenza or other infectious disease pandemics. It is reassuring to know that because of their compassionate nature and the nature of their role as caregiver, registered nurses are typically willing to respond. But many other registered nurses struggle with the call to respond. This is especially true if the nurse feels physically unsafe in the response situation, if there is inadequate support for meeting the nurses own family’s needs, or if the nurse is concerned about professional ethical and legal protection for nursing care in a crisis situation.

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These concerns faced by nurses represent a gap in our nation’s disaster preparedness and response systems. Critical questions remain unanswered as to what the registered nurse’s duty to respond is, especially if called upon to serve in a nontraditional role, and what expectations the registered nurse should have for physical, emotional, and legal protections. Resolving these problems would ultimately support registered nurses responding to a call for help will meet those needs and assure a robust response from registered nurses.

A Careful Assessment National associations like the American Nurses Association (ANA) are partnering with government groups, nongovernment organizations, employers and individual registered nurses to achieve systems, policies, and laws that enable the registered nurse and other providers to respond confidently, and to ensure that the needs of the American public will be met during a disaster.

In times of disaster we need to know that there will responders. But who will respond? It is evident that nurses have such a defined duty and this duty has some basis in licensure, regulations, and ethics.

There may be times when a registered nurse must make a choice between duties based on moral grounds. These choices are an important part of disaster planning and preparedness. Each nurse must know what line he or she will or will not cross when it comes to maintaining professional integrity. These concerns should be discussed prior to times of disaster. This is critical in disaster preparedness and planning. Hospitals, institutions, managers, administrators, and health care providers need to understand employer and employee expectations during times of disaster. Effective communication regarding a nurse’s ability to commit to providing any level of care to patients is essential when such events occur.

Nurses have a duty to uphold the standards of their profession. As such, they have a commitment to help care for and protect their patients while also protecting their own right to self-preservation and self-care. Nurses need to be proactive to address such issues. Nurses and the ANA are positioned to drive decisions regarding the conflict between a nurse’s duty to care versus duty to self.

Questions a Registered Nurse Might Ask

A hurricane rages through several states, destroying buildings, flooding roads, and falling countless trees and power lines. In several towns and cities, hospitals are struggling to remain open and serve the injured and ill victims from the storm, as well as to meet the routine medical needs of the community. Registered nurses are told to report to work, and a call is made for nurse volunteers. Some nurses are given patient assignments in areas and in physical locations that they are not accustomed to due to the austere conditions. What questions would go through a nurse’s mind in this instance?

Registered nurses think about safety. How can the nurse get to the hospital safely? Are there structural damages to the hospital that could cause injury? Is there risk of disease or exposure to the elements, which

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could cause the nurse illness or something that could spread to family or others in the home? Are security services at the hospital or at the site of care to prevent violence? What if the registered nurse has family members or other dependents that are affected by the disaster and need help at home? How can the registered nurse balance this obligation with a practice obligation to provide care to patients?

Registered nurses think about ethics. Registered nurses have an ethical obligation to put patients ahead of themselves, but in times where the registered nurse is in imminent danger by providing patient care, how can the nurse balance the ethical obligation to protect oneself? How will the nurse deal with being unable to provide care to everyone, especially if supplies and resources are scarce? What if the nurse or the medical teams face very difficult— almost unthinkable— situations and decisions regarding life and death?

Registered nurses would think about legal implications. Is there a law compelling the registered nurse to respond, even if the nurse has concerns about security and ethics? Is the nurse’s license protected? Are there assurances that the nurse would not become an easy target for lawsuits for negligence or malpractice, especially in circumstances of scarce resources or where practicing outside of the normal specialty area?

These are complicated questions, and individual registered nurses would answer them differently. The challenge, however, is before a disaster occurs, policies are in place that assure protections make clear the expectations of the registered nurse, the employer, and the government response systems.

Legal Elements

The legal elements of response can help or hinder a nurse’s decision to respond. In some cases, states have implemented laws that require licensed health care professionals to respond, and refusal to comply can be punishable. This approach does not help nurses feel comfortable about responding, especially when the other assurance systems for professional and personal protection are lacking.

A more helpful approach via the legal route is policymakers and governing bodies setting protocols for disaster medical responses that take account for the constraints of a disaster situation. Disasters can test the capacity of licensed practitioners to offer what would be deemed appropriate care in “normal” circumstances. They must ensure the legal protections such as liability standards, license verification, and definition of scope of practice for nurses and other licensed practitioners providing care in disasters.

The Uniform Emergency Volunteer Health Practitioners Act (UEVHPA) is model legislation drafted to alleviate some of these legal concerns. Produced by the National Conference of Commissioners on Uniform State Laws, the act establishes a system for rapid, streamlined deployment of licensed human service providers in areas of declared emergency. In addition, it provides legal safeguards for practitioners acting within their scope and in good faith, clarifies some interstate practice differences, and deems the legal scope of practice authority to the state requesting the practitioners to maximize their participation. Read the UEVHPA and see what states have adopted it as law.

Battlefield Medicine vs. Ingrained Ethics

One of the most difficult policies to hammer out deals with ethics. Ethics are certainly not black and white, and in a disaster situation, they become even more blurred. As a nurse, it may be difficult to fathom walking past a mortally wounded person to treat someone else, or to take a terminally ill patient off a ventilator to allocate it to a patient with a better chance of survival. But during a disaster, those and other ethical dilemmas can and do arise. For example, in New Orleans following the floods after Hurricane Katrina in 2005, nurses and physicians found themselves in terrible ethical situations, unable to provide life-sustaining

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care for patients, and faced with dire circumstances.

While every response situation is not that extreme, nurses and other health care personnel can find themselves operating in altered standards of care environments during a disaster. There is no clear consensus about mitigating ethical considerations, and continued uncertainty about applying altered standards of care. A utilitarian framework usually guides decisions and actions with special emphasis on transparency, protection of the public, proportional restriction of individual liberty, and fair stewardship of resources. Conforming to international emergency management standards and collaboration with public health officials and members of the healthcare team are essential throughout the event.

ANA works alongside government, non-government organizations and professional and academic medical groups as part of a forum on disaster medicine to confront some of these complicated and difficult policy questions. One deliverable has been a document written at the request of the U.S. Assistant Secretary for Preparedness and Response called Guidance for Establishing Crisis Standards of Care for use in Disaster Situations: A Letter Report. ANA, as a member of the Institute of Medicine’s Forum on Medical and Public Health

Preparedness for Catastrophic Events, participated in writing this framework. It suggests tenets that policymaking bodies should adhere to when designing the crisis standards of care for medical providers. Nothing in the framework will change nurses’ obligation practice ethically, but they do outline how protocols can be designed to protect medical professionals operating in extreme conditions and scarcities, and to ensure that the public receives the most adequate medical services possible in the situation.

This is the first step to establishing the ethical and legal framework, but the issue remains far from unresolved. ANA will continue to work with its partners to see these recommendations implemented at the state level, and will ensure that the ethical provisions in crisis standards of care mirror those in the Code of Ethics for registered nurses. Also, ANA will strive to educate individual registered nurses on the existence and application of this framework, as well as help them professionally prepare to be functioning in stressful and ethically challenging situations.

