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by
Bert Teekman
e.teekman@clear.net.nz
PURPOSE:
This thesis presents a study of reflective thinking in nursing practice. I
started off by exploring the available literature, focusing on both the general
and the nursing literature concerning reflective thinking. The seminal works of
Dewey (1933) and Schön (1983, 1987) were in-depth examined in order to arrive
at an operational definition of the concept of reflective thinking.
PUBLISHED IN:
Teekman, Engelbert Cornelius (1997). Reflective thinking in nursing practice.
Master’s thesis, Massey University, Palmerstown North, New Zealand. See the abstract of the dissertation in Dissertations,
Theses on this site. Instructions for ordering
the thesis are also given there.
COPYRIGHT AND CITATION INFORMATION:
©Teekman, Bert, 1998. The material on this page may be cited as:
Teekman, Bert (1998). Using
Sense-Making as the research method to explore reflective thinking in nursing
practice: Interview guide with one interview excerpt. Available [on-line]: http://communication.sbs.ohio-state.edu/sense-making/inst/iteekman97thesis.html
MATERIALS PROVIDED ON THIS WEB PAGE:
1. The “standard” questions which served to guide but not restrict the
interviews,
2. An excerpt of approximately 1
hour from the first of 2 interviews from one participant.
SAMPLE USED IN STUDY:
The literature suggested that reflective thinking is most prevalent in those
situations that produce perplexity, inner discomfort, doubt, or confusion. This
study proposed therefore that exploring these unusual, or non-routine, nursing
situations in a step-by-step approach would provide maximum opportunity to
expose not only instances of, but also trends in, reflective thought. All the
situations were self-selected by the 10 participants who were all practising
qualified Registered Nurses. All participants were involved in a minimum of 2
and a maximum of 3 interviews. Each interview lasted 55 to 80 minutes and was
tape-recorded.
THE INSTRUMENT
From a variety of interview techniques developed for Sense-Making, the present
study used the “Micro-Moment Time-Line Interview” (MMTLI). The Sense-Making
approach rejects the perception that any experience/situation can be seen as “a
single entity.” Rather, every experience/situation is made up of a whole range
of interrelated and interconnected micro moments called “steps.” Each interview
began with the participant sharing the “whole” experience or event. To ensure
that the participants could tell their story uninterrupted, I used two tape
recorders. On the first tape the participant shared the event/situation with me
and absolutely no questions were asked. After recalling the event we discussed
and identified together the “micro-moments,” or steps, within the
event/situation. Keeping these steps in mind, the tape containing the entire
event was replayed while the second recorder was activated. After completion of
each previously identified micro-moment the “event” tape was temporarily
stopped while the second tape continued recording. The participant was then
asked a range of questions related to the identified step regarding the
“SITUATION,” the “GAPS,” and the “USES.” Once this step was explored, the event
tape was reactivated and the process repeated. The advantage of using two tapes
was two-fold:
* The participants didn’t lose track of their initial story because there were
no interruptions caused by asking questions,
* The participants had the opportunity
to correct themselves if they had forgotten to mention something while telling
their story on the first tape.
A total of 59 micro-moments were identified and examined. During the second
interview four more questions were asked to obtain a better understanding of
reflective practice. These questions are indicated below in Italic. Please note
that 1 of these questions was already partially included during the first
interview with Susan on a trial basis. A third interview was arranged in those
situations where there was a lack of clarity or potential for misunderstanding.
The analysis of “SITUATIONS” was concerned with the identification of the
different ways in which participants saw their situation, or more precisely,
the analysis centred on the variety of ways in which participants perceived
their movement through time/space. The following questions focused on
“situations”:
* What impact did the experience have on you?
* What emotions or feelings did
you have? What led to them?
* What in the situation
“challenged” you?
* How did you perceive your situation?
“GAPS” have been defined as the questions participants constructed when
confronted with a situation that blocked movement through time and space. The
following questions were used to identify “gaps”:
* How did this event relate to
previous experiences?
* What questions or confusions did
you have?
* What aspects in the situation
prevented you from getting answers?
* What would have helped you, and
how would it have helped you?
“USES” refers to how the
information, gained from self-questioning, helped (or blocked) the
participants’ movements through, and contributed to new or better understanding
of, the situation. It was assumed that examining and coding the nature of these
questions would provide insight into reflective thinking. The following
questions were developed to analyse “uses”:
* What conclusions did you come to
as a result of the experience? What have you learned?
* How did the outcome of this
experience connect to, or influence your nursing practice?
* How did the outcome of this
experience connect to, or influence you as a person?
* How important were the questions
you were asking yourself?
* How, or in what way did these
questions help you? or, How did these questions help you to make decisions?
* What have you learned from the
situation/event you described since our last interview?
ANALYSIS OF INTERVIEWS
Because this study is concerned with exploring reflective thinking, the study
did not focus on the descriptive content of the event, but rather on
identifying what it was that the nurses reflect on in their clinical practice.
The descriptive content of the event, important as it may be for the
participant, was only “used” as the “vehicle” to expose reflective thinking.
