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I am currently a fourth-year general nursing intern who is nearing the end of my 18-week surgical placement. I am currently on a female surgical ward which specialises in gynaecological surgery and procedures as well as general surgery. This is a very specialised ward with many of the nurses being dual qualified as both general nurses and midwives. I have gained a great deal of new experience in both general and gynaecological surgery during my time on this ward and feel I can and will relate it to many future nursing scenarios that I will experience.
Throughout my four years as a general nursing student I followed the five domains of competence (NMBI, 2005). The competencies ensure that a registered nurse practices within their scope of practice and delivers safe, adequate care. (NMBI, 2005). These five domains of competence have guided me in both my learning and practice in the past 4 years and have ensured that as a student I accomplish lifelong skills such as reflection, problem solving and professional nursing abilities (NMBI, 2005).
The 5 domains of competence include:
- Domain 1: Professional/ethical practice
- Domain 2: Holistic approaches to care and the integration of knowledge
- Domain 3: Interpersonal relationships
- Domain 4: Organisation and management of care
- Domain 5: Personal and professional development
For the purpose of this reflection I am going to focus on the third domain which is interpersonal relationships. This domain ensures that the nurse establishes and maintains a caring and therapeutic interpersonal relationship with individuals and their families. It ensures person centred care and professional relationships that involve managing and communicating on agreed appropriate actions. This domain also ensures that patients receive and understand relevant information. It allows for patients to communicate their needs and to make informed decisions about their care. Finally, it ensures that patient notes are inclusive and documented to best practice standards (NMBI, 2005).
In order for me to reflect fully on my experience during this work placement I will use the Gibbs reflective cycle. Graham Gibbs developed the Gibbs reflective cycle in 1988. The aim of this cycle is to develop a structure that aids learning from experiences (The University of Edinburgh, 2019).
It has 6 stages which include:
- Description of the experience
- Feelings and thoughts about the experience
- Evaluation of the experience, both good and bad
- Analysis; to make sense of the situation
- Conclusion: what you learned and what you could have done differently
- Action Plan for how you would deal with similar situations in the future, or general changes you might find appropriate.
(The University of Edinburgh, 2019)
For the purpose of this reflection I will name the patient *Anna. Anna was a 32-year-old lady who was being investigated for a pregnancy of unknown location (PUL). She was 10 weeks pregnant and experienced per vaginal (PV) bleeding. She then presented to A&E and had a scan which revealed an empty uterus. This would usually be diagnosed as a miscarriage but as her Beta HCG hormone level in both her urine and blood were still so high, they couldn’t rule out an ectopic pregnancy, which is a pregnancy that develops in the fallopian tubes. She therefore had to stay over night and have repeat blood tests done the following day to again test her Beta HCG hormone levels. We received care of her the following morning, which was a bank holiday Sunday, this meant that no consultants were available and there was only two gynae registrars available to cover the whole hospital. *Anna was a Syrian refugee and spoke very little English, her husband had slightly better English, but communication was still extremely difficult. She couldn’t speak using sentences and could only communicate using words or by pointing at objects. Her husband unfortunately wasn’t able to stay with her all day as they had a young child that also had to be looked after. Unfortunately, a professional translator was not available to help on such short notice. This made communication even more difficult as he was an important part of the communication process and developing a relationship with this patient. *Anna was extremely distressed and anxious, this anxiety got worse when her husband was not present. She would repeatedly ask me question’s in her own language. When I tried to explain the situation to her, she became increasingly anxious and upset. I sat with her and held her hand numerous times, to try to reassure her as I felt this was all I could do, thankfully she seemed to appreciate this. I knew however that I had to do something more for her. I decided to ask various different doctors that were working on the ward if they spoke Arabic, luckily, I found one. I asked him to translate a few simple phrases and write them down to try to make her feel more relaxed and so we could begin to develop a trusting relationship. This doctor did this but unfortunately had his own patients and was not available to talk to the patient face to face. The few words that he translated for us did however help immensely. We could now identify if she had pain, if she felt nauseous or if she had any bleeding. It was a relief to be able to help ease the pain she had and help her by getting her extra pads for her bleeding. I also felt that she felt more at ease when she could let us know these things. The long wait for the registrar to come and inform the patient of the blood test result was still causing anxiety and stress for *Anna. The registrars on