QUESTION

 Reflective report 

The report’s instructions are as follows: the rest in the files section

Assignment type

And topic

a) Essay topic; An essay outlining an anonymised service user being cared

for whilst on clinical placement analysing signs and symptoms of the

condition, how this may impact on the person’s lifestyle, pharmacology, and

any other interventions. This will draw on scientific literature to support the

scientific principles

INTRODUCTION

Bassot, (2016), stated that reflective practice is vital for the professional development of nurses. All student are encouraged to actively reflect on their clinical practice as they near the end of their programme this is in line with the NMC 2015 requirement for registered nurses.

The goal of this assignment is to highlight the importance of reflective practice in nursing practice.  This assignment will focus on learning or common one which, is the application for evidence-based communication techniques and learning outcome 3 which is decision making.

Part of this assignment  will focus on the theory of  how nurse nurses make their decision  and the impact on patients wellbeing.

I will mainly concentrate on my second placement that I worked in, with my mental. The essay will look at the clinical decision-making regarding patients favor. will expand on an event that took place in the ward, and evaluate on the decision that was made, which led to finding ways of referring the service user for full physical checkup.  As a student nurse, I had to reflect on my experience in order to be aware of my ability to recognize difficult or positive situations and look at my judgment skills to see whether I had an impact on the service user (wilding ,2008). As I explore on my reflective practice, I will also add my appendix 1 that will be in more details. I will use anonymous name as part of (NMC, 2015) code of practice to protect the service user identity and confidentiality. Margate will be the name I will be using throughout this essay in order to protect her identity. As part of the reflective practice I will follow Gibbs’ (1988) cycle mode in order to guide the structure of the assay. This will be involving description, feelings, evaluation analysis, conclusion and action plan see appendix 2. Going forward, the learning outcome provided will be used to help my professional development

Description

One of the placement area I worked was at a recovery house. This service rehabilitated service user with forensic history and mental illness to return to the community. This service supports patients who are under forensics sections of the 1983 mental Health Act and suffer from various type of mental illness to maintain their well-being.  Margate, is a 73-year-old lady who been diagnosed with schizophrenia. She has been in the recovery house for them past three years under section 37/41 of mental health act.

On a day shift I saw Margaret pacing the corridors, talking loudly to herself and her trousers were wet.  She appeared very confused and disoriented to time and place. As I approached her there was a pungent odor of urine. .  I kindly asked her if she would   allow me to escort her to her room so I can support her with personal hygiene.

She initially resisted insisting it was water that had spill on her clothes. I again encouraged her to change her clothes. This time she pushed me and starched my arm. I left her for a few minutes.  I then returned and asked her if she needed help with finding clean clothing.  She was agreeable and she had a shower and I offered her clean clothes.

As the scent of urine was strong, I asked Margaret if she would give me a sample of her urine. She was initially reluctant. I explained to her my worries that she may have a urine infection and a sample was needed to rule it out. This seemed to be too much information for Margaret to process as she appeared confused and agitated. I offered Margaret a cup of tea which, she had and then asked to do her physical observation. She consented and I carried this out. A while later she agreed to submit a urine sample. After using a dipstick measurement on the urine, it revealed leucocytes and nitrites were present. Her temperature was elevated and her pulse near a 100 which is above her normal range. I reported my findings to nurse in charge. Towards the end of the shift I noted no one had taken any actions. Initially I was hesitant but, then decided to call the duty doctor asking her to see Margaret.  Upon visiting the duty doctor requested for a further analysis of the urine sample. The next shift it was handed over Margaret had a urine infection and was prescribed oral antibiotics. I asked the team if she could be put forward for a medication review as I noticed her mental health seemed to have deteriorated over the past week.

FEELINGS

I recall experiencing a mixture of emotions during this episode of care.  I felt concern and compassion for Margaret when I saw her in such confuse and undignified state.  Davidson (2009) explained compassion is important to providing nursing care. He conjectured patients and nurses would have their own personal definition of compassion. Their subjective definition may not be the common view held by others which, can cause tensions. I questioned how Margaret could be left to wander the corridor in such a confuse sates and thought the nurses on duty had deliberately ignored her. I am also aware that nurses are at risk of compassion fatigue which, can compromise patient safety (Peters, 2018).

