Bon Secours Memorial College of Nursing
NUR 4143 - Clinical Immersion
Mid-Point Guide for Reflection
Tanner’s (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 Tanner’s clinical judgment model (see below).
Background
The most challenging moment I have experienced in immersion so far was deciding whether a patient needed to be
transferred to a higher level of care or not. The patient had been back and forth from the ICU and step-down unit
throughout his hospital, had multiple health problems, and was rather non-compliant with his care. When receiving
morning shift change report, we learned the patient had refused to wear his BIPAP overnight.
Noticing
Upon assessing our patient, we noticed he was confused, shaky, and experiencing an increased work of breathing.
We attempted to arouse and reorient the patient but he became increasingly more confused and eventually obtunded.
We ordered STAT ABGs, placed him on oxygen via nasal cannula, consulted with his care team.
Interpreting
After receiving the ABG results, we interpreted the data and came to the conclusion that our patient was retaining
carbon dioxide and was in acute respiratory distress. This was caused by the patient refusing to wear his BIPAP the
night before. Because of his decline in condition, he was in need of a higher level of care.
Responding
When deciding how to respond, we considered the fact that this has been an ongoing cycle for the patient. His
condition improves so he is transferred out of the ICU. He then becomes non-compliant and refuses certain care on
step-down units resulting in his status to decline where he is then transferred back to ICU. However, this didn’t
change the fact that we had to do what was best for patient and because his respiratory status was declining causing
him to require continuous BIPAP, we had to transfer him back to ICU. In the future, our care team should be more
active in encouraging participation and compliance with care and remind the patient of the ultimate goal of being
discharged from the hospital.
Reflection-on-Action and Clinical Learning
When comparing my experience so far working one-on-one with a preceptor versus in a group of students with one
instructor, I would say you receive much more attention since your preceptor only has you to supervise. It is
definitely easier for your preceptor to observe and assess your growth, as well as evaluate how you are progressing.
When having multiple students in a clinical group, I’m sure it is difficult to keep up with all of our goals, needs, and
progress. I have already learned so much throughout the first part of immersion and received many helpful tips and
advice from my preceptor.
Write your midpoint program outcome objectives and discuss you have met them. This section
should address all 5 midpoint objectives:
1. Communication and Collaboration:
Mid-point: The student will adequately complete discharge teaching with at least one
patient by midpoint.
- Goal met 9/9/18 when student provided discharge teaching to a post-cath patient and
their family member.
2. Caring and the Health Care Ministry:
Mid-point: Student will be able to complete full assessments while considering patient
preferences, beliefs, specific needs, adapting to those by midpoint.
- Goal met by midpoint as student performing and charting complete assessments on all
patients.
3. Servant Leadership and Global Health:
Mid-point: The student will incorporate concepts of health promotion and disease
prevention into their daily teaching with patients by midpoint.
- Goal met 9/20 when student offered flu shot to patient being discharged and also
provided education on nutrition and exercises to improve mobility and health status.
4. Safe, Quality, Evidence-based Practice:
Mid-point: The student will be able to administer medications safely and correctly using
all the appropriate checks by midpoint.
- Goal met by midpoint as student is administering all medications to patients
according to protocol and using the appropriate checks.
5. Professionalism and Commitment to Lifelong Learning
Mid-point: The student will initiate and participate in learning opportunities in areas of
weakness by midpoint.
- Goal met by midpoint as student has eagerly participated in learning opportunities
such as sterile LVAD dressing changes, titrating drips such as insulin, dobutamine,
and heparin, administering blood transfusions, post-cath care and checks, providing
discharge teaching, and giving/receiving shift change report.
Nielsen, A., Stragnell, S., & Jester P (2007). Guide for reflection using the Clinical Judgment Model. Journal of Nursing Education, 46(11), p. 513-516.
