The Assertive Nursing Student
In this reflection paper, I will relate my experience of an incident that helped me to be more assertive, compassionate, and confident in my skills. I will be using the Gibbs model of reflection to write this paper. Gibbs model (1988) refers to the key processes within reflection itself, rather than as reflection as a process within general learning. The cyclical model, or more accurately a functional framework for reflective study, assumes repetitive experiential contexts and is split into six key areas. These areas are event description, feeling, and thoughts; evaluation, analysis; conclusion and action plan (Gibbs, 1988)
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In my second clinical placement, I was working in a general medicine unit of Grey Nuns Hospital. I was assigned to care for Karl (pseudonym). Karl was a delightful 82-year-old male, admitted with AECOPD (Acute Exacerbations of Chronic Obstructive Pulmonary Disease). Karl’s eldest daughter, Lisa (pseudonym) had dedicate her life to perform the duties of the primary caregiver and is an active participant with medical care and planning his daily needs. Both Karl and Lisa had no hesitation in welcoming me as a student to participate in Karl’s care.
During my head to toe assessment, Lisa was constantly commenting on what she thinks was the “best way” to perform nursing tasks for Karl. That left me feeling bullied and distraught, as Lisa was always questioning my head to toe assessment and nursing care. She did not allow me to perform my assessment and nursing care because she was always intervening by directing negative comments about my skill and offered clues on how it should be performed instead. I tried to explain to her my role and the importance of the head to toe assessment, but she kept telling me an expert such as a Doctor or Registered Nurse and not a Student Nurse in his second year should do the assessment. This feeling of inadequacy arose partly because of Lisa’s strong assertion of being the patient’s daughter and sole primary care giver.
Feeling and Thoughts
Nurses are responsible for providing safe, competent, and ethical nursing care to patients, when conflict arises between families and nurses; building trust through relational practice approach becomes difficult in developing the nurse-patient relationship. I found it difficult to provide care as my beliefs and values were tested, I felt as if I did not belong in that situation and that nursing was not the profession for me. Mitchell (2001) suggests that nurses need to examine their own moral development and the theories that guide their practice. She further explains that when nurses choose theories that enhance their ethical practice, “the confidence that comes from that choosing will help nurses have the courage to act according to the realities that each person and family brings to the situation” (p. 113).
I told my buddy nurse about Lisa’s assertive and demanding behavior. My buddy nurse also talked to Lisa about my concerns and told her that I should be treated with respect just as everyone in the health team and that I was of great help to Karl. I also spoke to my instructor on what had transpired during my first meeting with the patient, and how Lisa made me feel as though I lack self-confidence in my skill level. She suggested that we speak to Lisa about it together. My instructor talked to Lisa quietly in Karl’s room, and asked her why she was so uncomfortable with me doing the assessment and providing care for her dad. Lisa looked quite upset, she said she feels that a second year nursing student should not conduct such an assessment, as we are not experienced to identify certain health issues. My instructor discussed the importance of the head to toe assessment with her, and told her I was competent to perform the assessment, as I was educated in school to do so. I also strived to incorporate a holistic approach to the patient, in which the health care team, family, and the patient can benefit from the best nursing care possible. However, for once in my nursing career, I felt as though my practice was not safe, competent and welcomed.
The incident was extremely challenging for me. I thought that I should have acted on my critical thinking skills earlier. However, I am pleased that Lisa had partially agreed with me to perform the skills. This incident has taught me the importance of acting assertively and not to be bullied into one’s beliefs and values and to focus more on the patient’s concerns. On reflection, I realized that I was practicing from the stance of my nursing skills, while at the same time concentrating on not making mistakes; I strayed from my relational connection with Karl and Lisa. Though I tried my best to create a rapport with Lisa, I find it challenging to pursue as she was focused on her beliefs and values rather than the care myself and the health team are providing.
She commented negatively on every aspect of nursing care performed by myself. I realize that her negativity stems from her lack of knowledge of medical terms, AECOPD, and the rationale on why care is being provided. Valentine (1995) states, “This disappointment and vulnerability can be particularly severe when bullying is involved, and the victims of bullying need high levels of assertiveness to allow them to resist the associated stress. Hence, in general nurses use conciliation and escape as methods of coping with bullying and conflicts (p. 145).
During that week of practicum, I felt that I became more confident in my assessment. However, when I was confronted during my first head to assessment with Lisa, I was unable to provide a clear rationale on why I was performing my assessment the way it was, despite being competent in my skills. This affected my confidence because I was focused on doing my assessment correctly and lacked assertiveness when it mattered. Lisa was consistently critical of my head to toe assessment. I had sought out both my buddy nurse and instructor to confirm that my skill level was acceptable. I realized that lack of confidence was not skill related, but my inability to communicate the evidence-based reason to perform my assesment skill under constant pressure from Lisa. That placed me into a position where I looked like I was incompetent to perform my head to toes and other nursing care.
During, this ordeal, I was able to reflect on my practice, identify my weakness in confidence, and be proactive to seek out assistance from my buddy nurse and instructor in allowing me to develop my skill level as a student. I was also able to be more assertive when confronting Lisa. Assertiveness is a means, which can be used to work against bullying, improve stressful situations, and enhance empowerment (Fulton, 1997). Through a collaborative effort with my buddy nurse and instructor, I was able to clarify that my assertiveness, not my assessment skill level or knowledge base was not the reason rather my inability to effectively communicate when put under pressure, which in turn led to a lack of confidence in my skill and knowledge.
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I recognize that assertiveness is an important aspect of nursing practice and has a huge impact on ensuring the well-being of the patient is maintained. It is evident that my lack of confidence in my own ability when pressured by Lisa contributed to my feelings of being bullied and incompetentence. I have learned to be more assertive after that incident by implementing critical thinking and effective communication. That experience has made me more assertive when interacting with staff, patients, and families in this current rotation in Nurs 277.
Fulton, Y., 1997. Nurses’ views on empowerment: a critical social theory perspective. Journal of Advanced Nursing 26 (3), 529–536.
Gibbs, G. (1988) Learning by doing: A guide to teaching and learning methods. Oxford Further Education Unit, Oxford.
Mitchell, G. J. (2001). Struggling in change: From the traditional approach to Parse’s theory- based practice. Nursing Science Quarterly, 3 (4), 110-116.
Valentine, P.E., 1995. Management of conflict: do nurses/women handle it differently? Journal of Advanced Nursing 22 (1), 142–149.
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