Nosocomial infections still remain the most frequent complications in hospitalized patients. They are the fourth most common cause of mortality in the United States after the cardiovascular system diseases, cancer and strokes. Discussing background of the necessity of this question observation Schaffer et al stated that “Nosocomial infections are widespread. They are important contributors to morbidity and mortality. They will become even more important as a public health problem with increasing economic and human impact because of:

Increasing numbers and crowding of people.

More frequent impaired immunity (age, illness and treatments).

New microorganisms.

Increasing bacterial resistance to antibiotics.” (Schaffer et al, 1996).

Despite advances in infection control, the emergence and introduction into clinical practice of new antimicrobial drugs, improved diagnostic methods, improving the overall level of care, the issue of prevention and control of nosocomial infections is still valid. Thus, we are going to talk about nosocomial infections and their prevention with more details in the body of this paper.

First of all it is necessary to define the term a “nosocomial infection”, and analyzing medical literature it was found that the most commonly used definition was given by the World Health Organization. According to the World Health Organization “A nosocomial infection – also called ‘hospital-acquired infection’ can be defined as: ‘an infection acquired in hospital by a patient who was admitted for a reason other than that infection.’ An infection occurring in a patient in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility.” (Ducel, Fabry, and Nicolle, 2002) Analyzing a general timeline of infections, it is necessary to mention that infections occurring more than 48 or 72 hours after hospitalization are often considered nosocomial.

It is generally accepted position that there must be clinical signs of infection in the first place of diagnosing nosocomial infections, which are identified either by direct observations of the patient, or when analyzing the primary documentation about the patient (for example, diagram of body temperature).

In addition to the clinical signs of infection may be used the results of paraclinical methods of investigation (e.g., radiological examination for nosocomial pneumonia), as well as laboratory data (microbiological, serological, and rapid diagnostic methods).

In complex analysis of these data physicians should take into account the fact that some out-of-hospital infections have an incubation period of more than 48 hours, such as typhoid fever, and intrauterine infections, for example, the symptoms and signs of which appear shortly after birth. Thus, the above numerated infections did not relate to nosocomial infections according to their different nature.

Observing division of nosocomial infections we could mark out several classes: endemic and epidemic. Observing sources of infection appearance we see that the most important are still endogenous sources. First of all, it is obligatory flora of the patient (skin, gastrointestinal tract, etc.), and not only that flora which already existed in the patient’s admission to the hospital but also acquired in a second time in a hospital, and foci of chronic infection. Describing exogenous sources we see among them hands of medical personnel, medical equipment, tools, household articles, unsterile catheters, syringes, etc., aerogenic contamination, water and foodstuffs. It is frequently observed the combination of exogenous and endogenous factors in their interaction. In addition to previously stated information, Pinner et al added that “most are endemic, meaning that they are at the level of usual occurrence within the setting. Epidemic infections occur when there is an unusual increase in infection above baseline for a specific infection or organism.” (Pinner, 1982)

Research on the epidemiology of nosocomial infections provides essential information for making decisions in the event of outbreaks of communicable diseases in those or other departments, analyze the structure of pathogens, the level of phenotypes and their antimicrobial resistance, the prevalence of “rare” pathogens.

Structure of nosocomial infections depends on the profile of hospital, its policy in antibacterial drugs using, and patient contingent. Decisive for the choice of therapy in a particular health facility are the results of microbiological monitoring of antibiotic resistance in pathogens.

As it was stated in the beginning of this paper it is necessary to concern our attention not only on the nature of nosocomial infections, but also on preventive methods in the struggle against this kind of infections.

Wenzel troubled about the prevention of nosocomial infections and due to this described specific infection control measures in his work; and according to them we see that “Besides the committees and other leaders in infection control, much of infection control lies in the hands of the personnel in direct contact with the sick patient. These healthcare employees must understand specific guidelines in prevention of infection transmission through isolation and other good healthcare habits. Much of this information in disseminated through training and educational programs given by the infection control departments. An example of guidelines that are essential for the healthcare worker are specified as:

Hand washing;

Hygiene and uniform;

Barriers: caps, masks, gloves;

Injection practices;

Equipment safety;

Isolation.” (Wenzel, 1997).

Statistical data demonstrated that approximately 90% of all nosocomial infections caused by bacteria, a distinctive feature of which is resistance to many groups of antibacterial drugs (polyresistance) (Berntsen, 2004) In such a way exactly this its property causes problems in the treatment of nosocomial infections, predetermining a low efficiency and high cost of treatment. Resistant strains are formed in the hospitals under the influence of commonly used antibiotics out there. They can go to the hospital from an organism of patients-carriers. Health care personnel is involved in the transfer of bacteria from patient to patient in caring for the sick person, during the process of diagnostic procedures realization, etc. The problem connected with the treatment of nosocomial infections is widely discussed all over the world and medical facilities in conjunction with pharmaceutical companies are looking for ways to combat this kind of infection nowadays.

