This assignment will discuss proficiency from within the pre-registration clinical profile. The proficiency to be discussed shall be clause 4. 1 ‘Personal and Professional Development’. The rationale as to why this proficiency was chosen was to reflect on a challenging situation in regards a client with personality disorder, which the author experienced during a clinical placement. The client who shall be referred to as ‘Trevor,’ as to protect his identity in regulation to the Nursing and Midwifery Councils (NMC) 2004 Code of Professional Conduct regarding confidentiality (clause 3. , pp 5). To help facilitate this assignment, a reflective model (Gibbs model 1988) will be incorporated to discuss how the author has achieved the necessary level of competence during nurse training. The rationale to why this proficiency was chosen was mainly due to reflective practice being one of the pinnacle aspects to nursing, and especially so when faced with challenging situations. By reflection the student nurse can learn from past experiences by looking intensely at what the actual situation involved and to remember how emotions, thoughts and feelings played a part in the outcome.
By evaluating and analysing on these points the nurse can develop an action plan to support future clinical practice. From reflecting on clinical aspects a student nurse can make the transition to professional nurse. Gibbs (1988) model of reflection incorporates the following: description, feelings, evaluation, analysis, conclusion and an action plan. The model will be applied to the essay to facilitate critical thoughts, relating theory to practice where the model allows. Also appropriate legislations will be included to support the assignment.
A conclusion to the essay will then be given which will discuss how reflection skills contribute to acknowledging competence and provide evidence to personal and professional development. The primary part of Gibbs (1988) reflective cycles suggests a description of events. Whilst on placement on a busy, elderly medical ward Trevor a gentleman aged 60 years with a past medical history of personality disorders was admitted onto the ward. A personality disorder is defined by Woods (2005) as; “A group of disorders characterized by pathological trends in personality structure.
It may show itself by lack of good judgment or poor relationships with others, accompanied by little anxiety and no personal sense of distress. ” The first process in nursing was to admit Trevor onto the ward, and then assess the situation and implement care plans to assist in caring for him. His mental capacity, his level of communication and understanding, was severely limited, so my main source from which I could gain relevant information about Trevor, was by reading through his notes, mainly his ‘Easy care’ information ( a continuous care plan documentation which holds information e. . next of kin, medical conditions, medications etc, Leeds Teaching hospital 2007). I made the relevant care plans using information presented on the easy care documentation and went into the ward he was occupying to take his vital observations. After I had introduced myself to Trevor, I approached him in a non-threatening manner and explained my intentions, he started prodding me hard in the chest, shouting incoherent words, his tone was aggressive and I felt threatened.
Although I understood he may have felt disorientated and confused, I did feel frightened and completely out of my depth. I spoke to Trevor using a soft unthreatening voice as to gain his confidence in me; however this was to no avail as he continued to be aggressive. I felt a complete failure and momentarily questioned my choice of career. I tried to place myself in his situation, looking at how I would feel. I looked at reasons other than his health problem which would make him lash out, I guessed it might have been he felt threatened by uniforms.
Davies, Laker, Ellis (1997) suggested during a research which looked at the affect of uniform wearing amongst mental health patients found that most instances with aggression amongst mental health patients where found when uniforms where evident amongst nurses. Davis et al (1997) further conclude that patients with mental health problems improve much better when placed in surroundings which echo a non-clinical setting, furthermore when non-clinical settings are put into practice and staff are allowed to wear mufti, a more relaxed atmosphere is conducted and the principles of promoting autonomy and independence is established in most cases.
Davis et al (1997) further ascertain that for holistic care to be encouraged then systems of care delivery which promote wide-ranging individualized assessment and multidisciplinary care planning should be a main objective and attempts to encourage patients to participate in decisions about their care; patterns of communication which avoid exerting power and control over patients and attempts to modify the environment to promote independence and minimize risk encouraged.
When analyzing Davis et al (1997) research findings it seems the issue is to place patients such as Trevor in situations that where familiar to him, with staff that looked individual not uniformed. Trevor was obviously frightened and disorientated; this was a completely different environment to him. Vital observations are not routinely taken on mental health wards.
Smith (1996) stated that; mental heal nursing was emphasized on the importance of effective communication and interaction skills, Smith (19960 further concluded that these point are the fundamental part of a mental health nurses role, one could argue however that having good communication and interaction skills is the elementary role of any nurse? Another patient who occupied the ward who I shall refer to as ‘Alfie’ had recently been diagnosed with Brain Metastasises.
