I Will Use the Gibbs Model Which Incorporates the Following

This reflection will discuss the importance of the multi-disciplinary team (MDT) and how they work with the client to promote independence.The MDT within the mental health environment generally comprised of psychiatrist, clinical psychologists, nurses, occupational therapists and social workers, but other therapists such as family therapists, psychotherapists, dietician and counsellors mat also become involved in the care of the client (Perkins &Repper 1998). Multidisciplinary involvement is important within mental health nursing as people with mental health problems have multiple needs, so a variety of expertise is required to meet the needs of these people (Darby et al 1999).Ovretveit, (1993) defined the MDT as a group of practitioners with a wide variety of professional training who regularly meet to provide a service to clients.Throughout this reflection, the clients name and clinical setting will not be disclosed as this would breach confidentiality (NMC 2004). For this reason the client will be referred to as ‘Martin’. The first stage of Gibbs (1988) model of reflection requires a description of events.Martin is a 45 year old male, who is currently at a mental health rehabilitation unit as he suffers from paranoia schizophrenia. Paranoia results in episodes of delusions which can be accompanied by hallucinations, perception disturbances and auditory variety (BBC 2006). Schizophrenia is a psychiatric diagnosis that describes a mental disorder characterized by expressions of reality or by impairments in perceptions (BBC 2006).Martin was brought into the rehabilitation unit as he suffered from chronic delusions, which caused him to behave irrationally and destructive. Before he was admitted into hospital, he was causing danger to himself and others by setting objects on fire and was very paranoid about objects in the kitchen. He felt that the instruments in the kitchen were dangerous and always commented on the cooker and oven being broken. This resulted in him being unable to prepare himself food and eating fast food meals everyday.After spending 2 weeks in a mental health hospital he was transferred to a rehabilitation unit, which he had currently been in for a month.The MDT had to work together so Martin was able to overcome his fear

of the kitchen and able him to become independent. I had the opportunity to observe a MDT meeting and participated in the discussion about Martin. Throughout Martin’s time in the rehabilitation unit, many of the MDT members individually spent time with him.The consultant discussed with him any medical problems Martin may be having and gave Martin a description of the medication he had been prescribed and why it was essential they were taken (Kirby et al .2004)The psychiatrist discussed with him how he was dealing with the paranoia schizophrenia and gave Martin a better overlook of his overall life and what he would be able to achieve if he focused on trying to prepare meals. The psychiatrist allowed Martin to discuss his feelings openly and concentrated on whether his perception of cooking had changed over the month he had been in the rehabilitation unit. The occupational therapist also worked with Martin. The main role of the occupational therapist is helping individuals with everyday tasks to promote and maintain their independence and reduce the risk of relapse (Burke 2006). The occupation therapist guided and supervised Martin with his cooking which also gave them a chance to bond and communicate, while preparing their meals (Taylor et al 2001).The dietician was also notified about Martins lack of ability to prepare food. The dietician explained the risk of poor nutrition and what affects it could have on Martin. The social workers main duty was to help Martin cope with the environmental aspect of his life, by giving him and his family information about the ways to support him while in rehabilitation and when he returns home. The social worker also advised Martin to attend cooking groups so he could gain confidence in cooking. The social workers also encouraged Martin to join more social events/groups which would encourage social integration (Thompson 2006). I am now going to enter into the second stage of Gibbs (1988) model of reflection, which is a discussion about my thoughts and feelings.I felt very comfortable and accepted within the MDT meeting. The atmosphere was friendly and relaxed and the MDT discussed Martin’s progress. I felt quite nervous in contributing to the MDT discussion but felt as though I was Martins advocate and was speaking out on his behalf, as I had gained a strong bond with him. The MDT listened to my opinions and asked further questions on how I felt he was progressing. The MDT communicated well with each other and had Martin’s best interest in mind at all times. The discussions about Martin were held until the best outcome was achieved for him. This demonstrated the benefits and importance of

