Care Delivery & Management Essay

The purpose of this assignment is to reflect upon my personal and professional development. It will consider the quality of the care I provided, the skills I developed in my specialist placement, plus my learning since the commencement of my nurse training. Personal learning and self-reflection will be identified. I shall be using Gibbs (1988) Reflective Cycle to consider my practice. Gibbs (1988) Reflective Cycle looks at six aspects which include the following; what happened, what were my thoughts and feelings, what was good or bad about the experience, what sense can I make out of the situation, what else could I have done and if it arose again what would I do? Findings will be supported or contrasted by relevant literature. A conclusion will be offered to evaluate findings. I shall also include an action plan, which will address future professional and personal development needs and any factors that may help or hinder this. I will also consider why I have selected these issues fo r my action plan, what my goals are and how I aim to achieve them. At the beginning of my nurse training we were asked to write on a piece of piece what our definition of nursing was. I wrote ‘It’s about being human’. At the time these words were based on my gut feeling and personal belief. Now, two and a half years later, I would write the same thing, but this time my definition would be based on the skills, knowledge and experiences I feel privileged and grateful to have had during my training and not just on gut feeling and personal belief. How does this knowledge impact on me in terms of practice? I can now put my definition of nursing into a framework and relate the theory of it to practice, for example I can identify when I am actively undertaking anxiety management with a patient. This is quite an achievement for me. What else have I learnt? I have gained knowledge of illnesses and understand how bio-psycho-social aspects of mental illness impact on the individual, their family and their life. I have also developed a good basic knowledge of practical skills such as: counselling, anxiety management, assessment, nursing and communication models, problem-solving and psychotherapy. This knowledge and development of practical skills has enabled my self confidence and self esteem to grow. What things have had the most influence on my personal and professional learning? These things are what ‘It’s about being human’ means to me as a nurse. They include a humanistic care philosophy. Evidence suggests that patients have found the humanistic care philosophy to be positive and helpful to their well-being (Beech, Norman 1995.) Humanistic care believes in; developing trust, the nurse-patient relationship, using the self as a therapeutic tool, spending time to ‘be with’ and ‘do with’ the patient (Hanson 2000,) patient empowerment, the patient as an equal partners in their care (Department Of Health 1999,) respect for the patient’s uniqueness, recognition of the patient as an expert on themselves (Nelson-Jones 1982, Playle 1995, Horsfall 1997). Equally important to me is person-centred care, Roger’s (1961) unconditional positive regard, warmth, genuineness and empathy, recognition of counter-transference, self-reflect ion and self-awareness. I was on placement with Liaison Psychiatry also known as Deliberate Self Harm. The team consisted of my mentor and myself. In this placement we would assess patients who had deliberately self harmed. Patients would be referred via A&E only. We would see patients whilst they were still in A&E or after they had been transferred to hospital wards for medical treatment for their injuries etc. We would only see patients once they were medically fit to have a psychiatric assessment. The purpose of the assessment was to find out what was happening for the individual and see if we could offer any help via mental health services to the individual, this is done via implementing ‘APIE’ the nursing process (Hargreaves 1975). The main focus was to consider what degree of risk we felt the patient was in. Therefore we needed to establish what the individuals intent was at the time of the deliberate self harm, and if suicidal, whether they still had suicidal intent after the incident. We also held a weekly counselling clinic. I considered Gibbs (1988) Reflective Cycle. How did I feel about this placement? At first I was apprehensive as to how I would feel dealing with patients who do not necessarily want to live. I belong to a profession that saves lives, so I felt an inner conflict. This is an anxiety that is recognised in most nurses (Whitworth 1984). In my first few weeks I felt distressed by the traumatic events that these patients were experiencing. I felt guilty that I have a family who love me, a fulfilling career, a lovely home and no debts, then each day I talk to people who may have no home, no money, no one to love them and no employment. It was hard for me to make sense of these things when life circumstances, such as class, status, wealth, education and employment create unfairness. I felt a desire to help try and improve the quality of these patients’ situations. Midence (1996) has identified that these feelings are a normal response when dealing with others less fortunate that oursel ves. Patients’ who attempt suicide have lost hope (Beck 1986). I felt more settled and positive once I was able to make sense of the situation (Gibbs 1988). I