Reflective Cycle by Gibbs - Essay Example

?Contents Glasser, M., (1998), On Violence: A Preliminary Communication, The International Journal of Psycho-Analysis, 79 (5), pp 887-902. [Online] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9871829 (Accessed 16th April 2012). 19 Introduction This essay addresses the learning outcomes as laid out in the negotiated plan (Appendix A) by reflecting upon a client-centred experience that I encountered during one of my student clinical practice placements. Reflection has been defined as learning and acquiring new knowledge through experience which enhances self awareness or contribute to reformed understanding and perceptions in relation to one’s self and practices (Mezirow, 1981; Boyd & Fales, 1983; Boud, Keogh & Walker, 1985). Scott and Ely (2008) suggest that the purpose of reflection in nursing practice is to develop awareness of how and what can be learned from new experiences. One of the models of reflection will provide the framework for this essay. There are several models of reflection but the reflective model I have chosen is Gibbs Reflective Cycle (Gibbs 1988), with which I am familiar and I find it to be the most clear and concise than the other choices. The Gibbs Reflective Cycle (Gibbs 1988) will be applied throughout the essay to facilitate analytic thought and to assist in evaluating and relating theory to practice where possible. I have chosen to reflect on violence and aggression towards nurses in relation to patients with mental health and alcohol dependence issues. I will attempt to explore the elements that trigger violence and aggression. Besides, I will also dwell on the strategies that nurses may adopt in response to violence and aggression. This reflection will also include literature search and its detailed discussion. Discussion According to Jasper (2003), the Gibbs Reflective Cycle consists of the following stages: description, feelings, evaluation, analysis, conclusion and an action plan (Gibbs 1988). Therefore, I will begin with the first stage of Gibbs (1988) Reflective Cycle which necessitates a description of events. A pseudonym will be used to maintain anonymity and confidentiality as laid out by the Nursing and Midwifery Council (2010) in their standards of conduct for nursing students. The event occurred whilst I was undertaking a practice placement in the Accident and Emergency Department, where there was a high turnover of emergency patients. Miss March was a 42 years old patient, and suffering from depression and alcohol dependence and was prescribed medication for her depression. She was admitted to the department following an incident at home in which she had taken too many of her prescription drugs whilst under the influence of alcohol. I had not met or had any interaction with Miss March as I had been assigned to another area of the department for the morning. Miss March had already been stabilised in the resuscitation room and was just arriving in the area I was working in. I noted that she was confused and she appeared to be drowsy. My mentor told me that Miss March, while being moved, had an episode of urinary incontinence and asked if I would wash and change the patient. My mentor also asked to me to deal with this without delay as during assessment there were small areas of red, chafed skin found around Miss March’s vaginal area. Therefore, her skin integrity was already compromised. Before going ahead, I took a few minutes to read Miss March’s nursing notes and found a history of verbal challenging behaviour but no indication of any physical violence. Having collected the necessary equipment I made my way to Miss March’s cubicle to assist her in washing and changing. Miss March was sitting on the edge of the bed and I explained the reason for my visit. I continued to talk to her as I positioned everything to assist her but she did not respond in any way. Just as I lifted the wet sheet from the top of the bed to put it in the clear bag I had brought with me, Miss March yelled abuses at me then raised her arm to hit me. I attempted to reassure her but she lashed out at me again. Although Miss March had not managed to actually hit me, I was shocked and immediately knew that I should get assistance. I ensured that Miss March was safe in the cubicle and left to secure assistance. I later explained to my mentor what had happened and asked if this was something I should report. My mentor replied that we did not need to report it as I was not actually assaulted and that since Miss March had depression and was clearly intoxicated I should have been prepared for this reaction. The second stage of Gibbs (1988) Reflective Cycle requires a discussion of my thoughts and feelings. This event has stayed with me due to the fact that whilst undertaking practice placements I had never seen a patient react like that before. Primarily, I was concerned for Miss March and I was afraid that perhaps my actions or omissions had