communication within a team and how all contributions within meetings should be valued (Perkins & Repper 1998). I found it extremely interesting to see a MDT in action and witness the teamwork between different disciplines. Evaluation is the third stage of the Gibbs (1988) model of reflection and gives an account of the importance of MDT. There are many positive aspects of this particular MDT as they all worked well together as a team with the same goal in mind. The team discussed the different options available and all the problems that may arise. The MDT have to consider the current state of a client and if the change in lifestyle would benefit him in the long-term. The advantage of a multidisciplinary team approach is that all professionals work together by collecting the facts and by bringing information together, to obtain a complete view of the possible problems of each individual patient. In doing this they are able to make sure that the appropriate range of treatment is given (Onyett 2003).The MDT can have a large impact on the client’s life and can change their long-term way of living.Although, one of the major disadvantages of the MDT is that they work individually, therefore there can be a lack of direction, unclear goals and poor leader ship (Darby et al 1999) if effective communication between the team is not achieved. This could affect the care Martin given and postpone his discharge from the rehabilitation unit.Essential communication is vital in MDT as it allows the team to gain an understanding of how the client is coping and if the transfer from the mental health hospital to the rehabilitation unit benefited him. Stage four of Gibbs(1988) is an analysis of the event. If I had not given my opinion on Martin’s care, he may not have benefited from the MDT as much as he did. Contributing in Martins care meant that I was able to inform the other members of the MDT about his progress. I felt I did this well as I gave a description of his emotional state and how he was progressing with preparing food in the kitchen. The MDT appreciated me speaking about Martin, as they were able to identify new targets for him to achieve, so he would constantly be working towards reaching independence. In conclusion, stage five of the Gibbs (1988) models, it is clear to see from the MDT meeting that effective leadership and good communication between members of the team is vital to ensure there is a clear understanding of Martin’s outcomes (Taylor 2001). The MDT has to be equipped with all the information to overcome Martin’s individual problems (Taylor 2001). The team working together forms the basis of mental health nursing and can influence the success or failure of the care and treatment that Martin may

receive (Kirby 2004). The MDT has the potential to achieve positive outcomes for Martin, and give him the opportunity to reach independence. The final stage of Gibbs (1988) model is the action plan. If I found myself in this type of situation again, I would be more confident in discussing about the clients and their needs thus participating more within the MDT meeting. I have learnt from this situation that good teamwork and communication between each other is vital (Taylor 2001). I have gained a better understanding of the multidisciplinary team, and how the outcomes of these meetings can affect Martin and his family’s quality of life, which will help me to think very carefully about the decisions I make concerning client care in the future. References BBC ,2006, Schizophrenia, BBC news, Available from:[Online]: http://news.bbc.co.uk/go/pr/fr/-/hi/health/medical_notes/1079451.st m[Accessed: 20th August 06] Burke.L, 2006, Occupational therapists, [Online] Accessed from: http://www.occupationaltherapists.com/[Accessed: 2nd September 06] Darby, S. Marr, J. Crump, A Scurfield, M (1999) Older People, Nursing & Mental Health. Oxford: Buterworth-Heinemann. Gibbs.G 1988, Learning by doing. A guide to teaching and learning methods, oxford polytechnic, Oxford Kirby.S, Hart.D,Cross.D,Mitchell.G, 2004, Mental health nursing: Competencies for practice, Palgrave, Hampshire Nursing&Midwifery Council, 2004, NMC Code Of Professional Practice: Standards for conduct, performance and ethics, United Kingdom Onyett, S. (2003) Teamworking in Mental Health. Bristol: Palgrave Macmillan. Ovretveit, J. (1993) Co-ordinating Community Care: multidisciplinary teams and care management. Buckingham. Open University Press. Perkins, R. Repper, J. (1998) Dilemmas in Community Mental Health. Oxon: Radcliff Medical Press Ltd. Taylor.C, Lilis.C, Lemone.P, 2001, Fundamentals of nursing: the art and science of nursing care, 4th edn, Lippincott, Philadelphia Thompson.N, 2006 , Anti-discriminatory practice 4nd edn. Palgrave Macmillan, Basingstoke

The therapeutic relationship can be between two people. It is a relationship that is establish to meet the patient’s needs and therefore, it is client centered. I felt the need to develop therapeutic relationships with the client’s so that they could feel they could put their trust in me, also that I was there to listen and talk to them not just care for them. My final placement was an elderly rehabilitation ward which help the patient’s to adapt to changes in their life circumstances. The ultimate goal is to maximise the social well being of the individual and enabling them to regain their maximum quality of life and the rehabilitation involved all the individuals’ daily activities. I was not sure what to expect from this placement as it was my first experience of working on an elderly rehabilitation ward, as my first placement before was on a surgical ward. During my first days on the ward I found it very different as the patients needed more assistance with their activities of living, such as mobility when transferring and their hygiene needs. However the ward did use the same model of care on the ward as my last placement which was the Roper, Logan and Tierney activities of living model. This helped as the purpose of this model of nursing is to provide a framework mainly for nurses to plan and individualize nursing for those interventions which are related to the patient’s activities of daily living. Roper et al (2002, p434) states that living could be described as an amalgam within the activities of daily living and the way in which the activities are carried out by each person contributes to individuality in living.

