The purpose of this assignment is to critically reflect upon on aspect of my professional practice and development that arose whilst out in clinical practice. The paper will show emphasise based on communication. This reflection has been chosen to highlight the need for nurses to have therapeutic communication skills in order to provide holistic care and encourage a good nurse-patient relationship. Gibbs (1988) reflective cycle has been chosen as a framework for this paper. To satisfy the requirements of the Data protection Act (1998) as well as the NMC (2007) code of professional conduct, all names have been changed to protect identity in concordance with confidentiality purposes.
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Reflection is a way of analysing a past incident in order to promote learning and development. Gibbs (1988) reflective cycle can be seen as cyclical in nature which incorporates six stages to enable me to continuously improve my learning from the event for better practice in the future. The six stages are: 1. Description 2. Feelings 3. Evaluation 4. Ananlysis 5. Conclusion 6. Action plan.
Whilst out in placement I witnessed both positive and negative communication. During handover I was informed ‘Maisey’ has dementia, deafness, aggression and short term memory loss. During handover Maisey approached the nurses int he office who appeared to look very anxious and upset. The staff nurse raised her voice and in a fixed tone told Maisey to return to her bedroom, shouting ‘we are to busy now, go back to your room.’ The nurses and health care assistants present in handover giggled amongst themselves, exchanged knowing glances and mimicked Maiseys voice saying she can be such a nuisance. Having not previously met Maisey I offered to assist her with her personal hygiene needs and to make her bed. I knocked on her bedroom door to which I then entered. Maisey stood up defensively and appeared to be very agitated and irate. She shouted that she wanted answers. I explained that I came to help her and would do my best to help her. Maisey then explained that no one had explained to her why she was in hospital nor did she know the where abouts of her daughter (main care giver). Reviewing Maiseys care plan I found out she had a fall at her daughters (Barbara) house and her son informed me that Barbara was away on holiday for a week. After the discussion with Maisey I documented it in her notes so that other members of the Multi-disciplinary team would acknowledge that Maisey was uncertain about the situation she was in.
After speaking to my mentor and being more knowledgeable on Maiseys situation, I returned to her with my mentor close by. I pulled up a chair next to her and in a calm, reassuring, comforting manner explained the reason why she was in hospital. However Maisey appeared to look confused and asked me to speak to her in her left ear as she was deaf. I patiently repeated what I had said, she looked brighter after I mentioned her daughters name. Maisey asked a few more questions and I tried to answer them accurately and confidently. Maisey smiled and confided she is aware that she can be forgetful but feels that she is being ignored and that no one cared to what she had to say. She also said she could not sleep as other patients were disturbing her. After the discussion I gave Maisey assistance with her personal hygiene needs to which she thanked me for taking the time and ‘just talking.’ Maisey had said she felt a lot better that someone took the time to listen to her concers and explain what was going on instead of being ignored and ‘left in the dark.’
I felt very angry and disappointed that the staff easily agreed as a team that Maisey was just confused and describing her a as nuisance, without investigating as to why she seemed upset. I was in complete shock that as nurses they could be so quick to dismiss Maisey the way the did. I was highly annoyed that they all felt it was alrite to mimic and laugh at a patient. I felt a bit disheartened how no one took the time to explain what was going on to Maisey. Once I helped Maisey I felt happy that I took the time to get to know her and in turn see a different side to things. I felt proud I was able to reassure and relax Maisey so she could rest properly.