realised that could help by listening to these patient’s and help to restore hope, develop problem solving ideas to tackle some of their problems or referring them to gain the emotional help and support they needed from appropriate mental health services. Patients find help with problem solving extremely valuable and can help them feel able to cope (McLaughlin 1999). Generally, after most assessments, I learnt that listening, giving emotional support and problem solving helped restore enough hope in the previously suicidal patient enable them to feel safe from future self harm. In only a handful of cases did my mentor and I need to admit patients to any inpatient facility under the Mental Health Act (1983). This was because they still felt at risk of future self-harm. Through using Gibbs (1988) Reflective Cycle to consider my special placement area I feel I have been able to change my nursing practice in a positive way, initially from feeling anxious, guilty and helpless when dealing with suicidal patients to feeling useful, constructive and positive. I’ve learnt that by confronting my own feelings of guilt and discomfort I was able to help in a very positive, practical, constructive and empowering way. My mentor identified that one of my strengths is that I can generally combine common sense, logic and practicality in terms of risk assessment and problem solving and still build up a sensitive and caring, therapeutic relationship when dealing with patients whose circumstances are in crisis and complicated and they themselves are emotionally and mentally vulnerable. Nurses not only need good communication skills (Faulkner 1998) but they also need to have an environment conductive to open communication (Wilkinson 1992). Social barriers such as environment, structure or cultural aspects of healthcare can inhibit the application of communication skills (Chambers 2002) Utilising Gibbs (19988) Reflective Model, in retrospect; I feel our interview with some patients could have been done differently. On occasions when my mentor and I were in the A & E department the two rooms that we had available for our use were occasionally both in use. This meant that we would conduct our assessment interviews in the Plaster Room, if it was empty. This room was where medical patients would have plaster-casts applied. This was a very clinical room. However, due to limited room availability this was sometimes the only option we had at the time, it was not a welcoming or appropriate setting and would not have helped patients feel relaxed or valued. In reflection, I believe it was actually demeaning as we were asking patients who had attempted suicide to sit on a hard chair in a clinical workroom and share their despair with us. I am sad that this happened and I feel as though we were giving the patients the impression that a cold clinical work room is all they were worth. If this arose again (Gibbs 1988) I would suggest to my mentor that we wait for one of our allocated rooms to become available, where the rooms were relaxing, with soft armchairs and a feeling of comfort. Using Gibbs (1988) Reflective Model I shall describe a situation with a patient to highlight my learning. What happened (Gibbs 1988)? Neil had been bought to A&E by his son after he made an attempt to take his own life. His son explained that Neil’s wife had terminal cancer and had died the day before. Neil was unable to engage in conversation other that to repeat over and over again â€Å"I don’t want to live without my wife.† However the more disturbed and difficult to communicate a patient is the less interaction they receive therapeutic or otherwise from nursing staff (Cormack 1976, Poole, Sanson-Fisher, Thompson 1981, Robinson 1996a, 1996b). I found this too be true in Neil’s situation as some A & E nurses did not wish to approach him because of his disturbed state and unresponsiveness to verbal cues. What were my thoughts and feeling (Gibbs 1988)? After spending twenty minutes in the assessment interview Neil had remained unresponsive to our approaches and had remained distressed, distant and uncommunicative for the entire time. I had past experience of recent bereavement within my immediate family and I realised that counter-transference was at play and was a reason for my strong emotional reaction to Neil’s distress resulting in me having an overwhelming desire to ease his suffering. Even though another part of me understood the need for him to experience this extreme pain as a normal part of grieving. What was good or bad about the experience (Gibbs 1988)? This was not a good experience for me because as a compassionate person, I found it extremely hard to suppress my own feelings of wanting to protect him from such devastating distress, although I recognised that I was over-identifying with him due to my own grief. I considered that he might have been embarrassed by the emotional state he was in and his inability to control his grief; he could not speak, maintain eye contact or even physically stand. What sense could I make of the situation (Gibbs 1988)? We adjourned for a few minutes so that my mentor and I could assess the situation. I thought it might be appropriate to utilise Heron’s Six Category Intervention Analysis (1975) cathartic intervention as a therapeutic strategy to enable the patient to release emotional tension such as grief, anger, despair and anxiety by helping to (Chambers 1990). I hoped it would facilitate