Reflection can be described as; “a state of mind, like a quiet eddy in a fast moving stream, a place to pause in order to consider the fast moving stream and the way self swims within it. The space of guided reflection can be viewed as a space of stillness that enables the practitioner to reconstitute the wholeness of experience, a place to bring the heart home.” (Johns, Joiner, & Stenning, Guided Reflection, 2002, p. 11) The Gibbs Reflective Cycle (Johns, Becoming a Reflective Practitioner, 2000, p. 49) describes a 6 stage process for reflection; Description; Feelings; Evaluation; Analysis; Conclusion; and Action plan. This paper will describe two incidents that I have experienced within the clinical environment, which I will then reflect upon utilising the Gibbs cycle.
Description – What happened
At 1400 on a Monday in early October 2008, a 57 year old man was presented to the imaging department. Earlier that day the patient had been repairing a roof of a porch. After working for some time the man had become tired and had taken less care and fallen to the ground, resulting in injury to his wrists. The patient also complained of pain to his ribs. The request was read by a supervising trained radiographer, who deemed it to be an acceptable request.
I was then supervised performing an ‘anterior-posterior’ and lateral projections on both wrists. The left wrist lateral projection had be to repeated as a true lateral projection had not been achieved. The repeat showed a hairline fracture which was not clearly visible with the initial lateral image. The right wrist was an undisplaced longitudal fracture of the distal radius. The images were ‘red dotted’ and the patient was returned to the casualty department for further treatment.
Feelings – What were you thinking and feeling
The patient was in pain but not unduly so. He joked about being able to get home to complete his work on the roof. This suggested to me that a more light hearted approach to the patient might be the best means of setting him at rest and to ensure both projections that I need to complete the imaging procedure were taken. This appeared to work as the patient did everything exactly as I described to him, any physical contact was kept to a bare minimum, which prevented me from inflicting any further pain, from moving him myself. Infection control was a potential risk, not so much for the patient, but for subsequent patients.
The patient was slightly dirty from his manual work and fall to the ground, myself and the radiographer made a stringent effort in cleansing the imaging room, after imaging (particularly the imaging paddle). Radiation protection to the patient and the radiographic staff is always a concern whilst imaging. As the patient was still reasonably mobile the legs were made clear of the central ray, to prevent any undue direct exposure to the ionising x ray radiation. The exposures were made only when the staff were clear behind the radiation protection barrier, in front of the imaging console. This ensured that the concept of ALARA (as low as reasonably achievable) was followed. (Prasad, 2004, p. 98)
Evaluation – What was good and bad about the experience The wrist projections were performed (Carver & Carver, 2006, p. 47), even though I felt that I had followed the literature. The left lateral projection was rotated. With guidance from the radiographer the positioning was adjusted to give an adequate image. This was invaluable as this demonstrated the fracture which would have been hard to see on the initial image. After the imaging the radiographer again explained to me the ways to adjust wrist positioning, and they suggested that I use the textbooks more i.e. by reading; “Common error – Radius appears posteriorly in relation to ulna: Possible reason – excessive external rotation.” (Carver & Carver, 2006, p. 47) this would have minimised the chance of a poor image I produced which gave me a feeling of ‘uselessness’ as I felt I had tried my best but it was still not good enough. The incident has made me realise how to remedy another problem of the same nature.
All the images had a good adequacy of image, and the correct area of concerned as imaged. An exposure of 54 KVp and 3mAs was used, the good image contrast confirmed to me that I had chosen a good level for exposure. Not only for image quality but to ensure that only exposure to radiation as low as reasonably practicable had been achieved for the patient. This factor combined with the operators being behind the safety screen, meant this too had happened for the operators. As a repeat had to be carried out the ALARA (Prasad, 2004, p. 98) principle was diminished slightly, had a correct position been achieved a repeat would not have been required, ensuring that the patient and staff only receive a very minimum dose of radiation.
Analysis – What sense can you make of the situation I can use the advice of going to literature as a method of aiding problem solving in other areas not linked to positioning. The radiographer acted in an extremely professional manner, this has given me increased confidence in going to trained members of staff without fear of ridicule. I feel as this may be a more valuable tool going to trained personnel, instead of reading literature, as experience of different situation can provide a substantial depth of knowledge, unlike a limited book, which may only describe actions for ideal situations i.e. some patients find moving into certain positions described in books almost impossible, and alternative methods are required.
By Keeping a daily clinical log this gives me a sense of improvement in my clinical abilities in various areas. For example I can see if I am improving in performing wrist projection, sometimes it feels as though I am not progressing, but if I refer back to when I started the course, I can see that I progressed significantly. Also the use of the log is giving me a sense of achievement, by looking back at the positive things being written about my work as well as the negative, gradually my positives are outweighing my negative considerably.
Conclusion – What else could you have done The repeat exposure was the major factor that would have improved the patients journey. In hindsight, I should have improved my knowledge further before carrying out the exposure. It may have been a sense of overconfidence that caused this. Too many unchallenging patients may have caused me to fall into the ‘trap’ of thinking I knew what I was doing when I should be thinking through all exposures in more depth.
Communication between the patient and myself was fine, however I neglected the communication to other members of staff, I should have communicated more with the trained radiographer. This could have prevented the repeat exposure, and create an improved team bond to increase our workflow in the future. Action Plan – If it arose again what would you do For all areas of my clinical experience I need to start accessing more information(i.e. literature) from having this I will have an increased base of knowledge, and have a greater array of tools to ‘arm’ myself with to find solutions to problems that stand in my path, not just as a student but also as a trained radiographer. I need to concentrate on my workplace communication, this will lead to less mistakes being made, with a synergy within the workplace being made which will lead to improved patient journeys and enhanced career development for myself.