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In order to help me with my reflection I have chosen Gibbs (1988), as the model to help guide my reflective process. This model comprises of a process that helps the individual look at a situation and think about their thoughts and feelings at the time of the incident. Reflective skills help us to think about what could have been done, so that if a similar situation occurs again the experience gained can be used to deal with the situation in a professional manner (Palmer et al 1997).
To enable me to use this situation for my reflection the patient will be referred to as “James”. This is in order that his real name is protected and that confidentially maintained in line with the An Bord Altranais Code of Professional Conduct (2000). James, a seventeen year old boy was admitted with a fractured wrist who suffers with schizophrenia. Jame’s condition caused him to have delusions and hallucinations which made him act inappropriately towards other patients and staff.
He found it hard to relax and paced the ward a lot. James constantly needed reassurance and would ask other patients and staff if he was all right. His questioning involved wanting to know if he was in trouble and if his eye balls were ok.
Everyone would reply to his questions by saying: “yes James you are all right, your eyeballs are fine and no you are not in any trouble‟, but this was not enough, you also had to give the “thumbs up” as well to assure him that he was fine.
When James became agitated he would act out by kicking people. Due to his small size and light weight, the kick was usually light and didn’t hurt but sometimes it had strength in it. This acting out led me to question my preceptor if James’s kicking was behavioural or part of the illness and why it hadn’t been dealt with. My preceptor relayed to me that the nurses had used various techniques including behavioural therapy to stop James’s kicking but nothing had worked. Doctors had also tried a number of different drugs to help James with his schizophrenia but nothing had worked for him there either. He had been taking Clozaril for a few months but it was not doing anything for his psychotic symptoms.
James was even sent to the Maudsley hospital in England (a world leader in psychiatry research) to see if they could help him or if they had any ideas that could help him in his treatment but experts were mystified with him there also. Mealtimes were a very difficult process with James. If he could get away with it, he would never eat. He would play around with his food, smell it, ask if it was poisoned and ask various questions to distract the nurse from what he or she was trying to do (which was trying to get James to eat). It was a very tedious task for the nurse in charge of him that day to get him to eat. The nurses always handled it professionally and with a lot of patience. Usually by the end of the meal James had eaten almost half of it and so would also have to drink a fortisip later to make up for his lack of dietary intake. One evening after a long and tiring day, the nurse in charge of James was busy and I was put in charge of him eating his dinner.
As usual the task was very hard and James didn’t seem to take me very serious. I tried to emulate what I had seen the other nurses do but James would hardly touch his food. He even began spitting out his food on the plate and this really disgusted me. I tried not to let him know what I was thinking and behave like a professional. I also tried to encourage him by saying “come on now James, just a little bit more “and he did the usual by trying to distract me and asking questing like “Am I dead, I’ve no eyes”, but I wasn’t having it. This process went on for what seemed like an eternity and I was beginning to get very frustrated. I finally said to him, “if you don’t eat your food, I’m goanna have to feed you like a little baby”. I then took his fork, scooped up some food and held it in front of him. I then said “now open your mouth”. It was then that it finally dawned on me what I was doing and I immediately stopped. I was filled with embarrassment as I realised the implications of my actions. I glanced around at the other tables to see if the other nurses and patients had seen or heard me, but they had not. I felt very glad that no one had witnessed my actions but also very ashamed of myself for what I had done. James didn’t seem very bothered by me and carried on with his questions. I was glad he didn’t seem angry or upset by what I had said but I also wondered if my actions had an effect on his unconscious feelings.
When I had first saw James I was very intimidated and a little scared of him because he was very confrontational and tended to lash out. What was good about this experience was that I had finally gotten over my fear of him. By challenging him to eat, I felt more assertive and empowering. Kilkus (1993) claims that using assertive behaviour in nursing, empowers the nurse and is an invaluable component in the profession. The negative side to this incident was that I became too forceful and domineering. By saying to him “I’m goanna have to feed you like a little baby” was very sarcastic of me and subconsciously I was even mocking him. It also could have made James associate food with negative feelings and that would have set the nurses back in their progress with getting him to eat. Jacobsson et al (2004) asserts that food psychologically, can be associated with positive feelings of well-being and comfort or it can be associated with negative feelings of sorrow or burden.
Although James did not react to what I had said, this did not mean he did not comprehend it. It is common for schizophrenia sufferers to appear as though they have a lack of feelings. This is so, due to damaged pathways connecting the brain to facial expressions. Although it is possible that these feelings cannot be expressed, emotions are felt inside (Kring et al. 1993). James may not have understood the underlying meaning of what I was saying to him but we as human beings can convey and relate to others through expressions, gestures and body language. Whether one comprehends what you are saying or not, one can understand what you are really saying by how you hold yourself, showing how you feel and sometimes what you are thinking (Kozier et al. 2004). James often had trouble communicating what he wanted to say, which is a common aspect of the illness (Kring et al. 1993), and would often throw out words that made no sense to us.