the opportunity for Neil to open up and express his full feelings in a safe and supportive environment. I initially planned to sit quietly with him and briefly put a reassuring hand on either his hand, arm or shoulder. My mentor supported this action. I was aware that I ran a risk of misinterpretation by choosing therapeutic touch. Therapeutic touch may be criticised because it is open to misinterpretation by the patient and abuse of power by staff. The patient may view holding another’s hand as a sexual advance, violation or abuse, so nurses should always consider patient consent, appropriateness, context and boundaries. Clause 2.4 of the Nursing and Midwifery Council (2002) Code Of Professional Conduct says that at all times healthcare professionals must maintain appropriate boundaries with patients and all aspects of care must be relevant to their needs. Therapeutic touch appeared acceptable given his situation and seemed appropriate to the context it would be performed in, given that my mentor would supervise me. As per Gibbs (1988) Reflective Cycle I considered what else I could have done especially if the situation arose again and mentor not been there. I would may have chosen to utilise Hanson’s (2000) approach of ‘being with’ whereby I use therapeutic use of self through the sharing of one’s own presence, and not involved any form of touch, avoiding any misinterpretation or breach of boundaries. I was anxious because I felt concerned that my nursing skills would be inadequate to address his needs due to his acutely distressed state. In reflection my mentor helped me acknowledge that this was about my own anxiety rather than being accurately reflective of my nursing ability. I approached Neil and explained that if it was acceptable with him I would like to sit quietly with him so that he was not alone in his distress. â€Å"It is likely that the nursing process is therapeutic when nurse and patient can come to know and to respect each other, as persons who are alike and yet different, as persons who share in the solution of problems† (Peplau 1988). I gently placed my hand onto his. Neil reacted by given the impression that he physically disintegrated, he become extremely distressed and crying loudly, squeezing my hand tightly. This continued for several minutes. Neil became calmer and started to talk about his situation. This was a good outcome. I was able to utilise Herons (1975) cathartic strategy with positive effect via empathising with Neil’s situation and using myself as a therapeutic tool through the use of touch, thus enabling Neil to express his emotions and activate a nurse-patient relationship. Studies have shown that nurses can express compassion and empathy through touch, using themselves as a therapeutic tool (Routasalo 1999, Scholes 1996) and this has a cathartic value, enabling the patient to express their feelings more easily (Leslie Baillie 1996). The therapeutic value of non-verbal communication and its harmfulness is overlooked (Salvage 1990). Attitudes are evident in the way we interact with others and can create atmospheres that make patient care uncomfortable (Hinchcliff, Norman, Schoeber 1998) On one occasion, one nurse privately referred to Neil as a â€Å"wimp† because he was having difficulty coping with the death of his wife. I wondered whether her body language had transmitted her bad attitude towards Neil, contributing to his distress and difficulties in communicating with staff. Again using Gibbs (1988) Reflective Cycle, I shall provide another example to highlight my learning in practice. What happened (Gibbs 1988)? Cycle On one occasion my mentor and I received a phone call from A & E asking us to review an 18-year-old girl called Emma who had taken an overdose. They said she was medically fit to be assessed. When we arrived they claimed that she was pretending to still feel unwell and described her as â€Å"milking it†. We found her to be vomiting and discovered she had been left in a bed in the corridor of A & E for 8 hours. McAllister (2001) found that patients who had self-harmed were ignored, had exceptionally long waits and suffered judgemental comments. What were my thoughts and feelings (Gibbs 1988)? I felt very angry towards A & E staff as I felt that she was being unfairly treated because she had caused harm to herself, she had been labelled as a troublemaker by staff and I do not believe she had received good quality care. Emma explained that in the last month her father had died, she had miscarried her baby, discovered that her partner was having an affair, and she had been made redundant leaving her with debts that she couldn’t pay. As I looked at her, I saw a vulnerable young woman at the end of her tether. I felt saddened and disappointed by the judgemental attitudes of the A & E staff who had not even taken the time to talk to Emma or ask her why she had taken an overdose, instead they describe her as an â€Å"immature and attention seeking kid†. As per Gibbs (1988) Reflective Cycle, I felt this was a very bad experience of poor care, bad attitudes and unacceptable moral judgement being made by A & E staff. Cohen (1996) and Nettleton (1995) identify that social status; age, gender, race and class contribute to stereotyping and judgemental attitudes. I noticed that people who self-harmed were judged differently dependent upon their age and the younger they were the worse the attitude of A and E staff. Interestingly ageism towards youth is an area that I could find no research on. I believe ageism towards younger people is overlooked and is really only identified in the elderly. During the assessment I was aware of how my physical presence can impact on the care given. However, I have learnt about the importance of considering how one can communicate to the patient via body language. By attending to patients in a non-verbal or physical way it is another method of saying, â€Å"I’m interested, I’m listening and I care.