made her feel threatened, prompting her to lash out to protect herself. My initial thoughts were: What did I do wrong? Perhaps this was my fault? Perhaps I frightened her? I was stunned and found it difficult to understand why a woman would react like that towards someone who was trying to help her. I could feel myself beginning to panic and then I started to shake and perspire. The third stage of Gibbs (1988) Reflective Cycle requires an evaluation of the event. Jasper (2003) contends that in order to make a value judgement, exploration of what was good and bad about the experience is necessary. I believe I was adequately prepared for the task that I was assigned and ensured that I read the patient’s nursing notes to identify potential issues, before commencing the task. I took care to introduce myself and continued talking to Miss March, informing her of what I would be doing beforehand, to try to make her feel comfortable with me. I also made sure that the door was closed and the “Personal Care” sign was hung in view to ensure that Miss March’s dignity and privacy was not compromised. What was bad about this experience is that for my efforts, I was verbally and physically abused by Miss March. The fourth stage of Gibbs (1988) Reflective Cycle requires an analysis of the event, which Jasper (2003) describes as identifying, challenging, exploring and evaluating knowledge relevant to the event. Atkins (2008) explains that it is at this point in the Reflective Cycle that we attempt to make sense of the event. In order to arrive at a judgement we need to break down the event and consider its components, by exploring them individually (Jasper, 2003). Therefore, in the light of this event, I will search relevant literature, to try and find a rationale as to why Miss March had reacted the way she did. A literature search was carried out and the following databases were cross-searched via Nuinlink to enable multiple databases to be searched concurrently. Multiple databases searched in Nuinlink were, Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus), MEDLINE, Psychinfo via EBSCO, Cochrane Library, ScienceDirect (Elsevier) and Wiley online library. Other databases searched included the National Center for Biotechnology Information (NCBI, PubMed) and OVID database. Databases were searched using a Boolean search with the keywords “challenging behaviour” “violence AND mental health” “challenging behaviour AND nursing”, triggers AND aggression”, “aggression AND accident and emergency”, “aggression AND nursing”, “managing challenging behaviour”, “aggression AND alcohol” and alcohol AND nursing”. Other sources of information i.e. Google Scholar, Royal College of Nursing, Nursing Times, Nursing Standard, and Nursing and Midwifery Council were utilised. Government websites searched were The Scottish Government and The Department of Health (England) to obtain guidelines, action plans and protocols for responding to challenging behaviour/ violence and aggression in health and social care settings. The electronic search resulted in 150 articles. The literature search was then limited to English language only. Additionally, the words “Dementia” “Elderly” and “Child” were excluded from the search since Miss March was not elderly nor a child and did not suffer from Dementia. In addition, articles without authors were excluded and only articles relevant to “Nursing and Emergency Department” were included. After these exclusions 60 articles remained. After inspection of the titles, keywords and abstracts, the Nuinlink multiple databases search resulted in 15 appropriate articles that met the criteria for this essay. A further 20 eligible articles remained from the OVID and PUBMED search. In addition, 5 articles were identified by searching reference lists of the publications already obtained. Finally, 10 publications from an internet search of other sources of information i.e. Google Scholar, Royal College of Nursing, Nursing Times, Nursing Standard, Proquest and Nursing and Midwifery Council and 4 books satisfied the criteria for inclusion in the literature review. Thus, relevant theories from all the 54 sources as aforesaid have been considered for this study and a detailed reference list of the sources have been prepared and appended at the end of the paper as Reference List. Prior to this event, I had never encountered violence or aggression in the Accident and Emergency Department, though the literature suggests that this problem is not new and is a serious concern globally (Lyneham, 2000; Meuleners et al, 2004) and reports propose its prevalence is rising (Rose, 1997; Fernandes et al, 1999; Stirling, Higgins & Cooke, 2001; Winstanley & Whittington, 2004; Sands, 2007; Whelan, 2008). A study by Schnieden and Marren-Bell (1995) is relevant here, which states that 86% of nurses who responded had encountered verbal abuse while 35% had sustained assault by patients or their relatives. Another study by Rippon (2000) substantiates this claim, though the figure is placed between 65 – 82% with respect to verbal abuse. On the other hand it finds that between 30 – 80% has experienced physical assault (Rippon, 2000). Rippon’s findings are based on different studies conducted by Madden et al (1976), Kinross (1992), Lanza (1996), Shepherd (1996) and Whitehorn & Nowland (1997). Thus, it transpires that aggression, violence and sexual assaults on nurses have been prevailing over a long period of time, but “relatively little empirical research has been conducted into incidents of sexual harassments” (Rippon, 2000). All these studies include a wide range of literature review. Though some of these studies are old, their relevance comes from the fact that a mentally ill person’s attitude and behaviour will not change materially from one era to another, as can be discerned from the prevalence of the problem throughout the period of these studies, ranging from 1976 to 1997. A patient who lived 20 years ago and one who is sick now will manifest the same behaviour in this context. Thus, while these studies date back to several years, their findings are still relevant in the present day. Drawing from the literature, violence and aggression are discussed equally and studies reported that nurses are often the ones who are most likely to be exposed to aggression and violence from patients (Duxbury & Whittington, 2005; McLaughlin, Gorley & Moseley, 2009). While studies show that violence against nurses in general is increasing, student nurses and younger, less experienced nurses are often being identified in the literature as a high risk group (Whittington, 1997; Rippon, 2000; Wells & Bowers, 2002; Beech, 2007). The authors also have done exhaustive review of literature on the topic, through an exhaustive search of different data bases, refining the searches “by combining the key words” besides carrying out a review “of documents published in the 6 months” prior to the study (Wells & Bowers, 2002). Rippon (2000) describes violence and aggression as “A pervasive problem and an epidemic that constitutes an occupational hazard.” However, one of the difficulties in addressing violence and aggression is that it is extremely hard to define (Sommargren, 1994; Royal College of Nursing RCN, 2003; Crilly, Chaboyer & Creedy, 2004) due to lack of clarity or an absolute and reliable definition and this is believed to be one element that has hindered attempts to address the problem (Rippon, 2000; Krug et al, 2002; Ferns & Chojnacka, 2005). Another element identified was that violent incidents remain unreported as Emergency Department nurses may believe that it is futile to report any incident or they consider violence to be a ‘part of the job’ (Brennan, 2000; Lyneham, 2000; McLaughlin, Gorley & Moseley, 2009). Studies also suggested that nurses’ acceptance of violence and aggression as ‘part of the job’ (Lyneham, 2000; Chapman et al, 2009) and the under-reporting of violent incidents is due to duty, and the fact that nurses are expected to be caring and compassionate (McLaughlin, Gorley & Moseley, 2009). Excessive paperwork, lack of support from management and poor or ineffective reporting systems are also factors that contribute to the under-reporting of violence and aggression in health care (Rippon, 2000). There is a body of evidence to suggest that for various reasons, acts of violence and aggression against NHS staff continues to be under-reported (Arnetz & Arnetz, 2000; Rippon, 2000; Beech, 2001; Ferns, 2006). Studies show that nurses may fail to report a violent or aggressive incident for lack of intent or premeditation, as the patient suffers pain or is under intoxication or mental health issues (Levin, Hewitt, & Misner, 1998; Budd, 1999). Violence and aggression are subjective and what is interpreted as violence has different meanings and therefore differs among people, groups and cultures thus making it difficult to define (Lau, Magarey & McCutcheon, 2004; Linsley, 2006; Rippon, 2000). Krug et al (2002) proposes that violence may be a complex issue with ‘biological, psychological, social and environmental roots’ (Krug et al, 2002). However, the Department of Health (1999) has defined violence and aggression as any event where staff is subjected to abuse, threats or assault in circumstances associated with their work, concerning any overt or implied challenge to their safety, well-being or health. Although research has provided important initial information about the prevalence of violence and aggression, there is a lack of investigation into the factors that trigger violent and aggressive behaviour (Lau, Magarey & McCutcheon, 2004). The deficit of reliable evidence has in fact hindered research and investigation into the prediction and prevention of violent and aggressive incidents (Lau, Magarey & McCutcheon, 2004). Ferns (2007) identified age, gender, alcohol and drug use and mental status as variables that can be used in order to predict