Sample Undergraduate 1st Nursing Reflective Practice Essay

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Critical Exploration and Analysis of an Incident that Occurred in Clinical Practice

Introduction

Throughout this piece, I will use Gibbs’ (1988) reflective cycle to critically explore and analyse an incident that occurred within clinical practice that has had an impact on my learning and development. The use of Gibbs’ cycle will facilitate reflection by identifying feelings which could have influenced my practice, recognising strengths and weaknesses of my performance and exploring what impact this had within practice.
Reflection is an integral aspect of Nursing as it promotes ongoing professional development by exploring the impact of personal practice on quality of care delivery (Kiron et.al., 2017). The focus of this reflection will be how communication was adapted when caring for a patient with Dementia. This area of practice has been selected as the focus of this piece as Handley et.al. (2017) highlight that an ageing population and reduction in social care services have resulted in a higher prevalence of patients with Dementia being treated in hospital. It is essential that practitioners adapt their practice to facilitate effective communication as this is one of the fundamental principles of delivering high quality care - particularly for patients with diverse needs (Murphy and Maidens, 2016).
In concordance with the Nursing and Midwifery Council’s (NMC, 2015: The Code), all of the names of the people involved have been changed and the location of the placement has been omitted. The patients name has been changed to Margaret and my mentors name has also been changed to Helen.

Description

I received a handover at the beginning of my shift and was informed that a new patient was due to be admitted from the community following a fall with a suspected urinary tract infection (UTI). Upon arrival, Margaret appeared confused and was not orientated to space or time. She was verbally angry towards staff who were transferring her and was visibly distressed. We were informed in the handover that seven months ago, she had been diagnosed with Alzheimer’s Disease and that they believed the current presentation of signs and symptoms of Dementia were being worsened by a untreated UTI. To ensure all staff within the multi-disciplinary team (MDT) were aware of Margaret’s condition, the ‘Butterfly Scheme’ was implemented whereby a logo was situated at her bed station to identify that Margaret had Dementia. This is designed to highlight to other staff that Margaret may need care adapting due to her condition.
Effectively communicating with patients is a fundamental part of the Nurses role and Fakr-Movahedi et.al. (2016) highlight that when there are barriers to communication, it is essential that practitioners adapt and overcome this to ensure quality of care isn’t diminished. How myself and Helen adapted communication will be one of the main focus points of this piece as this was instrumental to delivering person-centred care.

Feelings

Admittedly, I was somewhat apprehensive when witnessing how disorientated Margaret was when she was admitted onto the ward. I was aware that staffing on the ward that day had been reduced due to sickness so was concerned that she would not receive care in a timely or safe manner as she was visibly distressed upon admission and would require additional support to meet her individual needs.
However, I was reassured by Helen’s calm approach and felt confident that I could learn from her experience of nursing patients with Dementia before, as I was aware she had a specialist interest in this area. I was also determined to provide person-centred care for Margaret and was eager to learn different ways of adapting communication to facilitate care delivery and meet her specific needs.

Evaluation

A strength of this incident was that throughout Margaret’s stay in hospital, staff were made aware using the Butterfly Scheme on her name board that she was exhibiting signs of Dementia and that communication and care may need to be adapted. This improved awareness and communication between staff and it was visible to see that in most cases, Margaret’s care was adapted to suit her needs because of this transparency.
Another strength of this situation was that Helen had a lot of experience and skills already in adapting care for people with communication difficulties. This meant that I was learning Nursing skills that were consistent with evidence-based, best practice guidelines that would enhance care. I was grateful to have the opportunity to observe how Helen interacted with Margaret as I recognise that I learn effectively from a vicarious approach – particularly as Helen was a role model for me within practice.
However, I did notice that at times due to staffing, communication appeared rushed when on the ward round and this negatively impacted Margaret. Witnessing the distress this caused her emphasised the importance of adapting communication more so and also reminded me of the importance of using nonverbal communication to convey warmth and empathy. When Helen and I communicated with Margaret, we ensured that our nonverbal cues emulated Egan’s ‘SOLER’ principles which are designed to convey active listening and open-ness. We found that using non-verbal cues like maintaining eye contact and touch helped us convey warmth and care to Margaret which also seemed to soothe and reassure her.
I also noticed that Margaret became particularly distressed when she was asked questions with medical jargon. Despite alerting all staff on the ward round of Margaret’s condition, it was disappointing that not everyone adapted their practice to make Margaret feel more comfortable and settled as the use of medical terminology clearly exacerbated Margaret’s sense of unease.
Overall, communication was adapted to meet Margaret’s needs the majority of the time. The use of nonverbal cues when conveying information certainly enhanced the therapeutic relationship and reduced Margaret’s anxiety whilst staying on the ward. However, observing others communicating with her, typically on the ward round highlighted that the use of medical terminology was detrimental to her care delivery and that this approach caused considerable distress.

