This essay will allow me to critically reflect on an episode of care that occurred during my placement. Hannigan defines reflection as a way of being thoughtful, innovative, and critical of our own practice when it comes to nurses and student nurses reflecting on their practice (Hannigan, 2008). Reflection is about being self-aware and critically evaluating our response to situations during practice (Finlay, 2008). Especially for student nurses as they develop their skills and knowledge during placement. Reflecting on episodes of care allows students and qualified nurses to have the opportunity to reflect on their work and gain new knowledge about different situations (Balla et al., 2009). To critically and thoroughly reflect on the episode of care that I have chosen I will use the Gibbs (1988) model of reflection. This has 6 stages of reflection, allowing me to analyze and evaluate the event thoroughly in each stage and allowing me to break down each stage easily (Balla et al., 2009). I chose this model compared to Schon`s reflection framework (1983) as Schon noted that there were only two components to the reflective practice; reflection in action and reflection on the action which does not allow me to thoroughly evaluate and be critical of the situation as well as it not allowing for thoughts and feelings to be reflected on (Greenwood, 1993). Gibbs' model will allow me to have an insight into what my strengths and weaknesses are allowing me to develop my skills and knowledge if a similar situation occurs. To keep to the NMC code of conduct I will be maintaining the dignity and confidentiality of the patient by using the pseudonym Mr. Hill to protect his personal information as well as not naming the trust or ward to maintain their confidentiality also (Nursing and Midwifery Council, 2018).
Whilst on my second placement during my first year in a mental health hospital in a men`s acute inpatient ward, I was dispensing and administering medication under the supervision of the nurse in charge. To continue developing and practicing my clinical skills I had to administer medication to Mr. Hill, a 35-year-old patient with avoidant personality disorder, dependent personality disorder, and depression and who was under assessment for paranoid schizophrenia. Mr. Hill who was sectioned under section 2 of the mental health act was in seclusion at the time of needing his medication due to a previous incident of self-harm, suicidal ideation, and aggressive behavior. When going to give him his medication I was told to place the medication tot on his desk so that he could get it himself. He refused to take his medication saying he would not cooperate with staff till he had spoken to his doctor about being discharged. I attempted to explain to Mr. Hill that it was important to take his medication as it included metformin which was important to take due to his diabetes. This was due to it being my duty of care to inform him of why the medication would benefit his health as the NMC code of conduct states that a nursing professional must balance the need of acting in the patient's best interests whilst respecting their right to refuse medication (Nursing and Midwifery Council, 2018). Mr. Hill still refused to take his medication and threw the medication at me whilst becoming aggressive and shouting, `you`re trying to poison me with that blue pill. This blue pill he was referring to was the 1mg of lorazepam that he was prescribed. Both I and the nurse in charge left the room and went back an hour later to try to attempt to get him to take his medication again. This time he was allowed to come into the clinic to allow him to witness me dispensing his medication straight from the packet so that he could see what the medication was. Mr. Hill accepted his medication this time stating that he was sorry for how he behaved previously. The nurse in charge debriefed me after the situation giving me their opinion on the incident as well as advising me not to take what Mr. Hill said when he was angry personally.
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After reading the patient information and background of Mr. Hill and reading about his potential risks, it made me aware that due to his diagnosis he may exhibit different behaviors in different situations meaning that his behavior can potentially become unpredictable. Due to this awareness, I wasn`t worried about administering the medication to Mr. Hill, especially as I had built a good therapeutic relationship with him before this incident occurred. Having a good therapeutic relationship with patients, especially in mental health nursing is the cornerstone to helping patients to improve (BROWNE, CASHIN, and GRAHAM, 2012). I felt pleased when Mr. Hill accepted to take his medication, as even though I was a student nurse I had been able to build rapport and trust with Mr. Hill that he wanted to accept his medication as well as being pleased that the plan to show him the medication being administered worked to gain his trust back in staff. However, during the incident, I felt intimidated when Mr. Hill was throwing his medication and shouting as I believed I had done something wrong. In addition to this, I also felt disappointed that Mr. Hill had suddenly begun to distrust the staff that was working with him and felt like the NHS had failed him due to his feeling this. This temporarily knocked my confidence in handling difficult patient situations as I was not prepared for this situation due to my lack of experience in handling these situations. However, after the nurse in charge debriefed me on the situation, I realized that it was not my fault that Mr. Hill was feeling this way and that it was due to his unpredictable behavior that caused his mental health condition.
