Reflection has increasingly become an essential element of nursing professionalism. However, the term ‘reflection’ is not clearly defined in the literature and most definitions could be described as complex or vague (Atkins and Murphy 1993). Williams and Lowes (2001) define reflection as;
‘….a way of exploring and evaluating previous experiences and appreciating their value on personal practice and self.’ (pg. 1)
Reflection is important to student nurses as it enables us to look at ourselves and our practice objectively. However, Mackintosh (1998), as well as other authors, are dubious that reflection can do all that it claims to do. What is agreed by nursing writers is that we can grow and mature as both a professional and a person by integrating our theory and knowledge into practice. The process of reflection can help move us from a student, to a nurse, and later to a competent and expert practitioner (Benner 1984). As nurses we should have the competencies to identify and respond to issues and make decisions that are informed and based on knowledge.
All healthcare professionals make daily decisions that have ethical implications. Ethics for student nurses can be challenging as many of these decisions are emotive and students find these feelings hard to dismiss and difficult to rationalise (Clarke 2003). In their study, Ellis and Hartley (2001) found that student nurses expressed concerns over ethical problems and their ability to deal effectively with them. With the focus on a legal and ethical issue which I encountered whilst on clinical placement, I will reflect upon and critically analyse the issues raised in the incident using a recognised model of reflection. The model which I have chosen for this purpose is Borton’s Reflective Framework (1970, in Jasper 2003) which is increasingly being used by healthcare professionals as an approach for reflection. Jasper (2003) describes Borton’s model as simple and pragmatic, which meets the needs of practitioners to describe, make sense of and respond to situations. However, the model has been criticised and Rolfe et al (2001) suggest it does not include the finer details of reflection and offers no prompts as to how reflection is to be conducted within each stage of the process. Even so, Rolfe et al (2001) do state that in comparison to Gibbs’s (1988, in Jasper 2003) and Johns (1998, in Johns 2005) models of reflection, it can be seen that the activity of reflection leads to action being taken in Borton’s framework, rather than just proposed, therefore moving from the realms of ‘maybe’ back into the reality of practice. The simplicity of the model and the proposal of action being taken in future situations prompted me to consider this model for this assignment purpose. Also, when reviewing the literature around reflective models, I found evidence by Burrows (1995) to suggest that nursing students under the age of 25 do not have the cognitive abilities and experience to reflect and alter their practice. Bulman and Schutz (2004) reiterate this perspective by implying that less mature students are more inclined to use more descriptive models such as Gibbs rather than more advanced, as these may not be of any use to them. As I would consider myself a mature student and want to develop my knowledge beyond that of a novice practitioner, taking into account the simple structure of the model as discussed, I feel that Borton’s Reflective Framework (1970) is an appropriate choice to use as a guide to my reflective account.
The incident I have identified to reflect upon involves the refusal of further treatment by a patient who is terminally ill. With a view to gaining new knowledge, insights and to further develop as a nurse practitioner, I will reflect upon the ethical and legal issues that arose from this encounter. These include autonomy, beneficence, capacity and informed consent, as well as my own feelings and preconceptions. I will maintain confidentiality throughout this assignment by changing the names of those persons involved incompliance with the Nursing & Midwifery Council (NMC) ‘Code’ (2008).
Reflection in nursing
Reflection is not just about adding to our knowledge; it is about challenging the concepts and theories as we try to make sense of that knowledge (Burton 2000). Kim (1999) argues that constructing knowledge from clinical practice is not enough and that nurses must also reflect on how that knowledge can lead to intentions to act. Several authors distinguish a gap between theory and practice in nursing (Conway 1994; Lauder 1994) and suggest that reflective practice may be the process with which to alleviate this. However, these authors do not support their claims with any evidence and are only offering opinion. The question still remains as to whether reflective practice produces better patient care as intended as there is very little research evidence on the benefits of reflective practice in nursing (Hargreaves 1997). Burton (2000) further reiterates this point by recognising that reflection relies entirely on information from patients and claims to be to their benefit, but is researched solely in the terms of the effects on practitioners.
