This assignment will show a detailed account based on an experience in my second year community placement. The framework I shall be using to reflect is Gibbs’ (1988) model of reflection. Within this model are six phases incorporated into a cycle. Each phase will allow me to think systematically about the experience and identify areas where improvement is needed. This reflective account will incorporate the Scottish Patient Safety Programme (SPSP) aim to ‘Prevent Pressure Ulcers’ (SPSP, n.d.a). Pressure ulcers are defined as “an area of damage to the skin and underlying tissue that is caused by unrelieved pressure, friction and/or sheer forces” (Posnett and Franks, 2008).
The SPSP is co-ordinated by Healthcare Improvement Scotland (HIS) and aims to improve patient safety and reduce adverse events. (SPSP. n.d.b). This aim is relevant to the patient involved in this experience as they are a high risk of developing a pressure ulcer therefore preventative measures need to be addressed. To ensure privacy and confidentiality in accordance with the Nursing and Midwifery Council (NMC, 2012a), I have renamed this patient Mathew for the purpose of this assignment.
Mathew is an 82 year old man who recently suffered a fall within his home and was admitted to hospital with a fractured hip and subsequently had to have a total hip replacement. Mathew was discharged from hospital back to his home with the care of District Nurses visiting him on a daily basis to administer his Clexane injection. Due to Mathew’s injury his mobility has been compromised and has subsequently become incontinent. During our first visit with Mathew my mentor asked me to carry out a ‘Waterlow’ assessment with him. This tool is a scoring system which identifies if a patient is at risk of developing a pressure ulcer (HIS, 2009). As the score was above 10 Mathew was deemed ‘at risk’. Both my Mentor and I discussed with Mathew regarding his risk level, we suggested a pressure… In this assignment, I need to reflect on the situation that taken place during my clinical placement to develop and utilize my interpersonal skills in order to maintain the therapeutic relationships with my patient.
In this reflection, I am going to use Gibbs (1988) Reflective Cycle. This model is a recognized framework for my reflection. Gibbs (1988) consists of six stages to complete one cycle which is able to improve my nursing practice continuously and learning from the experience for better practice in the future. The cycle starts with a description of the situation, next is to analysis of the feelings, third is an evaluation of the experience, fourth stage is an analysis to make sense of the experience, fifth stage is a conclusion of what else could I have done and final stage is an action plan to prepare if the situation arose again (NHS, 2006). Bairdand Winter (2005, p.156) give some reasons why reflection is require in the reflective practice. They state that a reflect is to generate the practice knowledge, assist an ability to adapt new situations, develop self-esteem and satisfaction as well as to value, develop and professionalizing practice.
However, Siviter (2004,p.165) explain that reflection is about gaining self-confidence, identify when to improve, learning from own mistakes and behavior, looking at other people perspectives, being self-aware and improving the future by learning the past. In my context with the patient, it is important for me to improve the therapeutic relationship which is the nurse-patient relationship. In the therapeutic relationship, there is the therapeutic rapport establish from a sense of trust and a mutual understanding exists between a nurse and a patient that build in a special link of the relationship (Harkreader and Hogan, 2004, p.243). (Peplau 1952, citedin Harkreader and Hogan 2004, p.245) note that a good contact in a therapeutic relationship builds trust as well as would raise the patient’s self-esteem which could lead to new personal growth for the patient.
Besides, (Ruesch 1961, cited in Arnold and Boggs 2007, p.200) mention the purpose of the therapeutic communication is to improve the patient’s ability to function. So in order to establish a therapeutic nurse-patient interaction, a nurse must show up caring, sincerity, empathy and trustworthiness (Kathol, 2003, p.33). Those attitudes could be expressed by promoting the effective communication and relationships by the implementation of interpersonal skills. Johnson (2008) define the interpersonal skills is the total ability to communicate effectively with other people. Chitty and Black (2007, p.218) mention that communication is the exchange of information, thought and ideas via verbal and non-verbal which both present simultaneously. They explain that verbal communication is consists of all speech whereas non-verbal communication consists of gestures, postures, facial expressions, tone and level of volume.
