Critical Reflection: Nursing Skills in Mental Health - Essay Example

Critical Reflection-Nursing skills in mental health Introduction This essay will present a critical reflection of various nursing skills which I usedduring my clinical placement. The first skill to be discussed involved my use of communication skills in the de-escalation of an aggressive patient encounter. I have considered such a skill because I was able to manage the patient during a particularly aggressive incident and get him to eventually calm down. I also wanted to improve my knowledge on effective communication with the end goal of securing effective nurse-patient relations. The other skill would consider the delivery of nursing care. I chose to discuss this skill as I noted that I was assigned a patient who refused treatment, and I wanted to know what and how I could manage a depressed patient refusing further care. For this critical analysis, I will apply Driscoll’s reflection model. It is a model which asks three main questions: What? So what? and Now, what? (Driscoll, 2007). These questions would help me assess my actions and the justification for these nursing interventions and skills. In accordance with the mandates of the Nursing and Midwifery Council (2008), the names of the clients and other involved health personnel shall not be used, instead, assumed names would be assigned to these patients in this paper. What? Mildred was a 36 year old woman who was assigned to me during my clinical placement in the mental health unit. She was diagnosed with bipolar disorder and often manifested aggressive behaviour during the manic phase of her disease. Bipolar disorder is a mental health issue wherein individuals go back and forth between very good or highly energized moods and depression (Goodwin and Sachs, 2004). The mood swings may in some cases be quick, but for some, it may take up to days or weeks. As discussed by (Goodwin and Sachs, 2004), bipolar patients can sometimes be severely depressed at one time and later on be highly charged, have poor temper control, be reckless, have little need for sleep, and be easily distracted. Their short temper and reckless behaviour can sometimes lead to aggressiveness and anger especially when they do not get what they want (Goodwin and Sachs, 2004). During my placement, my mentor asked me to administer to Mildred her due medications. As soon as I approached Mildred with the medications, she was already glaring at me, showing signs of aggression, like she wanted to hit me. She was also shouting for me to get away from her. When approached by other health providers, she also refused to calm down and turned even more aggressive in her actions by attempting to kick and hit some of the other health professionals. So what? Before I decided to calmly approach Mildred, I reassessed my safety in administering to her. As a result, I then made sure that were no objects she could throw at me and I made sure that she was not at the height of her anger and aggression. As discussed by Moyo and Robinson (2012), nurses must approach aggressive patients with care, ensuring that they would not put themselves and others in danger. This would include making the environment safe for all parties concerned (Moyo and Robinson, 2012). Since I approached the patient with care after noting that there were no objects she could use against me, I deemed it safe to administer care for the patient under the circumstances. I evaluated all these associated elements in order to protect myself, other professionals and the patient (Kynoch, et.al., 2010). I was also prompted to act efficiently in order to minimize the patient’s aggression and not to increase his stress and agitation (Kynoch, et.al., 2010). If I did not consider these elements, Mildred would have remained angry and aggressive and would have continued to pose a danger to herself and to others, myself included. As a student, I had my apprehensions in managing the patient, especially as it was my first time to encounter an aggressive patient. I therefore asked my mentor to observe and assist me in instances when Mildred would become unmanageable. The Royal College of Nursing (2007) discusses that with the assistance of teachers, mentors, and more experienced staff, students are able to gain the essential information they need to carry out their functions. As I was not very experienced in managing the patient, carrying out tasks without the assistance and guidance of more experienced staff, I would have also not been able to secure effective communication goals (Elcock and Sharples, 2011). Moreover, I was aware of the issues which would likely arise if I would not be able to secure effective communication with Mildred, and this made me even more focused in adopting in a calm and confident manner in initiating communication with the patient. It was crucial for me to secure an effective therapeutic communication with the patient using effective tools of communication (Cleary, et.al., 2012). One of the ways by which I could secure that was to school my body language to match my expressed words. As discussed by Dziopa and Ahern (2009), it is important for one’s verbal communication to also match one’s non-verbal communication skills because