Analysis

As a nationwide initiative, the Butterfly Scheme was implemented in accordance with the NHS Improvement guidelines for Dementia assessment and improvement framework (2017) and in this instance was recognised most of the time. Early recognition and transparency amongst staff aware of the Butterfly Scheme meant that Margaret was given more time to communicate by people who recognised her as experiencing Dementia. In these instances, her care dramatically improved and she was more involved in making decisions about her care and exhibited less anxiety and stress. However, as not all staff recognised this scheme and didn’t adapt their communication or practice to suit Margaret’s needs, this highlights the need for further training with staff and improved communication on the ward. Fetherstonhaugh, Tarzia and Nay (2013) emphasise that patients with dementia often report feeling excluded from making decisions about their care which contradicts the vision outlined in the NHS Constitution (Department of Health and Social Care, 2015) to provide safe and inclusive care to all patients.

Consistent with Bandura’s (1977) social learning theory, I identified early on that I learn most effectively through vicarious reinforcement so it was an incredibly useful experience to observe how Helen interacted with Margaret in practice. As I also identify similar personality traits to Helen, I believe this strengthened my learning as I noticed myself modelling my behaviour on her practice that I had witnessed. This is something I will ensure I remember for future placements as a student but it is also an aspect of teaching I will be aware of when mentoring staff in the future as my career progresses.
Using Egan’s (1975) ‘SOLER’ principles proved to be effective when conveying information to Margaret as it complimented a warm approach that was used by myself and Helen. Use of therapeutic touch put Margaret at ease and Stonehouse (2017) highlights that this can be a very useful approach to enhance trust and rapport in the therapeutic relationship – particularly for patients with dementia as there sensory perception can be altered.
Macdonald (2016) highlights that use of medical jargon can impede the therapeutic relationship which was observed in Margaret’s case. It is essential that patients are involved in making choices about their care to promote empowerment, dignity and respect (Truglio-Londrigan and Slyer, 2018). Farrington (2011) states that the use of medical terminology can intimidate a patient and prevent them from feeling included in care provision; diminishing empowerment and reducing the quality of their care. Whilst Helen and I ensured that our terminology was appropriate for Margaret’s needs, not every member of staff did which caused her considerable distress at times. Furthermore, as Margaret had dementia, it was essential that communication was adapted to suit her needs as Ellis and Astell (2017) emphasise that this will enhance quality of patient care and promote safety and transparency between staff and patients by ensuring that staff continue to act within her best interests.

Action Plan

To increase my understanding of Dementia, I will complete online training to learn more about the condition and what the best practice guidelines are when caring for someone with dementia. I think this will benefit my practice by allowing me to become more aware of how to deliver safe and effective, person-centred care for an individual with complex needs. To ensure this can be achieved by my next placement, I will complete the online training within the next four week and submit the completed certification as proof of Continuing Professional Development.
To further enhance my Nursing skills when caring for patients with Dementia, I will shadow a Specialist Alzheimer’s Disease Nurse to learn more about the condition and how best to adapt care to the individual needs of a patient. I intend to complete this within three weeks of my next placement as this will also contribute to my Continuous Assessment of Practice (CAP) document and help me achieve one of the Specialist Nurse professional learning logs.

