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my interpersonal skills in order to maintain the therapeutic relationships with my patient. In this reflection, I am going to use Gibbs (1988) Reflective Cycle. This model is a recognised framework for my reflection. Gibbs (1988) consists of six stages to complete one cycle which is able to improve my nursing practice continuously and learning from the experience for better practice in the future. The cycle starts with a description of the situation, next is to analysis of the feelings, third is an evaluation of the experience, fourth stage is an analysis to make sense of the experience, fifth stage is a conclusion of what else could I have done and final stage is an action plan to prepare if the situation arose again (NHS, 2006). Baird and Winter (2005, p.156) give some reasons why reflection is require in the reflective practice. They state that a reflect is to generate the practice knowledge, assist an ability to adapt new situations, develop self-esteem and satisfaction as well as to value, develop and professionalizing practice. However, Siviter (2004, p.165) explain that reflection is about gaining self-confidence, identify when to improve, learning from own mistakes and behaviour, looking at other people perspectives, being self-aware and improving the future by learning the past.
In my context with the patient, it is important for me to improve the therapeutic relationship which is the nurse-patient relationship. In the therapeutic relationship, there is the therapeutic rapport establish from a sense of trust and a mutual understanding exists between a nurse and a patient that build in a special
link of the relationship (Harkreader and Hogan, 2004, p.243). (Peplau 1952, cited in Harkreader and Hogan 2004, p.245) note that a good contact in a therapeutic relationship builds trust as well as would raise the patient’s self-esteem which could lead to new personal growth for the patient. Besides, (Ruesch 1961, cited in Arnold and Boggs 2007, p.200) mention the purpose of the therapeutic communication is to improve the patient’s ability to function. So in order to establish a therapeutic nurse-patient interaction, a nurse must show up caring, sincerity, empathy and trustworthiness (Kathol, 2003, p.33). Those attitudes could be expressed by promoting the effective communication and relationships by the implementation of interpersonal skills. Johnson (2008) define the interpersonal skills is the total ability to communicate effectively with other people. Chitty and Black (2007, p.218) mention that communication is the exchange of information, thought and ideas via verbal and non-verbal which both present simultaneously. They explain that verbal communication is consists of all speech whereas non-verbal communication consists of gestures, postures, facial expressions, tone and level of volume. Thus, in my reflection in this assignment would be discussed on my development of therapeutic relationship in the circumstance of the nurse-patient relationship using the interpersonal skills. My reflection is about one patient whom I code her as Mrs. A, not a real name (Appendix I) to protect the confidentiality of patient’s information (NMC, 2004).
In this paragraph I would describe on the event takes place and describe that event during my clinical placement. I was on the female psychiatric ward
having a 2 weeks clinical placement for mental health care in semester 3. Generally, there were two separated psychiatric wards which were male psychiatric ward and female psychiatric ward but both wards were sharing the small cafeteria in the area of psychiatric ward. The psychiatric wards were locked up from one main entrance. In the ward, the female psychiatric patients were encouraged to walk out from the female ward and combine with the male psychiatric patients at the small cafeteria during their meal time. During lunch, I noticed one lady was still sitting on her bed. She was Mrs. A, 76 years old been diagnosed a schizophrenia. She was unable to control the muscle also called tremor due to lack of the chemical as she was having a side effect of anti psychotic medication which was a Parkinsonism (Sahelian, 2005). She could not walk herself and need to be assisted if she wanted to stand or walk. So I took the Mrs. A’s lunch meal and fed on the bed. This old lady was unable to feed on her own. So I checked her diet and served her meal. I fed her meal until finished.
In this paragraph, I would discuss on my feelings or thinking that took place in the event happened. Before I started to feed her, I introduced myself and approached Mrs. A. So I tried to build a good rapport with her as I do not want her to feel strange as I was not her family members or her relatives. My first approached was to her was to ask whether she wanted or refused to take her lunch. She was on soft diet as she was having a difficulty in swallowing or dysphagia. Then I asked her permission to feed her. She looked at me and looked like blur. In this situation, I showed up my emphatic listening as I put
myself in her shoes and assuming I was having a hearing problem. According to Wold (2004, p73) the emphatic listening is about the willingness to understand the other person not just judging the person’s fact. Then, I touched her shoulder, kept saying, and raise my tone a bit because I was afraid if she had a hearing trouble. At the same time, I did some body gesturers which could be interpreted an action of eating. I paused, repeated my actions but this time I was using some simple words in the patient dialect. Then she looked at me again and nodded her head. Fortunately the body gesturers also helped me in the conversation with her. In the meantime, I was thinking whether the first language was not her mother tongue but I kept myself communicate verbally with her including using my body gesturers and facial expression. Body gesturers and facial expressions are referred as a non-verbal communication (Funnell et al, 2005, p.443). In my thinking, I needed to speak louder and know more words in her language so that she could understand and interpret of my actions towards her. I thought of the language barrier that breaks our verbal communication. Castledine (2002, p.923) mention that the language barrier arises when there are individuals comes from a different social background use their own slang or phrases in the conversations. Luckily, those particular body gesturers could make her understand that I was going to feed her lunch. During the feeding I maintained the eye contact as I do not want her to feel shy. This is because; my eye contact could show up my interest to help her in feeding. This is supported by Caris-Verhallen et al (1999) which mentioned that the direct of eye contact could express a sense of interest in the person to the other person involves in that communication. In the
meantime I communicated with my best with her do that she felt comfortable. As a result, she gave a good cooperation and enjoyed the meal until finished.