call were extremely busy in both the maternity ward and A&E all day. Despite me bleeping both of them on numerous occasions throughout the day, they were unable to come to the ward until 18:30pm that evening. By this time *Anna was extremely distressed and was still unsure whether she had, had a miscarriage or not. She was exhausted both physically and emotionally and there was very little we could do to comfort her, only be present. When the doctor finally arrived, I informed him that communication was going to be difficult and that she was extremely anxious. Unfortunately, the doctor didn’t have English as his first language and spoke with a strong African accent. I ensured I was present and there to comfort both *Anna and her husband while the doctor spoke to them. I also explained more clearly some pieces of information that *Annas husband couldn’t quite understand from the doctor’s accent. As he tried to explain that her blood tests had come back and she had unfortunately miscarried she still didn’t fully grasp what he was telling her, her husband was noticeably very upset as he had to translate and explain to his wife that she had lost her baby. It was an extremely distressing and upsetting situation to be a part of as her husband tried to explain the devastating news to his distraught wife. The doctor did however inform them that he would bring her back for further testing on the causes of her miscarriages as this was her third consecutive one. They would look at her past history of previous miscarriages and they then would try to resolve this ongoing issue for her. The doctor also ensured them that there would be a translator present for them at this appointment. Before the doctor left, I asked the husband did he want to ask the doctor any questions and did my best to act as a mediator between them both. When the doctor left, I ensured that both *Anna and her husband were as clear as possible on what was just explained to them. I explained again that they would get help and that a translator would be at their next appointment to make things easier for them.
Stage 2: Feelings
I experienced many mixed emotions during this experience. These included me feeling sad for *Anna and her current situation. She was far from her home and family. Her husband was her only support and now she was experiencing a devastating loss. I felt helpless when I was trying to communicate with her, I could only be a friendly and comforting presence and try my best to develop a non-verbal relationship with her. I felt that because of the situation it was of even more importance to develop a relationship with this patient and for her to be able to trust I found the language barrier very frustrating and the fact that we didn’t have an interpreter available to speak to her. I also felt frustrated and slightly angry with the registrars as they didn’t consider *Annas situation as life threatening or an emergency, they knew the results to her test and knew she wasn’t in any danger. *Anna or her husband didn’t know this information however and it caused them a great deal of stress and unnecessarily prolonged their anxiety and distress. I did feel a great deal of relief when the registrar finally arrived with her test result, this however was quickly followed by again sadness as they reacted to the upsetting news they were receiving. Personally, I felt extremely overwhelmed with the whole situation. I feel that the language barrier and delay of the registrar to see her, delayed my realisation of the gravity of the situation. This was a loss and bereavement for this woman and her husband, it was something to be treated with the utmost respect and dignity. I also felt completely unprepared to deal with this situation as it is beyond anything I had dealt with on previous surgical or medical wards. I feel that at the time and with my limited experience in situations like this, that I dealt with it to the best of my ability at. I feel now however that if a similar situation was to arise in the future, I would deal and have a better understanding of dealing with the situation and my emotions. Finally, I felt grateful for the nurses and midwives on the ward who were there to support me throughout the day.
Stage 3: Evaluation
On immediate evaluation I felt that there wasn’t a good outcome. On further reflection however I feel that there were elements of the situation that can’t be considered all bad as I will explain here.
Ultimately the worst part of this situation was the fact that her and her husband suffered the loss of her unborn child. Many things contributed to the way it was managed on the day. These include the poor communication between *Anna, her husband and I, the poor communication between the doctor and I and the poor communication between the doctor and *Anna and her husband. This insufficient communication was caused by a major language barrier, that ultimately was only partially solved on the day in question. The inability to effectively communicate caused a huge amount of anxiety and distress especially for *Anna. I felt I wasn’t giving her high-quality care because of the inability to connect and develop a trusting interpersonal relationship with her. Communication was also affected because of the time of the incident, the bank holiday weekend meant that fewer staff were available and the staff that were available were extremely busy and under immense pressure. The lack of supports that *Anna and her husband could avail of in the hospital and locality, that they could understand and truly benefit from ranged from very limited to non-existent, this also majorly negative.