The positive that came from this incident that occurred was that I was able to apply the communication skills that I had developed from clinical skills and experience effectively in a situation when dealing with a difficult patient, especially within a mental health setting. This improved my confidence as I know I can communicate with patients in a variety of scenarios. This incident also allowed me to identify how committed I am to helping the patients as I experienced how much of a difference I could make to a patient. I stayed calm and professional throughout the incident as I respected the patient`s choice to refuse their medication as well as balanced the patient's best interests. This means that I can identify the codes a nursing professional has to follow in practice (Nursing and Midwifery Council, 2018). I was also able to use and develop my practical skills of dispensing and administering controlled drugs to patients alongside their normal medication whilst under the direct supervision of the nurse in charge in addition to demonstrating and developing my pharmaceutical knowledge around controlled drugs and their usage. This improved my confidence in my knowledge and skills significantly when I was being praised by the nurse in charge for what I knew and how dedicated I was to develop my nursing knowledge and skills.
The aspects of this situation that I need to improve on are that I was unsuccessful in administering the patient`s medication to them at the first attempt due to his beliefs about the staff and his medication. This made me aware that I need to be prepared for what the possible reactions of patients may be in different situations so that I know what the best route is to go down to help these patients. Due to my lack of experience and knowledge as I am a student nurse, I was thinking more about what was in the patient's best interests, which in this situation I thought was getting him to take his medication, rather than acknowledging what the patient wanted and how I could have eased their frustration at the time of the incident. Due to the debrief from the nurse in charge and wider reading I understood that I must look holistically and critically at the outcome of what action I am about to undertake so that I am aware of what the consequences may be (Daly, 1998). I am now aware that I must also be cautious especially in an inpatient mental health ward as a patient may exhibit unpredictable behavior or even aggressive behavior due to their symptoms.
Patients who had been diagnosed with personality disorders are seen to experience interpersonal difficulties and poor self-concept. This means that these patients may feel distant from their feelings and may experience distress when they identify that they are experiencing a strong emotion (Gordon-King, Schweitzer, and Dimaggio, 2018) which is why Mr. Hill may have reacted to us in the way he did due to the string emotions he had been feeling whilst being in seclusion. Those who were diagnosed with depression exhibit psychological symptoms such as irritability, suicidal ideation, and self-harming which were the reasons why he was in seclusion to start with (NHS Choices, 2021). Mr. Hill could potentially have been experiencing a severe depressive episode at the time which can lead to paranoid delusions such as believing that we were trying to poison him with his medication (Mind.org.uk, 2019). This is likely as he had a history of experiencing severe depressive episodes during past hospitalizations. The NHS also recognizes that those who are diagnosed with paranoid schizophrenia experience paranoid delusions where they may feel that they are being harassed or prosecuted by those around them as well as recognizing that a patient`s behavior may be disorganized and unpredictable (NHS Choices, 2021), which links to why Mr. Hill`s behavior changed so suddenly from what I had seen before. As Mr. Hill`s behavior is unpredictable when not being treated it is important for him to adhere to his treatment plan which combines the use of medication and therapeutical treatments such as cognitive behavioral therapy. It is important for patients to adhere to their treatment plan as it proves to have positive outcomes for those with serious mental health conditions. Through research, it was found that adherence to medication among mental health patients was at 50-60% which is low as nonadherence leads to a higher chance of relapse as well as a higher chance of readmission to the hospital (Angell, 2006). If as nursing professionals we do not encourage and empower medication adherence among patients through shared decision-making strategies within the multi-disciplinary team as non-adherence can lead to a poor quality of life for the patient (Issues in Mental Health Nursing, 2016).
It`s a nurse`s role and responsibility to apply their knowledge and skills from their experience and academic work to help treat every patient that they come across in their career. Balancing a patient`s best interest and a patient`s personal choice is a skill that is required by nurses which includes respecting the patient`s choice to refuse to take their medication as Mr. Hill did (Nursing and Midwifery Council, 2018). Being on a mental health ward, a nurse's most important function is to have interpersonal interactions with patients. This enables a nurse to enhance a patient's personal development, autonomy, and psychological growth by forming therapeutic relationships with patients (RUNGAPADIACHY, MADILL, and GOUGH, 2004). In addition, it is now believed that caring for mental health nurses in the 21st century should include emotional intelligence and resilience as this can assist mental health patients to recognize negative experiences and start to look at these experiences with positive outcomes (Warelow and Edward, 2007). This means that a patient will be able to improve their condition in a positive environment as well as allow the nursing professionals to work in the same positive environment. These nursing responsibilities and attitudes will help Mr. Hill whilst he is in the hospital and after discharge as he will be able to understand what the necessary steps are to help himself get better and improve his symptoms so that he is able to live in the community with a good quality of life.