violence and aggression from patients. The author cites supporting evidence in his work besides depending on the logic that factors like age, gender, intoxication and mental status do influence violent behaviour in patients. While poor nurse-patient communication and environmental factors are reported to be a major precursor of aggressive behaviour (Dolan & Holt, 2000; Duxbury & Whittington, 2005) alcohol intoxication is also reported to be a significant factor to violent and aggressive behaviour (Lanza et al, 1994; Crilly, Chaboyer & Creedy, 2004; Meuleners et al, 2004; Ferns & Chojnacka, 2008; Hodge & Marshall, 2007). A major part of these studies identifies alcohol as a stimulus that induces violent behaviour. Another study conducted by Lyneham (2000) in Australia, which investigated the characteristics and scope of violence in Emergency Departments, supports this contention. It found that 88% of the 226 nurses interviewed thought that alcohol was a precipitating feature in violent incidents. Throughout the literature, a common theme for major triggers of violence and aggression in the Emergency Department is the consumption of, as well as the withdrawal of, alcohol and drugs. It is suggested that alcohol intoxication and drug usage diminishes the individual's capability to understand and interpret and also reduces inhibitory reactions during stressful periods (Dolan &Holt, 2000; Brewer, 2007, Ferns, 2007). Glasser (1998) considered that violent and aggressive acts could be categorised into two types: self-preservation and sado-masochistic violence. He suggested that self-preservation acts of violence are involuntary and a primitive response to perceived threats or danger. Research conducted by Whittington, Shuttleworth and Hill (1996) identified that intimate physical contact between nurse and patient in order to provide care i.e. undressing the patient was a strong precursor in patient violence and aggression. Falkner and Maguire (1994) had earlier suggested this and further argue that patients who are being treated for a condition can feel uncertain, threatened and disempowered causing them to respond in an aggressive manner. McHale (1999) as cited by Rew and Ferns (2005) identified loss of control or autonomy as well as feelings of depersonalization and lack of communication as the main causes of aggressive behaviour towards nurses. He also stresses that training in the development of skills in relation to de-escalate and defuse potential aggressive behaviour is of great importance. Frustration, limited or lack of options and the nature of the task being undertaken are also suggested triggers of violent and aggressive behaviour (Breakwell, 1989). Some studies suggest that negative staff and patient interactions is a causative factor in patient aggression (Nijman et al, 1999; Duxbury, 2002). It is suggested that institutional burdens or demands can also make nurses to act in authoritarian ways and, therefore, could be a factor that influences patients’ response (Gudjonsson et al, 2004). Nijman (2002) suggested that there is a need for more research into approaches and strategies that promote the effective use of positive therapeutic communication. The National Institute for Health and Clinical Excellence, (NICE, 2005) published a guideline for the short-term management of violence, which recommends a calm countenance when approaching a patient and ensure that choices are offered. The guideline states that there are certain risk factors which indicate an increased occurrence of violent behaviour and these are divided into categories such as: demographic/personal history, clinical variables, situation variables and antecedents/warning signs (Appendix D). De-escalation, defusing and breakaway techniques are recommended in decreasing patient agitation and the arousal of aggression (NICE, 2005). The Royal College of Nursing (2003) also published a guide which outlines how to anticipate potential violence and strategies to defuse violent situations (Appendix C). It states that violence and aggression education for pre-registration nursing students during the course of their programme is essential as well as continued education for registered healthcare staff. The fifth stage of Gibbs (1988) Reflective Cycle involves forming a conclusion which Jasper (2006) describes as the stage where we develop new learning and form new perspectives of the event. According to Jasper (2006) the skill of reflection can assist in learning from experiences and enhancing the quality of our own practice and that of others. To do this, we need to be able to analyse feelings, values and personal core beliefs honestly, in order to form a view about the way we see, feel and think about the experience (Jasper, 2003). While undertaking the literature review, I realised that when caring for a patient who is intoxicated and has a history of verbal aggression as noted in Miss March’s nursing notes, violent behaviour has to be