REFLECTION ON CLINICAL SKILL

Introduction

The reflection in clinical practise is important because it acts as an essential tool which can be used to recognise strength and weakness regarding certain clinical skills. Thus, reflection in clinical practice allows to develop own skill through self-directed learning and enhanced motivate along with improve care quality to be delivered by the individual. In this essay, the reflection regarding person-centred skill in mental health practise is to be discussed. For this purpose, the Gibb’s reflective cycle is to be used as the reflective model.

Reflection on Clinical Skill

In the placement, while caring for a patient suffering from schizophrenia, the person-centred care skill is used and reflection in context to the care to be presented. In reflecting on the skill in the practice, Gibb's reflective model is chosen to be used. This is because the model allows easier and systematic analysis of personal actions in specific incident to be identified for determining strength and weakness of the skill in the practice (Pringle, 2017). Moreover, the model allows to create learning through reflection over time and provides opportunity to make balanced as well as accurate judgement about the aspect of certain skill to be improved (Okamoto et al., 2017). There are six stages of Gibb’s reflective cycle which are as follows:

Description

In the placement, I was a mental health nurse who was allocated to care for an individual named Mr Z who is of 70-years-old and required immediate hospitalisation. This is because the person expressed increased hallucinations and disoriented thoughts out of schizophrenia which has been diagnosed 3 years ago that is interfering with his everyday life and activities even after care is been provided. Mr Z was admitted to the hospital by his neighbour as he was living alone with his son staying abroad for work. In the process, I implemented person-centred care skill to support and care for Mr Z’s condition. Thus, I initially determined the signs and level of cognitive distress, cognitive health, emotional condition and behaviour expressed by the patient with the help of a psychiatrist. In this process, the psychiatrist used Positive and Negative Syndrome Scale (PANSS) for measuring the cognitive and mental health symptoms of Mr Z. The PANSS is the medical scale which is used for identifying and measuring the positive as well as negative symptoms of the schizophrenia patient to determine their severity with the mental disorder. The PANSSS is rated on a 7 point scale which mentions absence of symptoms equal to point 1 (Harvey et al., 2017). Mr Z scored 6 points at the PANSS assessment which indicated that the schizophrenic condition is serious.

As a mental nurse, on reviewing the report provided by the psychiatrist it was seen that Mr Z is experiencing anxiety, difficulty in thought, disoriented speech, reduced social drive and lack of social interest as negative symptoms of schizophrenia whereas the positive symptoms expressed are hallucination in everyday life. In order to deliver person-centred care to Mr Z in this aspect, I used the Roper-Logan-Tierney model of care. This is because the model allows determining key activities of daily living (ADLs) of the individuals to be focused to determine the aspects to provide the patient holistic support for their health (Sargent, 2019). During the person-centred holistic care, the dignity and respect of the patient was tried to be upheld by me. This is evident as I always tried executing care based on Mr Z’ personal needs and demands along with valued his opinion regarding care interventions. In case of Mr Z, as mental health to execute person-centred care I assessed all the ADLs mentioned in the care model. The assessment of breathing efficiency in schizophrenic patient is required because the schizophrenic patients experience shortness of breath out of fear of inappropriate incidence during hallucinations (Sweeney et al., 2020).

On analysing breathing efficiency of Mr Z, it was seen that he executed 15 breaths per minute in resting state. The normal breathing in resting state of an adult is 12-16 breath per minute (Qadir and Asif, 2019). It indicates that Mr Z has no trouble with breathing efficiency. The hygiene environment management in case of Mr Z was found to be poor as it was informed that his house was quite dirty and untidy when he was last admitted to the hospital. The lack of hygiene occurs among schizophrenic patients out of their lack of awareness with reality and motivation in living life (Yang et al., 2018). The schizophrenia leads people to face difficulty in maintaining a continuous concentration for explaining train of thought which eventually leads them to express information in disoriented speech (Wu et al., 2017). In case of Mr Z, it is found that he expressed information in disoriented that was hard to be understood by me. Thus, he expressed inability to communicate properly. However, in this condition, I tried to communicate with him in short sentences and tried to ask objective answers for the questions asked by me. This led me resolve the communication issue to some extent but took additional person-centred care intervention to resolve the issue for Mr Z. On communication, I understood that Mr Z has not effectively continued his prescribed medication for schizophrenia as he was alone that resulted in relapse of the health issue.

