Gibbs (1988) reflective model consists of six stages.
Boyd and Fales (1983) offer a useful definition of reflection, suggesting that it is “the process of internally examining and exploring 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. ” According to Siviter, 2004, p165) explains that reflection is about gaining self-confidence, identifying when to improve, learning from own mistakes and behaviours, looking at other people’s perspective, being self aware and improving the future by from the past.
However, having knowledge about reflection does not necessarily mean that nurses are able to use reflection in a meaningful way during practice. Self reflection helps nurses to learn about the actual practice of nursing and helps them to evaluate their own practice and performance. Reflection may also be prompted by more positive states, for example, by an experience of successfully completing a task which previously was thought to being impossible. The reflective process can be used to reflect in two ways; reflection-on-action and reflection-in-action.
Reflection-on-action is often referred to as retrospective as it occurs after the experience has taken place, where as, reflection-in-action, involves exploring and reflecting upon an experience while in practice. Becoming a reflective practitioner will help me to focus upon knowledge, skill and behaviours that I will need to develop for effective clinical practice. Professional development should include opportunities to improve knowledge and practice of communication. Communication is an essential interpersonal skill, which people need as it is an integral to everyday life.
According to (Childs et al. 2009), communication is a process of interaction, meaning and understanding. In other words, a message is passed from one individual to the intended individual and/or group of people and will be received or not, interpreted or not, understood and/or misunderstood. The message can also act as a trigger creating a positive or negative response which in turn can affect the responding message and behaviour of the individual and/or group. Communication can be split in two, verbal and non verbal communication.
Non-verbal communication is without the use of verbal language and is as important, if not more so, than the verbal part. The use of touch as a way of non-verbal communication is very important in caring. Non-verbal communication is extensively used in learning disabilities and for those with speech impairment. Making eye contact with the person you want to communicate with, allows you to check their response. Learning disabilities nurses care for people who may not be able to express their needs; therefore it is especially important for nurses to refine their communication skills.
Many people with severe or profound learning disabilities may never develop the ability to signal their intentions. Others may have the cognitive ability to do so, but their signals can be hard to recognise because of physical or sensory problems. For example, an eye gaze will not be used by people with severe visual impairments. Effective communication in the healthcare setting improves recovery rates and reduces pain and complication rates. (Wilkinson et al, 2003). Many complaints to the NHS are attributed to poor communication. Effective communication is reliant on the nurse working in partnership with the patient.
It is essential that the nurse establishes a rapport and most of this will be achieved through the use of facial expressions. In my practice, it is important that develop a therapeutic relationship with the patients so that they can be able to put their trust in me. The therapeutic relationship is solely to meet the needs of the patient. In this relationship, there is a rapport established from a sense of mutual understanding and trust. To build a good nurse-patient relationship, I would have to show qualities of empathy, caring, sincerity and trustworthiness.
During practice, if I am approaching a patient and the patient looks anxious, I should approach with empathy. Self-awareness is the key to understanding the reasons why some interactions are successful and why others are not. Realising how much previous experience can affect us and how certain triggers can produce a response that surprises us, is a process that can take a long time. Issues of transference and counter-transference bring understanding as to why some interactions fail, (Dryden,1989). Having an understanding of yourself and your response to situations can lead to improved communication skills.
The barriers to effective communications are often generated by individuals’ own response to the situation at hand. Recognising our tolerance levels is important as this can affect the communication process. Developing strategies to manage stress levels is important in the work place. In accordance with the NMC (2002) Code of Conduct, confidentiality shall be maintained, and all names all in this text have been changed to protect the identity. Bridget is a lady with mild learning disability. She has Motor Neuron Disease. MND is a progressive neurodegenerative disease that attacks the upper and lower motor neurons.
Degeneration of the motor neurons leads to the weakness and wasting away of muscles, causing increasing loss of mobility in the limbs and difficulties with speech, swallowing and breathing. Bridget has lost all mobility of her arms and legs as well as speech. To communicate, she makes use of a communication board. Bridget is on a soft diet and is at risk of choking. All medication is given via a peg. She lives at home with a live-in carer. On my previous visits, Bridget, my mentor, Mary (Bridget’s sister) Grace (Bridget’s live-in carer) and I had agreed that I could spend a couple of hours with Bridget while Grace has a break.
