In the field of mental health nursing, professional accountability is highly dependent on effective communication with patient. This helps in building a therapeutic relationship by recognizing the psychosocial needs of patient. Effective communication skill is the means by which nurses and mental health care professionals can gain trust of patient and effectively engage them in care process. Trust, rapport, respect, genuineness and empathy are the important values for establishing therapeutic relationship with mentally ill patient. This is also possible by following the person-centered approach to care (Videbeck 2013). However, building rapport and developing therapeutic relationship does not come instinctively for all and critical reflection regarding clinical situation enables nurses to make sense of the situation and determine ways to improve their care and professional skills in nursing practice. The Nursing and Midwifery Council also emphasize nurse and midwives to engage in meaningful reflection process to improve professional practice (Nicol and Dosser 2016). This report further explores the importance of reflection through the description of an interaction event with patient in mental health nursing and shows how this experience expands the knowledge in mental health nursing practice.
While in a nursing placement, I have witnessed both positive and negative correspondence with patients and co-workers. During my placement in acute mental health facility, I had been allocated under the care of a 60 year old patient with dementia, deafness, hostility and night time wakefulness. Due to confidentiality reason, the patient will be henceforth referred to as Mr. X. At the first instance, I found the patient to be exceptionally restless and agitated. The other nurse instead of responding to him yelled at him ‘we are too occupied now, backpedal to your room.’ The medical attendants and medicinal care associates giggled among them gave suspicious looks and imitated Mr. X voice saying he can be such an aggravation.
During my first interaction with Mr. X, I warmly greeted him and explained him my duty as a nurse under his care. According to the handover report of the patient, I got to know that his wife failed to manage him at home because of his night wakefulness and increase in disorientation. He had been admitted following a fall when he desired to walk about at night. The nursing responsibility for care of Mr. X including assisting Mr. X in ADLS (activities of daily living), managing his medication, routine assessment of patient and taking care to minimize any risk of fall. I offered to help him with his own cleanliness needs and to make his bed. During the first day of interaction, I found that he was exceptionally upset and incensed about being admitted to the hospital. Mr. X then clarified that nobody had disclosed to him why he was in healing facility nor did he know the where about of his wife.
After the dialog with Mr. X’s wife, the physician reported me that his wife is unable to take care of him due to her own deteriorating health and Mr. X does not understand the reason for his admission due to his failing memory. I reported it in my notes so that different individuals from the Multi-disciplinary group would recognize that he was indeterminate about the circumstance he was in. After addressing my senior doctor and being more educated on Mr. X life history, I came back to him with my senior. I grabbed a place to sit beside the patient and in a quiet, consoling, soothing way clarified the motivation behind why he was in healing center. However, Mr. X seemed to look befuddled and requested that I address him in his left ear as he was hard of hearing. His mobility was very poor and I knew that managing him would be a challenging task for me. I consulted the senior nurse regarding how to manage such patient with disorientation, poor mobility, failing memory as well as deafness. The nurse advised me regarding consulting him before any medication dose and using a pressure mat on his bed to get alert about when he wake up. I thanked my senior nurse, as I felt a little better and confident to take care of Mr. X after this advice.
The next 2-3 days was difficult, as he could not make sense of the situation he was in and often displayed non-verbal signs of aggression instead of verbally expressing his concern. He was often lost and asked for his wife. I started with short conversation with him followed by conversation that made him feel better. After few days, I observed he finally trusted me and discloses to me about his reason for unrest. He said that could not rest as different patients were aggravating him. I offered to provided him a better environment and his toileting and other needs were also well-attended. He even finally affirmed that he felt a ton better that somebody set aside the opportunity to hear him out concerns and clarify what was happening as opposed to being disregarded and ‘left oblivious.’ Hence, he was finally less fearful, cooperated with routine clinical care task, and was happier to engage with staffs while at the facility.
The above mentioned event of interacting and caring for patients with dementia is a significant clinical experience for me as it expanded my understanding regarding the complexity found in patients with dementia. Secondly, it also tested my clinical knowledge in mental health nursing practice as monitoring and caring for people with symptoms of disorientation, poor mobility, ageing and agitation is the most challenging task in nursing practice.