In my evaluating, I feel I make the right decision to accompany and assist Mrs. A in feeding. Furthermore, I could develop my nurse-patient relationship. Although McCabe (2004, p.44) would describe it as a task-centred
communication as one of the element caused the lack communication among nurses, but I think my nurse-patient relationship communication both involved a good patient-centred communication and task-centred communication. In my personal opinion, I attended to Mrs. A as a patient to show my empathy because she was unable to feed herself. It was also as my duty to feed her so that I could make sure the patient get the best care in the ward. So my involvement in this nurse-patient relationship does not only restrict to the task-centred
communication because (Burnard 1990, and Stein-Parbury 1993, cited in McCabe 2002, p.44) define attending as a patient-centred process as wells as to fulfil the basic conditions as a nurse to provide the genuineness, warmth and empathy towards the patient. I was able to improve my non-verbal communication skills in my conversation with her during the feeding. As she was having a hearing problem and could not communicate in the first language properly, so the non-verbal communication plays a role. Caris-Verhallen et al (1999, p.809) state that the non-verbal communication becomes important when communicating with the elderly people who develop a hearing problem. Hollman et al (2005, p31) suggests some effective ways to maximize the communication
with hearing impairment people such as always gains the person’s attention before speaking, visible yourself to prevent them feel frighten and try to use some sensitive touch. I feel this is a good experience to me because I learn to develop my non-verbal communication. I used most of the body gesturers because of the language barrier was being a gap in my conversation with Mrs. A. She could speak very limited in the first language so I tried to speak in her dialect. Furthermore, Wold (2004, p.76) mention that gesturers are one specific type of non-verbal communication intended to express ideas and are useful for people who cannot use much words. However I also used my facial expressions to advise her to finish the meal. It might be not so delicious because she withdraws the meal after few scopes but I smiled and assured Mrs. A that it was good for her health to finish her meal. In addition, the facial expressions are most expressive which are not limited to certain cultural and age barriers (Wold, 2004, p.76). Therefore my facial expression worked out to encourage her to finish the meal. Although I could not explain detail to her about the important nutrition diet that she should take, but I could advocate her to finish the meal served because the meal was prepared according to her condition.
In order to analysis of the event, I could evaluate that, my communication skills are very important to provide the best nursing care to Mrs. A. My communication with Mrs. A was the interpersonal communication. This is because the interpersonal communication is a communication which involved of two persons (Funnell et al 2005, p.438). I realized that my nonverbal
communication did help me a lot in my duty to provide the nursing care to Mrs. A. Even though she could understand few simple words when I was asking her but I noticed that one of the problems occurs within the communication was the language barrier. As the patient was not using the official language and the second language, I tried to speak in her language. I still could manage the communication in our conversation. However, it was quite difficult to promote the effective verbal communication with the patient. Besides, White (2005, p.112) recommend that a nurse should learn a few words or phrases in the predominant second language to put a patient at ease for better understanding. Although it was quite difficult but using the nonverbal simultaneously with the verbal communication did encourage her to speak on her best to make me understand her words. In the event showed that, there was a response from Mrs. A. when I was asking her questions. Funnel et al (2005, p.438) point out that a communication would occur when a person responds to a message received and assigns meaning to it. She nodded her head to assign that she agreed with me. Delaune and Ladner (2002, p.191) explain that the channel is one of the component of the communication process which act as a medium during the message is sent out. In addition, Mrs. A also gave me a feedback that she understood my message by transmitting the message via her body gesturers and eye behaviour. Thus I could consider that the communication channels used in my conversation were visual and auditory. Delaune and Ladner (2002, p.191) state a feedback is that the sender receives the information after the receiver react to the message. However, Chitty and Black (2007, p.218) define feedback
is a response to a message. In my situation, I was a sender who conveyed the message receiving the information from Mrs. A, the receiver who agreed to take lunch and allow me to feed. Consequently, I could analyse that my communication with Mrs. A involved of five component of communication process which are sender, message, channel, receiver and feedback (Delaune and Ladner, 2002, p.191).