The schizophrenic individuals out of delusional thoughts regarding food activities are often seen to be develop eating and drinking disorder (Aguiar-Bloemer et al., 2018). In case of Mr Z, on analysis of his personal health it is seen that he express eating disorder and often avoid eating meals due to which his body weight has been abruptly reduced to 40kg and his BMI rate represented to be 17 which indicates he is underweight. However, Mr Z expresses no issues with elimination and performs the activities on his own without expressing any need of assistance. Mr Z expresses issues with washing and dressing which was evident as when he was admitted in the hospital his clothes were dirty and did not fitted him properly. He expressed no issue with mobilisation but avoid interacting with others in the hospital along with show hindrance to take his own medication at time. He expresses no desire to die and his sexual expression is normal. However, Mr Z reports of insomnia as sleeping disorder because he always fears and doubts things in the surrounding out of delusion thoughts. On the basis of the holistic health assessment of Mr Z, the person-centred care actions is been implemented.

In order to maintain hygienic environment for Mr Z, as mental health I ensured all his surrounding at the hospital remains clean. Moreover, I teamed with the social care services for Mr Z so that after release from the hospital they can assist him in managing hygienic environment at home along with support in eating and drinking and washing and dressing which is reported to be key needs at the present due to schizophrenia. In the hospital, I personally took care for maintaining hygienic environment for him and took the responsibility to feed him along with administer him the medication in timely manner. At the hospital, while supporting him to eat it is seen that he would often express fear regarding certain foods and avoid eating. I was unable during the entire care tenure for Mr Z to make him eat adequate amount of food due to which no progress in his body weight or BMI rate was seen. In order to resolve communication issue such as disoriented speech faced by Mr Z, I included him to undertake speech and language therapy which was effective to some extent in enhancing his speech and communication ability.

In order to resolve Mr Z's washing and dressing needs, I personally took responsibility to meet the need but he would avoid getting dressed with my help in the entire span of care. This led him to remain at time inappropriately dressed in the hospital and I would often lose patience along with make him dress properly with force at times. In order to resolve his issue with working and social engagement out of schizophrenia, I involved him in the Cognitive Behaviour Therapy (CBT) with the help of a psychiatrist. This is because it would help to resolve behavioural disorder and cognitive difficulties faced due to schizophrenia by Mr Z which would eventually help him to get socialised and work with zeal. In addition, anti-psychotic medication provided to Mr Z such as olanzapine and quetiapine to manage his hallucination that is interfering with his social life by following NICE guidelines (NICE, 2014). In order to manage insomnia in Mr Z, as a mental nurse under the prescription of the physician, I administered him prescribed dose of melatonin along with the antipsychotic medication to maintain his hallucination along with sleeping disorder. At the end of the care, it was seen that Mr Z’s eating disorder and issues with dressing and managing everyday chores at homes remained unresolved. Thus, in this aspect, I communicated with the social care services so that they can provide extended care in this aspect to resolve the issues after discharge of Mr Z from the hospital.

Feelings

At the initiation of the person-centred care process for Mr Z, I feel that I effectively followed the ethical value of maintaining privacy and confidentiality for the individual according to NMC Code of Conduct (2018). This is evident as anonymity for the patient was maintained by not revealing his name. I also feel that effective dignity and respect towards Mr Z was maintained before the initiation of his care which is evident as since his hospitalisation he was managed polite and compassionate manner by me. However, I feel that I was unable to maintain effective politeness towards Mr Z during the care which is evident as I report to get frustrated by not complying with me in eating and dressing as executed by me. This may have hindered his dignity and respect to some extent during the care. I feel that my lack of patience and increased workload could have been reason behind such behaviour I need to resolve it. During caring for Mr Z to meet his disoriented speech issue, I think I implemented effective person-centred approach as I arranged one-to-one speech and language therapy session for him to specifically resolve his communication issues raised due to schizophrenic condition.

