An example journal - use this as a guide! Journals are to be scholarly written and should reflect a 4th year university student quality. APA format, 3-4 pages, use of SCHOLARLY research to support your thoughts. Do not confuse Journal with the term “Diary”. The student hand guide elaborates on this further and you should be familiar with journaling at this point. I expect quality work on this one assignment. PLEASE WATCH FOR PLAGIARISM.
My story (Event)
Upon completion every nursing program, it is required to consolidate at the end to gain more experience and knowledge. In the beginning of the winter semester, we were required to chose three places where we would like to consolidate. I chose dialysis as my first placement, ambulatory as my second and long-term care as my last option. I received an email week prior about dialysis placement which made me very excited. I chose dialysis unit because I found it fascinating when it was covered in complex health challenges course. I started my consolidation in the second week and to my surprise it was different from what I expected.
On my first day, I was welcomed well by the staff and clients. In the middle of the shift my preceptor oriented me to the unit and informed the unit was an outpatient and required special certificate to practice and moreover, they only accept nephrology students not nursing students. In the second week, I got hang of routine and started helping with vitals and basic assessments. I asked my preceptor my expectations, she emailed the student recruitment manager because she was not sure. Based on the email that received from the recruitment manager, I was limited to a lot of things at the unit. I tried talking to my preceptor if I can connect and disconnect patients from the dialysis machine and she said that also requires special certificate. My preceptor told informed me to observe and assist with basic things such as pre and post assessments. It made me feel bad because I felt like I will not be utilizing my nursing skills and also will not be learning at this stage of my education. I emailed my faculty of my concerns and I was informed it might be too late to switch to another facility.
What is learned is from this situation is to conduct a thorough research prior in making big decisions in life as well my nursing career. Consolidation is a big part of my education and choosing dialysis without unit without thorough research can impact me in my practice. I feel I would have benefit from other units than the dialysis units. Though dialysis may be different, I will do my best and learn as much as I can by asking questions, making notes at the unit, watching Youtube videos, reading nursing journals on dialysis and conducting research on hemodialysis.
Example of what is expected. ( Journal)
Title
In the Intensive Care Unit (ICU), decisions about continuation of life-saving measures and end-of-life care are commonplace, and often incur feelings of moral and ethical distress among all care partners, including patients’ families. Prior to my clinical preceptorship experience, I took steps to try and prepare myself mentally for the role, reviewing nursing skills and knowledge I felt relevant to ICU patient populations. I was unprepared for the emotional burden of being involved in these decisions, as well as the feelings of confliction that would come from providing care for life-extending measures and seemingly futile interventions. In my short time in the ICU, I have realized that despite the team’s best efforts, there is a great deal of patient suffering and loss of dignity that occurs. This aspect of critical care appears to be challenging for team members, in particular the nurses who are providing the bulk of the day-to-day medical and personal care for these gravely ill patients.
Trigger Event
In my first few weeks of clinical I cared for three different patients that had complex medical histories, were critically ill with multi-system organ failures, had poor projected outcomes and high mortality risk, underwent multiple invasive treatments and procedures, and appeared to be suffering significantly. They all showed physical signs of pain with routine care, they had significant skin breakdown, required ongoing cardiovascular and respiratory support, and had few appropriate neurological responses. All three patients died in the ICU eventually, but only after days and weeks of prolonged care measures. It is obvious to me that the decision to withdraw life support for a loved one is not something taken lightly and causes pain, guilt, and countless other emotions for family members put in these positions; despite this, I was left wondering if and why families are unable to see patients’ suffering, and how appropriate it is for nurses to convey their observations in these situations. A physician also suggested that it is more a ‘loss of dignity’ that health care workers are
able to appreciate in these patients rather than physical pain, and though the loss of a dignified death is no doubt perceived by nurses in many circumstances, I wondered if that was something distinct from the physical suffering I witnessed in the ICU.