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In both of these placements I have interacted with a large number of patients, all of whom have been admitted for a variety of difference reasons. This involves me admitting these patients, their overall care during their time either in hospital or in other care centres right up to their discharge. When I first started on the ward I was a little bit concerned when meeting patients when other staff were present as I thought that I was in the way and I would be unprepared when asked to do anything or answer any questions that the patient may ask, as the other staff seemed so professional. Prior to starting each of my

placements I attended classes which involved how to act appropriately around the patient’s and other members of the team in which I was working and it was to prepare us for our practice placement, but when you get out in practice and are faced with the real thing it is much different. I knew this was something I needed to overcome and as I started to settle in and understand the routine of the ward the easier it became. Freshwater et al (2005, p101) suggests the nurse patient relationship can be viewed as a major therapeutic tool of effective patient care. McHugh Schuster (200, p7) sates that communication plays an important role in the therapeutic relationship. Clark & Bridge (1998, p2) suggest that forms of communication such as asking questions, allowing patients to express their feelings, or reassuring patients by means of touch will also result in important patient care, and increase patient satisfaction and well being. Nichols (cited in McQueen 2000, p723-731) also suggests that the nurse is the central figure in the patient care and is best placed to provide much of the psychological care and this demands good interpersonal skills to form a therapeutic relationship with patients and to communicate more effectively with relatives and other health professionals. Communication covers a wide range of things including touch, play, and enthusiasm. Touch is important as it showed that I was listening to the patient’s, touch can mean different things, and it is a silent language of non verbal behaviour. Touch is an affectionate way of transmitting warmth. Whilst I was on the ward an example of touch would be when patients are upset or anxious I would maybe hold their hand or give them a comforting hug. Not all patients are comfortable with using touch but I knew the boundaries with each individual patient. Another non verbal communication skill could be silence giving both the patient and the nurse time to reflect upon prior or future events in the patient’s care. Although it is important that the patient’s needs are still met and that the focus is still on them. Therefore it is important that the nurse involves the patient through other means of communication which again could be through touch or play. There are many ways of forming a relationship and gaining the trust and respect of the patient and I had to work out the different things

that make a good therapeutic relationship. Hinchliff et al (2003, p102) states there are a number of important elements that make a good therapeutic relationship, but it is important to make clear that a therapeutic relationship is a formal relationship between a medical professional and patient. The Nursing and Midwifery Council (2004) maintains that at all times nursing staff must maintain appropriate professional boundaries in the relationships they have with patients and clients. The NMC (2004) states that the nurse must recognise and respect the role of the patient/client as partners in their care and the contribution they can make to it. This would be the phase of identification in Peplau’s (1988) model of the nurse patient relationship. Peplau (cited in Hinchliff et al 2003, p130) views the nurse patient relationship as passing through four phases orientation, identification, exploitation and resolution, with identification being when the patient finding out more about the reason for health care and the people who can be relied upon for help and advice and how the patient can become more involved in their own care. In this piece of reflection I did not have to obtain consent from patients as I generalised and have not discussed individual cases. However confidentiality is of major importance whilst confirming a patient and it is essential that informed consent is valid as each patient has the right to keep their caring need private. Riley (cited in Cutcliffe et al 2005, p304) suggests that therapeutic relationships are about patient’s disclosure of personal and occasionally painful feelings with the nurse at a calculated emotional distance near enough to be involved but objective enough to be of help. Neal (cited in Hinchliffe et al 2003, p102) states that confidentiality and trust are two sides to the same coin and trust is another important attribute to the therapeutic relationship as the patient will place their trust in the nurse.

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This element is important as in the nurse patient relationship the patient is in a vulnerable position. People become vulnerable whenever their health or usual function is compromised. This vulnerability increases when they enter unfamiliar surroundings, situations or relationships. Older patients and those with dementia