if these cues do not match, the patient may become distrustful and aggressive. I noted however, that it would have helped the situation more if I had more time to engage in small talk with the patient, mostly as a means of establishing trust and rapport (Belcher and Jones, 2009). Nevertheless, I did my best to stay calm at all times in order to help relax the patient and for her to see me less as a threat (Belcher and Jones, 2009). As discussed by Rigby, et.al. (2012), one of the initial interventions in managing aggressive patients is to calm them down from their outburst of aggression or anger. Once such point is reached, it would be easier to gain the patient’s cooperation. Since Mildred showed an outwardly aggressive behaviour, I decided to gradually and calmly approach her, discarding any threatening or aggressive actions (Duxbury, et.al., 2010). Mildred was going through the manic stage of her disorder and as such, she was highly agitated and irritable and had a diminished control over her temper. At one point during her care, she had to be isolated from the other patients in order to cause less agitation to the other patients. Based on the communication skills discussed above, I was able to move Mildred into a more private area away from other patients. I talked to her calmly and reasonably and got her to agree that she could use some private time as well (Morgan, 2005). I was encouraged by her cooperation. In order to ensure effective communication, I took Mildred into one of the staff rooms which was not being used at that time, away from the clinical and intimidating atmosphere of the mental health unit. As I talked to her, I maintained a therapeutic and respectful distance, at least 3 feet and I observed that she did not want me any closer than three feet. Holmes and colleagues (2012) discuss that encroaching on a patient’s personal space can increase their agitation and their aggression. I therefore maintained a therapeutic distance during my talk with Mildred. I also sat on a chair slightly inclined towards her, but not too directly as to make her feel uncomfortable (Holmes, et.al., 2012). I did not stand because it was important for me to maintain at least eye level with the patient in order to make them feel engaged in the communication process (Glick and Berlin, 2008). I also schooled my facial features into a non-threatening and casual expression. I adopted these measures in order to make myself appear less of a threat to Mildred (Glick and Berlin, 2008). These measures also indicated that I was very much eager to listen to Mildred. My mentor’s presence also helped me get through the encounter. I used direct and short questions during my interview, allowing the patient to elaborate more on her answers (King, et.al., 2010). At some point, Mildred did not want to answer, however, I noted that some of the answers I asked were too general. King, et.al., (2010) discusses that general questions can be vague for patients to answer. In order to encourage her to answer, I therefore took my time in asking the questions; moreover, I also tried to rephrase the questions where necessary (Rimondini, et.al., 2009). I also assured her that all her answers would remain confidential. Securing confidentiality is important for patients because it can help them open up and be more trusting of the communication process (Rimondini, et.al., 2009). While communicating with Mildred, I did my best to empathize with her by allowing her to share and to vent her feelings without making judgments (MacNeela, et.al., 2010). As discussed by MacNeela and colleagues (2010), empathy can help secure trusting relations with clients, allowing them to feel safe and secure. I noted that Mildred felt agitated with some of the questions, and although she did not expressly indicate her agitation, I could sense this from the way she would shift her gaze away from me and how she appeared tearful at times. This supports the idea that non-verbal cues can provide an idea of how some patients may be feeling (Hewett, 2011). Knowing how to detect these can help secure improved communication processes with the patient. Now what? In my future practice, I realized that it is important for me to establish a therapeutic relationship with the client by maintaining an open, empathetic, observant, and calm demeanour towards the client (Jones, et.al., 2012). I learned that these traits are also essential towards securing a more engaging partnership with the client (Jones, et.al., 2012). The improvement in Mildred’s demeanour indicates that effective communication is an important element in securing improved patient outcomes. It is a tool which can be used in order to reduce barriers in patient care (Shattrell, 2011). The importance of empathy and care for nurses has been highlighted above, especially as trust is an essential element in securing effective and therapeutic relations between the client and the nurse (Shattrell, 2011). I observed significant changes in Mildred’s demeanour which proved encouraging to me as a student nurse. She was not so angry anymore and even during her manic phase, it was easier to talk and communicate with her. In the process of communication, I learned that she liked drawing as it