Reflective practice is also a fundamental concept of nurse education, with students encouraged to challenge their clinical practice and widen their knowledge base. However, Mackintosh (1998) stated that;
‘The implementation of reflection for students is as uncertain as its definition, with no guidelines or uniform method of application available.’(pg. 7)
This criticism is evident in more recent literature, with Ireland (2008) and Hong and Chew (2008) both recognising that there are no definite guidelines on how to structure reflective practice in education. Writing reflective journals is one way reflective practice is encouraged in education as it allows students privacy and also to look back at previous entries to see how they have developed as nurse practitioners. However, Hargreaves (1997) suggests that reflective journals can be repetitive and time consuming, leading to boredom for the student. Hargreaves (1997) also proposes that when students are required to reflect in groups, this can lead to low self esteem as there is a lack of privacy. Also, when reflecting-on-action for assessment purposes, students may feel anxious about writing open and honest accounts in case of bad marks, leading to them writing what they think others want to hear and not the truth (Teekman 2000). When reflecting-on-action for this assignment purpose, I have been aware of these issues and this has encouraged me to reflect a true account of the incident, regardless of how difficult I may have found it to expose myself in such a way.
Ethical issues relating to confidentiality also arise when reflecting, both for the person writing them and for the patient, as writing ‘stories’ about them without their consent can been seen as bad practice. However, Hargreaves (1997) argues that nurses have always ‘used’ patients and it is these experiences with patients that shape practice and it can be proposed that if a patient’s case is discussed but she has no knowledge then it can cause no harm and may actually benefit the patient directly or indirectly (Hargreaves 1997). Despite these criticisms, as opposed to giving care uncritically, reflection allows nurses to examine, question and learn from their experience and Andrews et al. (1998) recognise a danger of nursing care becoming ritualistic if it is not challenged.
Using the three basic starting points in Borton’s Reflective Framework (1970) as a guide to the structure of my account, I am now going to reflect on the ethical and legal issue which I encountered recently whilst on clinical placement.
What?
It is important to recognise before recounting the incident, that as well as students being inclined to alter the scenario when reflecting-on-action as acknowledged, hindsight bias (Jones 1995) is also a concept by which a person’s recollection of events is influenced once they know the final outcome of the situation. Factors involved in hindsight bias are the desire to appear correct, maintain self esteem and to enhance feelings of competence (Jones 1995). Also stressful situations can affect attention and Saylor (1990) concluded in his study on recall, that for novice nurses and students in difficult interpersonal situations, such as topics on death, these are likely to cause stress resulting in less important issues being remembered.
I had been involved in Mrs Jones’s care for a number of weeks and I was aware that she had returned from theatre the day before where she was to have had a secondary tumour removed. I was also aware, as was she, that she was terminally ill. I was in the room with Mrs Jones and her husband and we were chatting as I did her clinical observations. She was telling me that she was not afraid of dying and that she had been very lucky and had had a wonderful life. I felt very saddened by this and can clearly remember thinking to myself that I must remember what they told us in University about communicating with the dying patient, as I didn’t know what I was going to say once she finished speaking. In the end I decided that it was best if I say nothing rather than saying something inappropriate. This made me feel guilty at my own incompetence.
The consultant then entered the room with my mentor and I asked my mentor if I should leave, but Mrs Jones insisted that I stay. The consultant then told Mrs Jones that they had been unable to remove the tumour. Mrs Jones nodded at this and said that she thought that would be the case. I suddenly felt out of my depth and wished I could just leave the room. The consultant continued by saying that he could offer Mrs Jones radiotherapy to try and shrink the tumour and prolong her life. He told her the side effects of the treatment, the frequency and also that it would not cure her, only ‘give her more time’. Mrs Jones stated that she did not want any more radiotherapy and just wanted to be pain free. I felt quite upset at this point and was trying not to make eye contact with anyone else in the room as I knew I would probably cry. The consultant continued by saying that although radiotherapy had side effects, it could add months to her life, and that there were options available to help counter the side effects and that it might be worth considering. I remember thinking that Mrs Jones will probably decide on the radiotherapy if the doctor says it is the best thing to do, I couldn’t make sense of why she wouldn’t. Mrs Jones stated again that she did not want any further treatment, that she had discussed it with her family and that all she wanted was for her kids to see that she was happy, pain free and peaceful. Mrs Jones’ husband was crying at this point but told the consultant that they had talked about it and that he respected his wife’s decision and they would now like some time alone. At that the consultant, myself and my mentor left the room. The incident played on my mind immediately afterwards and although I wanted to talk with someone about it, I knew if I opened my mouth to speak I would cry so I busied myself with other things.
So What?
