NUR 302 Module 6 Simulation Reflection Example

The Second Attempt: Reflecting on a Simulated Encounter With a Resident Who Resisted Evening Care

[Student Name]

Southern New Hampshire University

NUR 302: Clinical Judgment and Holistic Assessment in Nursing

Module Six Simulation Reflection

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

The Second Attempt: Reflecting on a Simulated Encounter With a Resident Who Resisted Evening Care

I have cared for patients with dementia for most of my nursing career, so I expected this simulation to be straightforward. It was not. My first attempt ended with the simulated resident, Mr. W., pushing me away and shouting, and my score reflected it. To examine what happened, this reflection uses the clinical judgment model described by Tanner (2006), with its four phases of noticing, interpreting, responding and reflecting. My central finding is uncomfortable: the resident's behavior was a reasonable response to the way I approached him, and the skill I lacked was not knowledge about dementia but the habit of treating resistance as information.

The Scenario

Mr. W. was an 84-year-old resident of a long-term care unit with moderate Alzheimer disease, osteoarthritis in both knees and a history of benign prostatic hyperplasia. The simulation began at 7:00 p.m., during shift change, when my task was to help him with evening care and his scheduled medications. The report from the day nurse said he had been restless and had refused his shower. When I entered the room, two aides were talking in the hallway, the television was loud, and Mr. W. was standing near the window holding on to the curtain.

Noticing

In my first attempt I noticed the task more than the man. I saw that he was standing, that evening care was due and that his medications were on the cart. I introduced myself from the doorway, walked toward him from the side while explaining that it was time to get ready for bed, and reached for his elbow to guide him to the chair. What I did not notice were cues that were visible from the start: the noise from the hallway and the television, his grip on the curtain, a grimace when he shifted weight, and the fact that he had not used the bathroom since before dinner according to the flow sheet. According to Tanner (2006), a nurse's expectations going into a situation shape which details stand out at all. I walked in expecting a routine bedtime, and the details I registered were the ones that fit it.

Interpreting

When Mr. W. pulled his arm away and said I should leave him alone, I interpreted his behavior as agitation caused by his dementia. That interpretation was not wrong, but it was incomplete, and it led nowhere useful. Kales et al. (2015) describe behavioral symptoms in dementia as having several possible causes at once, including disease-related changes, unmet needs such as pain or a full bladder, caregiver approach and environmental triggers, and they recommend that these causes be investigated before medication is considered. In the debrief I realized that all four were present. His knees hurt, he probably needed to urinate, I had approached him in a way he could not read, and the room was loud.

Jablonski et al. (2011) explain care-resistant behavior as a fear response to caregiver actions that a person with dementia perceives as threatening, even when the caregiver intends to help. Approaching from the side, touching without warning and giving several instructions at once are among the actions that can trigger that response. Reading their account after the simulation, I recognized my own first attempt almost step by step.

Responding

My second attempt began in the doorway, but this time I stopped there. I lowered the television volume, asked the aides to continue their report down the hall and waited until Mr. W. looked at me. I approached from the front, stopped at arm's length, bent slightly to be at his eye level and introduced myself by name and role. I asked one question at a time: whether his knees were sore, then whether he wanted to use the bathroom. He answered yes to both. I offered my arm rather than taking his, walked with him to the bathroom and gave him privacy. Afterward I offered his scheduled acetaminophen, and he took it without difficulty. Evening care went more slowly than the task list suggested, but it happened, and he was calm when I left the room.

Reflecting

The difference between the two attempts was not information; I had the same report both times. The difference was what I treated as the problem. In the first attempt the problem was a resident who would not cooperate. In the second, the problem was a frightened man in pain with a full bladder in a loud room, and each of those was something I could change. Tanner (2006) describes reflection-in-action as noticing, while care is happening, that a response is not working, and changing course. I did not do that in the first attempt; I pushed harder. That is the pattern I most want to change.

The simulation had limits that are worth naming. A virtual resident responds according to a script, so the second attempt succeeded partly because the program rewarded the approaches it was built to reward. A real resident might still have refused, and pain or a full bladder might not have been the whole story. Even so, the script was built on the same principles the literature describes, and the contrast between my two attempts was too sharp to explain away as luck. The learning I take from it is about my habits, and those will come with me to the unit.

The simulation also showed me that shift change is a hazardous time for residents with dementia. Noise, unfamiliar faces and a rushed schedule arrive together, and residents who resist care during that hour are often labeled difficult in report, which shapes the next nurse's expectations before that nurse even enters the room.

What I Will Change in Practice

Three habits come out of this. The first is to treat resistance to care as a cue to investigate, beginning with pain, toileting and the environment, before I repeat a request. The second is to use the threat-reduction habits from the second attempt as my default approach: front approach, eye level, name and role, one step at a time, and an offered arm instead of a guiding hand. The third is to change how I give report, describing what a resident responded to rather than calling the resident difficult, so the next nurse starts with information rather than a label.

References

Jablonski, R. A., Therrien, B., & Kolanowski, A. (2011). No more fighting and biting during mouth care: Applying the theoretical constructs of threat perception to clinical practice. Research and Theory for Nursing Practice, 25(3), 163-175. https://doi.org/10.1891/1541-6577.25.3.163

Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioral and psychological symptoms of dementia. BMJ, 350, Article h369. https://doi.org/10.1136/bmj.h369

Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. https://doi.org/10.3928/01484834-20060601-04