Together a Solution is Possible A concerted effort is essential to bringing some of these very difficult and high-level concepts into practice. The federal government has a role in setting the vision for seamless, coordinated, safe response efforts. The states—legislatures, planners, policymakers and response agencies—have a role in creating non-punitive environments that enhance the registered nurse’s efficiency and capacity to provide ethical care in response efforts. Employers need to create, maintain, and constantly improve disaster plans that help meet the medical needs of the community within a system that protects registered nurses and other employees or volunteers. This should include the provision of sufficient, appropriate personal protective equipment, immunizations, physical security, and operational protocols.

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ANA and other national associations must continue working to ensure that policies and plans for disaster response, including the creation of crisis standards of care, meet the needs and expectations of communities and registered nurses. As the largest nursing organization in the U.S., and one of the few nursing organizations actively engaged in national disaster response policy conversations, ANA is poised to continue this work. Visit ANA’s disaster preparedness webpage to learn more about efforts to advocate for nurses in disasters.

Individual registered nurses are critical participants in this work. They must be aware of their employers’ emergency response plans, as well as have a general sense of what state and local disaster preparedness and response efforts are taking place where they live and practice. They should be aware of their expected role in any response efforts—some employers make plans for their registered nurse staff that the individual nurse might not even know about. If they know they want to be an integral responder in a disaster, they should volunteer with a disaster registry, such as federal Disaster Medical Assistance Teams, nationally or locally with the American Red Cross, or their local Medical Reserve Corps. This will ensure they have the proper credentialing and training for responding to a disaster, and will be part of an organized system.

Nurses must be professionally and personally prepared. They should know in advance that they may be called upon, and will need to make arrangements with their families for communication, and even for care of children or dependents during their absence. Registered nurses need to be aware of the ethical situations they may encounter, especially in times of scarce resources and supplies when they may face unimaginable patient care decisions. They need to advocate for systems and protocols that protect their ethical obligations as nurses, as well as ensure equity and fairness in disaster medical care planning. Human rights may be jeopardized in extraordinary contexts related to fields of battle, pandemics, political turmoil, regional conflicts or environmental catastrophes where nurses must necessarily practice under altered standards of care. Provision 8 of the Code obligates nurses to always “stress human rights protection under all conditions, with particular attention to preserving the human rights of vulnerable groups such as women, children, the elderly, prisoners, refugees and socially stigmatized groups.”

Future disasters all are but guaranteed to occur. We cannot stop them, but we can be better prepared to for them. Creating better systems for nurses to respond, including ensuring an ethical and safe environment for response and recovery, will give some assurance that when the call for nurses goes out, there will be a robust answer.

Reflective practice: a iearningtool for student nurses

Peter Mark Wilding

AbstractReflection is a vital skill in contemporary nursing with student nursesexpected to engage in reflective learning from the very beginningof the nurse educational programme. This article demonstratesthe meaningful learning that resulted as a consequence of usingcritical reflection on practice. Gibhs' (1988) cycle aided the processhiglilighting the practical application of this cyclical framework to theauthor – a first-year student nurse. Matters concerning gender issuesin nursing and professional conduct emerged from the analysis andwere inherently explored. The article concludes hy demonstrating thepersonal henefits of using Gibbs' (1988) cycle to varying situationsand thus promoting its excellence as a learning tool for student nursesworldwide as a consequence.

Key words: Gender • Intimate treatment • Learning • Reflection •Student nurse

The novice first-year degree nursing studentencounters a steep learning curve in a relativelyshort amount of time. I am a first-year male studentnurse who found the reflective process a cathartic

exercise which helped me cope with a practice-related issueexperienced during my first clinical placement. Reflectionis a vital skill in modern nursing and its use is expectedfi-om the beginning of the programme.

This article highlights the deep learning that resulted as aconsequence of using Gibbs' (1988) cycle, thus demonstratingthe practical application of reflective practice to a first-yearstudent nurse's clinical placement. Furthermore, the articlealso explores how the cycle was adapted and used to providean effective learning experience, through which the authordcnionstrates that reflection is of worth – rebutting anyclaims regarding the learning potential of reflection, as somelearning is better than no learning, particularly if it providesa vital step toward.s greater knowledge. The inclusion of theauthor's reflective piece within the text serves to evidenceits efficacy in informing practice and provides the contextfor this critique.

Peter Mark Wilding is Second-Year Student Nurse, School of Health

and Social Care, University of Lincoln. Brayforil Pool

Accepted for publication: May 2008

BackgroundBenner (2001) explains chat nurses 'have not been carefulrecord keepers of their own clinical learning'. Reflectionprovides a thorough record, and it is a well-established toolfor learning. O'Donovan's (2007) review of the literatureclarified the success of reflection as an aid to learning innursing. Guided reflection has been defined as:

*… a journey of self-inquiry and transformationfor practitioners … to realize desirable practice asa lived reality. The journey is written as a narrativethat reveals the transformative drama unfolding.Along the journey, the vision of desirable practiceis constantly explored and shifting as newunderstandings emerge' (Johns, 2006 p36).

Moreover, reflective practice and guided reflection are nowa respected and required learning and assessment methodin many nursing programmes worldwide. The Nursingand Midwifery Council's (NMC) The Code: Standardsof Conduct, Performance and Ethics for Nurses and Midmves(NMC, 2008), states that nurses must keep knowledge andskills up to date throughout their working life. In particular,they should regularly engage in learning activities todevelop and maintain clinical competence and performance.Reflection can aid the maintenance and achievement ofclinical competence, hence an important tool in the nurse's'repertoire of skills' (Matthews, 2004). Reflection has beenused to explore and learn from issues concerning ethics,confidentiality, communicating with patients and relatives,and other critical matters (Keen, 2000).

There are numerous definitions of reflection withdifferent purposes in mind (Chirema, 2007). Whateverdifferences exist around the definition, there appears to be aconsensus relating to the importance of reflection in nursing.Reflection 'has maintained a high profile on the nursingagenda' (Williams and Lowes, 2001); this is further illustratedthrough advocacy for reflection by nursing and governmentprofessional bodies. Reflection requires self-awareness andanalysis (Schutz et al, 2004), thus it is a skill that needs to beacquired, developed and maintained.

The personal nature of reflection and the fact that it issometimes used as an assessment method for learning canbe a barrier to truthfully accounting the story (Schutz etal, 2004). This was a major dilemma in my own reflectivewriting. I therefore made a pact with myself to let go of thebarriers and inhibitions, so as to permit full reflection andallow a more expansive learning experience. Williams andLowes (2001) described a lack of definition for reflection

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REFLECTIVE PRACTICE

Figure 1. Reflection practice of the author based on Gibbs' (1988) Reflection Cycle.

What would you do If thesituation arose again?

tWhat other options were

open to you?

What happened (story)?

What were you thinkingand feeling?

What were the thoughts andfeelings of others involved?

and an anibitiiious approach as barriers to effective reflection.These authors purport'the true process oí" reflection is onlyinitiated once the primary stage of writing has finished'(Williams and Lowes, 2001). which suggests that reflectionis a journey and not an ending (see Figure I for oudine ofmy personal reflective journey).

By engaging with Gibbs' (1988) model, I found manybenefits and it suited niy personal style of learning. Havingthe right reflective process has bonuses for the patient,nurse, and student. Hilliard (2006) also found Gibbs' modelprovided her with a focus by promoting her awarenessof the skills she possessed, thus building confidence andenhancing her professional autonomy. In contrast to this, ifreflection reveals a lack of skill, it may potentially leave thestudent feeling insecure and demotivated. O'Callaghan's(2005) reflective piece related to helping a student escapethe bonds of ritualistic practice in wound dressings andmake progress with evidence-based practice to benefitthe patient. These statements mirror Mooney and Nolan's(2(K)6) comments that reflection is seen as a method ofliberating nurses and creating better understanding andbuilding a greater body of nursing knowledge, whichbenefits the profession.