are especially vulnerable. I felt on the placement the patient’s could put their trust in me as when taking personal information from patients I would ensure to the patient in the early stages of the relationship that information provided is treated as confidential, but will be shared on a need to know basis, with others involved in the delivery of their care. Even something as simple as when I put a patient on the commode and I inform them I will be back to check on them in five minutes I always return straight away as I told them and if I was tied up I would ask one of my colleagues to check on them this helps to maintain their trust in me. Chambers (cited in Cutcliffe et al 2005, p308) states that empathy is also an important feature to the therapeutic relationship and suggests empathy is the ability to recognise and understand the patient’s feelings and point of view objectively. According to Riley (cited in Cutcliffe 2003, p93) empathy expressed verbally conveys caring, compassion and concern for patient’s but never implies that the nurse can fully experience patients feelings, also listening is an important element as it is critical to hear what the patient is saying, verbally and non verbally. Smyth (cited in McQueen 2000, p723731) suggests that our personal experiences can make a contribution to their emotional work and ability to empathise and by reflecting on personal experiences nurses may be better able to identify with patients. Whilst I was on placement and listening to the patients concerns and worries, using qualities mentioned by Hinchliff el at (1998, p225) of care, concern, compassion and respect I explained that it was a natural reaction to feel nervous and unsettled and this helped to lesson their underlying anxieties. In order to be genuine it was necessary to be honest and put some of my own feelings into the situation like getting into their shoes and trying to see things like emotions and experiences from their perspective where possible. Chambers (cited in Cutcliffe 2005, p308) states that therapeutic relationship differs in terms of focus, length, depth and degree of closeness, regardless of this; they need to be grounded in respect for the patient. Getting the message of respect to the patient can be done in a number of ways as part of the therapeutic relationship like making sure that all conversations take place in private, whilst the

doctors are doing ward rounds being present, listening and validating material that is disclosed. Honesty and genuineness play a key role in conveying respect, even when the information shared may be difficult for the patient. The NMC (2004) states that respect in the general sense recognises the worth of a patient irrespective of gender, age, race, disability, sexuality, culture, religion, economic status or personal beliefs. Whilst on placement I had to be aware of the aspects of treatment in respect of race and religion. This can be seen through communication, religious beliefs and special dietary needs. Each person has a right to be treated in a way their religion dictates. An example of this is through the dietary need for Muslims in the hallal way of preparing meat for hospital meals. Other patients may also have special dietary needs such as patients with diabetes. Much of nursing is on a one to one basis and is intimate of nature. Dignity is a major issue to many patients and should be respected at all times when working on a ward or other health care situation. Windang & Fridlund (2003 cited in Cutcliff et al 2005, p81) states that dignity mainly comprises as seeing the whole person, being respected and being seen as trustworthy. I have respected the dignity of others by understanding the need for respect and privacy due to the patient’s personal feeling and religious beliefs. In building a therapeutic relationship I had not really considered the environment for doing so. Birrell et al (2006, p43) state how important it is that sensitive issues are discussed in side rooms or an area with an element of privacy and not just at the patient’s bedside. Although when talking to patient’s privately I drew the curtains around the bed I still had to lower my voice so that other patients could not hear our conversation which was particularly difficult if the patient had hearing difficulties. On reflection I now realise that I should have found a quite room in which to discuss private matters with patients or waited until the bay was quieter or when the other patients were busy or out of the room. The main purpose to this reflection has been to show the difference between a normal everyday relationship and a relationship between a medical professional and a patient. In a nurse – patient relationship as the NMC (2004) states there is a duty of care. This

expresses itself, especially in a hospital setting. One of the important elements of nursing is establishing a therapeutic relationship. Until I had considered Gibb’s cycle I had not really thought about the elements that make up a therapeutic relationship. These I now appreciate include verbal and non verbal communication, such as touch, humour, compassion and listening appropriately to the patient and it id further shaped by the concepts of power, trust, respect and intimacy. Professional interpersonal skills arise from a variety of experiences whilst engaging with patients, relatives, colleagues and other health welfare practitioners. Egan et al (1995, p1) suggests that interpersonal skills refer to those interpersonal aspects of communication and social skills that professionals use in direct person to person contact. In looking back I feel as though I have developed my interpersonal from a normal everyday relationship to that in a medical setting. I have learnt how to listen and talk to patients, staff and family members for me as a first year student this was a daunting task at the beginning but I felt I developed this and my confidence come from personal experience. I would hope in the future to develop further interpersonal skills and help patients in what ever setting I find them. I need to make all patients feel equal and attend to all their needs in privacy and with dignity and cooperate with their individual needs separately. In the future and having the knowledge gained through this piece of reflection I