Reflective thinking is a cognitive activity in which the individual
deliberately and purposely engages in discourse with self in an attempt to
critically, yet creatively analyse, and make sense of past and current
experiences or phenomena. As it is argued in this study that self-questioning
is an integral component of the reflective thinking process, encouraging
participants to focus on these questions, and the possible confusions that
resulted from their experience, may produce common variables that are
representative of, or characteristic for, reflective thinking.
The three aims that structured the
analysis were:
1. To identify how participants
saw their situation by describing their emotions and feelings, and the ways in
which they were challenged by the situation;
2. To describe the perceived gaps
participants had to overcome to be able to “keep on nursing”;
3. To identify how information,
gained from self-questioning, helped (or blocked) the participants to make
sense of, or better understand the client, the situation, and/or themselves.
It is important at this point to
acknowledge that these aims require some sort of “structure” to guide the
project. However, structure does not imply that the project was constrained by
these guiding aims. Thus, the questions used were adjusted to “fit” the
situation and participants were encouraged to tell their own “story,” using
their own words, feelings and perceptions. It is expected that analysis of
these questions will produce a tension that is inherent in contextualised
“interpreting” of wholistic phenomena. The interpretation of text focused on
the mutually agreed upon micro-moments of each transcript by the researcher.
During the second interview, these interpretive accounts were shared with the
participant. The focus was on portions of text that addressed specific
questions first, followed by examination of the text as a whole for
understanding the complete contextual situation.
AN EXCERPT FROM ONE INTERVIEW
The following is an excerpt from an interview with a
36-year-old Registered Nurse. Consent has been obtained to use this information
for publication. To maintain confidentiality I will call her Susan. Susan
qualified at age 21 and has worked ever since either full or part-time. For a
number of years she went overseas where she did a course in Intensive Care
Nursing. During the last 15 years Susan has worked in a wide variety of
settings and is regarded as an excellent nurse. Her knowledge and skills have
not gone unnoticed and her current employer has delegated “special projects” to
Susan or placed her in managerial positions.
The texts in Italic are the steps
in the Time-Line, the Micro-Moments, as mutually agreed between the participant
and myself. Each Micro-Moment (Story) is followed by a conversation in regards
to that particular section between myself, “B”ert, and “S”usan. Although the
interview was verbatim transcribed, the text below has been partly “cleaned up”
to aid readability.
Story: What I wanted to talk about happened a couple of months ago,
it must be about four months ago now. I was the nursing co-ordinator, which
means that I was responsible for the hospital. It was a Saturday or a Sunday
afternoon, that’s important because it meant I was on my own. It meant that I
was managing the entire hospital and doing all the staffing as well. It was a
really busy day. It was one of those days where you know it’s an absolute
nightmare day. The hospital was really busy but staffing wise is was okay, so
that was all right. We had ___, over the entire shift I had three arrests and
one trauma call. As co-ordinators we co-ordinate all those, we run those and
all three arrests were unsuccessful and the trauma call was a real disaster.
The guy lived in the end but it was, you know, I mean it was, what I call, a
really traumatic shift. The worst one was a guy we got in who was only 44. He
came into our coronary care unit, I didn’t see him in the A & E stage of
his admission. He went straight away up to the coronary care unit. He was
accompanied by his partner of 1 year. He’d been divorced and he had grown up
children. He and his new partner had been together for a whole year and they
were pretty close. He seemed like a really fit sort of a guy, you know, when
you looked at him. He’d come straight off the bowling green. He’d been playing
bowls at 12 o’clock. He’d got chesty, he was in the bowling rooms at 2 o’clock,
having a few beers. He got chest pain and they put him in the ambulance by three
and when I saw him it was four.
B: So, when you went to see this man for the very first time it was around four o’clock. Tell me, what impact did that first encounter have on you? What went through your mind?
S: Other than that I could tell
that he was unwell not much I suppose. Every patient that I see as a
co-ordinator I categorise, and it are the ones like him that I have to keep an
eye on. That means that I have to keep coming back to make sure that they’re
getting the appropriate treatment or that they’re responding appropriately or
that I do need to reorganise things. So other than that I thought to myself
“This is a patient that I have to keep my eye on,” because of his age and
because of his respiratory rate and his drop in oxygen saturation corresponding
with that. That was the main thing, other than that he was young to be having a
heart attack.
B: What emotions or feelings did
you have at that time?
S: None really other than concern
I guess. You know that would be it, it would be concern.
B: Why were you concerned. What
was the reason for that?
S: Because of his age, because he
was, oh the other thing I forgot to tell you is, I’d seen his ECG and he had
massive ST elevations. So I could tell. The nurses in the unit responded the
same. They said “Look, he’s had a big coronary, you know he’s having a big
coronary, it’s a definite infarct.”
B: What in this situation challenged you?
S: It was the assessment.
Corresponding his drop in saturation to his respiratory rate and making, I
thought that I had made it clear to the nurse that this was something that
could develop into something else, something more serious, you know what I
mean. So therefore we should keep a close eye on it.
B: What questions or confusions
did you have?
S: Hmm, the question that I
thought of at the time, but that I didn’t give it a huge amount of thinking
time was “Why is he dropping his respiratory rate, what’s the cause of that?”,
and because I didn’t know the answer, I was concerned enough to say to the
nurse “Keep an eye on that particular thing.”
B: How important were these
questions for you at that stage?