From the hand over report of Mr. X and observing his state of mind and clinical presentation at the acute mental health care facility, I learnt many things about the reason for high risk in such patient group. I could derive this meaning when I found Mr. X in a very restless, agitated and fearless state during the initial days of care. These are also the manifestations of dementia. This is because the degenerative brain disease results in decrease in thinking ability and daily functions in people. People with dementia mostly show signs and symptoms of emotional problems, language difficulties, memory loss, disorientation and impaired reasoning and judgment. Memory loss is a major issue for them, which makes them impulsive as fail to understand the reason why they are in a particular situation (Mitchell et al., 2014).
The issue of impulsiveness and fearfulness was also shown by Mr. X as he was shouting at staff and wanted to know the reason for which he was at the facility. However, instead of taking care to make him calm by answering his queries, the staffs ignored him and ignored him. This experience helped me to learn that many health care staffs fail to realize the dementia patients also have the same basic needs as everyone else. They also seek comfort and want to live in a normal zone. However, due to the disease, they fail to recognize their needs and adequately communicate with patients. They take out this frustration in the form of aggression (Morgan et al. 2013). In the clinical situation of Mr. X, he became even more agitate because he was not treated with respect by the staff. From this experience, I learnt that people with such complex illness unfortunately experience discrimination by health care staffs during treatment. This is not ethically correct as it breaches the right of people with dementia (George et al. 2013). Report suggest that ageism and lack of capacity to challenge and report is the major reason for which they face discrminition in treatment. Lack of mental capacity makes them vulnerable to discrimination (Alzheimer’s Society (2017). However, as a nurse accountable for care of Mr. X, I took care to respect and preserve his right in care by informing him about the reasons for his admission and by engaging in supporting and compassionate communication with patient. This attitude and value only helped to build trust with patient and gain his support during the care process.
Hence, the reflection on my experience in care of dementia patients made me aware about the complex symptoms and challenges for dementia patient. I also got to learn that health care staffs are also involved in aggravating the condition of patients. Instead of recognizing their difficulties in meeting basic needs and supporting them in recovery, many staffs are found discriminating against them due to their poor mental capacity and communication difficulties. This display by common people is accepted, however such conduct by health professional is unaccepted and irrational for which action is immediately required. Another important learning from the event is regarding the reason for aggressiveness in almost all people with dementia. Patients like Mr. X are aggressive when their needs are not adequately met. This experience informed me that if patients are aggressive, it is a sign of their unmet needs. As a nurse, I will make it my priority to address and meet their unmet needs in order to stimulate them to stop this behavior (Harris 2017).
The analysis of the event and my experience with Mr. X made me a confident mental health nurse. It enhanced my communication skill in nursing practice. I could develop this skills after my experience of caring for Mr. X, a elderly people with dementia and mobility related issues. The communication event with Mr.X was the most important part of my learning. It tested my nursing competencies to extreme level. This was because Mr. X was not only struggling with dementia related symptom and he had other problems of deafness and mobility issues too. After my nursing training, I came with the assumption that clinical care and communication will be an easy task for me as I am good at communicating with patients. However, all my assumptions failed once I realized the effort and skill that is needed to communicate with such patients. I developed this feeling when I first interacted with Mr. X. Although I tried to communicate with him in the most soothing and compassionate manner, Mr. X was not ready to trust our service. He had many confusions and responded only by infrequent gestures for few days. I struggled not only by my personal inefficiency in communication, this was also because of the communication inappropriate attitudes of other staffs (Houghton et al. 2016). Hence, I was looking to address a patient who already came with aggravating conditions of illness and faced difficult situation again due to the unethical and discriminatory attitude of other nursing staff.
For two-three days, I was very disappointed with myself. I questioned my own skills and wandered whether I have it in me to become a responsible source of support for patients with mental illness. At this point, I used my value of compassion and utilized patient-centered care approach to look for things that gave comfort to patient. I was glad to monitor that this worked in a great way in reducing aggression in patient and increasing response of Mr. X towards my care. I took the responsibility to facilitate communication with Mr. X. In the initial days, I observed and assessed Mr. X regarding his language deficits and communication pattern. As he was not responding to me initially, I had to interpret his unclear verbalizations by non-verbal signs and anticipate his needs accordingly. I could do this by means of other information regarding eating, toileting and sleeping patterns, upsetting scenario and source of comfort for Mr. X (Hesson and Pichler, 2016). This strategy proved very useful in meeting unmet needs of Mr. X and building a therapeutic relationship with him. Hence, I was not proficient in caring for Mr. X in the beginning, however the challenges and mistakes in the process helped me to reflect, deconstruct my weakness and adopt strategy to learn and develop my professional skills in mental health practice.