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References Birrell, J., Thomas. D., Jones. C.A. (2006) Promoting privacy and dignity for older patients in hospital. Nursing Standard, Vol 20; No, 18 Middlesex: RCN Publishing Company. Bridge, W. and Macleod Clark, J. (1998) Communication in nursing care. Chichester: Wiley Chambers, M. (1998) Interpersonal mental health nursing: research issues and challenges. Journal of psychiatric and mental health nursing 5: 2003-211. Cited in Cutcliffe, J. and Mckenna, H. (2005) The essential concepts of nursing. London: Churchill Livingstone. Cutcliffe, j. and Mckenna, H. (2005) The essential concepts of nursing. London: Churchill Livingstone. Egan, G. 1998) The skilled helper: a systematic approach to effective helping 5th ed cited in Ellis, R.B., Gates. B, Kenworthy. N. (eds.) (2003) Interpersonal communication in nursing. Theory and practice 2nd ed. London: Churchill Livingstone. Freshwater, D. and Johns, C. (2005) Transforming nursing through reflective practice. 2nd ed. Oxford: Blackwell. Hinchliff, S., Norman, S. and Schober, J. (eds.) (2003) Nursing practice and health care. 4th ed. London: Aronold. Jasper, M. (2003) Reflective practice. Foundations in nursing and health care. Cheltenham: Nelson Thornes. McHugh Schuster, P. (2000) Communication the key to the therapeutic relationship. Phiadelphia: F.A. Davis Company. Neal, K. (2003) Nurse patient relationships cited in Hinchliff, S., Norman, S. and Schober, J. (eds.) (2003) Nursing practice and health care. 4th ed. London: Aronold. Nichols, K.A. (1993) Psychological care in physical illness. 2nd ed. London: Chapman & Hall. Cited in McQueen, A. (2000) Nurse patient relationship and partnership in hospital care: The journal of clinical

nursing. Vol 9 (5), 723-731. Nursing and Midwifery Council. (2004) The NMC code of professional conduct: standards for conduct, performance and ethics. London. Peplau, H. (1998) interpersonal relationships in nursing. New York: Putman. Cited in Hincliff, S., Norman, S. and Shober, J. (eds.) (2003) Nursing practice and health care. 4th ed. London: Aronold. Riley, J. B., Kelter, B.R, Schwecker, L.H. (2003) Communication: cited in Cutcliffe, J.R. and McKenna H.P. (2005) The essential concepts of nursing. London: Churchill Livingstone. Roper, N., Logan, W. and Tierney, A. (2001) The Roper - Logan Tierney model of nursing: Based on activities of living. Edinburgh: Churchill Livingstone. Widang. I, Fridland, B. (2003) Self respect, dignity and confidence: conceptions of integrity among male patients. Journal of Advanced nursing. 42: 47-55 cited in Cutcliffe, J.R and McKenna, H.P (2005) The essential concepts of nursing, London: Churchill Livingstone. Smyth, T. (1996) Reinstating the person in the professional: reflections on empathy and aesthetic experience. Journal of advanced nursing 24 (50), 932-937. Cited in McQueen, A. (2000) Nurse patient relationship and partnership in hospital care: The journal of clinical nursing. Vol 9 (5), 723-731.

In keeping with NMC guidelines, all names and locations have been changed, to protect the identity of the individuals involved. However, it must be stated that individuals who work with the client groups may recognise the individuals concerned, due to the information provided. In this respect, it is not always possible to completely protect the individuals concerned; however, it is also the duty of other professionals concerned to remember their own responsibilities regarding protecting the client’s rights of privacy and

dignity. The purpose of this essay is to reflect upon a critical incident that took place on the first of my specialised placements, which, in my case, was mental health. To achieve this, I will use the reflective cycle (Gibbs 1988) cited by Palmer et al (1994). I will start by giving an outline of my placement. For reasons of confidentiality, (UKCC 1992), the client's name will be changed to `Clive'. I shall then discuss the critical incident; by providing details of what took place and when; this will lead on to details of what I found the most satisfying and what troubled me about the incident. I shall finish by relaying what I believe I have learned from the incident. My placement was in a day hospital, caring for elderly people with mental health problems. According to Griffith (1988), community care should support people who are affected by problems including mental illness and mental handicap. The clients attended the unit throughout the week, giving their carers a much needed break. Research shows that four out of five older people who have mental health problems are cared for at home, (Gearing 1990). Levin (1983) stated that caring for someone with mental health problems twenty-four hours a day leads to total exhaustion.In the unit, there were three trained mental health nurses, one occupational therapist and one nursing assistant. Care within the unit was based on Roper's nursing model, and the twelve activities of daily living, which are communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying. As a model, this concerns the idea that, if the client has some type of health problem involving these twelve activities, then they require the needs of a trained nurse. The unit also worked with evidence-based practice in their treatment. Evidence-based practice is where current practice procedure can be evaluated and questioned upon how effective it is and whether it can be changed to improve treatment.