S: At that stage they weren’t. As
far as my assessment was concerned, yes he had had a coronary. Yes he was
unwell, but he was in the coronary care unit. They were starting treatment, you
know, he had two senior staff nurses who were going to be able to look after
him. In actual fact, I had other pressing things elsewhere i.e. the boy in ward
C who had meningitis and who needed to get to ICU and I’d already been at one
arrest. Remember this was only 4:30 or whatever. I’d already been at one arrest
and I had to make sure that a) the family will be looked after you know, and b)
that things were in process for that deceased person cause that all falls onto
us during the weekend.
B: Now my next question is in
regards to aspects in this situation that prevented you from getting answers to
your questions. Now you mentioned already that you were busy, that there were a
lot of other patients that you needed to see. How did that play a part in you
getting or not getting answers to your questions?
S: Because of that boy that made
me leave the unit, you know. Yeah, perhaps if I had stayed longer and I could
have seen some pattern developing with his respiratory system we may have
averted, we may have been able to bring that, those things forward because that
staff nurse didn’t pick that up.
Story: I saw him at around
4.30. My initial assessment of him was that he was fit, sure he smoked but you
know he had quite a fit physique. He wasn’t overweight, he’s a tall guy and
young, you know, I mean 44 was nothing. He still had pain. They were trying to
put Streptokinase up at that time when I saw him. The coronary care unit was busy.
It was staffed by a very senior staff nurse and another staff nurse, who I
perceived at that time to have been there a long time. My expectation of her
was that she was a senior staff nurse but that wasn’t to be. Her and I, this
second staff nurse were standing over him and I was talking to him and his
partner just to see where they were at. My assessment of him at that stage was
that his breathing was shallow. He was still having some chest pain which they
were trying to get on top of with Morphine which was, you know, it was all sort
of pretty routine up until then but my assessment of his respiration was that
it was very shallow. He was dropping his oxygen saturation, he was having
periods of apnoea which would last say up to about 20 or 30 seconds. I pointed
this out to the staff nurse and I said “Look, just keep an eye on his
respiratory rate and if his saturation continues to drop, you know because he’s
dropping his respiratory rate, then give the medical registrar a call.
B: What impact did the experience
have on you, getting this assessment info and looking at the patients
condition?
S: Again, not a huge impact at
this stage but I was concerned about him. Enough concerned to want to give
instructions to coronary care staff, usually I don’t because of their
seniority. They are usually aware of all the things that can go wrong so I
don’t often tell them. I mean, it’s like telling your mother how to suck eggs.
I was concerned enough to say “Just watch his respiration,” which showed my
concern because normally I wouldn’t have said that to the staff because, I mean
they know all that stuff, you know, they know to watch for those things.
B: Can you recall any emotions or feelings that you had at that time?
S: No. Because I mean, I didn’t
have time to have emotions or feelings. You know what I mean? Because at this
stage it was fairly routine you know, it was just routine. The whole thing that
I talked about on the tape was making sure where they were at. As a senior
nurse, a lot of the time when I go in, it’s more to check out where the family
are at. To see that they’ve got all that they need; Do they need to use the
phone to contact other family members? Have they got everything at their
disposal that they need in this time of stress? You know, because the primary
focus of the staff nurse in the coronary care unit is the patient. I want to
make sure that, if you want to look at it holistically, that she (the wife) is
also being cared for and I know that the nurses don’t have time to do that at
that stage. It was just really to say to the wife “Look I’m around if you need
somebody to talk to, the staff are busy but you can come and see me or, you
know, just give me a yell, I can be contacted by pager.”
B: What in this situation
challenged you?
S: At this stage nothing because
my mind was already wanting to go to see where that boy was at.
B: Did you have any questions or
confusions at that stage?
S: No, nothing other than his
respiratory rate, but that was just an inkling at that stage. It wasn’t like a
huge alarm bell ringing, it was just like “this is a concern” but no I didn’t
have any other concerns. My concern was the other boy and making sure that, if
he had not left the ward that hopefully he would be in the ICU by the time I
got there.
Story: I got an arrest call to
go to the coronary care unit about 3/4 hour later. I went up expecting it to be
someone else but found out that it was this chap who had arrested. In actual
fact, he had respiratory arrested. His respiratory rate that I’d observed had
continued to deteriorate. The nurse had not done anything about it and yeah, so
he’d respiratory arrested, we bagged him successfully (artificial respiration
with a “ambubag” and high flow oxygen).
B: What impact did the experience have
on you when you realised that the emergency call was for this 44 year old man?
S: The impact of the experience?
Okay. I guess a bit of shock because my initial assessment of him hadn’t been
that he would be the one that would arrest. Yeah, initial shock and “Oh god,
he’s only 44,” you know. Like a lot of the times you go into an arrest, and it
may sound quite callous, but you can go into an arrest and you can judge pretty
much in the first 30 seconds whether its going to be a successful arrest or not.
I don’t know how but I guess mainly by looking at the person, seeing how blue
they are, what their heart rhythm is, their medical history and all this sort
of stuff, and how well the “arrest” is going and if your person is in their
80’s, which often they are and often I’ll know that they are the person who the
staff have been concerned about. You know that they’ve got a terrible medical
history and all this sort of stuff and you think “Okay, we are going to go all
out here,” but I would know that if we’re not going to make things happen the
registrar will pull out (stop the resuscitation attempt). You know what I mean?