What happened (my story)?IJuring the course of my clinical placement, 1 encountereda patient, a middle-aged woman, who had recentlyundergone a vulvectoniy and an operation on her inguinal

lymph node. The nursing care required the daily cleansingand dressing of the excised area. I was introduced to thepatient, and verbal consent was obtained from the patientfor me to observe the dressing procedure.

For the first stage of the cycle, Gibbs encourages adescription of the eventsThe story was very simple and easyto convey. Gibbs' learning cycle is appropriate for accountssuch as mine, as my thoughts and feelings were importantaspects of this reflection. Following the description of thestory I was in a position to concentrate on the importantelements. Not all narrative accounts of incidents are succinct,but I consciously endeavoured to edit the description inorder to benefit from an integrated approach dealing withmy thoughts and feelings directly after the explanation ofthe incident. Othervise I believe the complexity of writingand reading would be overwhelming and more time wouldbe spent matching the story to the outcome and seekingclarity, rather than reflecting and learning.

What was I thinking and feeling?On the way to the patient's house the staff nurse gave me abrief history of the patient. 1 was able to determine what avulvectomy was for myself and the nurse simply confirmedit. It dawned on me that the cleaning would require thepatient to be partly undressed. My first feeling was thatof slight shock and I wondered how it would go. Manyquestions entered my head: Where should I look? Whenshould I look? What body language and approach would be

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most appropriate? Particularly because I am male. What arethe implications that flow from this? How will I deal withthis situation when I am a registered practitioner and mighthave to deal with this on my own? What will it be like?How will I respond? What is the paradigm of professionalconduct in this area? All of which I thought, but I did notknow the answers to all those questions, so my approachwas a cautious one.

The Nursing and Midwifery Council's (NMC) Tlic Code:Standards of Conduct, Performance and Ethics for Nurses andMidwives (NMC, 2008) states that the professional nurseis personally accountable for protecting the interests anddignity of patients and clients regardless of their personalcharacteristics or circumstances. Paramount in my mind waspreserving the patient's dignity, not only because the Codesays so, but human decency requires it. Dignity appearsto be the guiding light of intimate treatment, guidingnursing practice. 'Dignity must he protected at all times'(Peatc, 2005). One of Coller's (2006) four core values isrespecting and protecting patients' dignity and sense ofself-respect, especially when illness or other circumstancesmakes them particularly vulnerable and powerless (Coller,2006). The Code is there to protect the public, and servethe client, including protecting their dignity. Withoutfurther experience on how best to act in these situations, Irecognized and acknowledged my own limitations, mainlythat I am only equipped to observe thus far and to takeinstruction from the qualified nurse, spraying dressings withsaline solution, for example. I am still at the novice stage inlearning and doing (Benner, 2001).

I kept my eyes down for most of it, looking could easilybe misinterpreted and I kept a good distance back so as notto be too invasive. I looked now and then, so as to see andlearn, but I reduced it to the bare minimum. Nurses mustwork together to bring about healthcare environments thatare conducive to safe, therapeutic treatment and all withinthe gamut of ethical practice (NMC, 2008). My conduct,therefore, had to be ethical and this was achieved by directlyobserving periodically w îthout staring.

1 did feel slightly protected by my uniform and the factthat my uniform has meaning to others, thus requiring meto uphold the highest standards. Despite the uniform, mygender does make a difference. Women are seen as natural-born carers, and thus good nurses; the experience of menin nursing, in stark contrast, is a different story (Seed. 1995).Seed's study found that 'female nurses found it difficult toaccept the fact that their male colleagues should be fullyinvolved in the care of women'. Even though there arereports of instances where female patients see a male nurseas a breath of fresh air (Smith, 1992), societal expectationsand stereotypes are in full force. Did the patient see astereotype of a nurse observing the procedure or did shejust see a caring person training to be a nurse before her?Does she have faith in my professionalism? Did I liveup to the unspoken professional promise? I think that Idid; I certainly endeavoured to. It reflects upon me as anindividual as well as a future professional, as according toFagermoen (1997), 'the nurse provides care in a form ofself-presentation through which nurses actualize their values

and communicate their personal meanings' (Fagermoen,1997). Therefore, it follows that it is impossible to predicthow gender plays a part in the professional nursing role andmoreover it is impossible to generalize gender equity incaring relationships (Smith, 1992: Seed, 1995).

This second stage of the Gibbs cycle provides a sectionto explore how I felt and the thoughts 1 had. This andits complementary section were the most important partof my exploration and learning process. My commentswere not directly restricted to my 'thinking' and 'feeling',accompanying them were some elucidation of the storyand also evaluation, supported by evidenced-based research.This seemed to be the most natural and productive way oflearning from the experience and enabling me to presentthe information in an informed manner. Gibbs' cycle,therefore, has undergone some expansion here, such anapproach was necessary for learning to emerge and toenable the flow of accounts.

What were the thoughts and feelings of othersInvolved? How do you know?My intuition led me to believe that the nurse I accompaniedhad no discernable feeling one way or the other about thesituation. She acted as a professional, i.e. a task had to bedone and she did it. In many ways it is just another woundto be cleaned and dressed, albeit in close proximity togenitalia. On the other hand, the patient must have beenembarrassed; in today's society, private parts remain privateand exposure to others is restricted. Permitting strangers tosee her genital area must have felt invasive. Especially withme observing the dressing procedure, and as a male studentnurse, I felt superfluous to the process and only added to thepatient's discomfort. But she seemed to accept my presence;more than likely because her priorities at that time were tomake a full recovery and take life day by day. Professionalcaring properly understood, is a moral imperative, borne ofaltruism and a sense brotherhood (Dowling, 2004), a senseof which I had on this occasion. This poses no problem solong as the patient understands and has faith in her carers asprofessional practitioners.

The third section of the Gibbs process required meto delve into what others thought. As such it demandedan empathie view, putting myself in their shoes. Thisstage was useful because it allowed the fusion of what 1observed: their body language, the things that were said,and the way I might have viewed things if 1 was in theirsituation. This stage of the cycle permitted me to analysehow I perceived the motives and reactions of others. I wasenabled to tease out the 'commonalities and differences'in other's views (Benner, 1994), which is the very goal ofinterpretive phenomenology. It is here where personhoodand individuality can be examined.

What other options were open to me?Not many other options were open to me. I could havebeen less sensitive and stood closer, thus enabling me toobtain a more detailed view of the nursing care applied.However, at what cost? The patient's dignity could havebeen needlessly intruded upon, violating tbe principles

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REFLECTIVE PRACTICE

in the NMC (2008) Code. Hence, I felt that no betteraltcrndtc options were open to me. This fourth stage ofCiihbs" cycle therefore provided only the opportunityto explore the negative consequences of my presence.Learning, through reilectioii, enhances an ethical senseof the morals of nursing practice, and thus provides theanswers to why. In the world of nursing knowing why is thedifference between mechanistic repetition, and acting as aconsequence of knowledgeable decision-making.

