Case study on diabetes management

The following reflection is based on my experience of observing the care of MJ, a diabetic patient, using the model proposed by Boud, Keogh and Walker (1985). The reason for choosing this reflective cycle is because it provides space in its third phase, for analysing the learning acquired after the field experience is finished (Boud, Keogh and Walker 1985: p10). This stage of the model is commensurate with the current reflective activity. Furthermore, various characteristics within this phase of the Boud et al (1985) approach are offered, which I was able to integrate into the present reflection of learning account. For instance, I was able to revisit the learning experience, attend to affective behaviour and re-appraise the learning event. These elements facilitated a recollection of the initial practical experience, as well as the feelings that were triggered in response to it. In effect, I was able to incorporate new information and assimilate this in a meaningful way, into my existing knowledge base (Boud et al 1985: 21). The concept of meaningful learning, from the perspective of the learner is supported by theorists such as Kelly (1963). In his personal construct theory, he argues that each individual has their own set of constructs that they use to make sense of the world. Thus ‘people can be seen as differing from each other, not only because there might have been differences in the events they sought to anticipate but also because there are different approaches to the anticipation of the same event’ (1963:55). Thus, what someone may regard as representing the ‘truth’ may not be applicable to my internal representation of reality. Another reason for choosing to use the Boud et al (1985) approach is due in large part to it’s’ flexibility. As this reflective activity proceeds, it will be seen that some aspects of their cycle become more salient than others. This aspect of the model is highlighted by Boud et al (1985) who emphasise that the reflective process may involve ‘…repetitions of important elements and lingering over particularly significant components.’

(p: 27). As a result of my practical placement, I was able to observe the nursing care provided for MJ, a 50 year old female patient who has been suffering from Type II diabetes for the past 10 years. Upon reflection, I realise that being involved with MJ’s care, albeit indirectly facilitated important knowledge that I was hitherto unaware of. As a result, I have gained practical experience that has engendered the ongoing development of my knowledge and skills base. This feature of reflective practice is reiterated by Boud et al (1985: 7) who argue that ‘reflection is an active process of exploration and discovery which often leads to very unexpected outcomes.’ In the first instance, I am more sensitised to the NMC code of conduct regarding the provision of high standards of practice and care at all times (2008, p: 4). This came about as a result of observing the due consideration given to MJ as an individual diabetic patient, with her own history and specific needs. To this end, an effective assessment was conducted by the nurse I was observing, who explained to me that this was necessary in order to ensure that MJ received the nursing care that was required. An interview revealed that the day before, she started to feel shivery, was feeling nauseated and ached all over. By morning she began to vomit and also had diarrhoea. As a result of the vomiting MJ lost appetite and was unable to eat. This triggered the fear of developing a hypoglycaemic reaction and consequently she refrained from administering her insulin injection. The next morning her husband became very concerned, because she was drowsy and breathing strangely. He called for an ambulance, and MJ was taken to hospital immediately. A measurement of appropriate vital signs revealed that her urine contained large amounts of glucose and ketones. As a result of these assessments, it was decided to administer insulin and fluid into a vein, after which MJ felt considerably better. As a result of reflecting on this particular practice placement, I have been able to generate a variety of new constructs, in relation to my existing knowledge of respect for patient individuality. Boud et al refer to this procedure as association, and may be seen as a necessary precursor to the integration stage of reflection. This is because it allows earlier knowledge to be modified to accommodate new ideas (1985:31). Learning theorists such as Ausubel (1968), believe that the ability to link new material to previous knowledge constitutes one of the most important features of learning. Boud et al, argue that integration involves drawing inferences based on the information that we are appraising (1985, p: 32). I have incorporated into my cognitive structure of ‘considering all patients as individuals’ the recognition that assessment is important in achieving this goal. This acquisition of new perspectives, is referred to as insight by gestalt psychologists, and is when the student becomes aware of the relevance of a particular learning experience (Reece and Walker, 1997: 105).

Hence, I have developed awareness that the nursing process enables the planning of interventions to meet the particular needs of the patient. This is echoed by Nettina (2006:4) who stresses that ‘assessment constitutes a planned, problem solving approach to meeting a patient’s health care and nursing needs’. Thus, I observed the implementation of personalised care, that enabled MJ to survive an episode of diabetic ketoacidosis. Therefore, I have also learned the value of the nursing process in providing a framework to alleviate the problems that the patient may be confronted with. My experience has afforded me the chance to merge theory with the reality of practice, which has enhanced my skills development. I am therefore able to acknowledge the significance of the NMC code of conduct, which emphasises the importance of practical experience in order to advance professional practice and competence (2008, p: 4).

Prior to discharge, MJ worked in collaboration with the nursing team by discussing the best ways to manage her diabetes. This process bodes well with the Framework for Managing Long-Term Conditions which emphasises the importance of a personalised care plan for people with chronic illnesses (DoH, 2008:19). As a result of observing the planning of MJ’s post-discharge care, I now recognise the value of appreciating the experience and knowledge of individuals with a long-term condition in general, and diabetic patients in particular. Upon reflection, I am conscious of how presumptuous it is to criticise diabetics for bad self management by focusing solely on overall blood control. Indeed, the consultation revealed that MJ had good adherence to the various aspects in the self-management of her diabetes. Therefore, she did not need information on how to manage her condition on a day-to-day basis. On the other hand, MJ agreed a plan that involved a range of practical tools to help in assessing risks and planning what to do in the case of illness. The Diabetes National Service Framework stresses the importance of offering patients the opportunity to be partners in their own care (DoH, 2008:18). This provides a structure in which care is chosen to respond to the individual patient’s needs, in addition to their different requirements, rather than assuming a ‘one size fits all’ attitude. According to Boud et al, the final stage of reflective activity is concerned with outcomes which can be affective in nature (1985:34). This is supported by the fact that, I am looking forward to more opportunities to develop my professional practice, in order to expand my professional value base and competence. Boud et al, confirm this aspect of the outcome of reflection, by stating that ‘reflection has the objective of making us ready for new experience’ (1985:34). Considering patients as individuals has become part of my value system which I know, will play a significant role in informing my continuing professional development. Boud et al, describe this as appropriated knowledge, and argue that other integrated constructs may be appraised in the light of it (1985, p: 34). This is demonstrated by the general theme running through the present review: Treating patients with a long term condition as individuals, is essential in order to be able to deliver high standards of health care.

Ausubel, DP (1968) Educational Psychology: A Cognitive View. Holt Rinehart & Winston.

Boud D, Keogh R & Walker D (1985) Turning Experience Into Learning. Routledge

DoH (2008) Five Years On: Delivering the Diabetes National Service Framework. DoH: London

Kelly GA (1963) Theory of Personality: The Psychology of Personal Constructs. W W Norton and Company. New York

Nettina SM (2006) The Lippincott Manual of Nursing. Lippincott Williams & Wilkins. USA

NMC (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives

Reece I, Walker S (1997) Teaching, Training and Learning: A Practical Guide. Business Education Publishers. UK

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