Gibb’s Reflection Cycle Essay

Running head: GIBB’S REFLECTION CYCLE
GIBB’S REFLECTION CYCLE
Name of the student:
Name of the university:
Author note:

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Introduction:
In the clinical setting, reflective practice is considered as one of the most suitable means
of evaluating nursing practice and facilitate professional development (Tanaka, Okamoto &
Koide, 2018). The purpose of the essay is to reflect on the use of digital health record in hospital
settings and the need to adopt ongoing learning concerning e-health. The key area that this essay
intended to cover includes self-reflection regarding the responsibility in documenting and
vaulting clinical care in the digitalized health care setting, professional identity, role and
boundaries and strategies that would assist the transition into practice as a registered nurse.
Personal and Professional self-reflection: (500)
This section of the essay will provide self-reflective discussion and incorporate the
feelings associated with the clinical incidence. In the clinical setting, it is a legal and ethical
obligation of the registered nurse to involve in proper documentation and evaluation of clinical
care so that the patient receives safe and responsive care (Considine, Trotter & Currey, 2016).
The electronic health record enables nursing professionals to understand the medical, health and
social history of the patient and facilitate the clinical documentation along with emulation of
clinical outcome. Ruseckaite et al. (2017), suggested that appropriate documentation enable
nursing professionals to involve in a comprehensive assessment of care, identify the changes in
the health status and evaluate the clinical outcome of the care provided. In my opinion, in order
to experience the transition into the clinical practice, it is important to gather skills of effective
verbal and nonverbal communication, active listening, expertise in technical writing, critical
thinking, accurate concentration, record management. Moreover, I feel it is important to gather

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skills for collaborative practice, it is fundamental is also crucial to inform critical information to
the members of the multidisciplinary team so that proper documentation can be conducted. Lack
of documentation leads to common clinical errors such as medication errors, administration
errors and incorrect assessment of vital signs. Therefore, in order to involve in competent clinical
practice, acquiring skills of appropriate documentation in electronic health record is crucial. In
the clinical setting, I have encountered one such clinical incident that assisted me to gain an in-
depth understanding of my professional role and responsibility as a registered nurse. I was
instructed by a senior nurse to document the medical history of two patients with their vital signs
respectively. Since I was new in the clinical setting and new to the experience of documenting by
using electronic health record, during documentation, I entered incorrect name with surname due
to similarity in the first letter. Due to similarity in the first letter, the incorrect documentation of
name resulted in incorrect documentation of vital signs of the patients. While supervising, the
senior nurse informed me that I made a documentation error due to similarity in the first letter
and I documented incorrect vital signs. The senior nurse provided me with a feedback that I
must acquire essential skills of documentation and evaluation of critical care for successful
transition into practice. At first, the situation appeared to be new and challenging to me as I was
unaware of the skills required for handling electronic health record. I felt nervous and
apprehensive that I incorrectly documented the name of the patients along with vital signs. While
I received feedback from the senior nurse, I was genuinely concern about the fact that for
involving in competent clinical practice, documentation is fundamental part of the clinical
assessment and I incorrectly document it. The documentation error could be prevented in the first
place with the comprehensive skills and knowledge of handling electronic health record. At this
point, I felt I would require to involve in the mentoring and clinical supervision as I incorrectly

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document name and vital signs of the patient. I felt relieved when the senior nurse prevented
other clinical errors by reviewing electronic health record and responding to incorrect
documentation in a timely manner.
Evaluation:
This section will demonstrate the positive and negative experience associated with a
clinical incidence that was elaborated above. This section will also provide an in-depth
discussion of how the clinical incidents were supported by the literature. Considering the positive
experience, I have identified that I gathered an opportunity to involve in the documentation
process which is a fundamental part of the competent nursing practice. I got the opportunity to
facilitate the skills of effective communication with my co-workers and patients which I can
incorporate in my future practice. . Moreover, the senior nurse also involved in the situation and
feedback from senior nurse is a positive experience since I will incorporate it in my future to
involve in proper documentation practice. However, considering the negative experience, I have
identified I incorrectly document the name of the patients along with their vital signs. The
incorrect documentation impacted my clinical practice and provided me with an understanding of
significance of documentation in quality clinical practice. As discussed by Kerr et al. (2016) in
the clinical setting, in order to comply with professional role and responsibility, registered nurses
are required to provide care for the interest of the patient and ensure that the care practice meet
the unique need of patients. The best interest of the patient can be ensured through proper
documentation of name, vital signs of patients, social and clinical history of patients, changes in
health status of patients (Amin et al., 2018). The significance of appropriate documentation can
be discussed through Eriksson's theory of health and suffering. Eriksson's theory of health and
suffering suggested caritative caring consists of love and charity and nursing professionals are