Gibbs Reflective Cycle Example in Nursing: A Step-by-Step Clinical Guide

During a morning shift on an acute respiratory ward, I was caring for a 72-year-old male patient, referred to here as 'Mr Smith' (pseudonym) to maintain confidentiality in accordance with NMC (2018) guidelines. Mr Smith was admitted with an exacerbation of chronic obstructive pulmonary disease (COPD). During my routine observations at 10:00, I recorded a respiratory rate of 26 breaths per minute and an oxygen saturation of 89% on room air, generating a NEWS2 score of 7. A consultant-led ward round was occurring at the nurses' station. I hesitated to interrupt the round, resulting in a 15-minute delay before I successfully escalated the score to the Nurse in Charge using the SBAR (Situation, Background, Assessment, Recommendation) framework. Medical review and supplementary oxygen were subsequently provided.

Initially, I felt confident in my clinical psychomotor skills whilst obtaining the vital signs. However, upon calculating the NEWS2 score of 7, my internal state shifted rapidly to anxiety. I felt acutely intimidated by the presence of the multidisciplinary team (MDT) conducting the ward round. I experienced a sense of imposter syndrome, questioning whether my assessment was accurate enough to warrant interrupting senior clinicians. Once I delivered the SBAR handover and the Nurse in Charge validated my findings, I felt profound relief, though this was quickly followed by internal frustration and guilt for allowing my lack of confidence to delay Mr Smith’s care.

The primary positive aspect of this incident was my accurate physiological assessment and correct application of the NEWS2 scale, which successfully identified clinical deterioration. Furthermore, my eventual utilisation of the SBAR tool ensured the handover was structured and actionable. Conversely, the negative aspect was unequivocally the 15-minute delay in escalation. In the context of acute respiratory compromise, a 15-minute delay in initiating supplementary oxygen and securing a medical review contravenes the principle of prompt intervention and placed the patient at unnecessary risk of hypoxia.

Making sense of this communication delay requires an examination of the human factors that govern clinical environments. The NMC (2018) Code mandates that nurses must act without delay if they believe there is a risk to patient safety. My hesitation fundamentally breached this standard, driven by what literature identifies as an 'authority gradient'. Authority gradients exist where junior staff or students hesitate to communicate urgent clinical concerns to senior colleagues due to a perceived hierarchical disparity (Smith and Jones, 2022). Research by NHS England (2023) highlights that high ward acuity and the presence of senior medical staff often exacerbate this barrier, causing cognitive overload and reducing clinical assertiveness in students.

Conversely, my eventual use of the SBAR tool proved highly effective in mitigating this hierarchy. SBAR is an evidence-based communication framework endorsed by the World Health Organization specifically designed to standardise clinical handovers and remove ambiguity (Brown, 2021). By framing my escalation entirely around objective patient data rather than subjective concern, SBAR enabled me to bypass the authority gradient and secure immediate intervention. Ultimately, while evidence-based protocols like NEWS2 and SBAR were utilised correctly, my initial submission to hierarchical intimidation temporarily compromised patient safety.

In conclusion, this incident highlighted a critical disparity between my clinical assessment skills, which are developing well, and my non-technical communication skills, which require immediate refinement. I have learned that I must trust my objective clinical findings (a NEWS2 score of 7 is an indisputable trigger for escalation) rather than allowing the subjective social environment of the ward to dictate my response time. I now recognise that the duty of care and patient safety must consistently supersede any personal discomfort regarding ward hierarchy.

To ensure this delay is not repeated in future practice, I have formulated the following SMART objectives. Firstly, I will review the local Trust's explicit policy on NEWS2 escalation pathways prior to my next clinical shift, ensuring I understand the exact timeframes mandated for medical review. Secondly, to build my clinical assertiveness, I will request that my Practice Assessor observes me delivering SBAR handovers during the next two weeks of placement, asking for specific feedback on my delivery and confidence. Finally, I will apply for a high-fidelity simulation module focused on deteriorating patients when returning to university next semester, allowing me to practice multidisciplinary communication in a safe, controlled environment.

During week ten of my placement on a busy surgical ward, I was undertaking a medication round at 20:00, towards the end of a 12-hour shift. The ward was operating short-staffed due to sudden sickness absence. I was preparing intravenous (IV) Paracetamol for a postoperative patient. Mid-preparation, I was interrupted by a relative asking for directions to the visitors' lounge. Upon returning to the preparation area, I mistakenly picked up a prepared vial of IV Co-amoxiclav intended for a different patient. My Practice Assessor intercepted the error during the mandatory double-checking procedure before we approached the bedside. The error was documented, and the correct medication was subsequently administered.

When my Practice Assessor identified the wrong vial, I felt an immediate surge of panic and acute embarrassment. I felt entirely overwhelmed by the noise and pace of the ward, and deeply disappointed in my lack of focus. I briefly feared the incident would result in an immediate failure of my placement. However, my assessor managed the situation calmly and constructively, which allowed my panic to subside into profound relief. Post-shift, my primary emotion was gratitude for the double-checking safety net, coupled with a lingering anxiety regarding my susceptibility to distraction.

The overtly negative aspect of this incident was the near-miss itself; had the antibiotic been administered to a patient with an unrecognised penicillin allergy, the outcome could have been fatal. The positive aspects, however, were systemic. The Trust’s mandatory double-checking policy for intravenous medications functioned exactly as intended, catching human error before patient harm occurred. Furthermore, the non-punitive, supportive response of my Practice Assessor fostered an environment where the error could be discussed openly rather than concealed.

Analysing this near-miss requires moving beyond individual blame to understand the human factors at play. The NMC (2018) Code mandates the preservation of safety, yet literature consistently demonstrates that task interruption during medication rounds is a primary catalyst for administration errors (Westbrook et al., 2018). My cognitive fatigue, occurring at hour ten of a 12-hour shift on an understaffed ward, severely diminished my working memory capacity. According to Reason’s (2000) 'Swiss Cheese Model' of system accidents, errors occur when multiple defensive layers fail simultaneously. The environmental pressure (understaffing) and the active failure (my distraction) aligned; however, the final defensive layer (the second checker) remained intact.

Furthermore, this incident highlights the critical importance of the professional Duty of Candour (NMC, 2015). By addressing the near-miss transparently with my assessor, we operated within a 'learning culture'. Had the ward environment been governed by a 'blame culture', the fear of punitive action might have incentivised the concealment of such near-misses, ultimately degrading long-term patient safety.

This incident revealed that my pharmacological knowledge was not the root cause of the error; rather, it was a failure in my situational awareness and environmental management. I learned that clinical vigilance degrades significantly under the compounding pressures of fatigue and interruption. Most importantly, I concluded that robust systemic safeguards and a transparent, non-punitive reporting culture are just as vital to patient safety as individual clinical competence.

Moving forward, I will strictly adhere to the Trust's 'Red Tabard' (Do Not Disturb) policy during all future medication rounds to visually deter non-urgent interruptions. If intercepted by a relative, I will practice clinical assertiveness by politely stating I cannot speak until the medication round is safely completed. Additionally, prior to my next clinical placement, I will complete the NHS e-Learning for Healthcare (e-LfH) module on Human Factors and Patient Safety to deepen my understanding of mitigating cognitive fatigue in acute care settings.