What would I do If the situation arose again?My conduct would be similar. Patients are people and:i people are different, some are indifferent, others areconcerned. In the times subsequent when I revisited thepatient my approach was similar (and will be in the future).To safeguard the dignity, respect and trust of the patient itis better to err on the side of caution and be aware of thesensitive nature of intimate nursing care. It seems that achaperone, in any intimate examination/treatment, can beuseful to both patient and nurse {Peate, 2005), especially inthis age of lawsuits. The Royal College of Nursing (RCN,2002) recommends actively providing a chaperone whenattending to intimate nursing care procedures.

On balance, initially I need not have been so demure.It is easy to intrude upon a patient's privacy, especiallyif their preferences are not known (Back and Wikblad,Í99H). Caution was appropriate here because space, touchand interaction are seen differently by different people(Edwards, 1998). Such views relate to varied criteria, suchas gender, age and even height, more often unknown to thestranger (Edwards, 1998). My own personal values can havea profound influence on the way 1 interact with patients onwhatever level, one must be aware of this and the potentialfor problems to arise, hence my cautious interaction withthe patient in this case. Although, I think my inherent valueshelped, they could be a hindrance in other circumstances,for example, being needlessly cautious. But, by numerousvisits and observing a tittle at a time, I have been able to putthe treatment together in my head, like a jigsaw puzzle, so 1have been learning without being too obtrusive.

One easily adjusts to situations. For example, in the areaof leg ulcers, what at first repulsed, is now just anotherwound. Applied to this situation, one could easily lose sightof the sensitive nature of wounds such as this; the activity isloaded with great risk of becoming ritualized, habitualizedand insensitive when applying treatment, at great cost tothe patient.

At my latest visit, the nurse removed the dressing, thewound had healed, and we thus noted in the paperwork.Aware of the need to re-assess patients, as their situationcould alter, the patient remains on file and we remain 'oncall'. In areas related to this. I will try and keep an 'empathieattitude" (Rogers, 1980) to enable me to better tailor myresponse and better address the chent's needs.

In the fifth and final stage of the Gibbs reflective process,I was able to explore the potential situations 1 could foreseearising again, perhaps with different patients. I could thenapply what I learnt to those future situations. I am now, asa consequence of critical reflection, able to examine my

philosophy as it applied to this event and how it couldcascade to other future events. I was facilitated to look atmyself and see where any impediments may be and thushow a remedy might be fashioned.

Critical reflection (commentary)I feel I need to learn and understand more about theplight of patients in this situation. Dealing properly withthe aftermath of gynaecological surgery is important, it hassignificant imphcations, not only for physiological reasons,but also from a psychological perspective considering theloss of womanhood, femininity and sexuality for patientsundergoing such evasive surgery. It is essential that nursesare aware of the consequences of vulvectomy surgery fromboth a physiological and psychological perspective. Sexualexpression and self-esteem may be impaired as a result.

Almost 15 years ago a qualitative study was conductedthat concluded some surgeries physically 'disfigure' thetreated area (Corney et al, 1992). However, the fear ofrecurrent cancer in the future remained constant as 60% ofpatients in the study stated that fear of cancer recurrencedid not dissipate over time. Potential for major distresswas also uncovered, with 68% feeling markedly or severelydistressed about their postoperation life, younger womenespecially. Sexual problems presented in 76% of the sexuallyactive patients within 1 year of the operation, in contrastto 19% before operation (Corney et al, 1992). Hence, itseems to me that even those who are not sexually activemay have trouble forming relationships, for fear of problemsbeing encountered. The study concluded that support ofemotional needs and information are the best tools to tacklethese problems, and counseUing should be freely available(Corney et al, 1992).

Allowing for questions and givingjargon-free explanationscan also help the patient (Peate, 2005), As my clinicalplacement is in the community, 1 have noticed thatnurses do play a counselling role in some way. offeringinformation and support. I believe this is exactly whatnurses should do and furthermore be observant of non-verbal communication, adopting a holistic approach, andoffering support at the early stages of care. These needsshould be recognized and addressed,

American sources claim that of gynaecologicalmalignancies, 4% of them are vulvar cancer (Di Saia etal, 1979; Venes, 2005). Unfortunately, it is unlikely thatprevention of this disease is possible, it is rare and as of yetthere is no available effective screening method for vulvalcancer (RCN, 2005).

I have learnt a lot from this experience, not just from mypersonal reflection but also from reviewing the evidenced-based literature, in particular relating to a topic I wouldotherwise not have researched. Gibbs' model does notadvocate a concluding critical commentary. Although 1 hadweaved critical elements into the actual reflection, I wascompelled to add this section in order to evaluate the biggerpicture, as in this case, to the related aspects 1 witnessed. Iwas looking to turn this learning experience into knowledgeapplicable in other situations related to intimate treatment.The critical reflective process permitted me to examine and

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reflect on the psychological aspects of this type of surgeryand thus transported me beyond this stage to engage in thethoughts and feelings of others involved, as that was basedupon contemporaneous assessment and some afterthoughtand interpretation. My analysis uncovered real studies ofreal people exploring knowledge beyond what I couldobtain from the patient. The efficacy of the Gibbs processstimulated me to learn more. Perhaps an interesting additionto the cycle would be a section that is updated at a later date,so progress can be gauged.

ConclusionThe foregone discussion demonstrated the potential powerof reflection as a tool for discovery and possible learning.It is clear to me that Gibbs' cycle is of use in manycircumstances. The cycle is cyclical, it can be altered andadapted to the varying situations and crises nurses are facedwith, which means the cycle can be applied to ahnost anyevent or issue. Thus, such a structure is ideal for first-yearstudent nurses, with the lack of complexity permittingbetter engagement with the process. It also follows thatreflection should not be bound in a cast-iron structure, itmay be better to have no structure at all in some cases.More than likely different reflective cycles will benefitdifferent situations, much like a plumber selecting the righttool for the job. There is evidence of Gibbs' framework inmany reflective models (Jasper, 2003), which illustrates thatmany models share a commonality, which implies a sharedknowledge base, thus knowledge obtained from the Gibbscycle would more than likely similarly emerge with the useof other reflective frameworks.

Reflection occurs as a result of a critical thought process;the written word will not fade and can be consulted to aidlearning or mark progress. Reflection is the perfect mediumto evaluate the 'what and how' of nursing care and the widerimplications of inter-professional relations; thus informingother discreet issues. Reflection can be written evidenceand the product of an inquiring mind. The time needed toeffectively reflect is immense, and not withstanding theenergy invested in recalling the experience, writing,researching, reading, synthesising, thinking, followed withmore writing, is significant. But it is a worthwhile exercise,considering the theory-practice gap that Kyrkjebo and

KEY POINTS

Reflection is a well-established tool in learningand is common to nursing programmes nationally.

I The Gibbs* cycle is ideally suited to the reflectiveneeds of student nurses because of its simplicityand malleability.

I Gender plays a role in the application of intimatetreatment.

Reflection stimulates deeper exploration of topics.