Appraisal
The nature of death and dying in the ICU makes it difficult to understand, and there is little research to understand patients’ experiences at end-of-life, however suffering may be considered in the context of total pain, which includes psychological, emotional and physical distress (Su et al., 2018). A study completed of nurses’ perceived suffering among ICU patients receiving Renal Replacement Therapy (RRT), which is a treatment used to prolong life in patients with kidney injury, found perceived elevated suffering in the last week of life for patients with acute kidney injury (AKI) (Ramer et al., 2021). It found that these patients also experienced more symptoms such as painful skin issues and fecal incontinence that contributed to suffering, and the level of suffering was related to factors caused by the RRT itself or the pre-existing AKI, and other factors such as a patient or substitute decision maker’s preference for aggressive, life-prolonging care measures (Ramer et al., 2021). Su et al.’s (2018) study supports this finding and suggests that as many as 41% of patients experience severe suffering in the week before their death and 33% encounter loss of dignity.
Survivors of ICU admissions with positive expected health outcomes also experience reduced quality of life (QOL) in a number of domains, reporting ongoing physical, mental, and cognitive issues, as well as new dependency and health comorbidities (Geense et al., 2021). Herbland et al. (2017) studied thank-you letters from ICU survivors and found themes in recounts of their ICU experiences, which included the unpleasantness of the ICU experience; They referred to negative physical aspects such as pain, mutism, nudity, loss of physical autonomy, suffering, and dependency, as well as psychological aspects like anxiety, nightmares, fear, and distress (Herbland et al., 2017). Additionally, there is evidence to indicate that the mental burden on patients’ families persists after
ICU discharge, including post-traumatic stress symptoms, and even though the burden lessens over time their mental health scores are still lower at 12 months after discharge than that of the general population (Alfheim et al., 2019). Family and caregivers often have to support patients during the acute and recovery phases of illness and research suggests that many take sick leave from work to do so, and report poorer mental health (Alfheim et al., 2019).
Exploration
With ample evidence supporting suffering, loss of dignity, and high mortality rates in the ICU, especially in frail elderly people (Flaatten et al., 2017) it is apparent that my observations of this patient population and my emotional reactions to their experiences are substantiated and valid. Nurses are apt at accurately assessing patients’ QOL as well as predicting mortality of ICU patients (Su et al., 2018), and this allows for nurses to best advocate for patient needs and improve care practices for these critically ill patients; however, the complexities and uncertainties of whether care is beneficial or inappropriate make care decision-making difficult for health care practitioners, patients and families alike. As nurses it is important to self-reflect on our own interpretations of QOL as it influences what therapies are considered futile (Chen, 2021), and the practice of self-reflection in nursing is one required by the College of Nurses of Ontario (CNO) (2018). The term “potentially inappropriate” is favoured by ethicists and critical care clinicians over “futile”, and ICU physicians are obliged to only offer clinically and ethically appropriate options for treatment (Chen, 2021). Nurses witness death and dying in clinical settings regularly, and with the prolonged and unprecedented levels of burnout and mental health issues among nurses throughout the COVID-19 pandemic (Registered Practical Nurses’ Association of Ontario, 2021), it is important that nurses recognize and take steps to prevent moral injury and moral distress where they can (Hossain & Clatty, 2021); undignified death and unnecessary pain and suffering are no doubt sources of moral injury within the context of the ICU, and in particular throughout the challenges of the pandemic.
Regardless of these emotional impacts, nurses have a responsibility to provide care to all patients in these situations and require coping tools to mitigate effects on their psychological well-being. One such coping tool may be building moral resilience, which requires nurses to “maintain perspective, keep a situation in context, and understand that some conditions are out of one’s control” (Hossain & Clatty, 2021).