During the care, I feel that I represented ineffective person-centred care skill for Mr Z in managing his washing and dressing activities. This is because I was unable to specifically modify the care action for gaining compliance of Mr Z in allowing me to properly dress and wash him. Moreover, I also feel that I was unable to make effective person-centred care decision regarding Mr Z to resolve his eating disorder due to which his body weight remained low. However, I feel that I took effective person-centred care decision for Mr Z in helping him to cope with insomnia and inappropriate sleeping pattern. This is because I took actions to specifically determine medication to resolve his sleeping pattern issue along with ensured his anti-psychotic medication are continued to help him cope with hallucination. After the completion of care for Mr Z, the referral towards the social care services was an effective person-centred approach because it led me to arrange specific care to meet his everyday living needs after discharge from the hospital such as washing and dressing along with eating.

Evaluation

On evaluation of my action as mental health nurse, it is seen that the good thing happened is that I have effective ethical skill regarding the way confidentiality of patient is to be maintained as in all cases I marinated anonymity of the patient due which the individual's real identity can be determined in any condition. The Data Protection Act 1998 mentions that no details of the patient are to revealed without their permission and privacy of their identity is to be maintained (legislation.gov.uk, 1998). Thus, I was able to follow the Act and executed my responsibility with competence by ensuring confidentiality of the patient is maintained. During the care, the other good thing happened is that I effectively represented my competence in presenting person-centred care skill for assessing care needs of Mr Z. According to NMC, the initial procedure of person-centred care is assessing mental and physical health and well-being of the individual (NMC, 2018a). In this respect, I used Roper-Logan-Tierney care model in making holistic physical health assessment and determining physical needs of Mr Z. Moreover, I referred Mr Z to psychiatrist who used PANSS to assess his mental and cognitive health and well-being needs.

During the care, one of the bad things happened is that I represented hindered person-centred care skill to plan, provision and manage person-specific care support for Mr Z. This is because NMC mentions that effective dignity and comfort of the patient is to be maintained for successful- person-centred care (NMC, 2018a). However, I failed to maintain effective comfort and dignity of Mr Z while caring for him in regard to eating disorder and while supporting him to wash and dress. The NMC mentions that appropriate actions are to be taken to minimise discomfort or pain of the patient as a part of planning person-centred care (NMC, 2018a). However, I failed to mitigate the discomfort of Mr Z regarding eating habit and dressing that result me to fail in delivering effective person-centred care to him in these aspects. The NMC mentions that dignity and privacy of the patient are to be maintained at all times during care (NMC, 2018a). This is because it makes the patient feel valued and care, in turn, shows competence to avail care (Robison et al., 2017). However, I also failed in this aspect; as my forced act of dressing Mr Z instead of his wish may have made him feel less dignified and valued.

The NMC mentions that personal capacity or independency to make care decision by the patient is to be focused on delivering person-centred care (NMC, 2018a). However, I failed to make any judgement regarding self-efficacy or independency of care to be made by Mr Z which represent that my person-centred care skills to plan care for patient is a bad aspect in the experience. The partnership or multi-professional working is important in delivering integrated person-centred care to the patient. This is because coordination and consultation between different professionals can be made to determine most effective care to be delivered based on the specific health condition and symptoms of the patient (Goulding et al., 2018). In caring for Mr Z, it is seen that I involved in working together with psychiatrist and speech therapist to delivery CBT and speech and language therapy to the patient. This indicates I was able to perform person-centred care by working together with other professional in delivering quality care to Mr Z which was a good thing in the care context and my professional performance.

