This assignment is a reflective account of events that arose for a nursing student during their first clinical placement in a community hospital. A brief definition of reflection will be given, with emphasis placed on communication. This reflection has been chosen to highlight the need for nurses to have therapeutic communication skills, to provide holistic care for those diagnosed with dysphasia or speech loss and the scope of learning opportunities it has provided to improve practice in this area.
All names in this text have been changed, to respect the confidentiality of the patient and other healthcare professionals (NMC 2002).
Reflection, in this instance, is a way of analysing past incidents to promote learning and improve safety, in the delivery of health care in practice. The Gibbs reflective cycle has been chosen as a framework for reflection (see appendix 1).
Mr. Comer was admitted to his local community hospital for respite care. He has suffered multiple, acute strokes in the past, which has left him with severe disabilities. These include paralysis rendering him immobile, aphasia (speech loss) and dysphagia (swallowing difficulties). He relies on carers for all normal activities required for daily living (Roper et al 1996) and is advised to have a pureed diet and thickened fluids.
My mentor asked me to observe her feeding Mr Comer. She had prepared my learning the week previously by providing literature on the subject of feeding elderly patients and discussion on safe practice for feeding patients with dysphagia.
I was alarmed and unprepared for the physical sight of this patient, who was coughing noisily and laboriously and a thick, green stream of mucus was exuding from his mouth.
I observed Mr. Comer being fed and noticed he was coughing more than normal during his meal, but was informed that this was quite normal for him. I was asked to feed him the next day. When I uncovered Mr Comer’s meal he started to cough in the same manner that I had witnessed before, but this time he evaded all eye contact. I was feeling extremely anxious, but proceeded to load a spoon with his meal. His coughing increased in intensity accompanied by rapid eye blinking, turning his head away from me and throaty groans that I can only describe as distressed vocal growling.
I was terrified at this point and called for assistance, thinking Mr. Comer was having some kind of seizure. I discovered very quickly from another health carer who knew Mr. Comer well, that he was protesting profusely about the pureed dinner I was going to give him which he dislikes immensely. On the previous day, he had received an ordinary meal, mashed to a smooth consistency, which is what his carers provided for him at home.
This experience left me feeling very uncomfortable and inadequate in my role. I tried to understand why he reacted so alarmingly by putting myself in his position. I felt anger and frustration, but more importantly the feeling of helplessness. Not being able to voice my dislike to the meal offered exacerbated the urgency of hunger or thirst.
Although this experience was very frightening for me and frustrating for the patient, it has highlighted the need for me to improve my communication skills. NMC (2002) outlines that we must not add extra stress or discomfort to a patient by our actions and we must use our professional skills to identify patient’s “preferences regarding care…and the goals of the therapeutic relationship“.
Severtseen (1990) cited by Duxbury (2000) applies the term ‘therapeutic communication’ as the dialogue between nurse and patient to achieve goals tailored exclusively to the patients needs. In this case dialogue is used by Mr. Comer in the form of body language and noise to communicate his needs because of speech loss.
Nelson-Jones (1990) states that facial expressions are an intrinsic way to express emotions and eye contact is one way to show interest. The avoidance in eye contact displayed by Mr. Comer showed his distinct lack of interest. Compounding these factors was his facial paralysis, which made it especially difficult for me to ascertain the exact nature of his feelings.
The nurse must be the sender and more importantly the receiver of clear information. Patients with speech impairment or loss have a more difficult task sending the messages they want and are sometimes unsuccessful in making themselves understood. (Arnold & Boggs 1995).
It appeared to me that Mr. Comer’s cough was not only a physiological disorder caused by his condition, but a way for him to communicate, in this case, his displeasure. Critical analysis of this experience has pointed to the fact that I have inadequacies in my skills, to identify covert and overt clues provided by Mr. Comer to his needs. I had focussed too much on the presenting task to feed him, with my mind occupied on his safety due to the nature of his swallowing problems. I had not considered his other needs like his wishes or desires and I had not gathered enough personal information about him beforehand to know this (Davis & Fallowfield 1991).
I had been unsure about what to say or do to alleviate Mr. Comer’s apparent anxieties and had adopted what Watson & Wilkinson (2001) describe as the blocking technique. By continuing my actions to carry on with the meal, I was cutting short the patients need to communicate a problem. I was influenced in this decision because I felt obliged to be seen to reduce his anxieties, knowing my actions would be judged by an audience of other care workers and patients on the ward. I did not respond efficiently to reduce his distress and this pressure led me to deal with the situation inadequately and for that I felt guilty (Nichols 1993).
I should have allowed more time to understand what Mr. Comer was thinking and feeling by putting words to his vocal sounds and actions. I could have shown more empathy in the form of my own body language to promote active listening (Egan 2002) and not worried about other peoples views on my decisions and beliefs to act in a way I felt comfortable with and thought was best for my patient.
Gould (1990) cited by Chauhan & Long (2000) have suggested that “many of the non verbal behaviours we use to reassure patients, such as close proximity, prolonged eye contact, clarification, validation, touch, a calm and soothing voice, the effective use of questions, paraphrasing and reflecting thoughts and feelings and summarising are all sub skills with the totality of empathy”.
There is an abundance of information about communication, especially for nurses because it is considered by many as the core component to all nursing actions and interventions. Lack of effective communication is a problem that still exists because the learning process that leads to a skilled level of ability may take years of experience to develop (Watson and Wilkinson 2001).
It has been quite difficult for me to admit my inadequacies in communication, but Rowe (1999) explains that a person must identify their weaknesses as an initiative for becoming self-aware. Only with acceptance of ones self, can a person begin to acknowledge another persons uniqueness and build upon this to provide holistic care.