The purpose of this assignment is to reflect upon an incident witnessed on a recent clinical placement, and for this I will use the Gibbs (1988) reflective cycle (see appendix 1). Jasper (2003) suggests that reflection is one of the key ways in which we can learn from our experiences. I am currently enrolled on the BSc Adult nursing course and the incident discussed will be from the mental health branch. In accordance with the Nursing and Midwifery Council (NMC) Code of Professional Conduct, performance and ethics (2004) and to protect the confidentiality of the trust and staff members all names will remain anonymous, for the purpose of this essay the patient will be known as Tom.
The first stage in the Gibbs’ (1988) cycle of reflection is a description of the event. I arrived on the ward at 7.30 am and as always I began my shift by helping the health care assistant (HCA) with organising the patients’ hygiene needs. One of the patients that required assistance was a seventy four year old gentleman called Tom who was admitted to the ward in preparation for a procedure called a transurethral resection of the prostate (TURP), this is to reduce the size of an enlarged prostate (Shannon 2000). He also suffered from Dementia, this is a syndrome of gradual progressive cognitive decline which brings with it confusion and memory loss (Insel and Badger 2002).
Tom greeted us with a big smile, we wished him a good morning and he seemed to be in a jovial mood. We asked Tom if he was ready for his bath, as he sometimes became confused and forgetful it was necessary for us to supervise him at bath time. He was very capable of washing himself and I just helped by washing his back for him as he requested. After he had washed I asked him if he was ready to get out of the bath, he started shouting personal insults and swearing saying he didn’t want to get out, he shouted for us to fetch his wife, he was agitated, upset and angry. As I had assisted with Tom’s admission to the ward I was aware that his wife had died six years previously. Patients with dementia often hold onto good memories from the past and such reminiscences become reality (Jacques & Jackson 2000). I spoke in a calm manner, even though I was a panicking inside, and I told him he could stay in a little longer if he wished, fortunately this diffused the situation quickly.
Stage two in the Gibbs’ (1988) cycle of reflection is to explore feelings about the incident. My feelings at the time were mixed; I wondered whether something I had said or done had made Tom react in this way. I felt upset and guilty that I had caused a previously happy patient to become distressed and agitated and I was embarrassed that other patients and staff members may have heard Tom’s reaction. I also felt very sad that Tom thought his wife was still alive and pondered his reaction if we were to tell him otherwise. On the other hand even though I was shocked and somewhat frightened by his outburst, I stayed with the patient until he was calm. Roberts and Dyer (2004) suggest that the ethical and professional obligation is not to abandon the patient. I was pleased that I was able to ease the situation and calm him down. The situation is illustrated in a flow chart in appendix 2.
Evaluating positive and negative components to the incident is the third stage in the Gibbs’ (1988) cycle of reflection is. The negative part of this experience was that I had been verbally abused and insulted by a patient I was trying to help. I was also a little bewildered at the lack of response from the HCA who showed no reaction when Tom became verbally aggressive. The positive things about this experience are that I followed procedures and assisted Tom with his hygiene needs. Assisting patients to meet their hygiene needs is a very important part of nursing care (Baillie 2005). The Department of Health NHS Plan (2000) outlined the importance of meeting hygiene needs and improving patient care as ‘getting the basics right’. I was also happy that I felt strong enough to stay with the patient until he had calmed down.
Stage four of the reflective cycle used is analysis. I was nervous at the prospect of having to face Tom again as I had a feeling that he has taken a dislike to me. However, because of the nature of dementia, Tom had no recollection of the incident which gave me the confidence to continue to provide the appropriate level of care. Trivial events can cause a sudden change in mood in a person suffering from dementia which can result in the patient lashing out. Irritability and emotional changes can also result in aggression (Adams & Clarke 2001). The patient generally does not mean to be aggressive and doesn't want to hurt anyone, the aggression stems from a lack of control of their emotions (www.dementia.com 2006). Knowing this helped me to make sense of Tom’s reaction.
To conclude and put in place an action plan, which is stage five and six in the cycle of reflection, I can look back and identify actions that I could have taken to prevent the incident happening. During my research on communicating with people who suffer from dementia I discovered that a study carried out by Walsh and Kowanko (2002) found that patients were more comfortable with having personal care given if the nurse communicates throughout with small talk as this distracts them and avoids embarrassment. If I had used this technique I may have been able to make Tom feel more at ease with the situation, thus avoiding the verbal aggression, this is a skill I will carry forward and utilise in the future. Reflecting upon this incident has enabled me to identify gaps in my knowledge of mental health issues which I can strive to bridge as I progress through my course and continue to improve upon throughout my nursing career.
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Flow chart of events