The unit combined a holistic and client-centered approach which, according to Rogers (1951), will assist the client to reach his/her full self. The client's well being was taken into consideration, which included their social, physical, psychological and spiritual needs. Each client was under the care of a named nurse and underwent an initial assessment over a six to eight week period, which involved multi-disciplinary participation, consisting of a community psychiatric nurse, psychiatrist and a social worker. According to Naidoo & Wills (2000) Mental Health nurses work with people who are mentally ill and ensure that they are able to cape. The unit used therapy as a means of treatment and this involved the use of a living dog, which wandered around the unit, and the clients interacted with it. Sylvester (1988) stated that, `nearly half the households in Britain own a pet, so they are a normal part of life far many people'. Therapy methods used included reminiscence. The use of reminiscence is to develop and aid the client value their memories, (Coleman 1986). Other therapy methods were set within a multi-sensory environment. This is where clients can handle interactive toys involving microchip technology. This play-based activity promotes considerable attention, participation and commitment (Pulsford et al 1999). I discussed with my mentor the possibility of some of these and other activities being demeaning to clients of this age group. We managed to come to a mutual understanding between ourselves over these activities, that the clients enjoyed partaking in the activities and none of them refused to do so. The critical incident itself happened during the second week of my placement, over a period of two days. On the first day, after the clients had arrived, we started to serve them cups of tea or coffee. When I approached Clive, he asked if he could speak to me. I sat beside him and he began telling me that he had had a bad dream, which had really upset him, he said had never felt like this before following any other dream he ever had. He also mentioned he had never felt as low in life as he did at that present time. We spoke for about five minutes and I told him I would mention it to

someone, which I did, though no action was taken at that time. The following day; I was discussing my placement with my mentor when, as the clients began to arrive, the ambulance crew came to report that Clive did not wish to come to the unit and appeared very upset and agitated. My mentor arranged for someone to go and see him. Later that day, Clive arrived at the unit, very well presented, but very quiet. Following lunch, I spoke to him and he asked if he could have a talk with me. I took him through to the dining room and Clive began by telling me he wanted to talk to someone, as something was bothering him, but he was not quite sure what it was. He began his story by telling me about his past, and how ill his father had been and all about his mother and how well educated and how respected she had been. He also told me how his father would collapse for no apparent reason. Then Clive started telling about his war-time experiences as a Prisoner Of War at the hands of the Japanese and how he enjoyed this part of his life, as he never caught any of the illnesses and enjoyed being able to help others who were ill. Clive kept referring back to his mother. It appeared to me that he looked up to her and always tried to equal her achievements. Again, Clive repeated to me that he never felt as low in his life as did at that present time. He once again referred to his father, who, he told me, committed suicide and it was Clive who found him. He continued referring back to his mother and comparing himself and his achievements to hers and how he could not measure up to her. I attempted to reassure him that he had his own merits that he should be proud of ,I brought to his attention the fact of his achievements in the war and how he helped others who were less able to cope than he was. Clive appeared to take notice of this, as he said he had never thought of it that way before. It was interesting to note haw he kept referring to the past. Sndyer (1987), cited in (Kegan and Evans 1998), stated that, `our knowledge of self acts as a guide in helping us choose our actions, the situations we meet, and the relationships we enter'. According to Hinchliff el al (1998), depression is focused entirely in the past