The NMC Code of Conduct mentions that to maintain professionalism the nurses are to display effective personal commitment in care and maintain integrity in care (NMC, 2018a). In order to maintain integrity, the nurses are to follow each aspect of professionalism even under strict condition to care for patients (NMC, 2018). In the person-centred care for Mr Z, I maintained effective integrity in care as I show commitment and honesty to arrange medication for the patient under all condition to resolve his sleeping disorder without any side-effect. The NMC mentions that effective person-centred care can be delivered if the nurses follow directed procedural competency in medication administration to the patient. In order to accomplish it, the nurses are to assess the personal efficiency of the patients to take medication and accordingly arrange medication administration (NMC, 2018a). In case of Mr Z, it is seen that I personally assessed his ability to take medication and after determining that he was incompetent to take medication on his own I personally intervened to administer him medication orally. Thus, the medication deliver in persona-centred care for Mr Z was a good approach. However, I think that after completion of the care the involvement with social carers to provide support to Mr Z at home was a good approach. This is because it would lead the patient to avail continued care for executing everyday life activities without hindrance after release from the hospital.

Analysis

In the person-centred care for Mr Z, the care aspect of managing his cognitive and behavioural health complication has gone well. This is because I used Cognitive Behaviour Therapy (CBT) which is regarded as a best practise to promote emotional, cognitive and behavioural aspect of the patient was used. The CBT was best practise in managing hallucination and promotion of socialisation of individuals in schizophrenia because it is one-to-one therapy in which the therapists educates patients regarding the way they are to control disrupted thoughts and emotions and differentiate between imagination and reality to develop stable emotion and normal behaviour (Morrison et al., 2018). The aspect of managing mental health of Mr Z has gone well in the person-centred care because I was able to administer effective anti-psychotic medication to the patient in controlling his hallucination or delusional thoughts. This is evident as I administered him Olanzapine that acts to block different neurotransmitter in the brain to avoid the brain influence the individual to develop delusional thoughts as seen in schizophrenia (Larsen et al., 2017).

The person-centred care action for managing sleeping action and maintaining hygiene also went well because effective use of medication and personal commitment to care is implemented. However, the person-centred care to resolve eating disorder and enhance body weight of the patient was unable to be achieved. This is because of lack of trust of the patient towards me along with my failure to show effective compassion and politeness in feeding the patient appropriately. Moreover, the other bad thing happened is that I failed to provide improved person-centred care to Mr Z to support him to wash and dress properly. This may have occurred because the patient failed to trust me due to my impatient attitude along with my failure to provide effective privacy to the patient while changing his clothes. The referral of Mr Z after completion of care to be further supported by social carer in executing everyday action went well. This is because I had effective ability to make multi-agency connection in providing person-centred care to patients.

Conclusion

The reflection on the personal experience as a mental health nurse mentions that I have effective ability to maintain confidentiality of the patient. Moreover, I have effective person-centred care skill to assess mental and physical needs of patient along with provide them safe care. I have person-centred care skill to meet emotional and psychological need of schizophrenic patient along with effectively manage them to support their sleep pattern. However, I lack patience in delivering person-centred care to Mr Z while managing his eating disorder. Moreover, I lack person-centred skill in meeting washing and dressing needs of Mr Z during his care for schizophrenia.

Action Plan

In future, while playing the role of mental health nurse to provide person-centred care support to schizophrenia patient I would try to increase my patience and improve my commitment to care. It is to be executed by analysing the working actions of other experienced nurses to develop the techniques used by them to enhance my patience in levering care. I would improve my ability to maintain privacy during dressing and washing of schizophrenia patients in hospital by using separators to block the area where the patient’s dresses are to be changed. Moreover, I will develop compassionate communication with schizophrenia patients and avoid any forced attitude to make them comply with me in each aspect of care so that I could represent better personal-centred care skill toward them.

Continue your journey with our comprehensive guide to Redefining Healthcare Dynamics.

References

Aguiar-Bloemer, A.C., Agliussi, R.G., Pinho, T.M.P., Furtado, E.F. and Diez-Garcia, R.W., 2018. Eating behavior of schizophrenic patients. Revista de Nutrição, 31(1), pp.13-24.

Goulding, A., Allerby, K., Ali, L., Gremyr, A. and Waern, M., 2018. Study protocol design and evaluation of a hospital-based multi-professional educational intervention: Person-Centred Psychosis Care (PCPC). BMC psychiatry, 18(1), pp.1-8.