The good outcomes that can be gathered from this experience included getting the Arabic doctor to translate simple phrases that made communication about issues such as pain, nausea and bleeding easier between us. Understanding that she was experiencing any of these issues meant that we could manage it and relieve these symptoms thus developing a trusting relationship that began to ease some of her anxiety. Having her husband present while the doctor was delivering the news was a comfort to *Anna, as she had a familiar face she could turn to and he could also understand and explain more of the issue to her. Finally, the fact that the doctor was going to follow up with *Anna and her husband and carry out further tests to try to understand the ultimate cause of her consecutive miscarriages. A translator would also be present for this appointment which would make it a less stressful experience for them both.
Stage 4: Analysis
Reflecting on this experience has really helped me to make sense of the situation. It has highlighted many things for me including the important role the nurse plays during a miscarriage and the the importance of developing a good interpersonal relationship with the patient. According to Arnold & Underman Boggs (2016) a good interpersonal relationship improves communication between the nurse, the patient and the multi-disciplinary team. Effective interpersonal skills in nursing can also help to reduce stress and promote the wellbeing of the patient. These factors can have an overall effect on the quality of the patient’s life (Vertino, K., 2014). Advocacy is also an integral part of nursing and it is essential that we as nurses can advocate for patients who are unable to do so for themselves. Patients in hospital can become very vulnerable especially when they are from a different ethnic or cultural background. These patients need us as nurses to be their voices (Verino, K., 2014). Advocacy is most successfully utilised when important information is communicated and heard (WHO, 2019). Unfortunately, it proved difficult to be an effective advocate for *Anna because of the language barrier. A language barrier can often feel like a major obstacle to overcome in the delivery of healthcare. Adequate healthcare can be delivered through the use of interpreters and through bilingual healthcare professionals (Bischoff, et al., 2003). There aren’t many other services available to healthcare workers unfortunately only an interpreter, which I now realise are not always readily available. Future planning and organisation are all that can be done to resolve this issue, if *Anna was staying another night I would have pushed to have an interpreter available the following morning. Nursing a woman who has experienced a miscarriage requires a skilled, caring and sensitive nurse (Evans, 2012). Many nurses who work in gynaecology units have developed and improved on vital skills throughout their career that help them in dealing with miscarriage. They are supportive and have a professional manner while also having the ability and experience to deal with their own emotions. Nurses who are inexperienced in dealing with these situations often find it overwhelming (Evans, 2012). I personally found it emotionally overwhelming. During my time on this ward I have unfortunately seen other women experience a miscarriage. I have seen different coping mechanisms and the effects that different cultural beliefs have on the person experiencing the miscarriage. Many women who experience a miscarriage, experience it as a bereavement and it can have a devastating effect on their lives (Evans, 2012). A nurse is involved in many roles during a bereavement including, advocacy, patient centred care, family centred care and professional development (Raymond et al 2016). I feel I have developed and improved on these skills through this reflection.
The Health Service Executive (HSE) 2016, developed national standards for bereavement care following pregnancy loss and perinatal death in a hospital setting. These include four standards that outline the support a family will receive following a miscarriage or still birth. The four standards are Bereavement care as a central mission of the hospital, The hospital has systems in place to ensure that bereavement care is the central mission of the hospital, That each family and their baby receives high quality care that is appropriate to their needs and that the staff are educated and trained to provide this specialised care.
Stage 5: Conclusion
If this situation was to arise again, through reflecting I realise there are things that I would do differently. I would have pushed more for the doctor to come sooner, I would have stressed the point of her anxiety and despair waiting such a long period to find out life changing news, that the doctors didn’t feel was an emergency at the time. I would have also pushed harder to source an interpreter or someone in the hospital who spoke *Annas native language that could have been present when the doctor finally came to deliver the news. Having someone there who could explain the situation to both *Anna and her husband in their native language would have been more comforting and professional than *Annas husband having to explain the bad news to her. I would have tried to be more organised and get a specific time from the doctor on when he would be able to come. If *Anna had a specific time on when the doctor was coming at least then she would have had more comfort knowing that the doctor was coming, and he didn’t forget about her. Finally, I would investigate and improve my knowledge on services in the hospital that are available for vulnerable people, like *Anna and her husband.