Conclusion

Using Gibbs’ (1988) reflective cycle, I have explored my experience of adapting communication for a patient admitted onto the ward with Dementia. It has been essential to evaluate this incident as effective communication is a core principle of the Nurses role. Furthermore, adapting communication to suit the patients’ needs is an integral part of compassionate, person-centred care and can enhance the individuals’ experience of receiving care.
Due to an ageing population, nurses are caring for more people with Dementia on busy hospital wards. This piece has shown how essential it is that the approach to care is adapted to the individuals’ need to reduce distress and enhance their quality of care. Implementation of the butterfly scheme was helpful to a degree in this particular scenario but I also recognise that not all staff adapted their practice because of this. This piece has demonstrated the complexity of delivering care for a person with a communication difficulty and highlights that provision of care is largely influenced by personal attitudes and beliefs towards care delivery.

This piece has illustrated the importance of not using medical jargon when communicating with patients, particularly those with Dementia as this could exacerbate confusion and cause distress. It also highlighted how essential non-verbal communication cues were when conveying information but also when reassuring the patient.
Overall, I feel as though my initial reluctance and apprehension of taking responsibility for Margaret’s care provision soon diminished with the support of Helen. I recognise from this experience that I learn most effectively through vicarious learning and will be sure to replicate this in future placements and later in my career when I become a mentor to other staff.  Reflecting on this experience has been incredibly valuable to my learning as I have recognised areas of work that require development as well as elements of practice I feel more confident in. I believe that this incident demonstrates that I can practise safely and effectively, whilst ensuring that the patient remains at the heart of care delivery and that their care is enhanced through adapting practice to suit their needs.

Reference List

Bandura, A. (1977). Social Learning Theory. New York: General Learning Press.
Department of Health and Social Care (2015). The NHS Constitution. [Date accessed: October 2019] Available at: https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england
Egan, G. (1975). The skilled helper: a systematic approach to effective helping. California: Brooks/Cole.
Ellis, M. & Astell, A. (2017). Communicating with people living with dementia who are nonverbal: the creation of adaptive interaction. PLOS One. 12(8): 35-39.
Fakr-Movahedi, A., Rahnavard, Z., Salsali, M. & Negarandeh, R. (2016). Exploring nurse’s communicative role in nurse-patient relations: a qualitative study. Journal of Caring Sciences. 5(4): 267-276.
Farrington, C. (2011). Reconciling managers, doctors and patients: the role of clear communication. Journal of the Royal Society of Medicine. 104(6): 231-236.
Fetherstonhaugh, D., Tarzia, L. & Nay, R. (2013). Being central to decision making means I am still here: the essence of decision making for people with dementia. Journal of Aging Studies. 27(2): 143-150.
Gibbs, G. (1988). Learning by doing: a guide to teaching and learning methods. Oxford: Further Education Unit.
Handley, M., Bunn, F. & Goodman, C. (2017). Dementia friendly interventions to improve the care of people living with dementia admitted into hospital: a realist review. BMJ Open. 7(7): 15-25.
Kiron, K., Lamb, C., Gundogan, B., Whitehurst, K. & Jafree, D. (2017). Reflective practice in healthcare and how to reflect effectively. International Journal of Surgery: Oncology. 2(6): 20-21.
Macdonald, L.M. (2016). Expertise in everyday Nurse-Patient conversations: the importance of small talk. Global Qualitative Nursing Research. 10(11): 32-36.
Murphy, J & Maidens, G. (2016). Improving communication in dementia care. Nursing Times. 112(29): 18-21.
NHS Improvement (2017). Dementia assessment and improvement framework. [Date accessed: October 2019] Available at: https://improvement.nhs.uk/documents/1857/Improving_dementia_care_FINAL_v5_111017.pdf
Nursing and Midwifery Council (NMC, 2015). The Code. [Date accessed: October 2019] Available at: https://www.nmc.org.uk/standards/code/read-the-code-online/
Stonehouse, D. (2017). The use of touch in developing a therapeutic relationship. British Journal of Healthcare Assistants. 11(1): 11-15.
Truglio-Londrigan, M. & Slyer, J.T. (2018). Shared decision making for nursing practice: an integrative review. Open Nursing Journal. 12(1): 1-14.

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