† To do this during Emma’s assessment I utilised Egan’s (1982) acronym S.O.L.A.R. This meant that I sat facing Emma Squarely, with an Open posture, Leaning towards her, whilst making Eye contact and Relaxing myself, to give her the feeling of my willingness to help. This client centred care recognises her equality in the nurse-patient relationship. What sense did I make of the situation (Gibbs 1988)? I was very unhappy about the attitude of A & E staff but recognised that they had a lack of understanding and knowledge. In one study looking at self-harm admissions it was discovered that patients who deliberately self-harm are often deemed as unpopular patients, being labelled and judged as time wasters by A & E staff. Apparently 55% of general nurses perceived these patients as attention seekers and disliked working with them, 64% found it frustrating, 20% found it depressing and almost a third found it uncomfortable (Sidley, Renton 1996). What else could I have done (Gibbs 1988) After reflecting upon the experience with my mentor, I was able to realise that part of my role is to act as a representative for mental health. If this happened again what would I do (Gibbs 1988)? If staff were to make judgemental comments again it is part of my role to educate and inform them so they can have a positive understanding of the needs of the mental health patient and learn to address any judgemental comments made. This is a view supported by Johnstone (1997), who says that if we are made aware of our actions when we are judging and labelling people it is our responsibility to correct this. Medical staff need to be aware of mental health promotion, and need further training and education in respects of helping to care for and understand of this vulnerable patient group (Hawton 2000). This is a view supported by the Department of Health (DOH 1999a) who have recommended closer liaison between mental health and A & E services in an effort to address the poor understanding and negative attitudes of A & E staff. I have also learnt that I must look at both sides of each situation and should show more understanding towards the A & E staff’s feelings, as they are often confronted with shocking and distressing acts of self infliction which can make them feel despair, helpless and unskilled to deal with these sort of patient. I believe nurses negative attitudes develop because we all intuitively apply own our values and views to everyday situations, people, experiences and interactions. It may be the staff member’s own coping mechanism to keep their distance from the patient or to label them as attention seeking in order to make sense of the situation for themselves. This is a view supported by Johnstone (1997). In reflection, following the assessment and planning of care for Emma my mentor and I reflected upon the care I provided for her. I recognised that I felt nervous because it was my first experience of conducting an assessment. Having my mentor there to observe me made me feel secure because I trusted my mentor and could rely on her expertise to ensure that I provided safe practice for Emma. However, I still felt anxious as I was faced with an unknown situation. This made me realise how difficult and intimidating the assessment process may have felt to Emma. I had the security of feeling safe in the relationship with my mentor. Emma didn’t know either of us. This highlighted the huge value of the nurse-patient relationship and how the importance of utilising Rogers (1961) theory of client-centred care involving unconditional positive regard, warmth, genuineness and empathy towards patients. My mentor said that I provided evidence based care and I appeared to have a good humanistic approach, sensitively providing client centred care. She joked that I was so keen to ‘get it right’ that I was practically sat on Emma’s knee in my efforts to non-verbally show to Emma that I was attentive and listening to her. I think that whilst this was a joke, I will endeavour to continue to be keen but will relax a bit more, hopefully as I gain more experience myself. I will also use the insight and understanding from these experiences to benefit my future practise and the care I provide for patients. Boyd & Fales (1983) suggest, â€Å"Reflective learning is the process of internally examining an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of self, and which results in a changed conceptual perspective.