 I was concern for Margaret safety, dignity and wellbeing and felt I had a good rapport hence, I approached her. I was surprised at her resistance and angry that she had pushed me. I did not feel fear during this encounter as I felt she meant no harm. I was aware she can display aggressive behavior when she feels distressed.  Patient’s aggression towards nursing staff is well documented and there is greater risk of aggression on impatient psychiatric ward (Pekurinen et al., 2017). Goethals et al, (2010) explained nurses often respond in different ways when faced with conflict situations and do not always react immediately.  They react in different manner and one of the reaction is to nothing. Doing nothing was congruent with my actions after Margaret was aggressive towards me.  I left her for a few minutes and then returned determine to help her.

I felt proud that I was able to engage with Margaret in a clam manner and glad I took the initiative to ask for a urine sample and take her physical observations. The NMC (2015) states nurses must prioritize the patients and preserve safety by treating them with kindness, compassion, respect and upholding their human rights.  Furthermore as nurses we must identify, detect and assess signs of deteriorating health conditions. I felt I achieved this when I detected signs of urine infection and escalated the issues to the nurses in charge. I felt annoyed when it seemed to me nothing was done. The ward is a busy environment but, rationalized that this should be a priority.  ()agreed the ward is viewed as a hectic environment with complex patients’ cases. Their studies detailed that student felt accepted and welcomed by staff on the ward. However, students felt they were expected to carry out patient task and were not listen to or taken seriously when patient concerns were raised.  While I cannot account for discussion that may have after I raised my concerns about Margaret it seems nothing was done owing to my status as a student. I felt proud that I displayed the 6cs in this episode of care. Similarly, student nurses in the third year of their program are expected to collaborate with patients, promote their dignity and independence, actively listen to the patient’s concerns and address the patient issues in a manner showing they care about the patient (Curtis, 2013).

Evaluation

Having a good rapport and effective communication is vital when engaging patient. Identically Quick (2010) summarized the importance of having a good patient relationship as its vital aspect of communication.  Additionally, the way in which the nurse approach and communicate with the patient is just as important as what is said to the patient. In order to engage the patient more fully in decision making good communication is essential. Communication is one of the main component of a successful therapeutic relationship (Islam, 2016) . According to (Bodnar) non-verbal communication can be more influential than spoken words.  Effectively using Non-verbal communication skills with patients can help to establish trust.  The nurse’s body language can show what she is thinking and feeling. This can positively reinforce to the patient spoken words and help each party to understand the feelings being conveyed. Positively using both verbal and non-verbal communication with Margaret was helpful. She initially resisted but, non-verbal communication likely conveyed more meaning to her than words spoken.

There are times patients feel vulnerable owing to the nature of the mental illness and the busyness  of a ward setting. Margaret may have been feeling fearful and responded aggressively when approached. Skarbalienė  et al., (2019) expounds students are encouraged to pay attention to patients  body language, listened attentively and compliment them these all help to build a good rapport. Price (2017) claims having good rapport helps the patient to feel at ease during tense circumstances.  Rapport along with trust helps to establish a therapeutic relationship. The therapeutic relationship as described by Segaric and Hall (2015) is a partnership working between the nurse and the patient which, is based upon understanding and trust.  To have an effective therapeutic relationship the nurse needs to  be non-judgmental, and have a understanding of the patient attitude towards the role of the nurse.  The student nurse approached Margaret with calm and ease as she felt they had good  rapport and an effective therapeutic relationship was developing.

Nurses have a duty of care for their patients and must prioritize them (NMC, 2015).  The Code: Professional Standards of Practice and Behavior for Nurses and Midwives states nurses must treat their patients with kindness, compassion and respect.  The code of ethics added nurses need to collaborate with the patient to ensure care is delivered safely effectively. However, Middleton (2014) highlighted wards are extremely understaff resulting in patient safety being put at risk.  In reviewing the scenario, the patient was seen wandering the corridors in a distress state. It may well have been due to staff shortages safe patient care was not provided. It could also be due to staff shortage staff are overworked and under much pressures hence, Margaret’s needs was overlooked. Whatever the failings were it is  unacceptable to not provide appropriate care for the patient.

Is important to make decisions in the best interests of the patients. The decision was made to raise a concern regarding the state of the patient. This is keeping with the ethical standards set out by the Nursing and Midwifery council (2015) patient must be a priority and the nurse must preserve their safety.

Analysis

To develop as a professional decision making should be viewed as self-reflective process and student nurses need to develop this skill. Standing (2020) explains decision making uses judgement and links it to practice by choosing from the best available options. There is a great need for nurses to understand and know how to make decisions. This is vital as nurse’s decision- making directly affects patient outcome, Furthermore, decision making experience and knowledge are intertwined.  Aktas and karabulut, (2020) insist nursing student need a supportive clinical environment to apply their knowledge and experience thereby, enhance their decision-making skill.  For example the student nurse thought if she said nothing  about the state of the service user, there may have been further potential for neglect and more harm occurring to the service user. 

