A reflective commentary on Should dying patients be monitored? A reflective analysis of a critical incident by Alison Mulligan

Abstract

Reflection opens up a personal space for the practitioner to stand back from the drama of everyday practice to make sense of it all and consider how she or he might become more effective in meeting the needs of patients and their families. As Alison illuminates, her reflection is triggered by an uncomfortable feeling or anxiety. She felt her patient June might have a more comfortable, dignified and peaceful death if not monitored and subjected to what she feels are futile observations. At the nub of this experience are two issues. The first is her plea to her colleagues to see the person dying and adopt a palliative attitude. The second is her avoidance of conflict by pursuing the matter with the nurse in charge. Indeed, Alison is self conscious about fitting in as if she fears being rejected as a ‘difficult’ nurse. The consequence is that Alison suffers. Reflection is cathartic, it helps Alison to work out these feelings. She reflects on the ethics of what would be the best thing to do informed by her search of a relevant literature. She reviews what factors are influencing her. If she explored the literature on managing conflict she would recognize that avoidance is the style of managing conflict most adopted by nurses and nurse leaders (Cavanagh, 1991). This literature would also suggest a collaborative style of managing conflict that is the ideal for all areas of clinical practice. Yet how might a clinical area move from avoidance as a social norm to collaboration? It suggests a need for both individual and collective action. So as Alison suggests, she needs to act with integrity to fulfil her responsibility to her patient and challenge decisions that are not in the patient's best interests. She needs also to try and create the practice conditions where such issues might be explored more objectively, for example in establishing a working party to develop a protocol for palliative care patients. Can she be more assertive if faced with this situation again? Perhaps, guiding herself up the assertive action ladder might be helpful (Table 1). The reflective process heightens Alison's resolve to take action. She has challenged her responsibility; hence, she must grasp the nettle and see that she has authority to take personal action. Exploring the literature helps her construct a good argument. But does she have the courage? This is where a guide may be useful to infuse her with self-believe and courage. Perhaps in the heat of the moment, it is difficult to assert self because of the risk of open confrontation in front of patients and the family and the risk that someone will ‘lose’. Confrontation can be a difficult skill to master, because it can quickly degenerate into a situation of open conflict. Perhaps it might be better to raise it at a staff meeting, using her experience in nonconfrontational ways to raise the issue of ‘best’ palliative care. I am going to assume that all areas of clinical practice must strive to become what Senge (1990) describes as ‘the learning organization’. Reflection is at the heart of a learning organization, simply because it creates an ethos of learning through experience towards realizing best practice. The learning organization has five interrelated dynamics which I consider in relation to Alison's experience (Table 2). Senge's framework of the learning organization offers a useful model for a team of practitioners to consider the richness of their learning environment towards realizing desirable practice as a lived reality. Our patient, their families and ourselves deserve nothing less. Christopher Johns