NUR 6340 Module 6 Reflective Precepting Paper: An Experienced Nurse Moving Into Critical Care Example

Fifteen Years of Experience, Week One in the ICU: Reflective Precepting in Princeton

Student Name

M.S. in Nursing, Nurse Educator, Thomas Edison State University

NUR-6340: Healthcare Professional Precepting: Ensuring Career Success

Mentor Name

Month Day, Year

Fifteen Years of Experience, Week One in the ICU: Reflective Precepting in Princeton

An Expert in a New Place

The hospital and the nurses are invented. A 24-bed medical-surgical ICU at a hospital in Princeton accepts experienced nurses from other units when positions open. Gloria has worked on a medical-surgical unit for fifteen years, precepted many new graduates herself and is widely respected. She transferred to the ICU this month. Her preceptor, the writer of this paper, has been an ICU nurse for nine years and is completing an MSN.

In the first week, Gloria was efficient and confident with tasks she knew, such as wound care and family communication, and visibly frustrated with tasks she did not, such as titrating vasoactive drips. When the preceptor suggested a different approach to a sedation assessment, Gloria said, "I've been doing this for fifteen years." The preceptor realized that the usual approach to orientation, built for new graduates, would not work.

Reflection in Practice

Schön (1983) described professionals as reflective practitioners. He separated reflection during the act, when a practitioner rethinks on the spot because something unexpected happens, from reflection after the act, when the practitioner looks back. He argued that skilled professionals rely on tacit knowledge they cannot fully express and that surprises are moments when this knowledge can be examined and revised.

For Gloria, much of her expertise was tacit, built over years on a different unit. In the ICU, some of it transferred and some did not. Moments of surprise, such as a blood pressure that did not respond as expected, were opportunities to examine assumptions.

A Structure for Reflection

Gibbs (1988) laid out a reflective cycle of six stages: describing the event, naming one's feelings, judging what went well and badly, making sense of it, conclusion about what else could have been done and an action plan for next time. The cycle keeps reflection from stopping at a story, pushing it on toward a lesson.

Changing Assumptions

Mezirow (1991) described transformative learning, in which adults revise the frames of reference through which they interpret experience. Such learning often starts with what Mezirow called a disorienting dilemma, when experience refuses to fit one's assumptions, and proceeds through critical reflection on those assumptions, discussion with others and trying new roles. Mezirow argued that adult learning is most powerful when it changes not only what people know but how they see.

Gloria's comment about fifteen years was a sign that her frame, built on medical-surgical nursing, was being challenged. Transformative learning suggested that the challenge itself could become the start of learning, if handled with respect.

The Precepting Plan

The preceptor began by asking Gloria what she already knew and what she wanted to learn, and they built the orientation around her answers. Areas where her skills transferred, such as family communication and wound care, were checked briefly and signed off. Areas new to her, such as hemodynamic monitoring, drips and ventilator care, received more time.

During shifts, the preceptor practiced reflection-in-action aloud, describing what she noticed and how she was deciding, and invited Gloria to do the same. When something surprising happened, they paused, if safe, to ask what each expected and why.

After each shift, they spent ten minutes on reflection-on-action. Once a week, Gloria wrote a short reflection using Gibbs's cycle on one event, and they discussed it together.

Respecting Expertise

The preceptor learned to name Gloria's expertise explicitly. When Gloria handled a difficult conversation with a dying patient's son, the preceptor told her afterward what she had done well and asked her to lead the next family meeting. This was not flattery; it was a deliberate signal that Gloria's fifteen years mattered in the ICU, even as she learned new skills. Gloria later said that hearing her expertise recognized made it easier to admit what she did not know. The preceptor also asked the unit manager to let Gloria help orient the next transfer nurse in family communication, giving her a teaching role from early on.

A Turning Point

In week three, Gloria's patient on norepinephrine had a falling blood pressure. Her medical-surgical instinct was to give a fluid bolus first, which had served her well for years. The preceptor asked her to reflect in action: what else could explain this? Together they checked the infusion line and found it disconnected. Afterward, Gloria wrote a Gibbs reflection on the event, describing her frustration, her assumption and what she had learned about ICU-specific causes. She said later that this was when she stopped feeling like a failure and started feeling like a learner.

What the Preceptor Learned

Reflection ran both ways. Gloria asked questions about routines the preceptor had never questioned, such as why families were asked to leave during morning rounds. The preceptor took the question to the unit council, which began a trial of family presence on rounds. Gloria's skill with difficult family conversations also taught the preceptor approaches she had not used.

How Orientation Ended

Gloria completed orientation in ten weeks, two fewer than the standard plan for new graduates and two more than she initially expected. At their final meeting, the preceptor and Gloria reviewed her reflections together. Gloria noted that her early frustration had come from feeling incompetent after years of competence, and that reflection had helped her see the frustration as part of learning. Both agreed to continue a monthly coffee for the rest of the year.

Limits

Reflective writing can become routine if overused. Not every experienced nurse welcomes reflection, and some prefer a checklist. One relationship cannot show that the approach works generally.

Conclusion

An experienced nurse in a new specialty is both expert and beginner. Schön's reflection, Gibbs's cycle and Mezirow's transformative learning helped the preceptor treat Gloria's frustration as the start of learning, build orientation around what she knew and make reflection part of every shift. The preceptor learned too, showing that precepting can benefit everyone involved.

References

Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Further Education Unit, Oxford Polytechnic.

Mezirow, J. (1991). Transformative dimensions of adult learning. Jossey-Bass.

Schön, D. A. (1983). The reflective practitioner: How professionals think in action. Basic Books.