Thus, in my reflection in this assignment would be discussed on my development of therapeutic relationship in the circumstance of the nurse-patient relationship using the interpersonal skills. My reflection is about one patient whom I code her as Mrs. A, not a real name(Appendix I) to protect the confidentiality of patient’s information (NMC, 2004).In this paragraph I would describe on the event takes place and describe that event during my clinical placement. I was on the female psychiatric ward having a 2 weeks clinical placement for mental health care in semester 3.Generally, there were two separated psychiatric wards which were male psychiatric ward and female psychiatric ward but both wards were sharing the small cafeteria in the area of psychiatric ward. The psychiatric wards were locked up from one main entrance. In the ward, the female psychiatric patients were encouraged to walk out from the female ward and combine with the male psychiatric patients at the small cafeteria during their meal time.
During lunch, I noticed one lady was still sitting on her bed. She was Mrs. A, 76 years old been diagnosed a schizophrenia. She was unable to control the muscle also called tremor due to lack of the chemical as she was having a side effect of antipsychotic medication which was a Parkinsonism (Sahelian, 2005). She could not walk herself and need to be assisted if she wanted to stand or walk. So I took the Mrs. A’s lunch meal and fed on the bed. This old lady was unable to feed on her own. So I checked her diet and served her meal. I fed her meal until finished. In this paragraph, I would discuss on my feelings or thinking that took place in the event happened. Before I started to feed her, I introduced myself and approached Mrs. A. So I tried to build a good rapport with her as I do not want her to feel strange as I was not her family members or her relatives. My first approached was to her was to ask whether she wanted or refused to take her lunch.
She was on soft diet as she was having a difficulty in swallowing or dysphasia. Then I asked her permission to feed her. She looked at me and looked like blur. In this situation, I showed up my emphatic listening as I put myself in her shoes and assuming I was having a hearing problem. According to Wold (2004, p73) the emphatic listening is about the willingness to understand the other person not just judging the person’s fact. Then, I touched her shoulder, kept saying, and raise my tone a bit because I was afraid if she had a hearing trouble. At the same time, I did somebody gesturers which could be interpreted an action of eating. I paused, repeated my actions but this time I was using some simple words in the patient dialect. Then she looked at me again and nodded her head. Fortunately the body gesturers also helped me in the conversation with her. In the meantime, I was thinking whether the first language was not her mother tongue but I kept myself communicate verbally with her including using my body gesturers and facial expression. Body gesturers and facial expressions are referred as a non-verbal communication (Funnellet al , 2005, p.443).
In my thinking, I needed to speak louder and know more words in her language so that she could understand and interpret of my actions towards her. I thought of the language barrier that breaks our verbal communication. Castledine (2002, p.923) mention that the language barrier arises when there are individuals comes from a different social background use their own slang or phrases in the conversations. Luckily, those particular body gesturers could make her understand that I was going to feed her lunch. During the feeding I maintained the eye contact as I do not want her to feel shy. This is because; my eye contact could show up my interest to help her in feeding. This is supported by Caris-Verhallenet al (1999) which mentioned that the direct of eye contact could express a sense of interesting the person to the other person involves in that communication. In the meantime I communicated with my best with her do that she felt comfortable. As a result, she gave a good cooperation and enjoyed the meal until finished.
In my evaluating, I feel I make the right decision to accompany and assist Mrs. A in feeding. Furthermore, I could develop my nurse-patient relationship. Although McCabe (2004, p.44) would describe it as a task-centered communication as one of the element caused the lack communication among nurses, but I think my nurse-patient relationship communication both involved a good patient-centered communication and task-centered communication. In my personal opinion, I attended to Mrs. A as a patient to show my empathy because she was unable to feed herself. It was also as my duty to feed her so that I could make sure the patient get the best care in the ward. So my involvement in this nurse-patient relationship does not only restrict to the task-centered communication because (Burnard 1990, and Stein-Parbury 1993, cited in McCabe 2002, p.44) define attending as a patient-centered process as wells as to fulfill the basic conditions as a nurse to provide the genuineness, warmth and empathy towards the patient.
