Megan Priddy

Bon Secours Memorial College of Nursing

NUR 4143 - Clinical Immersion
Mid-Point Guide for Reflection
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 that I have experienced recently in immersion has been having a patient who was in
the locked-in state, on a ventilator, and the family could not decided whether or not to suspend care and just do
comfort care or have the patient get a tracheotomy and a PEG tube. This was a challenging experience for me
because I could understand both the medical side as well as the personal side of the situation. Medically, I knew that
the patient was not going to get any better and would be stuck in the current state that he was in for the rest of his
life. Plus, talking with my preceptor and listening to the doctors, they were all saying that he was not going to
change out of the state that he was currently in. Personally, I understood why the family wanted to continue with
care so that they could have more time with the patient.
Noticing
Throughout my entire twelve hour shift with this patient and his family, I noticed that the wife of the patient was
more on board with going with comfort care for her husband, but I could tell that she was still conflicted about what
to do. The rest of the family was very adamant that the patient get a tracheotomy and a PEG tube so that his life
could be prolonged. Watching the interaction between the family and the patient, I noticed that it did not seem like
they truly understood the patients condition and the fact that it would be a complete miracle, for his condition to
change. A couple of days later for my next twelve hour shift, I noticed that the patient was still in the same exact
state as the previous shift and the family was still on the fence about what to do for him. By my third twelve hour
shift, I was told that the patient had passed away on his own, which I felt was such a blessing to the family because
then they did not have to try and make such a difficult decision on the care of the patient anymore.
Interpreting
Describe the clinical judgment or clinical reasoning that you performed. The example should include alternatives
you considered, and rationale for your decision.
The clinical judgment that I performed while caring for this patient was that I would make sure each time that I
went into his room to perform any task that I talked to him and let him know what I was doing, because even though
he was sedated I still wanted him to know that the tasks I was performing for him were to help him. I also made
sure that I answered any questions that the family had about the patients care, and if I could not answer the
question, I would defer to my preceptor so that the family was not getting any incorrect information. Overall, I
wanted to make sure that the patient knew what was going on with his care, even if he could not verbally or
physically respond to me. I also wanted to make sure the family was kept in the loop about what was going on as
well, because they were at the patients bedside for the entirety of my shift, plus we were hoping that if the family

understood what was going on with the patient then that could help them to make a more informed decision about
how to progress with his care.
Responding
What written evidence have you drawn upon for the care of your patient in this example? Provide cites/references.
When caring for patients who have locked-in syndrome, it is important to continue to treat them the way that you
would treat other patients. Also neurological checks should be done at the start of each shift so that you can see the
deficits as a part of your initial assessment of the patient. According to Katz, Haig, Clark, & DiPaola (1992), some
patients that have locked-in syndrome can still communicate their wants and needs through blinking their eyes since
they are paralyzed in all extremities and can no longer speak. This was the initial case with my patient who suffered
from this syndrome as well, he was able to blink yes or no to the family, nurses, and doctors, but then he rapidly
declined and had to be sedated and was no longer able to blink his requests for how he wanted to be cared for.
Overall, the care that you provide for these patients is the same as you would any other patient, making sure you are
talking to them so that they know what is going on, if they are able to communicate then use that so that you know
what they need.
Reflection-on-Action and Clinical Learning
Based on your experience as a student nurse on a unit with a preceptor, reflect on the differences of working one-onone with a preceptor versus a student nurse in a group of students and one instructor.
Working one-on-one with a preceptor is such a huge difference from working in a group of students with an
instructor. I get to have more nursing experiences working one-on-one. My very first day on the unit the first thing
I did with my patient was get a lab draw, whereas in a group of students with the instructor I would have had to wait
for my instructor to come into the room before I would have been able to do this. I also feel more like a nurse in the
one-on-one setting. I feel more at ease going into a patients room and completing tasks like giving medications and
assessing the patient. When giving medications one-on-one there does not feel to be as much pressure with the
preceptor as opposed to the instructor, even though both are there to help you succeed and learn, the feeling is more
relaxed with the preceptor as opposed to the instructor. It may be that I have more experience now in a hospital
working with patients and that is why each day working with my preceptor in the one-on-one setting I feel more
comfortable with my abilities and I feel like I can ask more questions if I am unsure of what to do or what is going
on with my patients.
Nielsen, A., Stragnell, S., & Jester P (2007). Guide for reflection using the Clinical Judgment Model. Journal of Nursing Education, 46(11), p. 513-516.

Reference
Katz, R. T., Haig, A. J., Clark, B. B., & DiPaola, R. J., (1992). Long-term survival,
prognosis, and life-care
planning for 29 patients with chronic locked-in syndrome. American Congress
of Rehabilitation
Medicine and the American Academy of Physical Medicine and Rehabilitation,
73, 403-408.