Reflection on Patient Experience: Standards of Fall Prevention

This essay reflects on a patient's care experience, particularly concerning fall prevention and the use of My Health Records, utilizing Gibbs' reflective cycle. The patient, Mr. William Taylor, experienced inadequate care, marked by a lack of fall risk assessment and education, and challenges within the healthcare system. The reflection highlights the importance of clinical governance, patient-centered care, and adherence to NSQHS standards. It identifies gaps in communication, therapeutic relationships, and individualized care planning, emphasizing the need for enhanced accountability and staff training to improve patient safety and care experiences. The student nurse's action plan includes professional skill development, knowledge enhancement of guidelines, and staying updated with the latest practices to ensure optimal care in future practice. This reflection underscores the critical impact of effective communication, adherence to standards, and patient involvement in care planning for improved healthcare outcomes.

Running head: REFLECTION ON PATIENT EXPERIENCE
Reflection on patient experience
Name of the student:
Name of the university:
Author note:

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REFLECTION ON PATIENT EXPERIENCE
Background:
The reflective practice is a tool that provides the health care professionals with the
opportunity to explore the positive and negative aspects about their own practice (Dubé &
Ducharme, 2014 pg no 91). This enables nurses to explore their strengths and weaknesses and
learn from the errors committed to inform practice. Hence, the importance of having a
reflective practice in the health care profession is extreme (Johns, 2017 pg no 2-18). In this
essay I will explore the aspects of patient care experience and partnering in care taking the
assistance of the interview of Mr. William Taylor. The essay will take the assistance of the
Gibbs reflection cycle to reflect on the standards of prevention of fall and My Health Records
in accordance with his experience.
Discussion:
Description:
It is the first stage of the Gibbs reflective cycle, which allows the nurse to explore the
experience of the patient in the care and its quality (Dubé & Ducharme, 2014 pg no 91). In
this case, a 75 year old patient named William Taylor had been interviewed regarding his
experience in the care. The patient had suffered from two consecutive falls and many other
illnesses for which he had to visit the health care facility many a times. However, the care
experience of the patient had been not up to the mark which affected his inclination to visit
health care facilities. Exploring the positive aspects of the care experience, Mr Taylor had
been informed about his present health adversities. Although, the negative experience
includes not being informed or educated about the falls prevention/ harm from falls and My
Health Record.
Feelings and thoughts:

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There are many areas of unsafe practice according to my best understanding of the
experience that the patient had such as fall risk management and My Health Records
(Safetyandquality.gov.au, 2018). As per the interview, the patient visited a General Practice
setting soon after the first fall, and the GP failed to provide and fall risk assessment and
prevention strategy to him. Due to the negligence and inappropriate practice standards he had
to undergo another which is deeply disheartening. Furthermore, the patient has had a terrible
experience of having to sit 11 hours with excruciating pain in the chaotic environment of
Emergency departments(ED) where he had to go up to the counter to fetch pain medication. I
believe this is extremely inhumane and morally distressing for a patient to be left unattended
in a chaotic environment.
Values and beliefs:
My values and beliefs centre on responsibility and accountability for the patients and
providing safe and optimal care to them. My care approach as a student nurse is dominated
by the moral righteousness and accountability for ensuring the safety and wellbeing of my
patients with respect to my background and upbringing. In this case, the casual approach and
negligence had resulted in a patient having a bad experience in the facility (Eaton, Roberts &
Turner, 2015 pg no 181). If I had been involved as a nurse in the experience I would have
ensured effective communication and information sharing with Mr. Taylor, most preferably
taking the assistance of My Health Records I would have also ensured taking fall risk
assessment and fall prevention strategies with his collaboration to ensure his safety. These
values and beliefs have developed me as a responsible and accountable nurse. These values
will help me continue safe and lawful practice which will benefit me as a professional and the
patient and their family as well ensuring safe and effective care.
Analysis:

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The care experience that Mr. Taylor had through the many health adversities and
incidents that he has went through had been inadequate. Justifying this statement, it has to be
mentioned that two very important standards of National Safety and Quality Health Service
Standards or NSQHS are clinical governance and partnering with consumers
(Safetyandquality.gov.au, 2018). As per the first standard, the care professionals must take
efforts to ensure reliability, safety and quality of health care and optimal health and wellbeing
status for the patients. This had been violated for the patient facilitated by inappropriate risk
assessment and care planning to address his care needs. As per partnering with consumers, a
person-centred health system with collaborative decision making of the patient is needed to
be established for safe and effective care. In this case, although the patient had been informed
about his complications, there had not been effective strategic care planning with the patient.
Drawing reference from the clinical governance standard again, there had not been any
initiative to introduce the patient to My Health records. This could have helped him to better
manage his multiple illnesses considering his age and remote location (Joseph & Bogue, 2016
pg no 339-351).
The second aspect of the inadequate care for Mr Taylor relates to the fifth NSQHS
standard, Comprehensive Care. This standard directs the nurses to integrate screening,
assessment and risk identification processes for an individualized care program for the patient
(Safetyandquality.gov.au, 2018). Mr. Taylor had sustained two consecutive falls and even
after his visit to the GP after his first fall no fall risk assessment or fall prevention planning
had been carried out for him. According to the standard 5.24. Preventing falls and harm from
falls, falls prevention, minimising harm from falls, and post-fall management are necessary
care steps after a patient encounters a fall. Neither of these necessary care interventions had
been taken for Taylor, which resulted in further adversities and deleterious incidents for him.
Phelan, Mahoney, Voit and Stevens, (2015 pg no 281-293), have stated the lack of proper fall

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risk assessment for elderly patients is an unsafe and inadequate care practice which
jeopardizes the health and wellbeing of the patient. Hence, I have considered these two
aspects as examples of inadequate care for William.
Conclusion drawn:
I would like to highlight the two main themes of the care experience that Mr. Taylor
had, lack of education and information sharing with the patient regarding risk prevention and
lack of adequate care to him. Concluding the analysis, the patient experienced negligence,
casual care approach and unsafe practice at different times he had visited the facility for. As
discussed by Nichols, Horner and Fyfe (2015 pg no 23-31), the aged patient population often
experience complicated co-morbidities and an individualized and systematic care planning is
imperative. Positive participation in the care planning and implementation is also a very
important aspect of care for elderly patients. Active participation and chance to collaborate
allows patients to have better control of their health and also provides a sense of
empowerment and value. In case of Mr. Taylor, both these crucial requirements of
compassionate care planning had been missing which deteriorated his experience and reduced
his help seeking behaviour (O’Beirne et al., 2018 pg no S1-S115).
Furthermore, the lack of fall risk assessment for Mr. Taylor is undoubtedly a grave
violation of the professional code and conduct (Safetyandquality.gov.au, 2018). The lack of
any effort from the care professionals to introduce him to My Health Record is also a notable
mishap in the clinical practice, which further deteriorated the quality of his experience.
Hence, a conclusion can be drawn that there is need for enhanced accountability in the care
providers and adherence to practice standards and protocol. The patient himself expressed the
need for better communication and development of a therapeutic relationship to improve care
experiences which I completely agree with. The impact of lack of effective communication

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and therapeutic relationship is predominant in the experience (Gelso, 2014 pg no 117-131).
Hence, there is need for reform of the care services involving training and skill enhancement
of the staff to provide better care experiences.
Action plan:
As a student nurse myself, I believe the lack of effective communication, therapeutic
relationship and adherence to practice guidelines contributed to the most of the challenges.
Hence, in order to ensure that I do not commit similar errors myself I will attempt to develop
my professional skills with training and workshops. I will also be taking the assistance of my
supervisors to enhance my knowledge of professional guideline and frameworks along with
research to be informed and updated about the latest practice guidelines and provisions
(Johns, 2017 pg 2-18).
Conclusion:
On a concluding note, this had been an excellent opportunity for me to explore the
aspects of safe and unsafe practice. This also helped me recognize and distinguish inadequate
care practices and its impact on the patient safety and care experiences. This essay
successfully identified many aspects of inadequate and unsafe practice and related it with
professional standards and legislations. It can be hoped that the knowledge gained about safe
and adequate care practices and partnering in care with patients will help me provide optimal
care in my future practice.

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Dubé, V., &Ducharme, F. (2015). Nursing reflective practice: An empirical literature
review. Journal of Nursing Education and Practice, 5(7), 91. Doi:
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Johns, C. (Ed.). (2017). Becoming a reflective practitioner. John Wiley & Sons. Retrieved
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