The student showed good decision-making skill when she raised concerns about the possible urine infection Margaret may have had. This is congruent with NMC (2018) ethics which explains nurse must use their knowledge to ensure patient safety and dignity is met. However clinical decision in nursing practice is a complex process (Banning, 2007).  It can be complicated by anxiety that novice nurses and student nurses experience with some data showing student nurses are unable to make decision independently (Jahanpour et al., 2010). Nevertheless, to best explain how the student nurse made the clinical decision Miller and Hill (2017) described several model one being the information processing model. Aston (2010) explained the way information is stored and retrieved is link to how decision is made. The knowledge acquired during the anatomy courses at university along with previous experience and Margaret’s presented condition helped the student nurse to retrieve the information about infection and make the decision to further investigate and raise concerns.

Another component that help to make the decision-making process more seamless is knowing and working together with the patient (Kelley et al., 2013). For this to work the nurses must understand the service user and interventions chosen.   In the episode of care knowledge of the service user was evident as the student nurse was aware the presentation and behavior were out of character for Margaret. While concern about Margaret health and well-being was raised the final decision about her care was made by the multi-disciplinary team. The MDT team was aware of what is important to Margaret which, is to maintain reasonable health she was consulted about starting an antibiotic and agreed to have a medication review thus, evidencing partnerships working (Standing, 2020).

Nurses are expected to spend considerable amount of time talking to and engaging the patient using various forms of psychosocial interventions. A vital part of patient treatment is providing psychosocial interventions (Butler et al., 2014).  Psychosocial interventions such as stress management, problem solving, psychoeducation and relapse preventions can help the patient to remain well and improved their understanding of mental illness (Precin, 2017). However, Mullen (2009) recent studies reveal risk assessment and observations are the main approaches being used on acute and recovery wards within the United Kingdom. The argument being it is important to keep the client safe and there are many polices which, reinforce the need to constantly observe the service user. Bowels et al., (2002) as cited by Mullen (2009) noted because nurses spend much time assessing the service user many don’t collaborate or consult the patient about their care.  They believe they already have the information to provide service user care.   A major issue with the close observation with the service user is mental health nurses spend more time reacting to patient’s situations. This time could be best spent on planning nursing intervention to benefit the service user.  This may explain why Margaret may have been hesitant to approach the nursing staff and perhaps some nurses may believe they know what is best for her. The student nurse did not observe any psychosocial intervention planned or used to address Margaret’s individual need.  Therapeutic communication and effective communication skill along with the previous established rapport with Margaret did have some effect in providing person centered care (Santana, 2018).

Effective communication is important for nurses to provide nursing care. For communication to be deemed as helpful and effective it must be delivered with kindness and compassion. Non-verbal communication is a significant aspect of effective communication  (O’Hagan et al., 2013).  Effective communication and both positive verbal and non-verbal communication is necessary for developing and establishing a therapeutic relationship.  The therapeutic relationship is an essential part of nursing care A well-developed therapeutic communication skill is necessary for nurses to help service user solve problems and use their clinical knowledge  (Mirhaghi, et al.,  2017).  Levett-Jones (2014) describes therapeutic relationship as nurse showing concern and interest in the patient by actively listening, empathizing and understating the patient.  Additionally, the foundation for a successful therapeutic relationship is rooted in activities such as mental health promotion, patient education and nurse patient interaction (Martin and Chanda, 2016). However, Brownie et al., (2016) explains there are communication difficulties that can occur between patient and nurse.  This can negatively impact the therapeutic relationship and diminish thrust.  In instances where there is miscommunication, communication breakdown or if the nurse perceives service user as difficult and challenging. This can lead to a break down in therapeutic relationship. However, Michaelson (2012) suggested there is no characterization of a difficult patient but, the difficult lies between the nurse patient relationship. The student nurse did not perceives Margaret as difficult and was enthused to advocate for her. Margaret’s notes along with some staff perception  stated she could be challenging and viewing this lends credence to Michaelson theory.

Conclusion

Having used the Gibbs reflective cycle I have leaned to review and reflect on the events that occurred in its entirety. Good communication skills are vital when dealing with nurses and patients.  Establishing good rapport and a successful therapeutic relationship  is essential  for providing  for nursing care. It the basis from which, to affect a positive patient outcome. Being put in a position where I advocated for Margaret has helped build my confidence. Even though I was advocating for Margaret it did feel as if I was stepping beyond my boundaries, you’re my boundaries with this stuff. start there for Therefore they were some lessons learn from this episode of care which, helped to develop an action plan.   For this reflective practice to be more than academic exercise I have developed an action plan to address areas for professional development.