I was able to improve my non-verbal communication skills in my conversation with her during the feeding. As she was having a hearing problem and could not communicate in the first language properly, so the non-verbal communication plays a role. Caris-Verhallen et al (1999, p.809) state that the non-verbal communication becomes important when communicating with the elderly people who develop a hearing problem. Hollman et al (2005, p31) suggests some effective ways to maximize the communication with hearing impairment people such as always gains the person’s attention before speaking, visible yourself to prevent them feel frighten and try to use some sensitive touch. I feel this is a good experience to me because I learn to develop my non-verbal communication. I used most of the body gesturers because of the language barrier was being a gap in my conversation with Mrs. A. She could speak very limited in the first language so I tried to speak in her dialect. Furthermore, Wold (2004, p.76) mention that gesturers are one specific type of non-verbal communication intended to express ideas and are useful for people who cannot use much words.
However I also used my facial expressions to advise her to finish the meal. It might be not so delicious because she withdraws the meal after few scopes but I smiled and assured Mrs. A that it was good for her health to finish her meal. In addition, the facial expressions are most expressive which are not limited to certain cultural and age barriers (Wold, 2004,p.76). Therefore my facial expression worked out to encourage her to finish the meal. Although I could not explain detail to her about the important nutrition diet that she should take, but I could advocate her to finish the meal served because the meal was prepared according to her condition. In order to analysis of the event, I could evaluate that, my communication skills are very important to provide the best nursing care to Mrs. A. My communication with Mrs.
A was the interpersonal communication. This is because the interpersonal communication is a communication which involved of two persons (Funnell et al 2005, p.438). I realized that my nonverbal communication did help me a lot in my duty to provide the nursing care to Mrs. A. Even though she could understand few simple words when I was asking her but I noticed that one of the problems occurs within the communication was the language barrier. As the patient was not using the official language and the second language, I tried to speak in her language. I still could manage the communication in our conversation. However, it was quite difficult to promote the effective verbal communication with the patient. Besides, White (2005, p.112) recommend that a nurse should learn a few words or phrases in the predominant second language to put a patient at ease for better understanding. Although it was quite difficult but using the nonverbal simultaneously with the verbal communication did encourage her to speak on her best to make me understand her words.
In the event showed that, there was a response from Mrs. A. when I was asking her questions. Funnel et al (2005, p.438) point out that a communication would occur when a person responds to a message received and assigns meaning to it. She nodded her head to assign that she agreed with me. Delaune and Ladner (2002, p.191) explain that the channel is one of the component of the communication process which act as a medium during the message is sent out. In addition, Mrs. A also gave me a feedback that she understood my message by transmitting the message via her body gesturers and eye behavior. Thus I could consider that the communication channels used in my conversation were visual and auditory. Delaune and Ladner (2002, p.191) state a feedback is that the sender receives the information after the receiver react to the message. However, Chitty and Black (2007, p.218) define feedback is a response to a message.
In my situation, I was a sender who conveyed the message receiving the information from Mrs. A, the receiver who agreed to take lunch and allow me to feed. Consequently, I could analyze that my communication with Mrs. A involved of five component of communication process which are sender, message, channel, receiver and feedback (Delaune and Ladner, 2002, p.191).In a nutshell, for my reflection of this event explores about on how the communication skills play a role on the nurse-patient relationship in order to deliver the nursing care towards the patient especially the adult. She needed quite some time to adapt the ability changes in her daily activities living where I was trying to help her in feeding. I was concerning my feeling and thoughts during the feeding so that I could improve more skills in my communication. I successfully communicated with her effectively as she enjoyed finishing the meal. So it is vital to build rapport with her to encourage her ability to speak up verbally and non-verbal.