and the patient's complaints of physical pain. Clive also mentioned about his knee giving him pain and trouble. Gearing et al (1990) also state that depression is common in old age. Clive did not manage to tell me what was troubling him, but he said he felt better for having talked to me. I will now discuss why the event was important to me and what I found most satisfactory about it. Listening to Clive describe his thoughts gave me a sense of being able to do something important and attempt to help someone, if only to listen to what they had to say. I also felt more confident in the discussion we had; I believe this was due to the interpersonal skills we covered in college. I found myself putting into practice what we had covered, to the best of my ability at this stage of my training. I still have limitations as to what I can achieve. However, I did find myself asking open-ended questions, as well as paraphrasing what Clive had told me. I attempted to reassure him of his own self-worth as I saw it, and his achievements during the Second World War, pointing out that this was a good quality and something he should be proud of. It was a nice feeling to hear Clive mention that this made him feel better and that it was nice of me to point that out to him., as he said he had never thought of it like that before. The most satisfactory part of the incident was that, through my conversations with Clive and the way I interacted with him and advised him, I felt that I had helped Clive think about this own life, if only a little, and I also believe it enabled him to get things of his chest. Kegan and Evan (1998 p12) state that `counseling helps people constructively to resolve personal problem(s) that may be long-standing or acute'. It encouraged me that he trusted me enough to want to confide in me and I may have been able to provide him with a little support. Some aspects of this incident troubled me. Although Clive appeared to enjoy our discussion, it troubled me that no other staff appeared to have the time to talk to him and told me that it was nothing he had not said before. Kogan and Evans (1998) argue that, if nurses give clients reassurance as a meaning of avoiding underlying concerns, it may do little to help the client. When I questioned Clive what it was that was bothering him, he was unable to remember. In our discussion, I referred to the fact: that he did not wish to attend the unit that day. Clive was not able to recall the fact that he did not wish to attend; in fact, he went on to say that there was no reason what he should not want to come, as everyone here treated him nicely. I asked him if he knew what the unit was for and what the people who worked in the unit were there to do. Clive was unable to tell me. He never asked me to explain and I did not feel as though it was my place to tell him. Other aspects that troubled me were not being able to help Clive more than I could, other than to keep

reassuring him of his own self¬-worth. I would then mention our conversation to another member of staff, who might be able to offer him more help. It also troubled me that, even though I did mention it to his named nurse, as far as I am aware, no record was made of it. I believe that there was a lack of communication from the trained staff towards Clive, to help him come to terms with his current problem in life. I believe I have learned from the incident and have developed communication skills. People with mental health problems have other physical illnesses as well. In Clive's case, this would be the knee, which he complained about. According to his case notes, he was also finding increased difficulty with his hearing and his walking and he was becoming increasingly forgetful. One needs to look into people's past history to gain a fuller understanding of what is troubling them at present and take this into account when assessing them far treatment. As Gearing et a1 (1990) state, a person's past life is unique to them. I now believe I have gained a better knowledge of people with mental health problems, despite being on the placement far only two weeks. I went into the placement not knowing what to expect, but with an open mind. I left realising that elderly people with mental health problems have often led normal active lives and many have, in their youthful years, provided inspiration to others, be that from teaching, working with others or, in Clive's case, helping people less able to cope than himself. Further discussion with my mentor included the way in which clients were treated. For example, when we laughed during a conversation, were we laughing at them'? This was something we had discussed in college. The conclusion reached was that everyone enjoyed this kind of interaction and it offended no one, especially the clients. In fact, many of then benefited from this sort of interaction. In future, I will be more aware of people with mental health problems and look at them with a holistic view, considering what they may have gone through, it is only through placements like this, that one can gain a fuller knowledge of all aspects of nursing.© Robert Sidwell 2005

Coleman, P. G. (1986) Ageing and Reminiscence Process. Wiley, Chichester. Gearing, B. Johnson, M. Heller, T (Eds) (1990). Mental Health Problems in Old Age. Open University Press, Milton Keynes. Griffiths, R. (1988) Community Care: Agenda for Action. A report to the secretary of state for social services. HMSO, London.

Gibbs (1988) The Reflective Cycle, cited in Palmer, A. Burns, S. Bulman, C. (1994) Reflective Practice in Nursing. London, Blackwell Science. Cited in Reflective Portfolio Handbook {2001} St. Martin's College, Lancaster. Kegan, C. Evans, ,T. (1998) Professional Interpersonal Skills for Nurses. Stanley Thornes Ltd, Cheltenham Levin, E. Sinclair, T. Gorbach, P. (1983) The Supporter of Confused Elderly Persons at Home. Extract from the main report. National Institute of Social Work, London. Cited in Mental Health Problems in Old Age (book 2) (1990). The Open University Press, Milton Keynes. Naidoo, J. Wills, 3 (2000) Health Promotion Foundation for Practice 2nd Edition. Bailleire Tindall, London. Rogers, C. (1951) Client Centered Therapy. Constable, London. Roper, N. Logan, W. Tierney, A. (1988) Learning To Use The Process of Nursing'. Churchill Livingstone, Medical Division of Longman Group UK Ltd, Edinburgh. Snyder; M. (1987) Public Appearance and Private Realities: The Psychology of Self Monitoring. Freeman, New York. Cited by Kegan, C. Evans, J. (1998) Professional Interpersonal Skills for Nurses. Stanley Thornes Ltd, Cheltenham Sylvester, J. (1988) Animal Crackers. Nursing Standard June 1 Volume 4 Number 3 pp28-29 1988. Pulsford, D. Conner, I. Rushforth, D (1999) Does Play Journal Of Dementia Care. Sep/Oct 1999 pp 15-16.