I had nursed Mrs Jones for a number of weeks and felt personally affected by her prognosis and her refusal of treatment to prolong her life. Mrs Jones was the same age as my own mother and had similar family dynamics to myself. I felt guilty that I could not offer some sort of comforting response when talking with her and during her interaction with the consultant. The feeling of guilt elevated as I felt inadequate to respond in what I felt was an appropriate manner. A study carried out by Kelly (1991) found that feelings of guilt are evident in students and appear more frequently as students gain experience. These findings are similar to those of Smith (1998) who concludes that guilt feelings in students are associated with a perceived inadequacy of personal responses and ethical dilemmas. The more experience gained, the more students felt fearful and guilty as they worry about what will be expected of them. I can relate to this evidence having worked in the health care setting for a number of years prior to starting my nurse training and now being in my second year, I have high expectations of myself and my practice. I feel that if I don’t match up to these expectations, and what I believe other people expect from me, I am letting myself and others down.
Smith (1998) recognises that students develop coping mechanisms such as detachment and adopt these when they are in situations that are difficult for them. I tried to detach myself from the situation by not making eye contact or speaking as I felt out of my depth within the situation. Although detachment can be seen as a threat to the nurse-patient relationship, Smith (1998) concluded that some degree of detachment is necessary for students to maintain the ability to function and prevent breakdown. I adopted this coping mechanism to prevent myself from crying and upsetting the situation further, which appears to support the findings proposed by Smith. However in a study carried out by Kralik et al (1997) on patient’s experiences in hospital, the participants stated that, when cared for by nurses who appeared detached, it was a negative experience and they felt vulnerable and insecure. I am aware that if I allow detachment to become embedded within my future practice it may affect my ability to offer compassionate care to patients.
Although I was aware of the knowledge around communication with the terminally ill, I was unable to reflect-in-action and apply this knowledge to practice. Schon (1983) describes reflection-in-action as the way that nurses think and theorise about practice whilst they are doing it. This is seen as an automatic activity that occurs subconsciously in practice. According to Street (1992), students experience difficulty connecting theory with the realities of practice. However, Street does suggest that there are indications that students are able to integrate theory gained in the classroom with practice, but at first it is deliberate and conscious. This evidence suggests that reflection-in-action is developed through experience.
I felt upset that Mrs Jones did not want any further treatment and I kept thinking that if it was my own mother I would want her to stay alive as long as possible. I may have felt like this as I did not want to experience the grief that comes with death, which appears now to be a selfish act.
The refusal of treatment with a view to end of life can sometimes be associated with voluntary euthanasia. This term involves the deliberate intervention or omission with the intent of ending an individual’s life at their request (Saunders and Chaloner 2007). Despite a Bill passing before parliament on assisted dying or assisted suicide, existing laws remain unchanged and euthanasia of any sort is illegal in the UK. However a person’s right to refuse treatment is legal in the UK and is supported in the NMC ‘Code’ (2008) which states; ‘You must respect and support people’s rights to accept or decline treatment and care’. Although the consultant was persistent in his offer of further treatment, he did not at any time disregard Mrs Jones’s decision to refuse treatment. UK law goes to great lengths to protect a person of full age and capacity from interference with personal liberty. In the case of Sidaway v Bethlem Royal Hospital (1985) it was stated that;
‘a capable adult has an absolute right to refuse to consent to medical treatment for any reason, rational or irrational, or for no reason at all, even where that decision may lead to their own death.’ (Lord Scarman 1985 pg. 3)
This absolute right has been upheld in more recent cases such as Re T (adult: refusal of medical treatment) (1997) and Re B (adult: refusal of medical treatment) (2002). The courts also recognise that in law there is a distinction between letting die (refusal of treatment) and killing a person (euthanasia), even though this is not accepted by some philosophers (Dimond 2005). Saunders and Chaloner (2007) question whether there is a moral distinction between withholding life sustaining treatment at the patients request and actively taking steps to end the patient’s life at their request. However, a concept that is shared amongst UK law, literature and philosophers is the respect for a person’s autonomy. This makes me consider whether the consultant, despite his persistence, did not disregard Mrs Jones’s decision as he was respecting her right to be autonomous.