Moreover, this ability could help her to communicate effectively with other staff nurses. Later, she would not be neglected because of her age or her disability to understand the information given about her treatment.(Hyland and Donaldson 1989, cited in Harrison and Hart 2006 p.22) mention that communication express what the patients think and feel. In order to communicate with adult, it is important to assess her common communication language and her ability to interact in the other languages. As I used some words in her dialect, I essentially encouraged the patient to speak out verbally and communicate non-verbal so that the message could be understood and do not break the nurse-patient communication. In my opinion, I evaluated that it does not a matter whether it was a patient-centered communication or task-centered communication because both communication mentioned by McCabe (2004) actually does involves communication to the patients.
So it was not a problem to argue which type of communication involves in my conversation with my patient. After I analyzed the situation, I could conclude that I was be able to know the skills for effective communication with the patient such as approach the patient, asking questions, be an active listening, show my empathy and support the patient emotions (Walsh, 2005, p.34). Actually helping the adult was a good practice in delivering the nursing care among adults. My action plan for the clinical practice in the future, if there were patients that I need to help in feeding or other nursing procedure, I would prepare myself better to handle with the patients who would have some difficulty in communication. This is because, as one of the health care worker, I want the best care for my patients. So in related to deliver the best care to my patients, I need to understand them very well.
I have to communicate effectively as this is important to know what they need most during warded under my supervision as a nurse. According to my experience, I knew that communication was the fundamental part to develop a good relationship. Wood (2006, p.13) express that a communication is the key foundation of relationship. Therefore a good communication is essential to get know the patient’s individual health status (Walsh, 2005, p.30). Active listening could distinguish the existence of barrier communication when interactions with the patients. This is because, active listening means listening without making judgment to listen the patients ’opinions or complaints which give me chances to be in the patients’ perspective(Arnold, 2007, p.201). On the other hand, it also crucial to avoid the barriers occurs in the communication with the patients. I could detect the language barriers by interviewing the patients about their health or asking them if they needed any help in their daily activities living.
However, I would remind myself for not interfere my communication with barriers such as using the open-ended questions, not attending to non-verbal cues, being criticizing and judging, and interrupting (Funnell et al, 2005, p.453). Walsh (2005, p.31) too summary that making stereotyping and making assumptions about patients, perceptions and first impression of patients, lack awareness of communication skills are the main barriers to communications. I must not judge the patients by making my first impression and assumption about the patients but I have to make patients fee devalued as an individual. I should be capable to respect their fundamental values, beliefs, culture, and individual means of communication (Heath, 2000,p.27).
I would be able to know on how to build rapport with the patients. There are eleven ways suggest by Crellin (1998, p.49) which are becomes visible, anticipate needs, be reliable, listening, stay in control, self-disclosure, care for each patient as an individual, use humour when appropriate, educate the patient, give the patient some control, and use gestures to show some supports. This ways could help and give me some guidelines to improve my communication skills with the patients. Another important thing to add on my action plan list is to know which the disabilities of the patients have such as hearing disability, visual impairment and mental disability. Once I could know the disability that a patient has, I could well-prepared my method of communication effectively as Heath(2000, p28) mention that communicating with people who was having some hearing impairment, sight impairment and mental health needs required the particular skills and considerations.
Nazarko (2004, p.9) suggest that do not repeat if the person could not understand but try to rephrase and speak a little more slowly when communicating with the hearing difficulties people. Hearing problem commonly occurs among adults because of ageing process (Schofield,2002, p.21). To summarize for my action plan, I would start a communication with a good rapport to know what affects the patients’ ability to communicate well and to avoid barriers in effective communication in future.