As my clinical experience of caring for dementia patient was my first experience in caring for patient with such mental health condition, I struggled a lot in fulfilling my nursing responsibility. However, with the commitment to analyze my weakness and utilize new approaches to manage practice, I could eventually promote recovery of such patient. I would take a note of all my weakness and do things differently and in correct way in the future to provide a safe and caring environment to dementia patient.
I aim to improve my communication skill at all level to achieve better outcome for dementia patient. On personal level, I will do this by taking note of my weakness in interaction with Mr. X and then consulting evidence based research articles and approach to engage with patients. The first weakness that I saw in me during the care of Mr. X was that I could not interpret the needs and response of Mr. X as he seemed to be lost at times due to failing memory. Even if he responded some time, he would just say ‘ I don’t know’ which gave me very little information to interpret his views. The review of literature showed that cognitive assessment is an interpersonally difficult task for care provider and very few staffs have confidence in this. The short phrases produced by patients can be validated only by means of facial expression of patient. Having informed knowledge about micro and macro-functions short phrase given by patient, health care providers can engage in rapport building conversation with patient (Hesson and Pichler 2016). Hence, in order to build better rapport with patients, I would utilize different approaches in the future. The main goal will be to elicit expression of feelings by dementia patient by decreasing the pace of interaction. Secondly, I will use non-linguistic communication styles by means of eye contact, smiles and pleasant attitude to get positive response from patient. The next approach will be to modify the patient environment during the communication process by closing the door because extra noise tends to confuse them. In addition, giving patients deliberate choices will be important so that they are informed about the rational for a procedure. This will reduce feelings of apprehension and fear in them and calm them (Weirather 2010).
From the care experience with Mr. X, I eventually got to know that dementia patients also have same needs as others. However, their difficulty is heightened by cognitive and reasoning impairment. In such case, identifying their needs and requirement for ideal environment around them is important. Research literature informs that impaired intellectual functioning greatly interferes with normal activities in dementia patient. They face difficulty in solving problems and controlling emotions (Enderby 2017). Hence, for a health care staff, temperament, tone and delivery of interaction with such patient is important to understand psychosocial needs of patients. Ideas related to personal centred care and developing positive approach to people with dementia would help to support them in normal activities. The understaning of Maslow’s hierarchy of needs would help to interpret the safety needs of dementia patient. This will help patient to feel secure and trust the health care facility and give a relaxed state of mind to them. Such patient often need stimulation within life through social contact, however environment often comes as a barrier in meeting their needs (Hughes et al. 2014). In such scenario, I will take care to minimize behavioral symptom of dementia patient by expressing affection and eliminating environmental factors of noise, distraction and other emotional trigger from patient.
The practice of critical reflection is not just about thoughtful consideration about professional practice, it is the opportunity to engage in a systematic and rigorous method of critiquing one’s practice. This practice is important for professional growth as it enables an individual to evaluate their current practice and develop new understanding that informs action in the future. It is a positive way to identify new learning and actions in nursing practice (Bulman and Schutz, 2013). The exercise of reflecting on my experience while providing care to an elderly patient proved to be very beneficial for me as it gave me the opportunity to analyze and grow in my professional practice. The practice of describing the situation, analyzing response to the action, identifying challenges in the process helped me to identify my incompetencies in practice. Secondly, the process of deconstruction and reconstruction of event helped me to identify my weakness and prepare accordingly to change my nursing strategies and action in the future. The outcome of this event is that I am now more confident as a nurse while caring for patients with complex conditions like dementia. I utilize effective approaches to respond to verbal and non-verbal cues of patient and build a positive relationship with patient.