The Canadian Nurses’ Association (CNA) (2017) outlines seven ethical practice recommendations for nurses in all roles, which include the promotion of health and well-being, promoting and respecting informed decision-making, and honouring dignity. In caring for persons incapable of making informed decisions about their own care, and in absence of advanced care planning, nurses must advocate for patients’ best interests ethically while paying attention to the inherent power differentials between nurses and patients and families so as not to misuse power in order to influence informed decision making (CNA, 2017). These ethical principles put emphasis on respecting patients’ and families’ wishes but also advocating for patients’ best interests when decision-making of others is compromising their health (CNA, 2017). The Registered Nurses’ Association of Ontario’s (RNAO) (2020) describes nurses’ roles in decision-making at end-of life as best practice, and support the idea that they play an active role in assisting patients and families come to decisions about their care by providing information and clarifying options and potential outcomes. This should all be done within the context of patients’ and families’ values for end-of-life care, while being aware of how their verbal and non-verbal interactions influence decision-making (RNAO, 2020). I have realized that the appropriateness of nurses’ conveying their observations of pain and suffering to family members is both a delicate balance of therapeutic communication and power in the nurse-client relationship, as well as it is an interpretation of QOL based on my own personal and cultural beliefs. It is also a learned skill that will hopefully come with time and experience.
Integration
Nurses’ perceptions of quality of patient death are lower than that of bereaved family members’ (Su et al., 2018), suggesting nursing culture and experience play a role in how suffering and QOL are viewed. As I transition into my role as a Registered Nurse, there are ways that I can improve moral resilience in these situations and meet the care needs of my patients and families as best as possible. Being an advocate for patients, specifically those who can not communicate for themselves is of utmost importance and may include advocacy for relief of suffering of symptoms, helping families make difficult decisions by providing reliable tools and support (RNAO, 2020), and encouraging improved communication between patients and families and the health care team. It is my impression that in some of these circumstances there is a significant lack of understanding of therapies and outcomes due to poor communication. Nurses place value in discussion of ethical concerns and their perspectives with providers as well as being included in ethics consultations, and organizations should support nurses with resources to resolve ethical conflict (McAndrew & Hardin, 2020). Research also suggests that QOL and functional outcomes are highly valued by patients and families, and what happens after ICU discharge is rarely discussed leaving patients and families unprepared for future challenges (Geense, 2021). Perhaps family members have very basic understanding of the long-term impacts of an ICU admission and have not considered future QOL. Speaking in simple terms and encouraging families to ask questions and be involved in care whenever possible may improve health literacy and provide them with more complete information to assist the decision-making process. Clarifying decisional conflict by discussing concerns and inquiring about patient and family values and belief systems can help improve the therapeutic relationship (RNAO, 2021). Lastly, it is important to not underestimate the trauma and emotional stress family members are enduring when required to make life and death decisions. Family-centered
nursing care is highly relevant in the ICU where patients’ families also experience a wealth of negative impacts and require ongoing grief support from the
How to write.
Example.
Stage 1:
Description of the event Describe in detail the event you are reflecting on. Include e.g. where were you; who else was there; why were you there; what were you doing; what were other people doing; what was the context of the event; what happened; what was your part in this; what parts did the other people play; what was the result.
Stage 2:
Feelings At this stage try to recall and explore the things that were going on inside your head, i.e. why does this event stick in your mind? Include e.g. how you were feeling when the event started; what you were thinking about at the time; how did it make you feel; how did other people make you feel; how did you feel about the outcome of the event; what do you think about it now.
Stage 3:
Evaluation Try to evaluate or make a judgement about what has happened. Consider what was good about the experience and what was bad about the experience or didn’t go so well
Stage
4:
Analysis Break the event down into its component parts so they can be explored separately. You may need to ask more detailed questions about the answers to the last stage. Include e.g. what went well; what did you do well; what did others do well; what went wrong or did not turn out how it should have done; in what way did you or others contribute to this
Stage 5:
Conclusion This differs from the evaluation stage in that now you have explored the issue from different angles and have a lot of information to base your judgement. It is here that you are likely to develop insight into you own and other people’s behaviour in terms of how they contributed to the outcome of the event. Remember the purpose of reflection is to learn from an experience. Without detailed analysis and honest exploration that occurs during all the previous stages, it is unlikely that all aspects of the event will be taken into account and therefore valuable opportunities for learning can be missed. During this stage you should ask yourself what you could have done differently.
Stage 6:
Action Plan During this stage you should think yourself forward into encountering the event again and to plan what you would do – would you act differently or would you be likely to do the same? Here the cycle is tentatively completed and suggests that should the event occur again it will be the focus of another reflective cycle Jasper M 2003 Beginning Reflective Practice – Foundations in Nursing a