expected. On reflection, I believe that perhaps as a student nurse, I was prepared to deal with patients’ emotions but at this point I did not have enough knowledge and training in violence and aggression (Nau et al, 2007) and felt inadequately prepared when faced with verbal and physical abuse from Miss March. This makes me feel that if mentors were to properly brief their students about the possibilities of such behaviour, they could be better prepared to tackle such situations. The questions I asked myself following this event was, had my actions or omissions made Miss March feel threatened? What did I do wrong? Perhaps this was my fault? Perhaps I frightened her? During the course of undertaking the literature review and accessing other learning materials, I was able to develop an understanding of why Miss March reacted the way she did. I believe that I may have approached her in a fashion that made her feel threatened and she responded by lashing out at me to protect her from what she perceived to be a threat. As Glasser (1998) suggested, some acts of violence are involuntary and due to self-preservation when a person feels threatened. I also believe that intoxication diminished Miss March’s capacity to understand and interpret what was happening (Dolan &Holt, 2000; Brewer, 2007, Ferns, 2007). The result of this incident was that I was unable to approach Miss March to assist her in washing and changing and as a consequence she had to remain in wet clothes. This is consistent with the findings from studies conducted by Fernandes et al (1999) and Arnetz and Arnetz (2001) who reported that staff who are involved in violent incidents may produce lower quality of patient care). I later found out that when Miss March was transferred to another ward, the nursing staffs were able to wash and change her. I felt guilty, inadequate and angry with myself that I could not provide proper care for Miss March. The fact that she did not respond when I spoke to her was a warning sign of potential aggression (RCN, 2003) and I failed to recognise this. However, in the light of the literature review, I am more aware of the risk factors and the strategies on predicting and preventing violent and aggressive behaviours. I pondered on whether there was something else I could have done. On reflection, I understand that there was not much that I could have done and I recognise that it was best to leave the room and allow Miss March time to calm down. However, I also recognise that perhaps I should not have attempted to lift the sheet a second time, which agitated her more. Since this event, I have attended a Crisis, Aggression, Limitation and Management (CALM, 2008) training session at the University, which provided an opportunity to gain awareness and knowledge in caring for patients who exhibit violent and aggressive behaviour. Not only was I able to develop a different perspective of why patients exhibit challenging behaviours, but I was also able to develop skills and techniques on how respond to violence and aggression. Another concern I had following the incident was my mentor’s suggestion that the incident need not be reported as the patient was intoxicated and I was not injured. This reaction suggested that she viewed this incident as ‘part of the job’ and had a preconceived belief that violence was to be expected (Brennan, 2000; Lyneham, 2000; Chapman et al, 2009; McLaughlin, Gorley & Moseley, 2009). It is suggested that nurses feel conflicted between reporting violent incidents and their role of caring (Sommargren, 1994). However, drawing from the literature, there is evidence to suggest that not only is under-reporting one of the problems in identifying the scope of violence and aggression in healthcare but it hinders research into developing the strategies for addressing and minimising violence incidents (RCN, 2003; Ferns, 2006). Therefore the incident, regardless of the fact that I was not injured, should have been formally reported. The final stage of Gibbs (1988) Reflective Cycle involves constructing an action plan and it is at this stage which Jasper (2003) invites us to look to the future and ask ourselves what we would do differently if the same situation arose again. Would we act differently or would we in fact adopt the same approach (Jasper, 2003)? The action plan stage is a process that facilitates the transformation of experience into learning, and learning into action to inform future practice (Jasper, 2006). During the development of the plan and the compilation of this reflective essay, I have had the opportunity to reflect on this incident and develop new learning and a fresh perspective of the incident. Although it was a negative experience, it has provided to be a valuable tool in learning how to improve my future practice and patient care. Conclusion: From my experience with Miss March and the resultant reflection on the episode, it transpires that the implications for practice highlighted