helped redirect her anger into less aggressive activities, eventually helping to calm her down. I capitalized on this preference while caring for her. I understood therefore that by listening to the patients, allowing them to share their feelings and concerns, I was also respecting them as persons, allowing their dignity as individuals (Lawrence, et.al., 2012). I also understood the importance of autonomy in patient care, allowing them to direct their care towards preferred activities. This helped make them more cooperative during the process of care (Lawrence, et.al., 2012). As was emphasized by Shattrell (2011), nurses must consider patient feelings and preferences in any plan of care as a means of securing effective patient outcomes. References Belcher, M. and Jones, L., 2009. Graduate nurses experiences of developing trust in the nurse-patient relationship. Contemporary Nurse, 31(2), pp. 142-152. Cleary, M., Hunt, G., Horsfall, J., and Deacon, M., 2012. Nurse-patient interaction in acute adult inpatient mental health units: A review and synthesis of qualitative studies. Informa Health, 33(2), pp. 66-79 Driscoll, J., 2007. Practising clinical supervision: A reflective approach for healthcare professionals. London: Elsevier Health Sciences. Duxbury, J., Wright, K., Bradley, D., and Barnes, P., 2010. Administration of medication in the acute mental health ward: Perspective of nurses and patients. International Journal of Mental Health Nursing, 19(1), pp. 53–61. Dziopa, F. and Ahern, K., 2009. Three different ways mental health nurses develop quality therapeutic relationships. Informa Health, 30(1), pp. 14-22 Elcock, K. and Sharples, K., 2011. A nurses survival guide to mentoring. London: Elsevier Health Sciences. Glick, R. and Berlin, J., 2008. Emergency psychiatry: Principles and practice. London: Lippincott Williams & Wilkins. Goodwin, G. and Sachs, G., 2004. Bipolar disorder. London: Health Press. Hewett, D., 2011. Intensive interaction: Theoretical perspectives. London: Sage Holmes, D., Rudge, T., and Perron, A., 2012. (Re)Thinking violence in health care settings: A critical approach. London: Ashgate Publishing, Ltd. Jones, J., Fitzpatrick, J., and Rogers, V., 2012. Psychiatric–mental health nursing: An interpersonal approach. London: Springer Publishing. King, A., Daniels, J., Lim, J., Cochrane, D., et.al., 2010. Time to listen: a review of methods to solicit patient reports of adverse events. Qual Saf Health Care, 19, pp. 148-157 Kynoch, K., Wu, C., and Chang, A., 2010. Interventions for preventing and managing aggressive patients admitted to an acute hospital setting: a systematic review. Worldviews on Evidence-Based Nursing, pp. 1-11 Lawrence, H., Copel, J., O’Keefe, D., Bradford, W., et.al., 2012. Quality patient care in labor and delivery: a call to action. American Journal of Obstetrics & Gynecology, pp. 147-148. MacNeela, P., Clinton, G., Place, C., Scott, A., et.al., 2010. Psychosocial care in mental health nursing: a think aloud study. Journal of Advanced Nursing, 66(6), pp. 1297–1307. Morgan, J., 2005. Psychology of aggression. London: Nova Publishers. Moyo, N. and Robinson, P., 2012. The safety of nurses during the restraining of aggressive patients in 5 acute psychiatric units. Australian Journal of Advanced Nursing, 29(3), pp. 5-13 Nursing and Midwifery Council, 2008. The code standards of conduct performance and ethics for nurses and midwives. London: NMC Rigby, L., Wilson, I., Baker, J.,Walton, J., et.al., 2012. The development and evaluation of a ‘blended’ enquiry based learning model for mental health nursing students: “making your experience count. Nurse Education Today, 32(3), pp. 303–308. Rimondini, M., Del Piccolo, L., Goss, C., Mazzi, M., et.al., 2010. The evaluation of training in patient-centred interviewing skills for psychiatric residents. Psychological Medicine, 40(3), pp. 467-476. Royal College of Nursing, 2007. Guidance for mentors of nursing students and midwives [online]. Available at: http://www.rcn.org.uk/__data/assets/pdf_file/0008/78677/002797.pdf [Accessed 18 February 2013]. Shattrell, M., 2011. Make them your friend: A phenomenological study of patients experience soliciting nursing care in the hospital setting. Virginia Henderson International Nursing Library. What? Adrian is a 31 year old male who I also cared for during my clinical placement in the mental health unit. Adrian was suffering from major depressive disorder. This disease is also known as clinical depression where a patient manifests with prolonged (at least 2 weeks) of low mood which affects most aspects of the patient’s life, negating their ability to take please in their activities (Schultz and Videbeck, 2009). These patients often linger over feelings of worthlessness, guilt, hopelessness, despair, and in some instances, they manifest suicidal tendencies or ideation (Schultz and Videbeck, 2009). In fact, the patient already attempted suicide two days prior to his admission. During my placement, I worked with Adrian in order to ensure that he does not attempt suicide, that he eats properly, and that he socializes with other patients. These measures were aimed towards improving his moods and to avoid any repeated suicide attempts (Sadock and Sadock, 2008). More often