Action Plan:

Moving forward I plan to continue improving in areas such as communicating effectively with patient, communicating professionally with staff building, therapeutic relationship enhancing my decision making skill and having a more in-depth underrating of patient mental health condition. I have drafted a plan see (appendix 3) address these areas for improvement 

Authors

Aktaş, Y. and Karabulut, N., 2020. A Survey On Turkish Nursing Students’ Perception Of Clinical Learning Environment And Its Association With Academic Motivation And Clinical Decision Making. 

Neil Davison, BN, DipN, FETC, Cert Ed, ONC, RGN, is lecturer and teaching fellow; Katherine Williams, MA, AdvDipEd, DipN, Cert Ed, RGN, is lecturer; both at Bangor University. 

BASSOT, B., 2016. Reflective Journal. London: Palgrave macmillan. 

Butler, M.P., Begley, M., Parahoo, K. and Finn, S. (2014) ‘Getting psychosocial interventions into mental health nursing practice: a survey of skill use and perceived benefits to service users’, Journal of Advanced Nursing, 70( 4), pp. 866-877.90. 

Curtis, K., (2013) ‘Learning the requirements for compassionate practice’, Nursing Ethics, 21(2), pp.210-223. 

Skarbalienė, A., Skarbalius, E. and Gedrime, L., (2019) ‘Effective communication in the healthcare settings’, Management, 24, pp.137-147. 

Price, B., (2017) ‘Developing patient rapport, trust and therapeutic relationships,’ Nursing Standard, 31(50), pp.52-63. 

MIDDLETON, J., (2014) ‘Staffing guidance falls short for patient safety’, Nursing times, 110(15), pp. 1. 

Jahanpour, F., Sharif, F., Salsali, M., Kaveh, M. and Williams, L., (2010) Clinical decision-making in senior nursing students in Iran. International Journal of Nursing Practice, 16(6), pp.595-602. 

Qureshi, A. and Zehra, T., (2020) ‘Simulated Patient’s Feedback to Improve Communication Skills of Clerkship Students. 

Islam, R., (2016) ‘My non-verbal communication skills made a big difference’, Nursing Standard, 30(46), pp.36-36. 

Segaric, A., and Hall W, (2015) ‘Progressively engaging: constructing nurse, patient, and family relationships in acute care settings’, Journal of Family Nursing, 21(1), pp.  35-56. 

Precin, .J., (2017) Efficacy of a Stress Management Module in Managing Stress and Clean Time in Dual Diagnosis (Mental Illness and Substance Misuse) Clients. Occupational Therapy: Occupation Focused Holistic Practice in Rehabilitation, p.67. 

Mullen, A., (2009) ‘Mental health nurses establishing psychosocial interventions within acute inpatient settings,’ International Journal of Mental Health Nursing, 18(2), pp.83- 

Santana, M.J., Manalili, K., Jolley, R.J., Zelinsky, S., Quan, H. and Lu, M. (2018), ‘How to practice person‐centred care: A conceptual framework’, Health Expectations,  21 (2), pp. 429-440. 

O’Hagan, S., Manias, E., Elder, C., Pill, J., Woodward-Kron, R., McNamara, T., Webb, G. and McColl, G., (2013) ‘What counts as effective communication in nursing? Evidence from nurse educators and clinicians’ feedback on nurse interactions with simulated patients’, Journal of Advanced Nursing, 70(6), pp.1344-1355. 

Mirhaghi, A., Sharafi, S., Bazzi, A. and Hasanzadeh, F., (2017) ‘Therapeutic relationship: Is it still heart of nursing?’, Nursing Reports, 7(1). 

Martin, C. and Chanda, N., (2016) ‘Mental Health Clinical Simulation: Therapeutic Communication’, Clinical Simulation in Nursing, 12(6), pp.209-214. 

Levett-Jones T, (2014) Critical Conversations for Patient Safety: An Essential Guide for Health Professionals. Pearson Australia, Frenchs Forest NSW.

Martin, C. and Chanda, N., (2016) ‘Mental Health Clinical Simulation: Therapeutic Communication’, Clinical Simulation in Nursing, 12(6), pp.209-214.

Michaelsen., JJ, (2012) ‘Emotional distance to so-called difficult patients’ Scandinavian Journal of Caring Sciences. 26,(1),pp. 90-97.

Appendix A

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