Lynch as one of the researchers who is interested in nosocomial infections prevention and treatment declared that “Most of these infections can be prevented with readily available, relatively inexpensive strategies by:

adhering to recommended infection prevention practices, especially hand hygiene and wearing gloves;

paying attention to well-established processes for decontamination and cleaning of soiled instruments and other items, followed by either sterilization or high-level disinfection; and

improving safety in operating rooms and other high-risk areas where the most serious and frequent injuries and exposures to infectious agents occur.” (Lynch, 1997).

Thus, summarizing the above presented information we could say that solutions of the problem of nosocomial infectious complications greatly depends on effective control and prevention measures, among which an important place occupies the use of modern aseptic and antiseptic remedies.

Microorganisms circulating in the hospital and attending the various environmental objects can interact with the patient in two ways. Under appropriate conditions, they are either the direct cause of infectious complications, causing the so-called exogenous infection or hospital strains replace patient’s microflora with impaired colonization resistance (mostly due to antibiotic therapy), forming part of its auto microscopic flora and become the cause of endogenous infection. In this case as it was previously explained patient nosocomial infection with strains of microorganisms and colonization of them can be prevented through the use of modern sterilization, disinfecting and antiseptic agents by disinfection and sterilization. These activities are not only important from a medical point of view but also considered economically viable steps in medical treatment.

We should remember that medical housekeeping of environment, sterilization of medical instruments, which are in contact with skin or mucous membranes of patient adherence to aseptic technique during any invasive manipulation, and currently remain the cornerstone in the prevention of nosocomial infections. The most important and maybe the most simple of these measures is to wash own hands before and after patient contact (even when wearing medical gloves). Discussing this side of the problem it becomes understandable that in terms of effectiveness of prevention of nosocomial infections is most advisable to use disposable instruments, gloves, catheters, equipment, factory-sterilized. However, this is not always possible. Thus, the question of decontamination of reuse medical devices consists of the following steps: disinfection, cleaning and sterilization. Under the pre-sterilized cleansing understand the mechanical removal of foreign, mainly organic material with disinfected surfaces. Disinfection – is a physical or chemical process, which destroyed virtually all microorganisms, except bacterial spores. Under the sterilization process physicians imply the complete destruction of all microorganisms including bacterial spores. And connecting disinfection with antibiotic treatment we should say that prophylactic use of antibiotics – is one of the methods of control of nosocomial infections, the theoretical basis of which is the need for surgical intervention during a certain concentration of antibiotic for the maintenance of microbial numbers in the field of surgical wound below the level at which infection may occur.

Thus, basing on the information presented in this paper we see that timely identification of infection sources, the detection mechanisms of microbial resistance are the key measure to combat nosocomial infections, which are required to take medical facilities. In such a way qualitative diagnosis, allowing in proper time to identify the carrier, plays a crucial role in preventing of nosocomial infections spread and favour the decrease of treatment costs.

In conclusion, nosocomial infections continue to be the great problem for the entire healthcare system throughout the whole world due to increased risks to patients and medical personnel. Nowadays there were developed a big quantity of effective infection control programs directed on the control and prevention of nosocomial infections. But for the best results it is necessary to continue educate medical personnel about the elementary hygiene rules and norms that are the first step of nosocomial infections prevention.

This paper will discuss the components of the Calgary Family Assessment Model and bringing into context Mrs. P.L., whom two nursing students had the pleasure to interview. This paper will also explain Rolland’s Chronic Family Life Cycle and how this framework links with Mrs. P.L as she is living with

multiple sclerosis

.

Calgary Family Assessment Model

According to Wright and Leahey (2009), “The Calgary Family Assessment Model (CFAM) is an integrated, multidimensional framework…” (p. 47). This model is widely used among nurses for assessing a family in the goal of resolving issues among the family. CFAM is composed of three major categories which include: structural, developmental, and functional. As a nursing student, CFAM was used for assessing Mrs. P.L. who holds the chronic illness of multiple sclerosis (MS).

Structural assessment

As stated in Wright and Leahey (2009), structural assessment is an important category of CFAM as it examines the structural component of the family. These structures can be more closely identified using the three aspects comprised of the internal structure, external structure, and context. To further understand the structure of P.L.’s family, a genogram was made of her family (Appendix A). According to Butler (2008), by viewing at least three generation levels, genograms highlight the family in a broad manner, by showing the individual’s ages, gender, and deaths, for example.

Wright and Leahey (2009) state that internal structure includes six subcategories which include: family composition, gender, sexual orientation, rank order, subsystems, and boundaries. P.L. was asked about her family composition. She answered that her family is composed of her husband whom she lives with, as well as her children who are adults now and live their own lives. When asked about who she would consider her family not related biologically, she responds that it would be her neighbour whom she gets along with quite well. According to P.L., she believes that family is love, understanding and composed of people who can talk with one another. As stated in Weigel (2008), the concept of family and what family means differs from person to person. With P.L., love and understanding are the most important components to her.