I feel I have learnt a lot from this experience with Maisey and how the nurses responded to her when she was at a very vulnerable time. It was not a nice encounter as I feel things like this should not happen in practice, however in terms of a learning prospective it was good as it taught me that it is paramount to be sensitive towards a patient who is feeling distressed. It went well as I have learnt how important it is to be patient, to take the time to listen to a patient as this can have cumulative effects on that persons well being and the outcome as to how they are feeling. The way the staff nurses reacted was not in the best interests of the patient. I did not like their approach, as they did not make an effort to show support or any understanding as she was known as a ‘difficult’ patient. Stockwell (1972) wrote the infamous book “The Unpopular Patient” where she explains that studies of communication in nursing demonstrate inadequacies in nursing practice. Stockwell (1972) describes the nurse-patient interaction, insisting that such interaction is not always satisfactory, especially when dealing with a ‘difficult’ or ‘unpopular’ patient. I feel the nursing team were ignorant to the fact that Maisey had difficulty in hearing which must have made it irritating for staff to keep repeating themselves. This could have been part of the reason as to why Maisey was considered an unpopular patient as she was seen as demanding.
There was no interaction between nurse and patient as Maisey approached the nurses’ station, and to be mocked then dismissed must have been a terrible experience for her. Davis (2008) explains how hectic times of the day such as handover, mealtimes and ward rounds leave insufficient time to help patients who need it. However, if the nursing team had engaged in a little conversation with Maisey, she might have felt valued and understood, instead of upset and belittled. The NMC Code (2008) clearly states many standards of conduct which a registered nurse should be trusted to do, these including “You must treat people kindly and considerately” and “You must listen to the people in your care and respond to their concerns and preferences”. If as nurses we should comply with The Code (2008), a lot of work is required to raise the awareness of the importance of communication in the delivery of care. In 2007 the NMC introduced Essential Skills Clusters. These Essential Skills are to be delivered by all registered nurses’, one of these clusters containing Care, Compassion and Communication. The NMC introducing these clusters show the importance of interpersonal skills in nursing care, and significance of communication in the nursing profession. On this occasion, the nursing team did not show care or compassion for Maisey, and certainly did not engage in therapeutic conversation.
As a student nurse I felt I had the knowledge and skills to approach the patient to appropriately calm and reassure her. Heyward and Ramsdale (2008) explain that a patient who thinks his nurse is not listening to them will lose faith in the service a nurse provides, and in the nurses’ willingness and ability to do as they have promised. They explain that sympathising with a patient shows willingness to understand their anxieties and make the patient feel more comfortable. As I entered the room the patient stood up with a defensive posture, which I assumed was using non-verbal communication to inform me that she was suspicious and distrustful of me. This was caused by the nursing team’s disability to make the patient their first priority and to listen and respond to her concerns. Santamaria (1993) tells us that nurses must deal with the full range of human behaviour, and at the same time deliver the highest quality of care. I acknowledged that Maisey was upset and gave her the opportunity to ask questions and voice her concerns, and in turn made her feel special by giving her my time. As Maisey asked me to speak loudly into her right ear I wondered if her history of deafness had been accurately assessed, as she was definitely not deaf but having communication difficulties. Eradicating this problem with help of a speech and language therapist or a hearing aid would have helped Maisey and the impatient staff enormously in this situation.
Although I had been informed that the patient could be aggressive, I managed the situation by relating to her position and understanding her point of view. Leadbetter and Patterson (1995) explain the prevention and management of aggression should be dealt with by showing empathy and respect for the patient’s individuality and being genuine, utilising an open and honest manner. Finally, integrity, and being aware of ones own competence to handle the situation. Egan (1990) considers non-verbal communication to prevent violent situations such as considering body posture, nodding to show interest and making eye contact, but not as though to threaten the patient in any way. Fortunately, empathy and respect for Maisey helped her to trust and confide in me.
The reason for analyzing this particular section of the scenario was to answer the question, “Why did the nurse not feel efficiently equipped to approach the patient herself, instead leaving the potentially aggressive situation with an unsupervised student?” In the NMC Code (2008), advice for a registered nurse is to recognise and work within the limits of your competence, but also to have the skills and knowledge for safe and effective practice. I believe communication skills within the nursing team must be rigorously developed and maintained as one professional alone cannot meet a patients requirements. We need to work collaboratively to provide maximum care delivery.
