Worked Reflective Account Using Johns' 5 Phases (Word Count: ~1,150 words)

Phase 1: Description of the Experience (Phenomenological Narrative)

During a weekend day shift on a 28-bed acute surgical ward, I was caring for Mr. Arthur, a 68-year-old male on postoperative day 3 following an elective laparoscopic hemicolectomy. At 10:30, during routine physiological observations, I recorded: BP 102/64 mmHg (baseline 138/82), HR 108 bpm regular, RR 22 breaths/min, SpO2 96% on room air, and Tympanic Temperature 38.6°C. Calculating his National Early Warning Score 2 (NEWS2), his aggregate score was 6 (a medium clinical risk threshold requiring urgent ward-based clinical review). When I inspected his abdominal wound, the dressing was intact; however, he reported new-onset diffuse abdominal tenderness and marked rigors. I immediately informed the surgical Foundation Year 1 (FY1) doctor at 10:45. The FY1 was currently managing an emergency readmission in the surgical triage unit and instructed me via telephone: "Administer 1 gram of IV paracetamol, repeat his vitals in one hour, and page me if his systolic pressure drops below 90." Hesitating due to my junior student status, I carried out the verbal directive rather than formally initiating the hospital's acute Sepsis Six pathway or escalating to the Ward Sister. By 12:00, Mr. Arthur's BP had plummeted to 84/48 mmHg, HR accelerated to 126 bpm, and capillary refill time was delayed at 4.5 seconds. A Medical Emergency Team (MET) call was initiated, yielding a diagnosis of septic shock secondary to an anastomotic leak, necessitating immediate resuscitation with IV crystalloid boluses, broad-spectrum IV piperacillin/tazobactam, and transfer to the High Dependency Unit (HDU).

Phase 2: Reflection ("Looking In" & Subjective Intentions)

Examining my internal psychological state, my paramount intention was to provide prompt symptom relief while avoiding interpersonal conflict with medical colleagues. When the FY1 dismissed the urgency of a NEWS2 score of 6, I experienced severe visceral anxiety, characterized by a sensation of cognitive paralysis and gut tension. Internally, I felt inadequate: as a student nurse, I harbored a subconscious fear of being perceived as incompetent, panicky, or burdensome by senior clinicians. Consequently, I prioritized deference to medical authority over assertive physiological advocacy. Emotionally, I was frightened by Mr. Arthur's deteriorating hemodynamic profile, yet I rationalized that "the doctor knows best." This internal dynamic illustrates what Johns (2000) categorizes as personal vulnerability overshadowed by institutional conditioning, where the practitioner prioritizes professional conformity above clinical intuition.

Phase 3: Influencing Factors ("Looking Out" & External Realities)

My clinical reasoning was profoundly constrained by multiple external and systemic factors. Environmentally, the ward was operating at 1:8 nurse-to-patient staffing ratios with two acute surgical admissions occurring simultaneously. Interpersonally, the hierarchical gradient between pre-registration nursing students and rotating junior doctors created a communication barrier. Under Section 16 of the Nursing and Midwifery Council (NMC, 2018) Code, registered nurses and students are legally and professionally mandated to "recognize and work within the limits of your competence, yet act immediately without delay if you believe that someone's health or safety is at risk." Furthermore, NICE Guideline NG51 (2016, updated 2024) regarding suspected sepsis dictates that any adult with an acute deterioration and a NEWS2 score ≥ 5 must receive face-to-face medical evaluation within 30 minutes and the immediate initiation of the Sepsis Six protocol (blood cultures, broad-spectrum antibiotics, fluid resuscitation, serum lactate measurement, high-flow oxygen, and hourly urine output monitoring). By passively accepting telephone reassurance, I allowed organizational hierarchy to override national clinical standards.

Phase 4: Could I Have Dealt With It Better? (Critical Alternatives & Ethical Dilemma)

Critically analyzing the scenario through evidence-based alternatives reveals that my clinical response should have adhered to structured assertiveness protocols. Rather than passively accepting the FY1's verbal order for paracetamol, I should have utilized the standardized ISBAR (Identify, Situation, Background, Assessment, Recommendation) communication tool. For instance, my recommendation should have been explicit: "Doctor, Mr. Arthur meets systemic sepsis criteria with a NEWS2 of 6, tachycardia of 108, and temperature of 38.6°C. Under our Trust sepsis policy, I require a physical bedside review within 30 minutes, or I will be required to escalate this call to the Surgical Registrar or Critical Care Outreach Team (CCOT)." If the FY1 remained unavailable, Section 25 of the NMC Code required me to immediately inform my mentor or the Ward Sister. Had early fluid resuscitation (500 mL Hartmann's bolus over 15 minutes) and blood cultures been drawn at 10:45, Mr. Arthur's hemodynamic collapse into severe septic shock at 12:00 could have been mitigated, potentially preventing HDU admission.

Phase 5: Learning (Transformative Behavioral Change)

Through Johns' reflexive framework, this critical incident has catalyzed a permanent shift in my clinical identity. I now recognize that professional advocacy is not insubordination; rather, it is the foundational ethical duty of nursing. To operationalize this learning into future practice, I completed advanced simulation training on the Graded Assertiveness PACE technique (Probe, Alert, Challenge, Emergency). In future clinical encounters where patient safety is compromised by delay, I will not hesitate to utilize formal escalation chains, regardless of professional hierarchies. This experience has anchored my commitment to the NMC tenets of safety and accountability, ensuring that subjective self-doubt never again compromises objective patient care.

Critical Warning: Avoiding Descriptive Narrative Trap

The single most common reason nursing students receive lower marks (50-59% 2:2 grade) in reflective essays is spending 60% of their word count detailing what happened (Phase 1). Academic university rubrics demand that Phase 1 (Description) occupy no more than 15-20% of your total word allowance. The remaining 80% must be dedicated to critical analysis across Phases 2, 3, 4, and 5!