I had seen a rapid change in his personality and it upset me greatly to see this once strong family man become a shadow of his former self. He would cry tears of pure frustration. He was a proud man, who has prior to his admittance onto the ward been fully independent. I felt such a feeling of empathy for this gentleman, especially as I had, had the opportunity to get to know the ‘real’ Alfie who was an intelligent and most likable character. I felt very pset at seeing his condition deteriorate and felt angry that life had dealt him such a bad card. I felt that nursing Alfie was more within my comfort zone and I understood the progression which would occur with his diagnosis, also I felt happy in knowing that I was contributing to him receiving the maximum care his condition would allow. However with Trevor I felt threatened and out of my depth mainly due to the aggression which came with Trevor’s illness.
It seemed that Trevor was reluctant to allow anybody into his frightened and tormented world; this made me feel very sad for Trevor. Later in the day after numerous challenging events concerning Trevor, a senior member of staff approached and told me to stay with Trevor because he was showing a signs of not only aggravation to patients, staff and visitors but the nurse was also concerned as his gait seemed unsteady; the concern for his and others safety was paramount.
Due to my earlier experience with Trevor I felt apprehensive of being too close to him, but I was also frightened of him hurting himself or other vulnerable patients in the bay. I also felt quite threatened about the position I was being placed in and felt my safety was being compromised. I knew I had to converse my fears to the senior nurse but felt quite frightened of approaching her, maybe like Trevor I felt belittled by her position on the ward? The power and knowledge she held made me feel quite inadequate.
Eventually after much deliberation I approached the nurse in question. I asked the nurse quietly if I could speak with her in private, as I felt I was being placed in an unfamiliar and challenging situation, which threatened not only my safety but the patients in the environment Trevor was occupying. The nurse ushered me to her office, once we had entered I expressed my concerns although I tried to keep my voice calm, but my voice kept breaking up. I explained that due to my inexperience I feared he might be a risk to the other patients on the ward.
The nurse seemed quite taken back that I had questioned her authority and suggested that I had a problem in nursing psychiatric patients. I explained I did not have a problem with nursing a patient with mental health problems but more a problem with not only my safety but the patients in the bay. I explained that although I fully understood Trevor’s condition was to blame for his aggressiveness, I did not feel safe and would prefer a more experienced member of staff to assess him.
I felt the adrenalin reach my stomach and the blood rush to my cheeks as I recalled an incident which occurred many years go in which I was viciously attacked. As I explained my past experiences to the nurse, for no unknown reason I started to cry and shake. Reflecting back to this situation I can only assume it was due to a genuine fear of the situation occurring again or due to the fact I was feeling inadequate in front of the senior nurse, for whatever reasons I certainly did not feel experienced enough to be placed in this situation.
Although I did feel a great deal of sympathy for Trevor and the inner torment he must be experiencing, I did not feel confident enough to nurse him to the standard he clearly needed. I felt I had acted in the correct manner by discussing my feelings in private and not in front of everybody else on the ward, however although I unquestionably acted in a professional manner; I felt very little and inadequate yet proud for being assertive. The NMC (2004) Guide for students of nursing and midwifery states that students should work within their level of understanding and competence (pp4).
The NMC (2004) further concludes that as students a conscientiousness in accepting responsibility for ones own actions should be practiced nevertheless the guidelines by the NMC (2004) further state that a student is not accountable; a right to decline clinical opportunities which the student feels unprepared for or unconfident in doing should always be adhered to. Furthermore matters which the student feels unconfident or unprepared in doing effectively should be discussed with a mentor as soon as possible, this giving the student opportunity to discuss the problems being experienced.
Violence is a feature which can occur in many ward areas for various different reasons however in 1999 the National Health Service (NHS) introduced a ‘Zero Tolerance Policy’ this being due to concerns about NHS workers being four times more at risk from attacks from patients and visitors. This current policy declares that if a patient/visitor is violent towards a NHS worker, then certain penalties will occur for example treatment may be withheld, however the policy does not apply to people with mental health problems or under the influence of alcohol or other toxic substances.
An attempt by Behr, Ruddock and Benn (2005) to challenge distinctions between users of mental health, and other services. It also aimed to propose an ethical underpinning to the implementation of this policy. The reality being any member of staff should not be placed in a position which is open to abuse or violence, and patients with a history of aggression or are a threat to others due to mental health problems should be placed in appropriate specialized wards. Care in the Community Act (1993) saw a massive shift in people with mental health problems being treated in the community rather than on specialized wards.