Buka (2008) proposes that to be autonomous means to be able to choose for oneself and involves individuals being able to formulate and determine the course of their own life. Autonomy consists of values and beliefs that are unique to the individual and that change with circumstances, so what Mrs Jones considered to be of value to her prior to her illness could well have changed at the time of the incident. Also what Mrs Jones believed to be of value to her could very well be different to what I would consider to be of importance. Begley (2008) acknowledges that dying well involves living well until the end of life and living well throughout the dying process depends on the responses of each unique person to the conditions in which they find themselves. Mrs Jones spoke about wanting her kids to see she was happy, pain free and peaceful, which appeared to me to be her main priority. Mrs Jones also spoke about how she was not afraid to die and that she had had a wonderful life. In their study of patients with incurable cancer, Voogt et al. (2005) found that while approximately a third of the participants strove for length of life, a third wanted quality of life. Mrs Jones’s values and beliefs may have been intertwined with an autonomous decision to die with dignity. Radley and Payne (2009) suggest that when people refuse treatment later on they want to spend quality time with their family without the side effects of treatment. Tingle and Cribb (2007) also recognise that although medicine can now provide the means of staving off death, the cost to the individual may be too high. Some may not want to spend their last days or weeks attached to tubes and drips. Tingle and Cribb further reiterate their point by proposing that it needs to be recognised that even if the pain of those who are terminally ill can be controlled, what they may fear the most is the technology that potentially leads to a loss of self-respect and self esteem. The concept of dying with dignity is supported in UK law, and Article 3 of the Human Rights Act (1998) states that ‘no-one shall be subjected to torture or inhuman or degrading treatment or punishment’, an article which can be used to support cases of withdrawal of treatment. An autonomous person is also defined by Beauchamp and Childress (2001) as an individual who has the capacity to make decisions for themselves, as well as being competent to evaluate and deliberate information in order to reflect their own life plan.
Capacity in the law is defined as the ability to understand information and make a balanced decision (Griffith 2007). Capacity is a fundamental component of autonomy and the Mental Capacity Act’s (2005) starting point is the presumption that a person has the capacity to make decisions for themselves unless it can be shown that they are incapable. Mrs Jones had been involved in decisions to do with her care throughout her treatment and the consultant knew her well. However, Tingle and Cribb (2007) suggest that patients are not very good at saying when they don’t understand and Pellegrino (2004, in Harrison et al. 2008) found in his study that patients suffering from cancer are on a negative spiral of events which may diminish their clinical competence and result in feelings of ‘powerlessness’. This evidence could suggest that Mrs Jones may have felt that she did not have the power to not only make a competent decision, but to tell the consultant that she did not understand what he was saying. The decision of whether a person has capacity is to be made at the time of the decision making (MCA 2005) and Larcher (2005) acknowledges that clinical competence may fluctuate, depending on the circumstances and compounding factors such as pain. Mrs Jones had regular analgesia to control her pain and did not before, during or after the encounter make any complaints of discomfort. She had support from her husband and was familiar with her surroundings as well as the staff present in the room. All these factors indicate to me now that Mrs Jones had the capacity to evaluate and deliberate the information given to her and make a decision that reflected her own life plan.
The main principle of the Mental Capacity Act (2005) stresses that a person’s right to autonomy must be respected and can be further supported by requiring steps to be taken to maximise decision making capacity. One of these steps is informed consent. The Mental Capacity Act (2005) states that information given must include the nature of the decision, the purpose for which it is needed and the likely effects of any decision made. The need to weigh the information as part of the process of making the decision has been described by the courts as;
‘The ability to weigh all relevant information in the balance as part of the process of making a decision and then use that information to arrive at a decision.’ (Re MB Caesarean section 1997, in Griffith 2007).
The consultant gave Mrs Jones information about her prognosis and treatment in compliance with the Mental Capacity Act (2005) as well as other health care policies (DOH 2007; 2008). He disclosed the factual details such as the advantages and disadvantages of the treatment and the potential side effects of undertaking further radiotherapy. However questions still arise as to how much information needs to be disclosed to the patient before consent can truly be said to be informed. As a moral matter it has been suggested that you should disclose whatever information a reasonable person would want to know plus whatever further information the actual individual wants to know (Radley and Payne 2009). However, research carried out by Clarke (2003) does suggest that patients demonstrate poor levels of knowledge and comprehension, particularly where bad news has been given. When the consultant told Mrs Jones that they hadn’t been able to remove the tumour she had replied that she had thought that might have been the case. This indicates to me that Mrs Jones had already taken the time to consider her options and the possibility that the tumour may not be removed, prior to the encounter with the consultant.
Seymour (2001) proposes that the informed decision to refuse treatment may be about regaining control in a situation where there may be few desirable options. Radley and Payne (2009) suggest that the decision to refuse treatment, is not a rejection of medicine but a rejection of false hope or an acceptance of another sort of hope in which quality of life is preferred over quantity of life. Mrs Jones had undergone intensive treatment in the months leading up to this final prognosis and I now consider that the finality of this diagnosis may have given her not the opportunity to ‘give up’ but to spend quality time with her family without the side effects of a treatment which was not going to cure her. Therefore Mrs Jones was taking positive steps to safeguard the death she wanted.