† Self-reflection helps the practitioner find practice-based answers to problems that require more than the application of theory (Schon 1983). I have discovered this to be true, especially in mental health nursing where problem solving may be in the realm of religious, spiritual or cultural beliefs, emotional or intuitive feelings, ethics and moral ideals, which sometimes cannot be theorised. With one patient I couldn’t understand his unwillingness to engage in therapy even though he turned up for a weekly appointment. Once I reflected on this with my mentor I realised that I was not considering his strict religious and cultural background, which complicated his care. I realised that I had been completely ignorant of his needs and had in-fact lacked self-awareness otherwise I would have recognised these issues sooner. According to Kemmis (1995) a benefit of self-reflection is that it helps practitioners become ‘aware of their unawareness’. I have learnt that there are barriers to reflection. On occasions after seeing a patient my mentor may interpret events in a slightly different way to myself. Newell (1992) and Jones (1995) criticize the idea of reflection arguing that it is a flawed process due to inaccurate recall memory and hindsight bias. Another criticism of refection is that it aims to theorise actions in hindsight therefore devaluing the skill of responding intuitively to a patient (Richardson 1995). I considered that my thought to hold Neil’s hand may have been intuitive but because we must use evidence based practice and appropriate frameworks of care, I theorised my care and utilised Heron’s (1975) framework. I believe self-reflection helps me to become self-aware. Self-awareness is achieved when the student acknowledges there own personal characteristics, including values, attitudes, prejudices, beliefs, assumptions, feelings, counter-transferences, personal motives and needs, competencies, skills and limitations. When they become aware of these things and the impact they have on the therapeutic communication and relationship with the patient then they become self-aware (Cook 1999). I have learnt through these experiences that reflection can be a painful experience as I have recognised my own imperfections and bias. I have felt angry with general nursing staffs attitudes towards mental health patients and have now been able to realise that this emotion is unhelpful and instead I should be more tolerant and understanding and help them to understand the patients needs. It is also difficult especially if one is experiencing strong emotions such as anger, frustration and grief (Rich 1995). At times I have over-identified with my patients and personalised their situation to similar situations of my own. This is known as counter-transference and has blinded my ability to address their care needs. Counter-transference is the healthcare professionals emotional reaction to the patient, it is constantly present in every interaction and it strongly influences the therapeutic relationship, but is often not reflected upon (Slipp 2000). Counter-transference can be defined as negative as it can create disruptive feelings in the clinician, causing misguided values and bias (Pearson 2001). I have learnt that it is crucial for me to consider how my reactions to a patient’s problem can impact on the care I provide. Whilst I endeavour to always give 100% best and unbiased care to each patient, I have realised I respond more favourably to patients that I like or identify with. For example I was extremely compassionate and biased towards both Emma and Neil and I feel that my personal life experiences influenced me because I could really empathise with them both. However, I realised that I am only human and that as long as I recognise the impact of counter-transference then I can use it positively as my self awareness of the fact that the process is occurring will enable me to address and challenge my own thoughts, feelings and responses. To conclude, I have been able to highlight my learning over the last two and a half years, both personally and professionally. This has enabled me to look at the areas that I am good at and the areas that I can improve on. I have been able to look at the quality of the care I have given patients and considered what I have achieved, how I felt, how I could have done things better, what was successful and unsuccessful, what issues influenced me and what understanding I had of the experience. I have also been able to recognise my role as a representative for mental health nursing and how I can promote it to other healthcare professionals. I have also identified the value of the role of my mentor in helping me to develop as a nurse. I will use the insight and understanding from these experiences to benefit my future practice and the care I provide for patients. ACTION PLAN Word Count 1086 What are my goals? My mentor and I discussed the areas that I want to improve on. We identified that my stronger points are common sense, logical approach and practical ability in terms of things like risk assessing and problem solving. I am also competent in the building of a therapeutic relationship, utilising a humanistic care philosophy, person centre approach, empathy, genuineness, unconditional positive regard and honest. I also have a good knowledge in respect of mental health promotion, anxiety management, basic counselling skills, understanding of the fundamentals associated with nursing, assessment and communication models and the basic principles of psychotherapy. I feel I have come a long way in two and a half years and have accomplished a lot. However, there are areas that I recognise that I can improve on and I am happy that I can address these as I hope this will improve my learning, skills and competency as a nurse in the future, providing better patient care. The areas I need to gain more knowledge and experience of include: understanding the religious, cultural and spiritual needs of