Maisey felt more relaxed, valued and safe, after we identified and resolved her concerns. Older people generally have more barriers to communicating effectively. These barriers are worth investigating, as the acquisition of a little understanding and basic skills is a simple and rewarding exercise. (Myerscough, 1992) The barriers Maisey faced, was the time the nurses had to spend with her, and the fact that she was deaf. Myerscough (1992) explains that this is overcome by speaking loudly and clearly, using clear lip movements to assist lip reading. Through actively listening to the patient and encouraging conversation we managed to focus on the problem that was causing unease. I do believe that Maisey was discriminated against because of her conditions and illness, as she was not given the time and energy that was given to other patients. The Human Right’s Act (1998) Article 14 explains that every person should be treated equally without any discrimination on any ground. This section of the act was broken when the staff failed to treat Maisey as they would the other patients. Maisey was confused and upset that she had not been given time to adapt to her surroundings, and was in fear due to the separation from her main caregiver. Most patients do suffer a degree of anxiety and apprehension and admission to hospital is in particular a disturbing experience for anyone. (Lloyd and Bor, 1996) They offer explanations for these anxieties, such as being in an unfamiliar environment and separation from family and friends. Loss of personal space is a factor mentioned, as is loss of independence and privacy. One that closely relates to the scenario is uncertainty of diagnosis and management. Maisey was uncertain of what was going on. By providing her with the information she required, she could understand a purpose for her admission and the decisions being made.
The reason for Maisey being upset, and the nursing team’s reluctance to help her, all stem from the same thing. As we have discovered communication and ones ability to reflect on practice have enormous effect on the capability to provide the highest possible quality of care. Additionally time and commitment to our patients is priceless as it can never be taken away from them. We also need to realise that ones own values have effects on interaction with our patients, so appreciating that our client has different values and beliefs to ourselves help us gain insight into the reasons they think and behave as they do. Some consider interacting with others as hard work, but we as nurses need to understand that communication is the gateway to successfully helping our patients and improving our skills.
On reflection I saw first-hand how easily communication can break down, if not between nurse and patient, then within the multi-disciplinary team. I will take the experience with me throughout my nursing education, remembering the importance of effective communication, and also the ability to look back at an experience and break it down to discover what really happened. Taylor (2000) defines how reflection on action occurs perfectly. He explains that only when details of events are recalled and analysed, unpicked and reconstructed considering all aspects of a situation, can one gain fresh insights and amend actions. He quotes “Critical thinking is essential for safe practice”. (Taylor, 2000) This should be an ongoing and extensive process for all nurses in practice. I will be more aware of my interaction with others and will constantly reflect on my experiences to see the whole package of care delivery.
Becker, E.L. (1991) Churchill’s Illustrated Medical Dictionary. 3rd Edition. USA: Churchill Livingstone
Data Protection Act 1998 London: HMSO
Davis, C. (2008) Tea and Empathy: discussing a project focusing on patient centred care. Nursing Standard. Vol 22, no. 32, p.18
Elliss, R.., Gates, B., & Kenworthy, N. (2003) Interpersonal communication in Nursing. 2nd Edition. London: Churchill Livingstone
Egan, G. (1990) The Skilled Helper: A systematic approach to effective helping. 4th Edition. USA: Wadsworth
Gibbs, G. (1988) Learning by doing: a guide to teaching and learning methods. London: Further Education Unit
Human Rights Act 1998 London: HMSO
Heyward, T. & Ramsdale, S. (2008) Interpersonal Skills. Chapter 1 IN Richardson, R. (Editor) (2008) Clinical Skills for Student Nurses. UK: Reflect Press
Lloyd, M. & Bor, R. (1996) Communication Skills for Medicine. New York: Churchill Livingstone
Myerscough, P.R. (1992) Talking with Patients: A Basic Clinical Skill. 2nd Edition. Oxford: Oxford University Press
Nursing and Midwifery Council (NMC) (2007) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC
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Santamaria, N. (1993) The Difficult Patient: An Important Educational Need of Registered Nurses. Unknown
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