than not, patients with a history of attempts at suicide are likely to try again (Herrman, et.al., 2009). Hence, they are usually placed under suicide watch during admission. During my placement, I supervised Adrian’s activities in order to get him to sleep and eat on time, and to encourage him to socialize with other patients. I tried my best to get the patient to socialize with other patients in order to reduce his feelings of isolation and depression (Rosenbluth, et.al., 2005). I sensed however that the patient just wanted to be left alone and at times, he just chose to withdraw from his environment even when placed in a group of people. So what? The goal of including the patient with the other patients during meals and during other activities was to get him to socialize with them (Silk, et.al., 2011). However during these times, he was hardly cooperative in socializing with other patients. He gave one word answers to questions and sometimes chose to keep to himself. I tried my best to integrate Adrian in the social environment of the inpatient facility, however, his general refusal to socialize was frustrating for the most part (Cunningham, et.al., 2009). However, I still did my best to find ways to get him to socialize with the other patients, mostly by asking him who he would prefer to sit with (Cunningham, et.al., 2009)). I applied verbal communication skills in order to inform Adrian of the importance of being with other people in order to for him to feel less alone and feel less hopeless (Rodin, et.al., 2009). Therapeutic communication is an important tool in getting uncooperative patients to open up. Admittedly however, depressed patients may not have the necessary understanding about their condition, negating any form of understanding attributed to the need for related interventions for depression (Rodin, et.al., 2009). It may be a more favourable option in this case to ask the patient to make the choice as to his seating companions, allowing him to choose one or maybe two other patients to seat with (Abaied and Rudolph, 2010). This set-up would likely help Adrian feel more comfortable and less overwhelmed in the company of other people (Abaied and Rudolph, 2010). Patients with a tendency towards isolation would feel more uncomfortable with a large group of people, but would feel less intimidated in the company of one or two people they can relate to (Durbin and Shafir, 2007). In addition, I can also engage Adrian in any activity he would prefer, which may include listening to music, reading, watching television, or drawing. This way, I can provide ways of distracting Adrian, reducing idle moments when he would feel sad and lonely (Teismann, et.al., 2012). In other words, I did not allow Adrian to be idle and alone because being alone and idle would make him even more depressed. Since he liked playing board games, I could have gotten him a chess board and played with him. Engaging him for these games would have helped in stimulating his mind and his interest in the world (Teismann, et.al., 2012). Even with my attempts in engaging Adrian, he still preferred to be alone and refused to talk with the other patients. I consulted with my mentor at some point for advice, explaining the patient’s condition and asking for her assistance. Afterwards, I noted that my mentor sat with Adrian and engaged him in casual conversation, talking about her own family and sharing funny stories about them. After a while, I noted that Adrian had a more engaging look on his face, like he was actively listening to what the mentor was saying. I then felt that I should have allowed a time for me and the patient to establish rapport with each other in order for him to see me as person he could relate and open up to (Moir, et.al., 2010). In retrospect, I believed then that it would have been more productive to consult with my mentor and with other more experienced nurses when faced with difficult situations with clients (Evans, et.al., 2012). As a student, I do not yet have the right tools in order to secure immediate positive outcomes. I am part of a team, and as a team, helping and consulting with each other is essential to patient care (Evans, et.al., 2012). Moreover, as a student nurse, supervision would help ensure the delivery of timely and appropriate nursing services. Now what? In instances when I would face a similar incident, I now know that it is important for me to collaborate and communicate not just with the patients, but with other nurses as well. Adrian’s failure to cooperate is part of his depression, part of his feelings of hopelessness and his having given up on life and on recovery (Gabbard, et.al., 2007). It is therefore important for nurses to give patients the opening to also share their feelings, developing a space where they can feel safe and where they can also make the choices in their care (Gabbard, et.al., 2007). As discussed by the Mental Capacity Act (2005) patients must be protected in their right to consider options in their care and their nurses must assist these clients in making the most appropriate choices for their recovery. Adrian felt more comfortable with one or two choice individuals with him. I now understand that it is important to reduce the stress