Harvey, P.D., Khan, A. and Keefe, R.S., 2017. Using the positive and negative syndrome scale (PANSS) to define different domains of negative symptoms: prediction of everyday functioning by impairments in emotional expression and emotional experience. Innovations in clinical neuroscience, 14(11-12), p.18.

Larsen, J.R., Vedtofte, L., Jakobsen, M.S., Jespersen, H.R., Jakobsen, M.I., Svensson, C.K., Koyuncu, K., Schjerning, O., Oturai, P.S., Kjaer, A. and Nielsen, J., 2017. Effect of liraglutide treatment on prediabetes and overweight or obesity in clozapine-or olanzapine-treated patients with schizophrenia spectrum disorder: a randomized clinical trial. JAMA psychiatry, 74(7), pp.719-728.

legislation.gov.uk 1998, Data Protection Act 1998, Available at: https://www.legislation.gov.uk/ukpga/1998/29/contents [Accessed on: 10 October 2020]

Morrison, A.P., Pyle, M., Gumley, A., Schwannauer, M., Turkington, D., MacLennan, G., Norrie, J., Hudson, J., Bowe, S.E., French, P. and Byrne, R., 2018. Cognitive behavioural therapy in clozapine-resistant schizophrenia (FOCUS): an assessor-blinded, randomised controlled trial. The Lancet Psychiatry, 5(8), pp.633-643.

NICE 2014, Psychosis and schizophrenia in adults: prevention and management, Available at: https://www.nice.org.uk/guidance/cg178 [Accessed on: 10 October 2020]

NMC 2018, Professional standards of practice and behaviour for nurses, midwives and nursing associates, Available at: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf [Accessed on: 10 October 2020]

NMC 2018a, Future nurse: Standards of proficiency for registered nurses, Available at: https://www.nmc.org.uk/globalassets/sitedocuments/education-standards/future-nurse-proficiencies.pdf [Accessed on: 10 October 2020]

Okamoto, R., Koide, K., Maura, Y. and Tanaka, M., 2017. Realities of Reflective Practice Skill among Public Health Nurses in Japan and Related Learning and Lifestyle Factors. Open Journal of Nursing, 7(5), pp.513-523.

Pringle, S.A., 2017. The challenges of upskilling health care assistants in community nursing. British Journal of Community Nursing, 22(6), pp.284-288.

Qadir, M.I. and Asif, M., 2019. A correlation exists between normal breathing rate and watching horror movies. Journal Lung Pulm Respir Research, 6(1), pp.17-18.

Robison, D., McInnis-Perry, G., Weeks, L.E. and Foley, V., 2017. Dignity in older adults with schizophrenia residing in assisted living facilities. Journal of psychosocial nursing and mental health services, 56(2), pp.20-28.

Sargent, L., 2019. H ealth is seen as the level of functional ability for an individual’s. Concepts for Nursing Practice E-Book, p.13.

Sweeney, M., Whiskey, E., Patel, R.K., Tracy, D.K., Shergill, S.S. and Plymen, C.M., 2020. Understanding and managing cardiac side-effects of second-generation antipsychotics in the treatment of schizophrenia. BJPsych Advances, 26(1), pp.26-40.

Williams, B.C., 2017. The Roper-Logan-Tierney model of nursing. Nursing2019 Critical Care, 12(1), pp.17-20.

Wu, C., Zheng, Y., Li, J., Zhang, B., Li, R., Wu, H., She, S., Liu, S., Peng, H., Ning, Y. and Li, L., 2017. Activation and functional connectivity of the left inferior temporal gyrus during visual speech priming in healthy listeners and listeners with schizophrenia. Frontiers in neuroscience, 11, p.107.

Yang, M., Chen, P., He, M.X., Lu, M., Wang, H.M., Soares, J.C. and Zhang, X.Y., 2018. Poor oral health in patients with schizophrenia: A systematic review and meta-analysis. Schizophrenia research, 201, pp.3-9.