I made the necessary research about the service user by consulting RIO, her care plan and other professionals involved. The essence of collaborative practice is vital in the care of people with complex needs. Earlier that day, Bridget had gone out with her sister. I met Bridget at home as she was returning. I was welcomed with a friendly smile from Bridget which ensured me she remembered, and still approved of me spending time with her. I assisted with transferring Bridget into the house. Mary had to leave immediately after dropping Bridget off. I explained and reminded Bridget my reason for visiting her , and she replied with a smile.
Before Grace left I made sure that I knew where everything was, including in-case of emergency details. I looked forward to spending the day using and improving my interpersonal skills while building the therapeutic relationship between Bridget and myself. I was challenged by the opportunity to communicate with a service user who was using a communication tool (communication board) which I had never used and seen before meeting Bridget. When we had settled, I began looking for Bridget’s communication board. I asked her if she had seen it and she indicated by using her eyes to check her bag, and the board was not there.
I looked around the house, with no luck. I tried to be aware of my body language as I did not want to alarm that I was starting to panic. I was aware that even though I could speak to her, Bridget had no way of communicating back except through facial expression and use of her eyes. I informed her that I could not find the board as she was starting to be distressed and anxious. I began to worry about what if she needed something but could not make her feelings known. I contacted the live-in care and Bridget’s sister to inform them of what was going on.
Mary had mistakenly driven way with the board in her car. After conveying the message to Bridget, she became less anxious which was quite a relief for me. I continuously reassured her that we would soon get her communication board, and I would do my best to make her feel comfortable. I was aware that this incident would make her feel disempowered. It was my responsibility to find alternate systems of communication. I had to find ways to maximize the ability for Bridget to communicate by making use of “yes” and “no” answers by writing it on paper and showing her.
I sat and read her, her favourite book. I offered her a cup of tea, bearing in mind her swallowing problems. I offered Bridget a hand message, providing her with sensory stimulation, which she enjoyed. During the event, I went through different emotions. Prior to the event, I felt confident about being able to communicate by making using the board. I was also nervous in case we had a communication breakdown. At the beginning, I was excited to get the opportunity to learn on practice about a service user who has such specific communication and health needs.
I felt empathetic towards the service user and sympathised with her condition. I was disappointed at myself for not checking the board was there. I was very stressed when Bridget was becoming distressed. At the end of the day, I felt a sense of achievement for making the best of a bad situation. “Evaluation implies judgement based on careful assessment and critical appraisal of given situations, which should lead to drawing sensible conclusions and making useful proposals for future action” WHO (1981, p9).
The incident was a good experience as it gave me the opportunity to be adaptive in my practice. I formed a good working relation with her in that short period. I have realised the importance of checking that you have all equipment before carrying out a task. Other then the initial period when we first realised that the communication board was not in the house, Bridget remained calm and was open to suggestions on how we were to spend the time before we received the board. I will be more vigilant, and confident should I be confronted again with a similar issue.
When analysing my experience, it made me question whether it was appropriate for me as a novice to be responsible for someone with such complex needs especially considering the service user did not know me very well. Considering that we had no communication tool, Bridget and I found other means to communicate. As a negative point, I am now aware that I over-compensated and spoke too much. Placement is a learning process which gives aspiring Nurses the opportunity to have on the job learning, acquire some experience and to gain confidence to cope with situations like this.
The incident made possible for me to gain some insight into Learning Disabilities Nursing. I also acquired a strong knowledge base both practical and theoretical related to diagnosis and management of patients in Learning Disability Nursing. My mentor gave me assurance that I did the right thing, and she took into consideration that I was a novice and even encouraged me. Personally, I realised that life becomes easier when you understand yourself and others better. I have discovered that by understanding myself and others better, I enjoy my social and academic life more.
In conclusion, I could have called for somebody whom Bridget is more familiar to. I could have contacted the community learning disability team which could have provided a solution. I could have also drawn a replica of Bridget’s communication board. The outcome in the end however, was good. The patient was calmed down and enjoyed sensory stimulation. For my action plan, I intend to improve upon my communication skills, both verbally and non-verbally. I also intend to improve upon my organising skills. I will have to be aware in my practice not to create barriers to communication. I would suggest to service users to have a spare communication board. If I was to do another reflection again, I would use Gibbs (1988) as it helped me to structure my reflection.
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