in this essay are that violence and aggression continue to be a global issue with reports of rising prevalence. Nurses and staff working in Accident and Emergency Departments should receive continuous training in violence and aggression management and have mandatory updates. Focus of the training should be on de-escalation and diffusion techniques as well as risk factors of violence and aggression. It is important that nurses know how to deal with a violent patient to ensure the safety of the patient and themselves. In the complex and dynamic discipline of nursing, reflection is relevant and necessary to enable nurses to use self analysis to learn from an experience and to ensure that their practice is appropriate, current and professional (Scott and Ely, 2008). In the process of writing this essay, I have had to go through a lot of studies that deal with this subject which provided me great insight into the topic both from the perspective of the patients as well as the caregivers. I understood that I need to be more composed and understanding while attending a patient with a history of aggressive behaviour. Writing this essay has also made me understand that I must look at the patient’s behaviour from the angle of a professional and understand their shortcomings so that I can remain prepared and handle situations more efficiently. I also realised the need to be more understanding and helping. Thus, writing this paper has helped me appreciate my professional responsibilities in a specific context that will help me deliver better patient care in my future practice. 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Appendix A Negotiated Assignment Plan Academic Supervisor (Personal Development Teacher): Dorothy Horsburgh Outline of selected topic (ensure that this 'sets the scene' for the reader as to the client centred aspect that you have selected and why you have selected it): In this essay, I will attempt to explore why aggression and violence occurs in some patients with mental health issues. I will consider the effects of aggression and violence on nurses and the patients themselves as well as the strategies that nurses may employ in the management of aggression, violence and challenging behaviours. I would like to identify and understand why some patients with mental health problems exhibit challenging behaviour towards nurses. The event I will be reflecting on occurred in practice placement where a patient with mental health issues lashed out to hit me while I was assisting her to wash and change. Initially I was stunned that a patient would try to hit someone who was trying to help her but, I was also concerned that I had done something that made the patient feel threatened. The incident made me interested in finding out more about why some patients with mental health issues exhibit challenging behaviours and the triggers that initiate this type of behaviour. Identification of reflective framework/model (full reference for framework/model should be provided and identification of stages within the model) The framework that will be utilised is Gibbs (1998) Reflective Cycle The Gibbs Reflective Cycle consists of the following stages; description, feelings, evaluation, analysis, conclusion and an action plan (Gibbs 1988 cited in Jasper 2003). The stages of the framework: Stage 1: “Description of the event - What happened?” (Jasper, 2003, pp. 78). The first stage necessitates a detailed description of the event. Stage 2: “Feelings & thoughts - What were you thinking & feeling?” (Jasper, 2003, pp. 78). The second stage requires a discussion of thoughts and feelings surrounding the event (Self awareness). Stage 3: “Evaluation - What was good & bad about the experience?” (Jasper, 2003, pp. 79). The third stage requires an evaluation of the event. In order to make a value judgement, exploration of what was good and bad about the event is necessary (Jasper, 2003). Stage 4: “Analysis – What sense can you make of the situation?” (Jasper, 2003, pp. 79). At this point in the Reflective Cycle an attempt is made to make sense of the event (Atkins, 2008). Stage 5: “Conclusion – What else could you have done?” (Jasper, 2003, pp. 79). This stage of the Reflective Cycle involves the synthesis of the information gathered during the previous stages. Detailed analysis and development of new learning can be achieved during this stage of the Reflective Cycle (Jasper, 2003). Stage 6: “Action Plan – If it arose again, what would you do?” (Jasper, 2003, pp. 79). The final stage of the Reflective Cycle solicits forward thinking and questions if faced with the same situation again, what would our actions be? Jasper, M., (2003) Gibbs (1998) Reflective Cycle, Frameworks for Reflection, Ch3, In: Jasper, M., (2003) Beginning Reflective Practice: Foundations in Nursing and Health Care. Cheltenham: Nelson Thornes. Atkins, S., & Murphy, K., (1994), Reflective Practice, Nursing standard 8 (39), pp.49-56, Nursing