Stage 6: Action plan
Person Centred Care (PCC) is an integral part of nursing and communication is an important part of delivering PCC (Health Innovation Network, 2019). PCC involves many different aspects including: putting people at the centre of care, considering peoples preferences, respecting peoples values, ensuring good communication, education and information, helping people to feel comfortable and safe, provide emotional support, involve friends and family and make sure people get the appropriate care and supports that they require. (Health Innovation Network, 2019) Through reflection I can now see the importance of delivering PCC to patients in my care and the difference it can make to the care that they receive. It was important for me to provide emotional support for *Anna and her husband during this difficult period. Although communication was difficult, I feel that they both still appreciated my presence that day and although I didn’t think so at the time, I feel like they acknowledged my efforts in trying to develop a relationship with both *Anna and her husband. This experience has really encouraged me to use PCC and highlighted the positive effects it has on patient the patients experience with their care. As well as using PCC in my future everyday nursing care and improving my PCC skills, I would like to improve services in the hospital for women and men who suffer the devastating loss of a miscarriage. I would like to suggest to nursing admin the idea of having a miscarriage clinical nurse specialist on the ward who would be available to support both patients, their families and nurses who deal with situations like these. Support is of great importance to someone who’s had a miscarriage, as many people regardless of length of gestation see it has a bereavement and a loss. I feel it is important that nurses are educated in cultural beliefs surrounding miscarriage and the impact it has on people from different cultures and their feelings towards it (Hannebaum, 2014).
- Evans, R. (2012) ‘Emotional Care for Women Who Experience Miscarriage’, Nursing Standard, 26(40), pp. 35-41. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22908762 (Accessed: 1st May 2019).
- Nursing and Midwifery Board of Ireland (2005) Requirements and Standards for Nurse Registration Education Programmes. Available at: https://www.nmbi.ie/nmbi/media/NMBI/Requirements-and-Standards-for-Nurse-Registration-Education-Programmes-3rd-Ed.pdf?ext=.pdf (Accessed: 30th April 2019).
- The University of Edinburgh (2019) Gibbs Reflective Cycle. Available at: https://www.ed.ac.uk/reflection/reflectors-toolkit/reflecting-on-experience/gibbs-reflective-cycle (Accessed: 1st May 2019).
- Health Service Executive (2016) National Standards for Bereavement Care Following Pregnancy Loss and Perinatal Death. Available at: https://www.hse.ie/eng/services/list/3/maternity/bereavement-care/national-standards-for-bereavement-care-following-pregnancy-loss-and-perinatal-death.pdf (Accessed: 3rd May 2019).
- Vertino, K, A. (2014) ‘Effective Interpersonal Communication: A Practical Guide to Improve Your Life’, The Online Journal of Issues in Nursing, 19(3) Manuscript: 1. Available at: http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-19-2014/No3-Sept-2014/Effective-Interpersonal-Communication.html (Accessed: 30th April 2019).
- Raymond, A., Lee, S, F., Bloomer, M, J. (2016) ‘Understanding Bereavement Care Roles of Nurses Within Acute Care: A Systemic Review’, Journal of Clinical Nursing, 24(13-14) Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/jocn.13503 (Accessed: 2nd May 2019).
- Bischoff, A., Bovier, P, A., Isah, R., Francoise, G., Ariel, E., Louis, L. (2003) ‘Language Barriers Between Nurses and Asylum Seekers: Their Impact on Symptom Reporting and Referral’, Social Science & Medicine, 58(9) pp: 1807. Available at: https://www.sciencedirect.com/science/article/pii/S0277953602003763 (Accessed: 2nd May 2019).
- Hannebaum, W. (2014) ‘The Rold of the Nurse in Family Coping after Miscarriage’, CORE Scholar, Available at: https://corescholar.libraries.wright.edu/urop_celebration/9/ (Accessed: 6th May 2019).
- Health Innovation Network (2019) What is Person- Centred Care and Why is it Important? Available at: https://healthinnovationnetwork.com/system/ckeditor_assets/attachments/41/what_is_person-centred_care_and_why_is_it_important.pdf (Accessed: 6th May 2019).
- Arnold, C, E., Underman Boggs, K. (2016) Interpersonal Relationships, 8th EditionSt. Louis, Missouri: Elsivier.
- World Health Organisation (2019) Community Based Rehabilitation Guidelines, Available at: https://www.who.int/disabilities/cbr/guidelines/en/ (Accessed: 5th May 2019).
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