Hage (2005) found students witness in practice. Reflectioncan be used as a quality assurance method to evaluate botheflective and poor practice. Moreover, as demonstrated frommy personal reflection on my novice nursing practice,reflection is a potent weapon in the armoury of learningand development. DH

Ackiio u'ieâgem et ils

The author ¡muid like lo liiaiik Paul Liiiilcyfor his support in writing this

article.

liack E,WikbIad K (1998) Privacy in hosphalJ Adv Nim 27(5): 940-5Beniier P (1994) The tradition aiid skill of inCerprerivL- piifnomenology- in

studying healdi, illness, and caring practices. In: Ik-niicr P. ed. liilerpn'tiivPlienomenolt^: Fjuhoiiiitwiit, Cnriiiji, mid Ethics in ikahh MUÍ ¡Umss. SACîEPublications Ine, London: 99-127

Beiiner P (2001) From Novice to Expert: Excclieme mid Power in Clinical JVwrsii;̂Practia: Commemorative edn. Prentice Hall Inc, New Jersey

C'hirenia KI? (2(MI7) The use of rfflective journals in die promotion ofreflection and learning in post-registration nursing students. .Vnr«' EducToday27(3): 192-202

C^oller BS (21)06) The physician-scientist, the state, and the oadi: thoughts torour dnies._/ CUn invest 116(10): 2567-70

Corney R, Everett H, HowelLs A, C^rowther M (1992) The care of patientsundergoing; surgery for gynaecological cancer: the need for information.emotional support and colln^eilillt;._/.-llÍI• Nurs 17(6): 667—71

Di Saia PJ, Greasman WT, Rich WM (1979) An alternate approach to earlycancer of the vulva.J OliiU-t Gytiecol 133(7): 825-32

Dowling M (20(14) Exploring the relationship hetween caring, love andintimacy in nursmg. BrJ Nurs 13(21): 12S9-92

Edwards SC (1998) An aiithropological interpretation of nurses' and patients'perceptions of the use of space and touch. J/IÎÎ!» Nurs 28(4): SO'J-17

Fagennoen MS (1997) Professional identity: values embedded in meaningfulnursing pracdce.J.-^i/i' Nurs 25(3): 86H-72

Cîihbs G (1988) Li-aniiiig By Doing: A Guide to Teaching aiid Learning Methods.FEU, London

Hilliard C (2(XMS) Using structured reflection on a critical incident to develop aprofessional portfolio. Nurs Stand 21(2): 35—40

Jasper M (2Ü03) Bef¡inning Ri;fícni"c Pr¡ictia': Foundations in Nursing and HvnlihCcire. Nelson Thornes Ltd, Cheltenham

Johns c; (2(M.)6) Engaging Reflection in Prmiice: A Narrative Approach. BlackwellPublishing Ltd, Öxfoni

Keen A (20110) Critical incident: reflection on the process of ternuna! weaning.

Kyrkjebo JM, Hage I (2005)What weknow and what they do: nursing students"e.xperiences of improvement knowledge in clinical practice. Nurse Bduclbday25(3): 167-75

Matthews E (2004) Concordance with pain medication: reflection on anadverse incident. BrJ Nurs 13(9): 551-5

Mooney M, Nolan L (2006) A critique of Freire's perspective on critical sotiiiltheory in niiriing education. Nurse Educ Thdijy 26(3): 24(t-4

Nursing and Midwifery C'ouncil (20U8) T¡ie Code: Standards oj (Conduct,Performance ami Ethics for Nurses and Midmi'es. NMC, London. Available at:http://tinyurl.coni/6kdup6 (last accessed 5 June 2008)

O'Callaghan N (2005) The use of expert practice to explore reflection. Nur.iS/flH^ 19(39): 41-7

O'Donovan M (2007) Implementing reflection: insights from the pre-registration mental health students. Nurse EducToday 27(6): 610-6

Peate I (2íH)5) Examining aduJt male genitalia: providing a guide for the nurse.

Rogers C R (1980) A Way of Being. Houghton MiSlin Company, Boston, MARoyal College of Nursing (2002) Chaperoning: The Rote of the Nune and thv

Rights of Patients. RC^N, LondonRoyal College of Nursing (2005) Gynaecologiml Gan(er – Guidanœ for Nursing

Staff RC'N, London. A™!ahle at: http://tinyurl.coni/6rkx5a (last accessed5June2(X)8)

Schutz S, Alcove C, Sharp P (2004) Assessing and evaluating reflection. In:Bulrnan C, Schutz S, eds. Rißvctivt- Practice in Nursing. 3rd edn. BlackwellPublishing Ltd, Oxford: 47-72

Seed A (1995) Crossing the boundaries – experiences of neophyte nurses. J / I lii»'»r.-21(6): 1136-43

Smith P (1992) Tlw Emotional Labour of Nursing — How Nurses Care. TheM.îcmillan Press Ltd, London

Venes D (2005) 'laher'f Cyclopedic Medical Diaionary. 20th edn. FA DavisCompany, Philadelphia

Williams GR, Lowes L (2C)01) Reflection: possible strategic"s to improve its useby quali6ed staff. BrJ Nurs 10{22): 1482-8

724 Urirish Journal i>f"Nvir4ini:,2()llM.V(il 17, N o li

Reflective practice: a iearningtool for student nurses

Peter Mark Wilding

AbstractReflection is a vital skill in contemporary nursing with student nursesexpected to engage in reflective learning from the very beginningof the nurse educational programme. This article demonstratesthe meaningful learning that resulted as a consequence of usingcritical reflection on practice. Gibhs' (1988) cycle aided the processhiglilighting the practical application of this cyclical framework to theauthor – a first-year student nurse. Matters concerning gender issuesin nursing and professional conduct emerged from the analysis andwere inherently explored. The article concludes hy demonstrating thepersonal henefits of using Gibbs' (1988) cycle to varying situationsand thus promoting its excellence as a learning tool for student nursesworldwide as a consequence.

Key words: Gender • Intimate treatment • Learning • Reflection •Student nurse

The novice first-year degree nursing studentencounters a steep learning curve in a relativelyshort amount of time. I am a first-year male studentnurse who found the reflective process a cathartic

exercise which helped me cope with a practice-related issueexperienced during my first clinical placement. Reflectionis a vital skill in modern nursing and its use is expectedfi-om the beginning of the programme.

This article highlights the deep learning that resulted as aconsequence of using Gibbs' (1988) cycle, thus demonstratingthe practical application of reflective practice to a first-yearstudent nurse's clinical placement. Furthermore, the articlealso explores how the cycle was adapted and used to providean effective learning experience, through which the authordcnionstrates that reflection is of worth – rebutting anyclaims regarding the learning potential of reflection, as somelearning is better than no learning, particularly if it providesa vital step toward.s greater knowledge. The inclusion of theauthor's reflective piece within the text serves to evidenceits efficacy in informing practice and provides the contextfor this critique.

Peter Mark Wilding is Second-Year Student Nurse, School of Health

and Social Care, University of Lincoln. Brayforil Pool

Accepted for publication: May 2008

BackgroundBenner (2001) explains chat nurses 'have not been carefulrecord keepers of their own clinical learning'. Reflectionprovides a thorough record, and it is a well-established toolfor learning. O'Donovan's (2007) review of the literatureclarified the success of reflection as an aid to learning innursing. Guided reflection has been defined as:

*… a journey of self-inquiry and transformationfor practitioners … to realize desirable practice asa lived reality. The journey is written as a narrativethat reveals the transformative drama unfolding.Along the journey, the vision of desirable practiceis constantly explored and shifting as newunderstandings emerge' (Johns, 2006 p36).