In a nutshell, for my reflection of this event explores about on how the communication skills play a role on the nurse-patient relationship in order to deliver the nursing care towards the patient especially the adult. She needed quite sometime to adapt the ability changes in her daily activities living where I was trying to help her in feeding. I was concerning my feeling and thoughts during the feeding so that I could improve more skills in my communication. I successfully communicated with her effectively as she enjoyed finishing the meal. So it is vital to build rapport with her to encourage her ability to speak up verbally and non-verbal. Moreover, this ability could help her to communicate effectively with other staff nurses. Later, she would not be neglected because of her age or her disability to understand the information given about her treatment. (Hyland and Donaldson 1989, cited in Harrison and Hart 2006 p.22) mention that communication express what the patients think and feel. In order to communicate with adult, it is important to assess her common communication language and her ability to interact in the other languages. As I used some words in her dialect, I essentially encouraged the patient to speak out verbally and communicate non-
verbal so that the message could be understood and do not break the nursepatient communication. In my opinion, I evaluated that it does not a matter whether it was a patient-centred communication or task-centred communication because both communication mentioned by McCabe (2004) actually does involves communication to the patients. So it was not a problem to argue which type of communication involves in my conversation with my patient. After analysed the situation, I could conclude that I was be able to know the skills for effective communication with the patient such as approach the patient, asking questions, be an active listening, show my empathy and support the patient emotions (Walsh, 2005, p.34). Actually helping the adult was a good practice in delivering the nursing care among adults.
My action plan for the clinical practice in the future, if there were patients that I need to help in feeding or other nursing procedure, I would prepare myself better to handle with the patients who would have some difficulty in communication. This is because, as one of the health care worker, I want the best care for my patients. So in related to deliver the best care to my patients, I need to understand them very well. I have to communicate effectively as this is important to know what they need most during warded under my supervision as a nurse. According to my experience, I knew that communication was the fundamental part to develop a good relationship. Wood (2006, p.13) express that a communication is the key foundation of relationship. Therefore a good communication is essential to get know the patient’s individual health status
(Walsh, 2005, p.30). Active listening could distinguish the existence of barrier communication when interactions with the patients. This is because, active listening means listening without making judgement to listen the patients’ opinions or complaints which give me chances to be in the patients’ perspective (Arnold, 2007, p.201). On the other hand, it also crucial to avoid the barriers occurs in the communication with the patients. I could detect the language barriers by interviewing the patients about their health or asking them if they needed any help in their daily activities living. However, I would remind myself for not interfere my communication with barriers such as using the open-ended questions, not attending to non-verbal cues, being criticising and judging, and interrupting (Funnell et al, 2005, p.453). Walsh (2005, p.31) too summary that making stereotyping and making assumptions about patients, perceptions and first impression of patients, lack awareness of communication skills are the main barriers to communications. I must not judge the patients by making my first impression and assumption about the patients but I have to make patients feel devalued as an individual. I should be capable to respect their fundamental values, beliefs, culture, and individual means of communication (Heath, 2000, p.27). I would be able to know on how to build rapport with the patients. There are eleven ways suggest by Crellin (1998, p.49) which are becomes visible, anticipate needs, be reliable, listening, stay in control, self-disclosure, care for each patient as an individual, use humour when appropriate, educate the patient, give the patient some control, and use gestures to show some supports. This ways could help and give me some guidelines to improve my communication
skills with the patients. Another important thing to add on my action plan list is to know which the disabilities of the patients have such as hearing disability, visual impairment and mental disability. Once I could know the disability that a patient has, I could well-prepared my method of communication effectively as Heath (2000, p28) mention that communicating with people who was having some hearing impairment, sight impairment and mental health needs required the particular skills and considerations. Nazarko (2004, p.9) suggest that do not repeat if the person could not understand but try to rephrase and speak a little more slowly when communicating with the hearing difficulties people. Hearing problem commonly occurs among adults because of ageing process (Schofield, 2002, p.21). To summarize for my action plan, I would start a communication with a good rapport to know what affects the patients’ ability to communicate well and to avoid barriers in effective communication in future.
In conclusion of my reflective assignment, I mention the model that I chose, Gibbs (1988) Reflective Cycle as my framework of my reflective. I state the reasons why I am choosing the model as well as some discussion on the important of doing reflection in nursing practice. I am able to discuss every stage in the Gibbs (1988) Reflective Cycle about my ability to develop my therapeutic relationship by using my interpersonal skills with one patient for this reflection.
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APPENDIX I The consent form is attached in the hard copy.
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