I think that’s a seniority that gives you that sort of knowledge. But with this
guy it was like it doesn’t matter what happens here, we’re going to go all out
no matter what, because of his age. I am not saying that we don’t go all out
for other people because we do, but it’s just some arrests you will stop at a
specific point and say “Okay, we have given them the best chance that we can
and they are not responding to treatment. You know, it’s kinder to pull out now
and. . . yeah.”
B: Can you recall what emotions or
feelings you had at the time?
S: Fright, always go into arrests
with a bit of fright.
B: What leads to that?
S: Is it going to go all right? Am
I going to know what to do? Is it going to be successful?
B: What in this situation
challenged you?
S: The fact that, cardiac wise, he
was still having some output. He still had an output throughout the arrest. He
still had a rhythm although he was starting to go into, this is just coming
back to me now, he was starting to go into heart block at this stage. People
often go into heart block and often you can get them out of it. Sorry what was
the question?
B: What was it that challenged you
in this situation?
S: Challenged me? Why had he
respiratory arrested and not cardiac arrested? The other challenge was, I
guess, just pulling it all together. You know, every arrest is challenging in
that you have to make sure that everything is there. That people are
functioning in the right way. Another challenging thing was that the wife was
still in the room at this stage. I wanted her there but then I didn’t want her
there. You know, like I think arrests are pretty frightening things to witness
but I have also a real thing about relatives being pushed away at that stage
because, in actual fact, if the person is going to die then I do want the
family to be there. So I would rather they stood in a corner and this is just
my feeling. I would rather they were there and perhaps traumatised by it but at
least later down the track they would know that they were there with their
loved one and that they were able to hold their hand. Often, even in an arrest
situation, I’ll have people standing there holding peoples hands, probably
scared shitless but at least they’re there, you know, and that’s a family
thing.
B: What questions or confusions
did you have?
S: Why did he have a respiratory
arrest and why not cardiac? That was still my biggest question. Why is this a
respiratory issue and why is he still cardiac functioning? You know what I
mean, like I kept expecting him to cardiac arrest as well. He seemed to respond
with the oxygen and the bagging which was okay, that’s fine, but why not cardiac?
B: How important were those
questions?
S: At that time they didn’t but in
hindsight they were. At that time it was an intellectual question. It was a
“Oh, I’ve never seen this before, this is interesting to me” type of question.
You know what I mean, yeah, so an academic question is that OK?
B: Yes that’s OK. What aspects in
this situation prevented you from getting an answer to the questions you were
asking yourself?
S: Time. Yeah, just the time
factor. If I had stayed longer I could have seen some pattern developing with
his respiratory system. More time yeah, and another thing too coming to think
of it. If I had had a registrar who knew her stuff, I would have felt
comfortable in saying “Hey, what’s going on here?” The relationship with the registrar,
her feeling of discomfort, you could just tell. Yeah, I could clearly tell by
her demeanour that she didn’t want to be there. She responded to that arrest
call cause that’s part of her job. But she didn’t want to, she looked really
out of place. You can tell when a medical person comes into a situation and
they are calm and they are cool. They know what they’re doing and it is an
almost automatic response, that’s how I function in arrest. I always go in with
fright and fear but I’m automatic. I automatically know what to do, what my
role is in any arrest situation, and that’s what I do. You know, but I could
see that she was unclear about where she fitted in and if I perhaps had been
able to sit down and say to her “Hey look, what’s happening here?”, you know
that may have helped but...the urgency of the matter. My lack of knowledge, I
couldn’t understand what was going on exactly.
B: What conclusions did you come
to as a result of the experience so far?
S: Again, that he was, now he’d
gone up in my expectations of illness. He was critical as far as I was
concerned. He was somebody that I really had to keep an eye on and be very
close to the coronary care unit. So if I was going to go anywhere it would be
within that immediate proximity, like I wasn’t going to go all the way down the
other end of the hospital to the women’s health unit. I wasn’t going to go to
paediatrics, I was going to stay in that tower block and I was going to, yeah,
I was going to be ready if they needed me again.
Story: Now often, when an
arrest team is called, the medical registrar comes, the anaesthetist, a nurse
from ICU, she is the one who looks after the bagging side, and there’s always
somebody from coronary care. Well we were in the coronary care so I had both the
coronary care staff nurses there and also one of the nurses from the ward had
come in to help out. And then there was myself, oh yes, and the A & E house
surgeon came up. We worked on him and he sort of responded quite well so it was
okay. At this stage, up in ICU, we had had, oh that’s right. When I’d left the
first time to go away I had to go and check up on a 16 year old boy in another
ward who was really crook. He had meningitis so I had organised a transfer of
him up to the ICU. I couldn’t get the ICU registrar down to assess this guy’s
respiratory system because he was busy with this boy up in the ICU so that was
a problem at the time. However, we did get him right somehow. We all left the
coronary care unit quite happy that this guy had sort of picked himself up, he
was sort of semi-stable. They had stopped the Streptokinase because his blood
pressure had been fluctuating too much. I then left because I had to go
somewhere else.