Being a student nurse, it is important that I develop my learning through experience on placement as well as in theory as there`s a high possibility that I may come across a situation like this again and so many other student nurses. Student nurses must be able to make judgments professionally about their practice theoretically. This shows that learning through experience will help student nurses to develop their knowledge and skills to make them ready to be qualified nurses as it allows nurses to understand that they to achieve a solution to a problem which is a major part of the cognitive theory of learning (Callery, 1990). In Mr. Hill`s case, this would be identifying and achieving a solution to getting him to take his medication. In order to improve on an existing skill a student nurse must deliberately practice their skills in different situations which is important within the cognitive theory of learning. The cognitive learning theory of learning is an internal process (Aliakbari et al., 2015) which is important as it allows the student to predict what the best solution would be to help the patient in different situations.
In conclusion, this episode of care has taught me that balancing a patient`s best interests and their health is hard when it comes to a mental health patient as there are different situations that need to be considered when it comes to a patient`s treatment plan and interactions with professionals. I now know that it is best to listen to what the patient wants and needs before taking any action as difficult situations may be able to be prevented by just listening to a patient. It may have been more suitable to ask the nurse in charge for advice on the situation immediately after Mr. Hill refused to accept his medication rather than telling him the benefits of taking his medication due to my lack of experience in this field of nursing as well as me not knowing the patient as well as the staff that were on the ward. I am aware that I was not prepared for handling the different and unpredictable reactions of patients with a range of mental health conditions before this episode of care. It would have been better to read through every patient's notes thoroughly before helping to attend to them medically as well as trying to build a strong therapeutic relationship with every patient beforehand as well.
If a similar situation was to arise again during my placement or nursing career, I would examine the situation thoroughly thinking about patient risks and history, and then think about what the appropriate action to take would be as well as ask for advice from superiors and more experienced staff about what they suggest that I do. Therefore, I will increase my knowledge and skills by doing wider reading about mental health conditions and how these patients may act in different situations.
Personal development plan
Personal development plans help to stimulate growth, performance and learning within the clinical practice (Employee motivation for personal development plan effectiveness | Emerald Insight, 2013). A personal development plan is essential for learning development within a professional environment as it encourages us to consistently develop our knowledge and skills through set goals. Using a personal development plan as a nurse is essential as it`s a systematic way to identify what your personal development needs are as well as being an encouragement for learning throughout your career as a healthcare professional and encouraging further development (Personal development planning, 2015). Using the SMART acronym, I will identify a set of goals and learning needs that were not fully met within my first year which was not achieved due to various circumstances that acted as a barrier to my learning during my year 1 placement. These goals and learning needs that I have identified are;
- Increase my knowledge of the types of mental health conditions
- Increase my pharmaceutical knowledge of common mental health medication
- Increase my knowledge of the major side effects of antipsychotics
- learn the process of admission and discharge in mental health hospitals
- develop my skills in care planning for different patients and their needs
- improve my confidence in communicating how a patient has been during multi-disciplinary team meetings
These goals and learning needs will be met by the end of the second year as it will allow me to follow my development plan with enough time to fully achieve these through further experience on placement as well as through the development of my knowledge within the theory. From these identified learning needs, I will be mainly focussing on learning the process when admitting patients onto a ward as well as the process for when patients are being discharged by producing a plan on how I will meet this learning need by the end of the second year. This was my chosen learning need as I did not get much exposure or experience with admitting and discharging patients due to my lack of confidence in communicating with new patients as well as not having enough experience in the workings of the steps that need to be taken when both admitting and discharging patients. I intend to develop my knowledge around the process of admission from a nurse's point of view such as what information is required to get from the patient when they are first admitted, if any physical observations need to be completed and how what level of therapeutic observations they require is decided. I will also develop my understanding of what actions need to be taken when discharging a patient such as how well their medication adherence be monitored if any information is needed before they leave and how it is determined where they are allowed to be discharged such as supported living or a parent`s house.
To show evidence that I have achieved this learning need from my personal development plan, I will record this learning need within my PAD document so that when I go to placement my mentor is aware that this is something that I would like to achieve as well as ensuring that staff members log comments within the document about how I performed these tasks with what my strengths are and what I need to improve on during admission and discharge. If I am unclear as to why a step within admission or discharge is being undertaken, I will ask the staff member that I am working with to explain this to me so that I have a deeper understanding of why there are certain steps that need to be completed during admission and discharge. I will also reflect on my experiences when learning about these processes so that I can learn from my own experiences. I can only log these experiences in my pad documents due to confidentiality surrounding the patients and staff that I am working with (Nursing and Midwifery Council, 2018).
To demonstrate that I have achieved this goal I will ask my placement supervisor if I can complete an admission or discharge under their supervision and once this has been completed ask to complete one independently and ask my supervisor to double-check my work during each step of the process as well as communicating with the multi-disciplinary team managing the care of the patient to gain more information about the patient that I am admitting or discharging. I aim to have achieved this learning need by the end of my last placement in the second year as this goal will require continuous practice within all my placements meaning that this time frame is the most suitable to achieve this goal.
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