and agitation on the part of the patients as much as possible in order to ensure their cooperation (Bonner, 2005). In the future, I believe in communicating with my clients and with my mentor. As a student nurse, I am still under her supervision, and improved goals can be secured faster if I were to consult with my mentor. I understand that patients may relate well with some staff members more than others (Chewning, et.al., 2012). I should therefore use this to my advantage in dealing with difficult clients. Establishing rapport with Adrian helped secure improved interaction with the client (Gabbard, et.al., 2007. Although I knew this early on, I was more concerned about having the patient interact with other patients, that I did not think about securing a therapeutic relationship with my patient first. In the end, this lack of insight made it difficult for me to achieve improved patient outcomes for Adrian. Conclusion This critical reflection has established that establishing good communication skills are an essential element in improved nursing care. I learned that nurses need to improve and master their verbal and non-verbal communication skills in order to help calm agitated and uncooperative patients; and these communication skills are also valuable in securing coordinated and collaborative care with other health professionals, especially those who are more experienced. This essay was able to establish that if I did not adopt a calm and empathetic demeanour with Mildred, that she would likely continue to manifest aggressive behaviour, making the rest of her care difficult. I have therefore learned the importance of securing a calm environment and a less stressful atmosphere for aggressive and agitated clients. The second part of this critical reflection has helped me understand depression and how it can significantly impair patient’s normal functions. This essay indicates that Adrian would have been more cooperative in engaging in socialized behaviour if I chose to establish my rapport with him first and to choose smaller groups in his socialization activities. I also believe that had I been more collaborative in my care, I would have achieved better results for Adrian. I believe therefore that it is important for me to be work within a team within the health services delivery. The case reflects the importance of securing significant goals in patient services, especially services which would ultimately reduce patient trauma and promote patient well-being. References Abaied, J. and Rudolph, K., 2010. Parents as a Resource in Times of Stress: Interactive Contributions of Socialization of Coping and Stress to Youth Psychopathology. J Abnorm Child Psychol., 38(2), pp. 273–289. Bonner, C., 2005. Reducing stress-related behaviours in people with dementia: Care-based therapy. London: Jessica Kingsley Publishers. Chewning, B., Bylund, C., Shah, B., Arorad, N., et.al., 2012. Patient preferences for shared decisions: A systematic review. Patient Education and Counseling, 86(1), pp. 9–18. Cunningham, J., Kliewer, W., and Garner, P., 2009. Emotion socialization, child emotion understanding and regulation, and adjustment in urban African American families: Differential associations across child gender. Development and Psychopathology, 21, pp. 261–283. Durbin, E. and Shafir, D., 2007. Emotion regulation and risk for depression. In: Abela JRZ, Hankin BL, editors. Child and adolescent depression: Causes, treatment, and prevention. New York, NY: Guilford. Evans, L., Costello, M., Greenberg, H., and Nicholas, P., 2013. The attitudes and experiences of registered nurses who teach and mentor nursing students in the acute care setting. Journal of Nursing Education and Practice, 3(2), pp. 67-74. Gabbard, G., Beck, J., and Holmes, J., 2007. Oxford textbook of psychotherapy. Oxford: Oxford University Press. Herrman, H., Maj, M., and Sartorius, N., 2009. Depressive disorders. London: John Wiley & Sons. Mental Capacity Act, 2005. Code of practice. Available at: http://www.dca.gov.uk/menincap/legis.htm [Accessed 18 February 2013] Moir, F., van den Brink, R., Fox, R., and Hawken, S., 2009. Effective communication strategies to enhance patient self-care. Journal of Primary Health Care, 1(1), pp. 67-70. Rodin, G., Mackay, J., Zimmerman, C., Howell, D., et.al., 2009. Clinician-patient communication: a systematic review. Supportive Care in Cancer, 17(6), pp 627-644 Rosenbluth, M., Kennedy, S., and Bagby, M., 2007. Depression and personality: Conceptual and clinical challenges. New York: American Psychiatric Pub. Sadock, B. and Sadock, V., 2008. Kaplan & Sadocks concise textbook of clinical psychiatry. London: Lippincott Williams & Wilkins. Schultz, J. and Videbeck, S., 2009. Lippincotts manual of psychiatric nursing care plans. London: Lippincott Williams & Wilkins. Silk, J., Shaw, D., Prout, J., O’Rourke, F., et.al., 2011. Socialization of emotion and offspring internalizing symptoms in mothers with childhood-onset depression. J Appl Dev Psychol. 32(3), pp. 127–136. Teismann, T., Michalak, J., Willutzki, U., and Schulte, D., 2012. Influence of rumination and distraction on the therapeutic process in cognitive-behavioral therapy for depression. Cognitive Therapy and Research, 36(1), pp 15-24 Read More