Moreover, reflective practice and guided reflection are nowa respected and required learning and assessment methodin many nursing programmes worldwide. The Nursingand Midwifery Council's (NMC) The Code: Standardsof Conduct, Performance and Ethics for Nurses and Midmves(NMC, 2008), states that nurses must keep knowledge andskills up to date throughout their working life. In particular,they should regularly engage in learning activities todevelop and maintain clinical competence and performance.Reflection can aid the maintenance and achievement ofclinical competence, hence an important tool in the nurse's'repertoire of skills' (Matthews, 2004). Reflection has beenused to explore and learn from issues concerning ethics,confidentiality, communicating with patients and relatives,and other critical matters (Keen, 2000).

There are numerous definitions of reflection withdifferent purposes in mind (Chirema, 2007). Whateverdifferences exist around the definition, there appears to be aconsensus relating to the importance of reflection in nursing.Reflection 'has maintained a high profile on the nursingagenda' (Williams and Lowes, 2001); this is further illustratedthrough advocacy for reflection by nursing and governmentprofessional bodies. Reflection requires self-awareness andanalysis (Schutz et al, 2004), thus it is a skill that needs to beacquired, developed and maintained.

The personal nature of reflection and the fact that it issometimes used as an assessment method for learning canbe a barrier to truthfully accounting the story (Schutz etal, 2004). This was a major dilemma in my own reflectivewriting. I therefore made a pact with myself to let go of thebarriers and inhibitions, so as to permit full reflection andallow a more expansive learning experience. Williams andLowes (2001) described a lack of definition for reflection

720 UHtish Journal of Nursing. 2008.Vol 17.Ni

REFLECTIVE PRACTICE

Figure 1. Reflection practice of the author based on Gibbs' (1988) Reflection Cycle.

What would you do If thesituation arose again?

tWhat other options were

open to you?

What happened (story)?

What were you thinkingand feeling?

What were the thoughts andfeelings of others involved?

and an anibitiiious approach as barriers to effective reflection.These authors purport'the true process oí" reflection is onlyinitiated once the primary stage of writing has finished'(Williams and Lowes, 2001). which suggests that reflectionis a journey and not an ending (see Figure I for oudine ofmy personal reflective journey).

By engaging with Gibbs' (1988) model, I found manybenefits and it suited niy personal style of learning. Havingthe right reflective process has bonuses for the patient,nurse, and student. Hilliard (2006) also found Gibbs' modelprovided her with a focus by promoting her awarenessof the skills she possessed, thus building confidence andenhancing her professional autonomy. In contrast to this, ifreflection reveals a lack of skill, it may potentially leave thestudent feeling insecure and demotivated. O'Callaghan's(2005) reflective piece related to helping a student escapethe bonds of ritualistic practice in wound dressings andmake progress with evidence-based practice to benefitthe patient. These statements mirror Mooney and Nolan's(2(K)6) comments that reflection is seen as a method ofliberating nurses and creating better understanding andbuilding a greater body of nursing knowledge, whichbenefits the profession.

What happened (my story)?IJuring the course of my clinical placement, 1 encountereda patient, a middle-aged woman, who had recentlyundergone a vulvectoniy and an operation on her inguinal

lymph node. The nursing care required the daily cleansingand dressing of the excised area. I was introduced to thepatient, and verbal consent was obtained from the patientfor me to observe the dressing procedure.

For the first stage of the cycle, Gibbs encourages adescription of the eventsThe story was very simple and easyto convey. Gibbs' learning cycle is appropriate for accountssuch as mine, as my thoughts and feelings were importantaspects of this reflection. Following the description of thestory I was in a position to concentrate on the importantelements. Not all narrative accounts of incidents are succinct,but I consciously endeavoured to edit the description inorder to benefit from an integrated approach dealing withmy thoughts and feelings directly after the explanation ofthe incident. Othervise I believe the complexity of writingand reading would be overwhelming and more time wouldbe spent matching the story to the outcome and seekingclarity, rather than reflecting and learning.

What was I thinking and feeling?On the way to the patient's house the staff nurse gave me abrief history of the patient. 1 was able to determine what avulvectomy was for myself and the nurse simply confirmedit. It dawned on me that the cleaning would require thepatient to be partly undressed. My first feeling was thatof slight shock and I wondered how it would go. Manyquestions entered my head: Where should I look? Whenshould I look? What body language and approach would be

UnrishJournal ofNursing.2(lOK,Vol 17. No II 721

most appropriate? Particularly because I am male. What arethe implications that flow from this? How will I deal withthis situation when I am a registered practitioner and mighthave to deal with this on my own? What will it be like?How will I respond? What is the paradigm of professionalconduct in this area? All of which I thought, but I did notknow the answers to all those questions, so my approachwas a cautious one.

The Nursing and Midwifery Council's (NMC) Tlic Code:Standards of Conduct, Performance and Ethics for Nurses andMidwives (NMC, 2008) states that the professional nurseis personally accountable for protecting the interests anddignity of patients and clients regardless of their personalcharacteristics or circumstances. Paramount in my mind waspreserving the patient's dignity, not only because the Codesays so, but human decency requires it. Dignity appearsto be the guiding light of intimate treatment, guidingnursing practice. 'Dignity must he protected at all times'(Peatc, 2005). One of Coller's (2006) four core values isrespecting and protecting patients' dignity and sense ofself-respect, especially when illness or other circumstancesmakes them particularly vulnerable and powerless (Coller,2006). The Code is there to protect the public, and servethe client, including protecting their dignity. Withoutfurther experience on how best to act in these situations, Irecognized and acknowledged my own limitations, mainlythat I am only equipped to observe thus far and to takeinstruction from the qualified nurse, spraying dressings withsaline solution, for example. I am still at the novice stage inlearning and doing (Benner, 2001).

I kept my eyes down for most of it, looking could easilybe misinterpreted and I kept a good distance back so as notto be too invasive. I looked now and then, so as to see andlearn, but I reduced it to the bare minimum. Nurses mustwork together to bring about healthcare environments thatare conducive to safe, therapeutic treatment and all withinthe gamut of ethical practice (NMC, 2008). My conduct,therefore, had to be ethical and this was achieved by directlyobserving periodically w îthout staring.

1 did feel slightly protected by my uniform and the factthat my uniform has meaning to others, thus requiring meto uphold the highest standards. Despite the uniform, mygender does make a difference. Women are seen as natural-born carers, and thus good nurses; the experience of menin nursing, in stark contrast, is a different story (Seed. 1995).Seed's study found that 'female nurses found it difficult toaccept the fact that their male colleagues should be fullyinvolved in the care of women'. Even though there arereports of instances where female patients see a male nurseas a breath of fresh air (Smith, 1992), societal expectationsand stereotypes are in full force. Did the patient see astereotype of a nurse observing the procedure or did shejust see a caring person training to be a nurse before her?Does she have faith in my professionalism? Did I liveup to the unspoken professional promise? I think that Idid; I certainly endeavoured to. It reflects upon me as anindividual as well as a future professional, as according toFagermoen (1997), 'the nurse provides care in a form ofself-presentation through which nurses actualize their values

and communicate their personal meanings' (Fagermoen,1997). Therefore, it follows that it is impossible to predicthow gender plays a part in the professional nursing role andmoreover it is impossible to generalize gender equity incaring relationships (Smith, 1992: Seed, 1995).