Standard. Identification of own strengths in relation to the topic A strength with regards to challenging behaviour as I currently work in a nursing home and have done for the past ten years. I have benefited from gaining hands on experience and knowledge of challenging behaviour in relation to mental health in this care setting. Learning materials, resources and training from University nursing programme such as CALM training which provided an opportunity to gain some knowledge in relation to caring for patients who exhibit challenging behaviours. Successfully undertaken some literature searching previously in preparation for written academic essays Identification of learning needs in relation to the topic Gain new knowledge and skills to understand more about the effects of challenging behaviour on patients with mental health issues. Relate theory to practice Develop knowledge and awareness of triggers for challenging behaviours. Develop new knowledge and skills on how to respond to challenging behaviours in future practice. Three learning outcomes, at Level Nine, to address the identified learning needs Review relevant literature related to challenging behaviour by patients with mental health issues. Evaluate strategies which nurses may employ in the response to challenging behaviour from patients with mental health issues. Construct a critical reflection with emphasis on new learning and implications for future professional practice in care of patients who exhibit challenging behaviour. The means by which the learning outcomes might be achieved (eg literature search and review/reflection on practice) Literature search and review; access relevant literature by locating journal articles and publications using Nuinlink. A cross-search of the Current Index to Nursing and Allied Health Literature (CINAHL plus), MEDLINE and Psychinfo via EBSCO. The National Center for Biotechnology Information (NCBI, PubMed) and databases via Nuinlink will be utilized. A Boolean search using the keywords challenging behaviour in mental health, challenging behaviour AND nursing, triggers of aggression, aggression AND mental health, aggression AND nursing, managing challenging behaviour and triggers of challenging behaviours in mental health will be carried out. Other sources of information will be acquired using internet search engines such as Google Scholar, nursing forums and Government websites to obtain guidelines and policies for responding to challenging behaviour and in health and social care settings. A search of the University library catalogue will be utilized for further resources. Reflect on practice placement experience in the light of the literature review; a model of reflection will be utilized to provide a framework on which to structure the reflective process. Synthesise new learning gained from the literature review with the event in practice to identify measures to enhance my practice and that of others. (937 Words) Please negotiate and identify the means (eg e.mail, telephone, face to face meetings) by which contact will be maintained between student and academic supervisor throughout preparation of the assignment. Contact will be by: Email. Signature of Student: Signature of Academic Supervisor: Date: Appendix B Gibbs Framework for Reflection The stages of the framework: Stage 1: Description of the event - What happened? Stage 2: Feelings & thoughts - What were you thinking & feeling? (Self awareness) Stage 3: Evaluation - What was good & bad about the experience? Stage 4: Analysis – What sense can you make of the situation? Stage 5: Conclusion – What else could you have done? (Synthesis) Stage 6: Action Plan – If it arose again, what would you do? From Gibbs (1998) Reflective Cycle Jasper, M., (2003) Gibbs (1998) Reflective Cycle, Frameworks for Reflection, Ch3, In: Jasper, M., (2003) Beginning Reflective Practice: Foundations in Nursing and Health Care. Cheltenham: Nelson Thornes. Appendix C RCN (2003) Anticipating and Defusing Violence Anticipating Violent Behaviour Increased restlessness, body tension, pacing about and excitability Raised voice/shouting, erratic movements Tense angry facial expression Refusal to communicate, no verbal response, withdrawal Thought processes unclear, poor concentration Violent delusions or hallucinations Verbal threats or gestures Behaviour associated with violence in the past Defusing a Violent Situation Appear calm, self-controlled and confident Ensure own non-verbal communication is not threatening Engage other person in conversation, acknowledge their concerns and feelings Ask for facts about the problems and encourage reasoning Maintain adequate distance Move towards a safe place, avoid corners Ask for any weapon to be put down (not handed over) Consider other methods (e.g. Medication) Explain intentions to patients and others Be aware of how to call for help in an emergency Taken from: Royal College of Nursing, (RCN, 2003), Dealing with Violence against Nursing Staff: an RCN guide for Nurses and Managers, London: Royal College of Nursing, 2003. Appendix D NICE (2005) Violence: The Short-Term Management of Disturbed/Violent Behaviour in In-Patient Psychiatric Settings and Emergency Departments Demographic or Personal History: History of disturbed/violent behaviour History of misuse of substances or alcohol Carers reporting service user’s previous anger or violent feelings Previous expression of intent to harm others Evidence of rootlessness or ‘social restlessness’ Previous use of weapons Previous dangerous impulsive acts Denial of previous established dangerous acts Severity of previous acts Known personal trigger factors Verbal threat of violence Evidence of recent severe stress, particularly a loss event or the threat of loss One or more of the above in combination with any of the following: cruelty to animals reckless driving history of bed-wetting loss of a parent before the age of 8 years Clinical Variables: Demographic or personal history Misuse of substances and/or alcohol Drug effects (disinhibition, akathisia) Active symptoms of schizophrenia or mania, in particular: delusions or hallucinations focused on a particular person command hallucinations preoccupation with violent fantasy delusions of control (especially with a violent theme) agitation, excitement, overt hostility or suspiciousness Poor collaboration with suggested treatments Antisocial, explosive or impulsive personality traits or disorder Organic dysfunction Situational Variables: Extent of social support Immediate availability of a potential weapon Relationship to potential victim (for example, difficulties in relationship are known) Access to potential victim Limit setting (for example, staff members setting parameters for activities, choices, etc) Staff attitudes S Antecedents and Warning Signs: Tense and angry facial expressions Increased or prolonged restlessness, body tension, pacing General over-arousal of body systems (increased breathing and heart rate, muscle twitching, dilating pupils) Increased volume of speech, erratic movements Prolonged eye contact Discontentment, refusal to communicate, withdrawal, fear, irritation Unclear thought processes, poor concentration Delusions or hallucinations with violent content Verbal threats or gestures Replicating, or behaviour similar to that which preceded earlier disturbed/violent episodes Reporting anger or violent feelings Blocking escape routes De-escalation: A service user’s anger needs to be treated with an appropriate, measured and reasonable response. Use de-escalation techniques before other interventions. Continue to use verbal de-escalation even if other interventions are necessary. In a crisis situation, staff are responsible for avoiding provocation. They should be aware of and monitor their own verbal and non-verbal behaviour. Staff should learn to recognise what generally and specifically upsets and calms the service user. This should be noted in the care plan. Where possible and appropriate, encourage the service user to understand their own triggers. Note these in the care plan and give a copy to the service user. Encourage the service user to discuss and negotiate their wishes should they become agitated. De-escalation Techniques: One staff member should assume control of a potentially disturbed/violent situation. This staff member should: a) consider which de-escalation techniques are appropriate for the situation b) manage others in the environment (for example, removing other service users from the area, getting colleagues to help and creating space) and move towards a safe place c) explain to the service user and others nearby what they intend to do, giving clear, brief, assertive instructions d) ask for facts about the problem and encourage reasoning (attempt to establish a rapport; offer and negotiate realistic options; avoid threats; ask open questions and ask about the reason for the service user’s anger; show concern and attentiveness through non-verbal and verbal responses; listen carefully; do not patronise and do not minimise the service user’s concerns) e) ensure that their own non-verbal communication is non-threatening and not provocative. f) Where there are potential weapons, the service user should be relocated to a safer environment, where possible. If a weapon is involved, ask for it to be put in a neutral location rather than handed over. Consider asking the service user to make use of the designated area or room to help them calm down. The seclusion room (in services where seclusion is practised) should not routinely be used for this purpose. Taken from: National Institute for Health and Clinical Excellence, (NICE) (2005), Violence: The Short-Term Management of Disturbed/Violent Behaviour in In-Patient Psychiatric Settings and Emergency Departments, National Institute for Health and Clinical Excellence, London. [Online] Available from: http://www.nice.org.uk/CG025 (Accessed 16th April 2012). Read More