B: What impact did that experience
have on you, this first CPR episode?
S: Impact. I felt okay, I felt
comfortable. I guess that would be the way to look at it because he responded
and we had reached a plateau with him so yeah that was okay, I felt
comfortable.
B: Can you recall any emotions or
feelings that you had at that time?
S: Frustration. Frustration at the
registrar that she was, she didn’t know where she fitted in and also a feeling
of discovery. The A & E house surgeon who’d been there was an English guy
who had just started. This was his first weekend in the hospital and I’d seen
him work the previous night down in the A & E and had been quite impressed
with him. He had stood back initially waiting to see what her response, to see
what was happening. There was none so he sort of stepped into the breach so to
speak, so yeah, surprised a little bit. It was quite nice to know that he had
taken up a little bit of the management that she’d been unable to do.
B: Any feelings in regards to
being successful with your CPR.
S: No. Sometimes you get a
feeling, you know with other people you get like a feeling of elation but for
me there was the feeling of “we’re not out of the woods yet but we’ve
plateaued,” you know.
B: What led to those feelings that
you thought you weren’t out of the woods?
S: Because he was really sick, you
know, you could just tell he was really crook. His blood pressure was down but
his respiratory rate was okay. He maintaining an oxygen saturation of around,
you know, I guess the low 90’s probably although I must add that he was on high
oxygen flow. But he was, yeah, I mean you could just tell, he was grey, he was
clammy, he wasn’t out of the woods.
B: What in this situation
challenged you?
S: Again, not understanding why he
had, you know, it was only a respiratory issue although he was starting to show
signs of heart block, yeah, I didn’t understand what was going, you know, I
couldn’t figure what was going on for him physiologically.
B: What questions or confusions
did you have?
S: Yeah, what was going on? What
was happening to him inside, that was my confusion.
B: Any other questions in regards
to what was happening. I mean not just in regards to your client but in regards
to any other aspects of that situation?
S: Ah, yeah. What was going on for
the staff nurse who was supposed to be the senior but who was showing real
signs of stress and showing real signs of incompetence.
B: Did you have questions in
regards to that? .
S: Just, what is she doing here if
this is her level of skill?, but not exactly that question, like, I was more annoyed than questioning that. I mean,
I did question that later but it was more of an annoyance thing like “Why
didn’t you pick up on that straight away? Why did he get to the stage where he
respiratory arrested before we were called back?”
B: When you say you questioned it
later, are you talking about a few minutes later, after you left the ward, or
maybe a day or a week later?
S: No, no. Oh, I had lots of
questions later later, but this was my initial questioning, yeah.
B: What aspects in the situation
prevented you from getting answers to the initial questions that you had?
S: Again, the relationship with
the registrar. Her feeling of discomfort, you could tell she was really
uncomfortable. A & E was full, she had lots of patients down there. We had
already lost one arrest, he was a sick guy and she (the registrar) was going to
have to go back to A & E and assess how ever many other patients. The other
thing was frustration with myself. I just knew there were other pressing issues
in the hospital at the time and I left, I made that decision and left.
B: What conclusions did you come
to as a result of this experience?
S: That I should have trusted my
instincts and stayed. I should have stayed but again the time issue was a huge
thing. I was expected in other areas and I can’t remember now what was so
pressing that it took me away from the unit. But I still believed that he was
in the hands of two very senior staff nurses who theoretically should have
coped with the situation.
Story: Another arrest call from
coronary care and sure enough this time he’d full blown arrested so we started
the resuscitation. Respiratory wise he went off really fast and quite difficult
to ventilate with an ambu bag. I immediately phone ICU to try and get the
registrar to come and intubate him because he was a definite candidate for ICU.
Sometimes if a person is, like in their 80’s, I don’t make that decision so
soon, you know. I would say “Oh well,
we’ll see how the arrest goes and if cardiac wise they pull through, then I’ll
get an ICU registrar to come down and do that.” It’s all in consultation with
the “floor” registrar but this registrar was hopeless. She wouldn’t make any
decisions, she wouldn’t agree to anything that I said. She was obviously
scared, so I soon became in charge because somebody had to. The ICU registrar
was unable to come and help intubate this guy because they were having trouble
intubating the 16 year old boy. The consultant was up in ICU, he couldn’t come
either because he was helping with the intubation. I was feeling myself go into
a panic by this stage, I was really worried. I rang theatre. I couldn’t get the
registrar in theatre. He was with a patient on the operating table so there was
nobody that I could get to intubate this guy so I said to the registrar “You
intubate him.” But she said “No, I don’t know how to intubate.” I said “Come on
then call the consultant.” “No, no, it’s all right, it’s all right.” So I said
“No, I’m going to call the consultant in.” So I called the consultant and by this
stage we were hand ventilating him with an ambu bag and an airway. He developed
pulmonary oedema and, although I had seen pulmonary oedema during the time that
I was involved in trauma work, I’d never seen anything like this. He was just
fluid, it was just everywhere. It was on the bed, it was all over me, I was
just covered in it. It was produced just as fast as I was trying to suction it,
you just couldn’t do it. The registrar at this stage was going to try and
ventilate and try and put the ET tube down. She couldn’t see his vocal cords
and wasn’t prepared to intubate him “blind.” But he was dying and I said “If
you don’t intubate him, I’m going to” and she said “Oh, no, no you can’t do
that.” I said “If you don’t intubate him, I will,” you know I was beside myself
because I had no where to go. The coronary care nurse, you know the senior one,
was excellent. She was great but the other one was next to useless, absolutely
useless. She didn’t know where to put things, she didn’t know how to respond in
an arrest, you know. We are talking about senior nurses here so it was like all
around me everybody was falling apart and at this stage the registrar could see
that I was really annoyed. I was really very very angry. She took the tube from
me because I had the tube in one hand and the laryngoscope in the other and I
was going to intubate this guy even though I had never done it before. I had
been taught how to intubate back in South Africa and I thought to myself even
if I go blind and I miss, he’s still having some chance as opposed to no chance
you know. She realised that I was going to do it so she took the stuff off me
and intubated him and thankfully got it in. Once we got him intubated we could
bag him properly. We did get the pulmonary oedema under control but by that
stage cardiac wise he was gone and he died.