This second stage of the Gibbs cycle provides a sectionto explore how I felt and the thoughts 1 had. This andits complementary section were the most important partof my exploration and learning process. My commentswere not directly restricted to my 'thinking' and 'feeling',accompanying them were some elucidation of the storyand also evaluation, supported by evidenced-based research.This seemed to be the most natural and productive way oflearning from the experience and enabling me to presentthe information in an informed manner. Gibbs' cycle,therefore, has undergone some expansion here, such anapproach was necessary for learning to emerge and toenable the flow of accounts.

What were the thoughts and feelings of othersInvolved? How do you know?My intuition led me to believe that the nurse I accompaniedhad no discernable feeling one way or the other about thesituation. She acted as a professional, i.e. a task had to bedone and she did it. In many ways it is just another woundto be cleaned and dressed, albeit in close proximity togenitalia. On the other hand, the patient must have beenembarrassed; in today's society, private parts remain privateand exposure to others is restricted. Permitting strangers tosee her genital area must have felt invasive. Especially withme observing the dressing procedure, and as a male studentnurse, I felt superfluous to the process and only added to thepatient's discomfort. But she seemed to accept my presence;more than likely because her priorities at that time were tomake a full recovery and take life day by day. Professionalcaring properly understood, is a moral imperative, borne ofaltruism and a sense brotherhood (Dowling, 2004), a senseof which I had on this occasion. This poses no problem solong as the patient understands and has faith in her carers asprofessional practitioners.

The third section of the Gibbs process required meto delve into what others thought. As such it demandedan empathie view, putting myself in their shoes. Thisstage was useful because it allowed the fusion of what 1observed: their body language, the things that were said,and the way I might have viewed things if 1 was in theirsituation. This stage of the cycle permitted me to analysehow I perceived the motives and reactions of others. I wasenabled to tease out the 'commonalities and differences'in other's views (Benner, 1994), which is the very goal ofinterpretive phenomenology. It is here where personhoodand individuality can be examined.

What other options were open to me?Not many other options were open to me. I could havebeen less sensitive and stood closer, thus enabling me toobtain a more detailed view of the nursing care applied.However, at what cost? The patient's dignity could havebeen needlessly intruded upon, violating tbe principles

722 British Journal of Ni.rsJi)g, 2(108, Vol 17.No II

REFLECTIVE PRACTICE

in the NMC (2008) Code. Hence, I felt that no betteraltcrndtc options were open to me. This fourth stage ofCiihbs" cycle therefore provided only the opportunityto explore the negative consequences of my presence.Learning, through reilectioii, enhances an ethical senseof the morals of nursing practice, and thus provides theanswers to why. In the world of nursing knowing why is thedifference between mechanistic repetition, and acting as aconsequence of knowledgeable decision-making.

What would I do If the situation arose again?My conduct would be similar. Patients are people and:i people are different, some are indifferent, others areconcerned. In the times subsequent when I revisited thepatient my approach was similar (and will be in the future).To safeguard the dignity, respect and trust of the patient itis better to err on the side of caution and be aware of thesensitive nature of intimate nursing care. It seems that achaperone, in any intimate examination/treatment, can beuseful to both patient and nurse {Peate, 2005), especially inthis age of lawsuits. The Royal College of Nursing (RCN,2002) recommends actively providing a chaperone whenattending to intimate nursing care procedures.

On balance, initially I need not have been so demure.It is easy to intrude upon a patient's privacy, especiallyif their preferences are not known (Back and Wikblad,Í99H). Caution was appropriate here because space, touchand interaction are seen differently by different people(Edwards, 1998). Such views relate to varied criteria, suchas gender, age and even height, more often unknown to thestranger (Edwards, 1998). My own personal values can havea profound influence on the way 1 interact with patients onwhatever level, one must be aware of this and the potentialfor problems to arise, hence my cautious interaction withthe patient in this case. Although, I think my inherent valueshelped, they could be a hindrance in other circumstances,for example, being needlessly cautious. But, by numerousvisits and observing a tittle at a time, I have been able to putthe treatment together in my head, like a jigsaw puzzle, so 1have been learning without being too obtrusive.

One easily adjusts to situations. For example, in the areaof leg ulcers, what at first repulsed, is now just anotherwound. Applied to this situation, one could easily lose sightof the sensitive nature of wounds such as this; the activity isloaded with great risk of becoming ritualized, habitualizedand insensitive when applying treatment, at great cost tothe patient.

At my latest visit, the nurse removed the dressing, thewound had healed, and we thus noted in the paperwork.Aware of the need to re-assess patients, as their situationcould alter, the patient remains on file and we remain 'oncall'. In areas related to this. I will try and keep an 'empathieattitude" (Rogers, 1980) to enable me to better tailor myresponse and better address the chent's needs.

In the fifth and final stage of the Gibbs reflective process,I was able to explore the potential situations 1 could foreseearising again, perhaps with different patients. I could thenapply what I learnt to those future situations. I am now, asa consequence of critical reflection, able to examine my

philosophy as it applied to this event and how it couldcascade to other future events. I was facilitated to look atmyself and see where any impediments may be and thushow a remedy might be fashioned.

Critical reflection (commentary)I feel I need to learn and understand more about theplight of patients in this situation. Dealing properly withthe aftermath of gynaecological surgery is important, it hassignificant imphcations, not only for physiological reasons,but also from a psychological perspective considering theloss of womanhood, femininity and sexuality for patientsundergoing such evasive surgery. It is essential that nursesare aware of the consequences of vulvectomy surgery fromboth a physiological and psychological perspective. Sexualexpression and self-esteem may be impaired as a result.

Almost 15 years ago a qualitative study was conductedthat concluded some surgeries physically 'disfigure' thetreated area (Corney et al, 1992). However, the fear ofrecurrent cancer in the future remained constant as 60% ofpatients in the study stated that fear of cancer recurrencedid not dissipate over time. Potential for major distresswas also uncovered, with 68% feeling markedly or severelydistressed about their postoperation life, younger womenespecially. Sexual problems presented in 76% of the sexuallyactive patients within 1 year of the operation, in contrastto 19% before operation (Corney et al, 1992). Hence, itseems to me that even those who are not sexually activemay have trouble forming relationships, for fear of problemsbeing encountered. The study concluded that support ofemotional needs and information are the best tools to tacklethese problems, and counseUing should be freely available(Corney et al, 1992).

Allowing for questions and givingjargon-free explanationscan also help the patient (Peate, 2005), As my clinicalplacement is in the community, 1 have noticed thatnurses do play a counselling role in some way. offeringinformation and support. I believe this is exactly whatnurses should do and furthermore be observant of non-verbal communication, adopting a holistic approach, andoffering support at the early stages of care. These needsshould be recognized and addressed,

American sources claim that of gynaecologicalmalignancies, 4% of them are vulvar cancer (Di Saia etal, 1979; Venes, 2005). Unfortunately, it is unlikely thatprevention of this disease is possible, it is rare and as of yetthere is no available effective screening method for vulvalcancer (RCN, 2005).

I have learnt a lot from this experience, not just from mypersonal reflection but also from reviewing the evidenced-based literature, in particular relating to a topic I wouldotherwise not have researched. Gibbs' model does notadvocate a concluding critical commentary. Although 1 hadweaved critical elements into the actual reflection, I wascompelled to add this section in order to evaluate the biggerpicture, as in this case, to the related aspects 1 witnessed. Iwas looking to turn this learning experience into knowledgeapplicable in other situations related to intimate treatment.The critical reflective process permitted me to examine and

lintishjinirii.ll of Nursing. 2fK)8.Vol 17, No 11 723

reflect on the psychological aspects of this type of surgeryand thus transported me beyond this stage to engage in thethoughts and feelings of others involved, as that was basedupon contemporaneous assessment and some afterthoughtand interpretation. My analysis uncovered real studies ofreal people exploring knowledge beyond what I couldobtain from the patient. The efficacy of the Gibbs processstimulated me to learn more. Perhaps an interesting additionto the cycle would be a section that is updated at a later date,so progress can be gauged.