It is little wander that people like Trevor become agitated and aggressive, when they are placed in unfamiliar territory? They may become disorientated and frightened, this may make them lash out on those trying to help them, through no fault of their own. Although in nurse training during the common foundation program exposure to mental health is experienced and discussed at lengths, the realization is as human beings everybody is individual and it is impossible to predict outcomes within certain groups, more specialized professionals are needed to assess mentally ill patients so the best possible outcome can be achieved( Davis et al 1997).
The Department of Health (2007) proclaims that in the United Kingdom one out of six people are or will experience a mental health problem at one time or another during their lives. As a student nurse many experiences with mental health patients have been encountered, mainly with dementia, although at times this can be challenging as a student nurse no problems with communication have ever occurred mainly because the nursing of patients with dementia is a common feature on general medical wards.
Nurses become competent in nursing patients with familiar symptoms but the main feature with nursing patients such as Trevor is not the mental health problem nurses are presented with but the unpredictable behavior and lack of information available to general nurses. Evidence shown by research such as Davis et al’s (1997) demonstrates that patients such as Trevor need to be placed in an environment which not only had the correct level of staff but also the specialized knowledge to treat Trevor appropriately, this would have also been beneficial in making sure other patients where safe from harm.
A few days later as I walked onto the ward to commence my shift, I was presented with Trevor with his hands round the throat of a nurse. Although previously I would have been very frightened of being placed in this situation, I never felt in danger just that a person was being attacked and needed help. I understood I had to act fast. I spoke to Trevor in a reassuring voice and gently offered him my hand, continually offering reassurance, to my delight he took my hand and followed me to his bed.
I really felt I had turned a corner in relation to developing professionally and in confidence. My fear had subsided and I felt very proud that not only had I handled the delicate situation in a sensitive and professional manner but Trevor had allowed me into his world. When evaluating my experience I looked at what was good and what was bad about the situation. The good points I felt were I spoke out about my fears and limitations. Confrontation can be difficult especially when a student is on a short placement and really needs to be accepted as part of the team.
I did not want to appear as if I was lazy but I realized that by speaking out, did not make me a failure it made me more confident. A confidence, which I shall be able to reiterate, in similar future situations. The senior nurse was empathetic towards me and explained that nurses do at times get faced with challenging situations but the primary point in situations such as these is to maintain safety to ourselves and those around us. I also feel pleased that I managed to control a challenging situation with sensitivity and professionalism.
I feel the bad points which came out was I felt I looked totally inadequate and felt completely out of my depth, which is an alien emotion to me, I am normally very confident and enjoy a challenge. I did feel a little embarrassed about stating my fears to the senior nurse and more so in becoming tearful as I felt it made me appear weak but by opening up in this manner, a lot of emotions surfaced which I feel helped me deal with my past personal experience and enabled me to move on psychologically.
In conclusion when I look at what else could have been done, I really feel I did make the best choice. As a student nurse I worked within my limitations and when I felt challenged I expressed my concerns to a senior nurse, I feel if I had proceeded to sit with Trevor and not voiced my concerns and fears, I would have placed not only myself in a situation which was out of my depth but also put the other patients which were occupying the ward in danger.
The final part of Gibbs (1988) cycle of reflection is to make an action plan should this situation arise in the future. I feel that as I gain more experience of nursing a wider range of patients my confidence will grow. From experience the student nurse will gain confidence, if this situation which I am sure I will encounter many times in my career as a registered nurse was to occur again. I would look at what my limitations are and assess the situation more effectively. As a Staff nurse I have a duty of care (NMC 2004) 1. , pp4) to all patients in my care and also have the duty to act to identify and minimize risks to patients and clients within my care(clause 1. 2, pp 4) therefore it is imperative that everybody’s safety is maintained . If the situation was out of my limitations then apart from making the area safe and hazard free, I would enlist the help of a psychiatrist and specialized nurse who has been trained appropriately in the field of nursing people with mental health problems.
This would be adhering to clause 2. 4 of the NMC (2004) Code of Professional Conduct which claims “The nurse as a professional should promote the interests of patients and clients. This includes helping individuals and groups gain access to health and social care, information and support relevant to their needs” In conclusion my reflection skills have developed through the production of this assignment. Using a model of reflection has assisted me in structuring my thoughts and feelings appropriately.
My level of awareness concerning different groups of people and their individual needs, and its importance, has been enhanced with the use of critical reflection. My competence, within this; communication skills, assertiveness and furthermore confidence, has been further developed and I now feel that my personal and professional development is progressing. Using this reflective model has helped me to realise that my learning experience is something which I must be proactive in. Furthermore as a student nurse I have recognised that reflection is an important learning tool in practice.