In conclusion of my reflective assignment, I mention the model that I chose, Gibbs (1988) Reflective Cycle as my framework of my reflective. I state the reasons why I am choosing the model as well as some discussion on the important of doing reflection in nursing practice. I am able to discuss every stage in the Gibbs (1988) Reflective Cycle about my ability to develop my therapeutic relationship by using my interpersonal skills with one patient for this reflection.
Reflection on a Clinical Skill
The purpose of this assignment is to reflect upon a clinical skill that I undertook whilst on my second year community placement. I have chosen to use Gibbs (1988) model of reflection. In accordance with the Nursing and Midwifery Council (NMC), The Code of Professional Conduct (2008), confidentiality shall be maintained and all names changed to protect identity. The clinical skill I have chosen to reflect upon during this assignment is the monitoring of capillary blood glucose (CBG). I have chosen this skill as during my previous acute placements as a student I was not permitted to undertake them, and whilst in the community the Primary Care Trust (PCT) allows it. Having yet to develop this skill I thought that by reflecting on carrying it out would help me to gain the knowledge and confidence needed to perform it in the future. According to Siviter (2004) reflection is about gaining confidence, identifying when you could have improved, learning from your mistakes and about your behaviour, viewing yourself as others do, self awareness and changing the future by learning from the past.
During a routine daily visit with my mentor Jane, a District Nurse, to Nisha, an elderly Asian lady who was Diabetic, Jane asked me whether I would like to take Nishas CBG. As I had only started doing CBGs during this placement I thought it would be a good learning opportunity so I agreed to do it. Jane asked Nisha whether she minded me doing her CBG and although she did not speak very much English she understood and consented for me to do it. I went into the kitchen and washed my hands. I returned to the living room where Nisha was and asked her whether her hands were clean, to which she answered yes. I then assessed that Nisha was sat down on a low sofa, and thought it best to kneel down and lay my equipment out on the coffee table so that they were all to hand. Once checking that the blood glucose monitor had been calibrated and that the test strips were in date I opened a test strip and placed it into the monitor.
I then put on gloves and asked Nisha whether she was comfortable and ready and which finger she wanted me to use, she said yes and held up her right third finger so I got the single use lancet and pricked the side of Nishas finger, disposing of the lancet into the sharps box. The blood came immediately and I applied it to the test strip and waited for the result, in the meantime I held a clean cotton wool ball to Nishas finger to stop the bleeding. I discarded the test strip and my gloves and recorded the CBG.I then washed my hands again. Once we had left Nishas property my mentor commented that I had done very well, but should have asked Nisha to wash her hands before commencing the CBG test.
When Jane, my mentor, first asked me if I wanted to do Nishas CBG I felt slightly nervous as I had only done a few previously and was aware that she would be observing me through the procedure which also gave me reassurance that if I were to do anything wrong she would be there to highlight it. Once Nisha had consented to me doing the CBG I felt pleased that she trusted me to carry out the process, which allayed my nerves. During the procedure I was aware that my mentor was watching me, which once again made me anxious, but she was encouraging me the whole time and totally supportive. When I instantly got blood once pricking Nishas finger I felt a sense of relief that I had done it correctly. Once the whole process was over Nisha held my hand and smiled and in broken English said “thank you, thank you”, I was humbled by her response as I felt I was just doing my job. Overall I was satisfied with my performance and felt positive that I wouldn’t be so nervous next time round.
On the whole performing this clinical skill went really well, and having not had much practice at doing this particular skill I was glad to have had the opportunity to do it whilst under direct supervision from my mentor. I think that my communication with Nisha, even though she spoke little English was very good and that I had formed a strong therapeutic relationship with her. I feel that on reflection I should of asked Nisha to wash her hands before the procedure, and that my mentor should have ensured this, to guarantee that the reading was not contaminated.