The reflection regarding the situation of Mr. X and evaluating challenges in the process informed me about the reasons for aggressiveness in dementia patient. This motivated me to provide a safe environment to patient and effectively understand emotional and psychological needs of such patients. From my communication skill and use of resource to assist patient in ADL, I have been able to reduce the burden of illness in people and improve their quality of living. Use of pharmacological intervention in Mr. X was particularly found to be risky because of his night wakefulness and the plan of providing psychosocial support to patient by means of affection, eye contact and conversation that interested people helped me to gain the trust of patient in care. Currently, patients are very satisfied with my care as I can understand their concern even if they do not express it clearly. Despite the confidence in communication with dementia patient, I think I still have to learn the practice of minimizing fall in patient. Due to their disorientation process, they are prone to vulnerable situation and I would like to adapt strategies to minimize this risk on patient. If given the chance again to look after Mr. X, I would have immediately removes all source of distraction that troubled patient. Secondly, I would use my communication skill in a better way to build rapport with Mr. X.
Conclusion:
From the exercise of critical reflection in nursing practice, the report informed about the opportunity of new learning and informed action in nursing practice. The practice of describing the situation about responding to Mr. X, a patient with dementia, poor mobility and other risk helped to describe the approach used at the beginning of interaction. Secondly, the reflection regarding challenges in the process and new approach needed to improve the situation helped me modify my knowledge and skills to increase my competencies in mental health nursing practice.
References
Alzheimer’s Society 2017. Equality, discrimination, and human rights – Alzheimer’s Society. Alzheimer’s Society. Retrieved 3 June 2017, from https://www.alzheimers.org.uk/info/20091/what_we_think/141/equality_discrimination_and_human_rights
Bulman, C. and Schutz, S. eds., 2013. Reflective practice in nursing. John Wiley & Sons.
Enderby, P., 2017. Promoting communication skills with people who have dementia. The Essential Dementia Care Handbook: A Good Practice Guide, p.102.
George, J., Long, S. and Vincent, C., 2013. How can we keep patients with dementia safe in our acute hospitals? A review of challenges and solutions. Journal of the Royal Society of Medicine, 106(9), pp.355-361.
Harris, J., 2017. Recognizing Pain and Preventing Aggression in Patients With Dementia. Caring for the Ages, 18(4), p.3.
Hesson, A.M. and Pichler, H., 2016. Interpreting “I don’t know” use by persons living with dementia in Mini-Mental State Examinations. Patient education and counseling, 99(9), pp.1534-1541.
Hesson, A.M. and Pichler, H., 2016. Interpreting “I don’t know” use by persons living with dementia in Mini-Mental State Examinations. Patient education and counseling, 99(9), pp.1534-1541.
Houghton, C., Murphy, K., Brooker, D. and Casey, D., 2016. Healthcare staffs’ experiences and perceptions of caring for people with dementia in the acute setting: Qualitative evidence synthesis. International Journal of Nursing Studies, 61, pp.104-116.
Hughes, T.B., Black, B.S., Albert, M., Gitlin, L.N., Johnson, D.M., Lyketsos, C.G. and Samus, Q.M., 2014. Correlates of objective and subjective measures of caregiver burden among dementia caregivers: influence of unmet patient and caregiver dementia-related care needs. International psychogeriatrics, 26(11), pp.1875-1883.
Mitchell, A.J., Beaumont, H., Ferguson, D., Yadegarfar, M. and Stubbs, B., 2014. Risk of dementia and mild cognitive impairment in older people with subjective memory complaints: meta?analysis. Acta Psychiatrica Scandinavica, 130(6), pp.439-451.
Morgan, R.O., Sail, K.R., Snow, A.L., Davila, J.A., Fouladi, N.N. and Kunik, M.E., 2013. Modeling causes of aggressive behavior in patients with dementia. The Gerontologist, 53(5), pp.738-747.
Nicol, J.S. and Dosser, I., 2016. Understanding reflective practice. Nursing Standard, 30(36), pp.34-42.
Videbeck, S., 2013. Psychiatric-mental health nursing. Lippincott Williams & Wilkins.
Weirather, R.R., 2010. Communication strategies to assist comprehension in dementia. Hawaii medical journal, 69(3), p.72.
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