B: What impact did this experience
have on you, this second CPR on this man?
S: It had two levels of impact,
one was the “right there” impact and then there is the “further down the line”
impact. The impact was huge because of all the feelings that I was experiencing
so the impact was fright, fear, anger, frustration, and confusion.
B: What led to those feelings?
S: The unstructuredness of it all.
You know, the fact that people weren’t doing what they were supposed to be
doing in an arrest situation. That I could not find the appropriate help that I
needed right there and then.
B: What challenged you in this
situation?
S: The challenge for me was to try
and keep him alive. That was my first challenge. The challenge was to try and
get the registrar to come on board with what I assessed as what needed to be
done in the situation. The challenge was to manage the arrest single handedly.
I felt that it was single handedly although when I listened to the story I said
I felt alone, you know, there’s a sense of aloneness there. I did have that
very senior nurse was there with me, that A & E house surgeon also came
back but again it was... I felt the responsibility that it was me.
B: What questions and confusions
did you have?
S: The questions I had in regards
to the client was “Why was there so much pulmonary oedema? I just couldn’t
understand it, you know. It was screaming inside my head, why is there so much
fluid? I didn’t have the answer, I didn’t know, like as I said, I had seen
pulmonary oedema before but I’d never seen it to this extent and I couldn’t
understand why there was so much fluid. Why at 44 was he so terribly
unresponsive to therapy, you know. Like it didn’t matter how much Adrenaline we
kicked into him, it didn’t matter how much Lignocaine we gave him or whatever
we were giving him, it made no difference to the arrest. You know what I mean?
Like he did not show one sign of response to any of the cardiac drugs that we
gave him and that was a big question. Why is he not responding, you know, he’s
only 44 and I didn’t have the answers then. That’s why at that stage I thought
it was our fault, you know, are we not doing something right here? Questions in
regards to the nurse, yeah, why isn’t she doing what she should be doing? You
know, this is second nature stuff, this is not “I have never been in this
situation before” stuff. This is “I should know this stuff this is my bread and
butter.” I should know so those were the questions “Why can’t I get any help?”
Questions in regards to the doctor What’s the matter with the women, why
couldn’t she function, you know, why couldn’t she take charge?
B: How important were these questions?
S: I just kept, the biggest thing
was I couldn’t understand the pulmonary oedema one. That was the biggest
question to me, you know. It just seemed so foreign to me. I couldn’t
understand why there was so much fluid. I mean, I was covered in it, it was all
over my uniform. It was on my hands, it was on my arms and I’m not one to let
body fluids get on me, you know. I’m normally pretty careful about where body
fluids go in relationship to my working environment but it was on the floor, it
was everywhere you know.
B: What aspects in this situation
prevented you from getting answers to your questions?
S: The urgency of the situation.
My lack of knowledge. I couldn’t understand, you know, my knowledge didn’t
extend that far and yeah..., so those were the ones. I couldn’t say to the
nurse “What are you doing?”, like it wasn’t professionally viable to say to her
“What is going on here?”
B: What conclusions did you come
to as a result of the experience, or maybe I should ask “What have you learnt
from it?”
S: At that stage? I didn’t learn
anything except that I felt that I’d let myself down because I couldn’t
understand the situation of events, like psychologically what had gone on here,
so yeah there was that..., can you ask the question again?
B: What conclusions did you come
to as a result of the experience.
S: That we had f.... it up. You
know, I don’t use that language lightly but we had made a huge mess and I felt
terribly responsible, terribly responsible. You know, he was 44, and 44 is just
a baby you know. I mean, in this job I dealt with death often, you know all the
time, and it is a huge part of our job. It made me mad to think that... often
when you deal with death in that job it’s like they have come in off a road
crash and there’s nothing that you could have done or you weren’t there and
they were drunk and all this sort of stuff. But it was different, he had
presented himself to us and we should have treated him better, you know.
Story: She (the registrar)
refused to tell the partner that he had died. It was left up to me to talk to
the relative and to tell her that it had been unsuccessful. I had to deal with,
you know, I mean there was no time for me to come to grips with what had gone
wrong for me. I had to go and face his wife who had been standing with him, having
a drink with him, an hour and a half before in the pub.