ConclusionThe foregone discussion demonstrated the potential powerof reflection as a tool for discovery and possible learning.It is clear to me that Gibbs' cycle is of use in manycircumstances. The cycle is cyclical, it can be altered andadapted to the varying situations and crises nurses are facedwith, which means the cycle can be applied to ahnost anyevent or issue. Thus, such a structure is ideal for first-yearstudent nurses, with the lack of complexity permittingbetter engagement with the process. It also follows thatreflection should not be bound in a cast-iron structure, itmay be better to have no structure at all in some cases.More than likely different reflective cycles will benefitdifferent situations, much like a plumber selecting the righttool for the job. There is evidence of Gibbs' framework inmany reflective models (Jasper, 2003), which illustrates thatmany models share a commonality, which implies a sharedknowledge base, thus knowledge obtained from the Gibbscycle would more than likely similarly emerge with the useof other reflective frameworks.

Reflection occurs as a result of a critical thought process;the written word will not fade and can be consulted to aidlearning or mark progress. Reflection is the perfect mediumto evaluate the 'what and how' of nursing care and the widerimplications of inter-professional relations; thus informingother discreet issues. Reflection can be written evidenceand the product of an inquiring mind. The time needed toeffectively reflect is immense, and not withstanding theenergy invested in recalling the experience, writing,researching, reading, synthesising, thinking, followed withmore writing, is significant. But it is a worthwhile exercise,considering the theory-practice gap that Kyrkjebo and

KEY POINTS

Reflection is a well-established tool in learningand is common to nursing programmes nationally.

I The Gibbs* cycle is ideally suited to the reflectiveneeds of student nurses because of its simplicityand malleability.

I Gender plays a role in the application of intimatetreatment.

Reflection stimulates deeper exploration of topics.

Hage (2005) found students witness in practice. Reflectioncan be used as a quality assurance method to evaluate botheflective and poor practice. Moreover, as demonstrated frommy personal reflection on my novice nursing practice,reflection is a potent weapon in the armoury of learningand development. DH

Ackiio u'ieâgem et ils

The author ¡muid like lo liiaiik Paul Liiiilcyfor his support in writing this

article.

liack E,WikbIad K (1998) Privacy in hosphalJ Adv Nim 27(5): 940-5Beniier P (1994) The tradition aiid skill of inCerprerivL- piifnomenology- in

studying healdi, illness, and caring practices. In: Ik-niicr P. ed. liilerpn'tiivPlienomenolt^: Fjuhoiiiitwiit, Cnriiiji, mid Ethics in ikahh MUÍ ¡Umss. SACîEPublications Ine, London: 99-127

Beiiner P (2001) From Novice to Expert: Excclieme mid Power in Clinical JVwrsii;̂Practia: Commemorative edn. Prentice Hall Inc, New Jersey

C'hirenia KI? (2(MI7) The use of rfflective journals in die promotion ofreflection and learning in post-registration nursing students. .Vnr«' EducToday27(3): 192-202

C^oller BS (21)06) The physician-scientist, the state, and the oadi: thoughts torour dnies._/ CUn invest 116(10): 2567-70

Corney R, Everett H, HowelLs A, C^rowther M (1992) The care of patientsundergoing; surgery for gynaecological cancer: the need for information.emotional support and colln^eilillt;._/.-llÍI• Nurs 17(6): 667—71

Di Saia PJ, Greasman WT, Rich WM (1979) An alternate approach to earlycancer of the vulva.J OliiU-t Gytiecol 133(7): 825-32

Dowling M (20(14) Exploring the relationship hetween caring, love andintimacy in nursmg. BrJ Nurs 13(21): 12S9-92

Edwards SC (1998) An aiithropological interpretation of nurses' and patients'perceptions of the use of space and touch. J/IÎÎ!» Nurs 28(4): SO'J-17

Fagennoen MS (1997) Professional identity: values embedded in meaningfulnursing pracdce.J.-^i/i' Nurs 25(3): 86H-72

Cîihbs G (1988) Li-aniiiig By Doing: A Guide to Teaching aiid Learning Methods.FEU, London

Hilliard C (2(XMS) Using structured reflection on a critical incident to develop aprofessional portfolio. Nurs Stand 21(2): 35—40

Jasper M (2Ü03) Bef¡inning Ri;fícni"c Pr¡ictia': Foundations in Nursing and HvnlihCcire. Nelson Thornes Ltd, Cheltenham

Johns c; (2(M.)6) Engaging Reflection in Prmiice: A Narrative Approach. BlackwellPublishing Ltd, Öxfoni

Keen A (20110) Critical incident: reflection on the process of ternuna! weaning.

Kyrkjebo JM, Hage I (2005)What weknow and what they do: nursing students"e.xperiences of improvement knowledge in clinical practice. Nurse Bduclbday25(3): 167-75

Matthews E (2004) Concordance with pain medication: reflection on anadverse incident. BrJ Nurs 13(9): 551-5

Mooney M, Nolan L (2006) A critique of Freire's perspective on critical sotiiiltheory in niiriing education. Nurse Educ Thdijy 26(3): 24(t-4

Nursing and Midwifery C'ouncil (20U8) T¡ie Code: Standards oj (Conduct,Performance ami Ethics for Nurses and Midmi'es. NMC, London. Available at:http://tinyurl.coni/6kdup6 (last accessed 5 June 2008)

O'Callaghan N (2005) The use of expert practice to explore reflection. Nur.iS/flH^ 19(39): 41-7

O'Donovan M (2007) Implementing reflection: insights from the pre-registration mental health students. Nurse EducToday 27(6): 610-6

Peate I (2íH)5) Examining aduJt male genitalia: providing a guide for the nurse.

Rogers C R (1980) A Way of Being. Houghton MiSlin Company, Boston, MARoyal College of Nursing (2002) Chaperoning: The Rote of the Nune and thv

Rights of Patients. RC^N, LondonRoyal College of Nursing (2005) Gynaecologiml Gan(er – Guidanœ for Nursing

Staff RC'N, London. A™!ahle at: http://tinyurl.coni/6rkx5a (last accessed5June2(X)8)

Schutz S, Alcove C, Sharp P (2004) Assessing and evaluating reflection. In:Bulrnan C, Schutz S, eds. Rißvctivt- Practice in Nursing. 3rd edn. BlackwellPublishing Ltd, Oxford: 47-72

Seed A (1995) Crossing the boundaries – experiences of neophyte nurses. J / I lii»'»r.-21(6): 1136-43

Smith P (1992) Tlw Emotional Labour of Nursing — How Nurses Care. TheM.îcmillan Press Ltd, London

Venes D (2005) 'laher'f Cyclopedic Medical Diaionary. 20th edn. FA DavisCompany, Philadelphia

Williams GR, Lowes L (2C)01) Reflection: possible strategic"s to improve its useby quali6ed staff. BrJ Nurs 10{22): 1482-8

724 Urirish Journal i>f"Nvir4ini:,2()llM.V(il 17, N o li