I will start by looking at the skill and the evidence supporting it. CBG monitoring is part of many diabetics daily routine. If a patient’s CBG goes up (hyperglycaemia) or down (hypoglycaemia) it can cause the patient to become unwell (Baillie, 2009). Dougherty & Lister (2008) state that in the short term CBG monitoring can prevent hypoglycaemia and ketoacidosis and in the long term can considerably lower complications arising that could affect the patient both vascularly and neurally. Patients can control their condition through diet, oral hypoglycaemic agents, insulin therapy or a combination of the above, (Higgins, 2008). By asking Nisha whether she minded me performing the CBG my mentor had gained informed consent in accordance with the NMC (2008), who say that consent must be gained before any treatment is commenced. I washed my hands following the Ayliffe (1978) technique in order to prevent the spread of infection, Pratt et al (2007) state that hands must be decontaminated between each and every episode of patient care. I asked Nisha whether her hands were clean, as one of the main causes of inaccuracy of CBG readings are fingers that are contaminated with foodstuffs (Alexander et al, 2000).
I assessed that Nisha was sat comfortably on a low sofa, Jamieson et al (2007) says to ensure patient comfort and prevent any injury occurring should the patient feel faint during the procedure . I then knelt down and laid my equipment out on the table, as Baillie (2009) suggests that all equipment needed for a procedure should be within easy reach, and avoid any twisting or stooping which could cause me injury, in line with the PCT Moving and Handling Policy and Procedure (2006). I then checked the CBG monitor had been calibrated and that the test strips were in date, to prevent false positive/ negative readings (Hastings, 2009). I then put on my gloves and asked Nisha whether she was ready and which finger she wanted me to use, Jamieson (2007) says that gloves should be used to prevent the patient and nurse from any potential blood borne infection. The NMC (2008) state that you must allow patients to make decisions about their care, and also that patients should be treated individually and with dignity.
Suhonen et al (2007) conclude that individualised patient care leads to positive patient outcomes, such as patient satisfaction, patient autonomy and patients perceptions on health related quality of life. I used both verbal and non-verbal communication, which involved speaking slowly and clearly so that Nisha could understand what I was saying. I also used non-verbal communication through touch, eye contact, facial expressions and body language, (Funnell et al, 2009). I then using a single use lancet, in accordance with PCT (2005) policy on blood glucose monitoring, pricked the side of Nishas right third finger and disposed of the lancet into the sharps box. Baillie (2009) suggests that the third, fourth or fifth finger should be used as the thumb and index finger are important for touch, and to use the side as it is less painful.
To prevent injury sharps and unused drugs must be placed in disposal boxes at the point of use, (Dougherty and Lister, 2008). I applied cotton wool to stop any bleeding and then disposed of the test strip and my gloves, washed my hands again using the Ayliffe (1978) technique and recorded my findings. Hastings (2009) recommends applying pressure briefly to the puncture site to prevent painful extravasation of blood into the subcutaneous tissues. The Department of Health (2007) state that to reduce the risk of cross infection any waste must be disposed of appropriately.
Flores (2006) maintains that it is important to wash your hands after removing gloves as bacteria can contaminate them through small defects in the gloves or during removal. Records should be completed as soon as possible following an event (NMC, 2008), and as a student all documentation needs to be countersigned (Siviter, 2004). My mentor said that I should have asked Nisha to wash her hands, not if they were clean the rationale being the same as previously stated, (Alexander et al, 2000), and also Cowan (1997) also agreed that patients hands should be washed to ensure a non-contaminated result.
In conclusion I now appreciate how in depth a “simple” CBG procedure actually is, when done correctly. I have looked further for evidence stating that
patients hands should be washed before the CBG test is performed and realise that I should have asked Nisha to do so as the result could potentially have been wrong. On reflecting on undertaking this skill I have developed my learning of the need to carry out this procedure and the importance of it to a Diabetic. I have also found that following guidelines is vital to accurate results.
In future when I carry out this procedure I will continue to practice as I have done as long as this is in line with local trust policy and supporting evidence. I will always ensure that the patient washes their hands before commencing the process, as this is what evidence suggests is good practice and also important for an accurate result.