B: What impact did that experience
have on you when the doctor left it up to you to talk to the family?
S: At that stage, anger but I just
knew I was really angry because she didn’t have the guts to go and talk to the
wife. At the same time I also knew that I was going to be much better at
telling her that he’d died than she was because I could see she was so
uncomfortable with it.
B: What challenged you in that
situation?
S: How I was going to say it in
such a way that she could maintain some dignity.
B: Was she present during the
second time?
S: No, at the second arrest I had
sent her out and she was waiting in the corridor. So I told her in the corridor,
you know, I mean I couldn’t take her away anywhere, there was no where to take
her to.
B: What questions or confusions
did you have in regards to the doctor not wanting to do it and leaving it over
to you?
S: No questions, I mean I was
pretty numb at this stage, no I didn’t have any questions. I just could see
that she wasn’t going to do it and that she didn’t want to do it. I could see
that if I didn’t do it she would probably do it very badly.
Story: So yeah, I mean I felt
really awful about it. In hindsight I spoke to my manager on the Monday and
told him what an absolute “balls up” the whole weekend had been. I asked her to
follow up on the post-mortem because I needed to know that cardiac wise, the
fact that we had balled up the arrest wasn’t going to make any difference. You
know, I was scared that..., what I was worried about was that he died because
of our incompetence. But he had completely blocked off all his coronary
arteries and there was just nothing, I mean cardiac wise he had killed off all
his muscle in one fowl swoop. In hindsight, the thing that makes me feel okay
about it, is knowing that we couldn’t have saved him anyway.
B: What impact did this total
experience have on you?
S: Really earth shattering. At the
stage when I spoke to my manager I didn’t realise, oh no, she let me tell the
whole story and then she told me about the post-mortem. I had asked her to
follow it up but she had actually already been to the post-mortem that morning
and had a look so she was able to answer my questions quite quickly. I felt
really let down by my colleagues, let down by my own lack of knowledge which I
have never, in many ways I have never had before. You know what I mean? I had
either been surrounded by medical staff who could say “Hey look Susan it’s
okay, this is what’s happening,” or other senior nursing colleagues who could
say “A B C, I have seen this before, bla, bla, bla.” That is what my supervisor
did, she said “Look,” and she recounted a situation where she had been in the
back of an ambulance with a guy who had massive pulmonary oedema. She said she
couldn’t even stand up, the floor was so wet, just covered in oedema. So I
thought “Oh yeah, okay so it’s not uncommon, you know, like it does happen,
okay now I know.”
B: Looking back at the experience
what emotions or feelings did you have?
S: Sadness, sadness that he had
died, sadness for his partner. Very frustrated still, frustrated at myself that
I didn’t know, that I hadn’t been able to follow the chain of events.
Frustrated at my lack of time to be able to spend with the staff, to be able to
spend with him, you know. I shouldn’t have, you know in hindsight, I shouldn’t
have gone I should have stayed. Feelings, what else. Anger, anger at the
registrar and disappointment in the nurse because she should have known better.
She should have known better. She didn’t even, when we put the, when we
intubated him, I was holding the tube and I asked her to fill the cuff. She
went to fill it with water, you know, I mean basic mistakes Bert, you know, she
should have known. So yeah, disappointment. Disappointment in my colleagues who
I felt had let me down.
B: What in this situation
challenged you, looking back at the whole situation, what were the challenging
aspects?
S: My knowledge that was the thing
that, you know, that I was challenged by most. I felt that my knowledge should
have been more and the frustration that I didn’t know more. Yeah, so that was
one of the more challenging things. To tell the wife... although I did it
automatically, you know, like I put myself into automatic modes. I know when
I’m doing it and it’s because whatever is happening around me is so traumatic
that it’s really important that I don’t fall apart. So I just go into automatic
mode and I’d done that to deal with the enormous sadness that she was
experiencing. Yeah, I found that quite, not challenging because I had done it
before so I knew how to do it, but there was that huge level of sadness.
B: Looking at this overall
situation, what questions did you have, what confusions did you have? You might
want to answer first the questions and then maybe later on the confusions.
S: Questions like why had there
been so much pulmonary oedema. Mark, my manager, answered that because cardiac
wise he had shut down and his lungs were responding to that shut down. Why was
he not responding, you know, that had been such a huge question, why had he not
responded. Well it turned out that at the post-mortem they were able to say
“He’d had chest pain for two weeks and done nothing about it and he had smoked
30 cigarettes a day.” My initial assessment was, sure he was smoker, lots of
people have a cigarette every now and again. Of course there is a difference
between one cigarette a day and 30 cigarettes a day, and 30 cigarettes a day at
age 44 will give you coronary arteries that don’t function. So automatically I
had answers and that but those were confusions as well cause I couldn’t figure
out in the initial stages why he hadn’t responded. Well that’s why he hadn’t
responded, you know so lights went on for me and the fact that he’d blocked off
all his coronary arteries that explained why he didn’t respond.
B: Earlier on you were saying that
you had heaps of questions, can you go a little bit into that?