After Mrs Jones initially refused the treatment the consultant went on again to say that ‘it could add months to her life’. I thought at the time that Mrs Jones may take time to consider this again given that the consultant was to me the ‘expert’. From a medical viewpoint, death is seen as a failure, rather than as an important part of life (Smith 2000), so there may be a conflict when a patient chooses to make a decision that is likely to end in death. Physicians who are unable to keep patients alive may struggle to avoid experiencing an inevitable sense of failure (Clarke 2003) as it is widely accepted that medicine’s primary goal is to restore a person’s health (Heaney et al. 2007). By offering Mrs Jones a treatment to delay the inevitable the consultant was acting in a beneficent manner and tension can arise when beneficence and autonomy are in conflict. With advanced medicines today life can be sustained for longer periods, however Van Kleffens et al (2004) found in their study that for the patients who refused the treatment, their decision was not based on the pros and cons of treatment from a medical perspective but a ‘circumstantial basis’. In a further study by Van Kleffens in 2005, the patients who decided not to accept further treatment said it was based on their own experiences, values and meanings in life. Voogt et al (2005) also proposed that physicians do not engage sufficiently with the world of the patient that extends outside of medicine. So although the consultant knew Mrs Jones well and had been involved in her care for many months, he had only been associated with her in the medical concept. Contemporary opinion suggests that where there is tension between autonomy and beneficence, autonomy should take precedence (Dimond 2005).
Now What?
Mrs Jones passed away how she wished, in hospital surrounded by her family. Consideration of the ethical and legal principles discussed required a depth of knowledge that I as a student did not hold for this particular situation which was to me personal, complex and difficult to define. From reflection on this incident I recognise now that I have gaps in interpreting theory into practice. Benner’s (1984) work proposes that nurses move from novice to expert as a result of both experiences and training. By analysing the situation with reference to theories and concepts, I have come to realise that only through experience, greater knowledge and confidence will these gaps begin to close.
I now know that no one solution was correct nor was it incorrect. Nurses have a legal and moral duty to act in a beneficent way which at times may conflict with the autonomy of the patient. However, providing the patient is of age and has the capabilities to make informed and balanced decisions, in cases of conflict the law will favour autonomy over beneficence. I have come to appreciate that the patient is the only one who can decide what matters to them and what is good based on the information given and as a nurse I am in a position to recognise when patient autonomy is at risk of not being respected and help to restore it. This would then result in the principles of autonomy and beneficence working in partnership rather than in conflict, with the act of beneficence being the action that increases the autonomy of the patient.
The process of reflection can bring up painful emotions again but if followed properly and supported appropriately, it can help the reflector to come to terms with their emotions and move on. I now know that the feelings I expressed were natural for a novice like me. Should this particular situation arise again I know I would be able to take this new knowledge with me but am unsure as to whether it would diminish my feelings of sadness, I am however confident that I could now put them to one side.
Conclusion
Reflection is an important aspect of nurse education and can assist student nurses in linking theory and practice and in developing self-awareness skills. Borton’s (1970 in Jasper 2003) reflective framework has assisted me in both reflecting on what was to me a difficult and personal experience and being able to structure an academic assignment based on it. Even though critics claim that Borton does not include the finer details of reflection or any guide as to how reflection is to be conducted within each stage of the process, I found that these omissions allowed me a wider scope and more freedom to analyse and challenge the situation and my own feelings. Had I used a model such as Gibbs (1988 in Jasper 2003), which consists of prompt questions, it may have restricted my reflection as I tried to answer the specific questions.
I am aware of the negative elements of reflection but feel that by acknowledging these within my assignment I was able to conduct a reflection that was an honest and true account. The ethical and legal issues that arose in the incident were autonomy, beneficence, capacity and informed consent. All these issues are interlinked and have an impact on each other and I now understand that each must be considered both as individual components and together in order to gain an accurate perception of a situation and provide patient centred care. My professional knowledge and understanding of these issues and the importance of reflection in nursing has increased considerably by completing this reflective assignment. I understand that by reflecting on situations that occur within clinical practice I will gain new insights, knowledge and understanding therefore empowering me in my practice. This will enhance my nursing practice in future in variety of ways, in particular by assisting me in continuous professional development throughout my nursing career, as required by the NMC (2008).
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