Sometimes he would talk about something that meant something else entirely different, for instance he might say; “Am I dead, I’ve no eyes” but would mean “I am worried about something”. Only the other nurses would know what he meant as they had experience with James over time. That evening while trying to get James to eat, he said “Am I dead, I’ve no eyes” and I took it as one of his usual ramblings that meant nothing. I should not have taken it at face value and tried to understand where it was coming from. If I am to become an effective nurse in the future I must have good communication skills with my patients. Only through good communication skills will I be able to establish the patient’s usual forms of communication and social interactions and identify any difficulties the patient may be experiencing. I must also learn how to treat the patient as an individual with their own individual needs and concerns (Taylor et al. 2008).By saying to James “I’m goanna have to feed you like a little baby” was very belittling of me. Perhaps a subconscious part of me was annoyed by his disease and I just did not want to deal with it.
Eventually, when I become a staff nurse I will have to deal with psychiatric patients, and so I must learn to be open to the patient (whether they have schizophrenia, Bipolar or any other psychiatric illness) by not having any prejudicial thoughts or perceptions. I must learn to show acceptance and respect (Browne, 1993). I was feeling very tired that evening and so because I was tired, I was probably a little irritable as well. Due to the way I felt and having the tedious task of getting James to eat, I may have acted in a way that I would not have, if I had not been tired. How nurses feel when they are tired may negatively impact their judgment and increase patient errors (Townsend &Anderson, 2009).Once I am a qualified staff nurse I am sure there will be days where I will be feeling very tired but that does not mean using the way I feel as a means to justify my actions. I must be a professional at all times, tired or not. Nursing is a professional practice that is constantly evolving (Fasoli, 2010), and I as a nurse must act as a professional if I am to succeed in the profession.
As a student nurse I need try to understand why James did not want to eat. One of the telltale signs of people with schizophrenia disorders is a deterioration in self-care skills. Individuals with the illness may not be interested in eating, may distrust the food and/or maybe too busy to eat or take care of themselves (Brooking et al. 1996). I was not taking this into consideration when I was trying to get him to eat his dinner. As a novice in the nursing profession, I could put this incident down to inexperience (Benner,1984). I could also put this experience down to bad judgement and bad communication skills on my behalf. Communication is not only the foundation of humanity but it is also the most crucial aspect of nurse-patient interactions (Taylor et al. 2008). I should not have tried to force James to eat. I should have kept trying to convince him to eat in a positive and understanding way (just like how I saw his nurse do before). By forcing James to eat I acted like a bully and could have subconsciously made him associate eating with negative feelings (Jacobsson et al. 2004).
I also could have shown more patience and empathy towards James. As a student nurse I must have patience and empathy for patients and also be sensitive to the patient’s psychological needs (Scully & Dallas, 2005). If this situation were to happen again, I would first examine my self-awareness. According to Bulman & Schutz, (2004, p.29) “Self-awareness may be described as the foundation skill upon which reflective practice is built”. It enables the nurse to view themselves in a specific situation and monitor what effect he or she has on the situation and what effect the situation is having on him or her. Nurses with a healthy self-awareness are likely to have a positive effect on patient care. Having a good sense of self-awareness is also necessary for creating therapeutic relationships with one’s patients. As a student nurse I must also learn to communicate to the patient with knowledge and awareness in order to strive for the best for them. Through self-awareness I would have realised that I was tired and kept in mind not to let it have a negative effect on the patient.
This is also another way to describe “reflection in action”. It is whereby the practitioner recognises a situation or problem and thinks about it while still carrying out an action (Schon, 1987). Also if this situation were to happen again I would remember what I had learned by my previous experience. My experience with James has taught me a lot about self-awareness, communicating effectively, empathy, patience, having a comprehension of the patient’s illness, respect, empowerment, not putting my feelings before the patients and staying positive. When this incident occurred I wanted to bury my head under the sand and wish that it never happened, but now I am grateful that it did happen because it gave me an opportunity to look deeper into the situation and deeper into myself. Using the Gibb’s Reflective Cycle model (Gibbs, 1988), has helped me to analyse what took place and examine my own insight and take on what happened. This experience was a learning curve for me as a novice and it will be beneficial to my learning experience as I have many learning needs as a student nurse. I know realise that only through experience and reflection will I be able to learn from them(Benner, 1984).
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