S: Things like why hadn’t he
responded, why was there so much pulmonary oedema, why aren’t we getting
anywhere with him, why isn’t the nurse functioning, why is the doctor like
this? Those were my heaps of questions. I could understand why I couldn’t get
help, that was easy to understand. I knew how to go about that, you know cause
I then just called the consultant in so that wasn’t an issue. So I didn’t have
any questions about that, but why? why was it not going smoothly?
B: So the consultant did come in
the end?
S: Yes, the consultant came in the
end and he was the one who actually pulled out on the guy and said “We have
gone nowhere.”
B: How important were the
questions that you were raising for yourself?
S: Very important because the
biggest impact for me was this feeling like that I didn’t have enough
knowledge. I didn’t have enough experience to be able to deal with it
efficiently and that was really important because I pride myself in being a
very experience nurse. I pride myself in saying “I know what I’m doing, you can
trust me, you know, you can trust me to help you make right decisions” and
that’s part of that whole sort of co-ordinating mentality. When you are in
charge and you are trying to sort of run the hospital, there’s a certain pride
in the fact that I am an experienced nurse. I am able to make decisions and I
am able to come up with answers. If I can’t come up with answers I will find
them out but this time I didn’t have the time or the experience or the
background and I didn’t have the answers and I couldn’t get them either.
B: Looking to the whole
experience, what conclusions did you come to as a result of that?
S: Conclusions? Well there are two
levels of conclusions really, there’s the professional one and then there is
the personal one. In retrospect we couldn’t have saved him, I mean there was no
cardiac muscle to work with so we were pushing it up-hill anyway but I feel
that I need to know more, you know, I need to have more information, I need to
have more knowledge. If you’re expecting senior nurses to operate at that level
then you have to have more knowledge. I should have trusted my instincts and
stayed with the client. I don’t want to learn by mistakes, not at that level,
you can’t afford to make mistakes at that level of seniority of nursing. This
is a person’s life, you don’t play around with that. Conclusions? I gave up my
position (managerial). That was one of the reasons, I came to the conclusion
that I didn’t want to be in that situation again unless I had some more
answers. I mean it’s not saying that I don’t have background (knowledge)
because I do, you know, you can’t have nearly 20 years of nursing and not know
what your talking about. I know what I’m talking about but I need to know more.
If I am going to say that I am a clinical expert in nursing then I need more
background. The experience took me down a peg or two. If you are going to stand
up and say “I am a good nurse” then you’d better make sure that you are.
On a personal level it just showed
me the vulnerability of me as a human, you know that I don’t have all the
answers, I may never have all the answers. The other thing that really shook me
personally was that you couldn’t rely on help, on people, whether it’s their
level of experience, their skills, or just their personality.
B: How does the outcome of this
experience connect to or influence your nursing practice?
S: I gave up my job. That was one
of the reasons, I mean there was a whole lot of family issues for me as well
but as I mentioned before I came to the conclusion that I didn’t want to be in
that situation again.
B: How did the outcome of this
experience connect to, or influence, you as a person.
S: I have a high opinion of the
way I nurse, you know, I believe I’m a really good nurse, I believe I’m a really
solid nurse who has the patient and their family’s best interest at heart. I
believe that is why I have done so well in nursing and will probably continue
to do well in nursing but it just showed me the vulnerability of me as a human,
that I don’t have all the answers. I may never have all the answers and I would
be very surprised if I did have all the answers one day, you know. But if you
going to stand up and say “I am” then you’d better make bloody sure that you
truly are. I think I am a really good nurse, you know. You could put me in lots
of situations and I would cope really well, but you can’t rely on medical help.
Yeah, that was the other thing that really shook me personally. I choose to
practise in the clinical setting because that’s where I feel comfortable. I
like working with doctors. I like working as part of a team and it really sort
of set me back saying that you can’t trust everyone, you know, you can’t rely
on people these days, whether it is on their level or experience, their
clinical skill or just their personality.
B: There is still a little bit of
focus now on you as a nurse but what about you as a person,
S: Other than it took me down a
peg or two... I guess I am re-evaluating life so to speak.
B: In how far has this interview
helped you to make sense of what was going on, has it in some way contributed
to an increased understanding?
S: Yeah, in some ways, I mean a
lot of it I had come to terms with myself anyway, you know. I felt pretty comfortable
about saying “well these are the things that really made me angry or these are
the things that made me feel good.” I mean talking through situations like
these and having questions asked about what you were feeling or what you were
experiencing was really good. I mean I would not have gone into it in such
depth, unless I had gone through a process like this and that’s why, really, I
responded to your request for participants because I thought to actually
explore this whole situation would probably be quite valuable, yeah.
RELATED MATERIALS ON THIS WEB-SITE:
See also:
*In Articles,
Papers, Commentaries, an abstract of Teekman’s article “Exploring
reflective thinking in nursing practice” as published in the Journal of
Advanced Nursing, 2000.
*In Articles,
Papers, Commentaries, an abstract of Teekman’s article “A Sense-Making
examination of reflective thinking in nursing practice” as published in the Electronic
Journal of Communication, 1999.
*In Dissertations
and Theses, an abstract of Teekman’s 1997 Master’s thesis.
*In Meetings,
Conferences, Workshops, Teekman’s contribution to a 1999 Sense-Making
workshop.
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Page last updated 6/04/02b |