the patient and how this impacts on their care and quality of life, recognising and working with counter transference and my tendency to feel the need to over protect patients as this does not help the patient to utilise choice, be responsible for themselves or empower themselves. I want to continue developing my own self awareness through self reflection. Finally I wish to develop my academic abilities and to train further so that I have more knowledge. Why have I chosen these issues? I have chosen to improve my knowledge and understanding of patients religious, cultural and spiritual needs and how this impacts on their care and quality of life, because by doing this I hope to be able to address their needs holistically. To successfully undertake a thorough assessment the healthcare practitioner needs to identify the holistic needs of the patient, failure to do so would neglect the patients physical, psycho-social and spiritual needs (Stuart and Sundeen 1997.) At present I feel I am unable to fully comprehend or provide best care as I feel I lack the skills and knowledge to do so. I also wish to further consider the impact of counter transference and my tendency to feel the need to over protect patients. I feel that if I gain more understanding and recognition of how counter-transference can change my reaction to a patient then I will be able to address it and have more control and choice over my nursing and my responses. In practice, I have experienced strong emotional reactions to some patient’s, perhaps because I could identify with some of their issues. However, this can result in my wanting to over protect them, which may disempower them, and this is unhelpful. Different characteristic in patients can influence the emotional reaction of the nurse (Holmquist 1998). I need to be able to recognise these characteristics in the patient and be self aware of the way I am responding. I want to continue developing my own self-awareness through self-reflection, as I will need to be able to exercise autonomous and expert judgement as a qualified nurse. The ability to use self-reflection as a learning tool to becoming self-aware will help me achieve this. This is a view supported by (Wong 1995). Boud, Keogh & Walker (1995) believe self reflection is an important human activity, essential for personal development as well as for the professional development of the nurse. By being able to mull over my experiences will help me challenge my beliefs and behaviour as an individual and a nurse. Finally I wish to develop my academic abilities and to train further so that I have more nursing knowledge. Experience alone is not the key to learning (Boud et al 1985). I wish to gain further qualifications so that I may further my career and knowledge, as this will provide a sense of achievement and fulfilment for me. How am I going to achieve my goals? I intend to develop my portfolio and keep an open reflective diary (Richardson 1995) to show evidence of my learning and prepare for my PREPP. Portfolios are seen as a collection of information and evidence used to summarize what has been learnt from prior experience and opportunities (Knapp 1975), and acknowledges professional and personal development, knowledge and competence, providing nurses with evidence of their eligibility for re-registration every three years (NMC 2002). I believe maintaining my portfolio helps with one’s self-assessment and will help me to develop my strengths, plus identify and critically evaluate my weaker areas, this is a view supported by Garside (1990). However in contrast Miller & Daloz (1989) suggest there is no evidence to suggest that self assessment contributes to enhance self awareness. A barrier to one’s ability to self-reflect may be time constraints and socio-economic factors such as high staff and management turnover, low staff morale and staff illness (Bailey 1995) I hope to overcome this by being a supportive team member to my colleagues and maintaining a positive mental attitude. I am happy to work on my portfolio and diary in my own time as I think it is a valuable learning tool. I will use my preceptorship, learning in practice, observation in practice and clinical supervision to help achieve my goals. Reflection on action is considered to be an essential part of clinical supervision (Scanlon & Weir 1997). I will continue to use Gibbs (1988) Reflective Model to help me develop my learning through reflection. I will need to feel confident that by sharing my portfolio, diary, reflection or seeking advice via preceptorship and supervision that this will not reflect negatively on me and effect my ability to feel able to trust my mentor. Students and staff sometimes feel unable to fully express themselves or belittled by the power relationship if supervision is not in a trusting relationship feeling it could be open to bias, personality clashes, counter-transference or could disadvantage them in terms of career development (Richardson 1995 Jones 2001). However, good clinical supervision enables nurses to feel better supported, contributing to safer and more effective nursing (Teasdale 2001, Jones A 2001). I hope to continue with life long learning and would like to be able to study for a degree in nursing. I shall do this by apply for funding once I am employed and hope that whoever my employers are they will support me in my goal to become better qualified. 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