Tilley, Stephen. (Ed)(] 997), The Mental Health Nurse, Views of Practice and Education. Blackwell Science Ltd, Oxford. Norman, I. Redfern, S. (1997) (Eds) Mental Health care for Elderly People. Churchill Livingstone. New York. Claridge, G. (1987) Origins of Mental Illness. Basil Blackwell, London.

Linda Broderick currently a HCA within the network has taken

a keen interest in communication with the patients. As part of her NVQ Linda wrote Reflection on communication in the intensive care unit, which has recently been published in the HCA magazine. Well done Linda! keep up the good work. REFLECTION ON COMMUNICATION IN THE INTENSIVE CARE UNIT This reflection, using Gibbs reflective cycle, describes a challenging communication issue in Intensive Care. Description A patient was admitted to the Unit from another ITU, she spoke no English and had a tracheostomy. Within thirty minutes we managed to find a healthcare professional within the hospital who could speak Italian, to explain to the patient that she was in hospital, quite safe, that her daughter had been informed and would be arriving in about an hour. When the daughter arrived, she was able to relay the patient’s preferences and needs which we decided to not only record in her notes but to also make a list which was kept on the desk by her bed to make it easier for staff involved in her care. The daughter also wrote down lots of useful questions in both Italian and English, enabling us to try our hand at a bit of Italian and for the patient to point to any of the questions she wished to ask us. We also went on the internet and found some useful words we were able to use. Feelings I was aware of how frightening it must be for the patient who was ill, had a tracheostomy and was surrounded by people who she did not understand. At times I felt quite useless when she was trying to talk to me and I had no idea what she was saying. I could only hold up the questions her daughter had provided and hope it was something on there that she wanted, then I would feel really pleased for her if it was and I could provide what it was. On occasions, when no matter how hard I tried I could not understand what the patient was trying to ask me, I would ask a colleague to see if they could understand what the patient was asking. I am pleased to say that between us, we always managed to work it out. Evaluation The good thing about the situation, was that it really challenged us and everyone did really well. Also the more we got to know the patient, the easier it became. On one

occasion, when an x-ray machine was wheeled into her room I noticed a look of fear on her face. Realising we had no means to explain an x-ray, I mimed to her that I was holding a camera and taking a photo and mimed a square on my chest. She immediately understood that we wanted to take a ‘photo of her chest’ and she smiled at me and nodded. On another occasion, we explained to her that we needed to change her position. She understood and acknowledged it was alright for us to do that. However, after putting the pillow behind her back, her facial expression and the fact she made attempts to remove the pillow told us she did not want the pillow there. We removed it and her expression then told us we had done the right thing. The bad thing about the experience was the frustration you feel when you are trying to understand what the patient is telling you and you can only imagine the frustration the patient must feel when, unlike us, she has nobody to help her try to ‘work it out’. It also made me realise how a situation could so easily become ‘unsafe’ when a person cannot tell you in detail how they feel. When verbal communication is so limited, it is so important to look for body language and expression if you are to meet this patient’s needs. When a male nurse was taking care of her and I went to assist with her personal care, she understood and agreed to a wash but made it clear she did not want the male nurse to do it by pushing him away. I asked if she wanted me to do it by miming a wash and pointing to myself she nodded and looked relieved that I was going to do it. Analysis The language barrier and the tracheostomy provided two communication challenges with this patient. However, whatever the communication challenge, you can overcome it to a degree, certainly enough to communicate with someone. Non verbal communication becomes even more important in these situations. We had a Spanish nurse who looked after her when on duty which worked well as they understood quite a bit of each other’s language and the patient enjoyed her company. Having internet access by the bedspace was very useful to quickly look up words too.

The patient’s daughter was invaluable but we had to be careful we did not breach the patient’s confidentiality in how we used the daughter to interpret.

Conclusion I don’t think any more could have been done. The patient was happy during her stay and everyone made a good effort to ensure that communication was not only questions and answers. Our attempts to speak Italian made her laugh a lot and she liked us to tell her about ourselves, such as if we had children. We told her the day and the time and many other things. The patient made it quite clear if she liked or disliked someone by a simple brush of the hand or holding your hand. Action Plan If the situation arose again, I would feel more confident in trying to learn a bit more about whatever language I was dealing with. There are many sites on the internet and I would certainly use that more. I know I could also contact an interpreter as well.