Denise Kropaczek

Bon Secours Memorial College of Nursing

NUR 4143 - Clinical Immersion
Acute Care Practicum Reflective Journal Guidelines
Instructions:
Reflective journals will document professional growth through your acute care practicum
experiences. You will submit one acute care reflective journal by the end of your acute care hours
(202 hours). You must reflect on the questions below. Unsatisfactory reflective journals must be
revised and resubmitted in order to receive a PASS for the course.
Final Guide for Reflection
(Example MUST be different than that provided at mid-point)
Tanners (2006) Clinical Judgment Model

Describe the most challenging moment or event you experienced recently. What actions did you
take and what would you have liked to do differently? What specific actions are you taking to
improve the outcome in future situations or to prevent recurrence of the situation? To answer this
question, use the guide for reflection using Tanners clinical judgment model (see below).
Background
The most challenging event I experienced recently during my clinical immersion was
balancing a patient load with individuals who required a significant amount of time and
attention. One of my four patients during that shift was very confused, and one of my patients
was experiencing trouble with pain control and required several infusion of antibiotics and
albumin in specifically timed increments. My confused patient was also on the CIWA scale for
alcohol withdrawal. My third patient had recently returned from surgery and required postoperative vitals and monitoring, and halfway through the shift when she was no longer drowsy
from the anesthesia, she requested not to have a student nurse (me) and eventually asked that she
not have a male nurse (my preceptor) for a majority of the care tasks she required. So, halfway
through the day, I picked up a different patient. My fourth patient was a middle-aged woman
who was independent in her care, but who was medically more critical than my other patients.
While I have become fairly adept at handling four patients on a shift, these patients were
particularly challenging for time management. Communication and collaboration with my
preceptor and the unit staff were essential to maintaining a safe environment and accomplishing
all our patient care that day.
Noticing
Initially, I noticed that the night nurses were still busy with their patients when I arrived
in the morning; we had to wait a bit to receive report. Ive learned that this typically means the
unit has a heavy patient load. I also noticed that one of my patients required the CIWA scale

Denise Kropaczek

every two hours, another was still within the time after her surgery requiring more frequent vital
sign checks, and a third was prescribed several IV medications that needed to be given at
approximately one hour increments.
As the day progressed, I noticed that the staff on 2N work extremely well as a team. I was
not the only one with challenging patients. My CIWA patient had a very confused roommate, and
their neighbors next door were two elderly, confused, fall risk patients. My preceptor and I tagteamed a few times, to ensure that the CIWA checks were done in a timely manner and that my
other patient received his antibiotics when he was supposed to. The other nurses, the patient care
techs, and I worked together to ensure that all of our confused patients were safe. We often
looked in on these patients for one another, and every available nurse was immediately there to
help when someones patient began attempting to remove his Foley catheter.
Interpreting
The clinical judgment I performed was knowing when to ask for assistance. I really
wanted to care for all four of my patients independently, to prove to myself that I could handle
such a challenging group. However, as a student, I realized that goal was likely beyond my
current abilities and I had help available when I needed it. I judged that it was in my patients
best interests to ask my preceptor to tackle some of the tasks during the day, so that each patient
had the attention they needed, when they needed it. The alternative I considered was trying to do
everything myself. My rationale was that I would one day need to do this on my own as a nurse,
so I should try to now. However, the decision I went with in the end turned out to be the best
choice, as my patients were kept safe and received their care in a timely manner.
Responding
For this patient care example, it is worthwhile to draw on written evidence regarding
effective communication in the healthcare setting. Research indicates that communication
failures account for the overwhelming majority of unanticipated adverse events in patients
(Leonard, Graham, & Bonacum, 2004). Had I not communicated with my preceptor about my
patients, there was the potential to have a delay in medication administration or my confused
patients could have injured themselves. Had the nurses on the unit not accurately communicated
the need for additional attention for the safety of several patients during shift change report,
some of the patients with altered mental status may have unintentionally caused harm to
themselves. Had the charge nurse not been informed of the patients status, they may not have
been placed in a room close to the nurses station where they could receive additional monitoring
and attention. If there had been any communication failures, there would have been a high risk of
an adverse event occurring based on patient population that day. Luckily, that unit works very
well as a team, and communication and collaboration was effective in preventing a major adverse
event that day.

Denise Kropaczek

Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: the critical importance of
effective teamwork and communication in providing safe care. Quality & Safety Health
Care, 13(Suppl 1), 85-90.
Reflection-on-Action and Clinical Learning
This precepted experience and working one-on-one with a dedicated preceptor has helped
me hone the skills I will need as a nurse. This includes both the technical skills required to
provide safe, quality care and the socialization skills necessary to work as a team with fellow
nurses, patient care techs, doctors, pharmacists, etc. Immersion has enabled me to become a part
of a unit, unlike previous clinical experiences where I felt I was more of a guest. The unit I did
immersion on is comprised of friendly, welcoming nurses and staff, who work extremely well
together as a team. Working one-on-one with my preceptor has helped me also become a part of
this team, as I learned how to interact with other nurses to give the best patient care we can. I
also learned about what additional resources are available and how to contact the appropriate
person when my patient needs something or I have concerns about their care, and my preceptor
has encouraged me to pursue these on my own so I can learn to do it for myself. Each of these
components of my precepted experience has contributed to my confidence level and feelings of
independence; I finally feel more like a nurse rather than like a student.
Nielsen, A., Stragnell, S., & Jester P (2007). Guide for reflection using the Clinical Judgment
Model. Journal of Nursing Education, 46(11), p. 513-516.