P.L. believes that a person is a person no matter which gender they are; we are all people and decide who we want to be. When it comes to the rank order of her children, she has three living children (boy aged 45, girl aged 40, and girl aged 36) and has had three miscarriages (P.L.’s Genogram, Appendix A). When P.L. is having tough times, her husband takes over and she also talks to him with problems she might face.

External structure is divided into extended family and larger systems (Wright & Leahey, 2009). When it comes to P.L.’s extended family, she mentions that she stays in close contact with one of her sisters by visiting at her house every Saturday. To stay in contact with her other siblings, she uses the phone. She also told us that she had a girlfriend whom she was very close to, however, was diagnosed with MS at 43 years old and unfortunately passed away. She was paralyzed neck down and it was a sad moment for P.L. When it comes to P.L., she tells us she was diagnosed with MS at 37 years old and there was no need for adjustments. She also has Menière’s disease; her last episode was three years ago, and Menière’s does not affect her as much as MS does.

Contextual structure is the family background with includes ethnicity, race, social class, spirituality (or religion), and environment (Wright & Leahey, 2009). When asked about her ethnicity, she replies that she was never a cook, but when it comes to traditions, P.L. makes meat pies on the occasions. She also tells us that her mother taught her how to sew and as well passed on her tradition of reading to P.L. She emphasizes that she loves reading with passion.

With social class, P.L. mentions that she moved every three years with her family when she was younger because her father was in the military. Presently, she has been living in the same house for 35 years and says she has no issue or difficulties. She feels that she is in a safe environmental neighborhood. P.L. also says that she is a Catholic; she does not go to church, but prays every night. She loves God and thanks him before going to bed in wishing that nothing more will happen to her. She wishes to God to not get into car accidents as well.

Developmental assessment

Developmental assessment is the second category of the CFAM. Along with the structural assessment, this component is also essential as it explains the family’s developmental life cycle (Wright & Leahy, 2009). Families progress through certain stages of development similar to Erik Erikson’s Theory of the psychosocial developmental stages (Potter & Perry, 2014). There are six stages in the developmental life cycle according to the CFAM and it is clear that P.L. is in the last stage because she is now a grandmother and her children have left the household onto the building of their own lives. Developmental assessment also includes tasks and attachments depending on the developmental stage the family in situated in.

P.L. is in the sixth stage of the developmental life cycle which is named “Families in Later Life” (Wright & Leahy, 2009). Looking back over her life, P.L. says that marriage gave her the most happiness along with her children being all grown up, healthy, and well in their skins. In addition, P.L. feels very fortunate that her MS is not presently severe. Need to add more

Functional assessment

According to Wright & Leahy (2009), functional assessment is the last major category of the CFAM. This component deals with how the individuals in the family deal with one another, known as interaction. The two basic aspects of family functioning include the instrumental and expressive. Instrumental functioning is about routine activities in daily living. For P.L’s health, she tries to walk on the treadmill she owns for about five minutes daily. P.L. mentions that she hopes to shovel the snow until she passes away. Knitting, crocheting, and cleaning the house are all things that P.L. loves doing and mentions in the interview many times how much she loves her house.

She does not like using her illness of MS as an excuse for certain symptoms, but as a precaution, she makes sure not to stand on her feet for too long (preventing postural hypotension). P.L. claims that she has no trouble performing activities of daily living (ADL) unless she is having an episode from the illness. She explains to us when she knows to take it easy. When she wakes up in the morning and sees the image of a cloud in her mind, this signifies her MS and it is a signal for her to be careful. This black imaginary cloud is the only barrier that can stop her from doing things. Last time she has seen this cloud was six months ago and last a couple hours.

She also mentions that she knows her left leg is not as strong as the right one, and takes appropriate measures. P.L. claims she has not been sleeping well, and could be due to her habit of drinking liquids before bed (not alcohol). Although she has not been sleeping well, in the morning she feels rested. (article, knows what to do, understand what she has to do) living with MS

As stated in Wright & Leahey (2009), there are nine aspects included in expressive functioning which were all covered during the interview (emotional, verbal, nonverbal, and circular communication, problem solving, roles, influence and power, beliefs, as well as alliances and coalitions). When asked how she would rank her emotional state, P.L. responded that she is easily bothered, and quite emotional. She is content with where children are at in their lives and is not worried about them. She says, “No news is good news”. P.L. understands that she cannot hold her children on a string, and has to cut it at one point.

When it comes to verbal communication, she has trouble saying what bothers her, so she keeps it to herself. P.L. will not initiate communication because as a child she had no discussions with her parents. Her parents would always tell her to play outside, but her siblings were busy doing their own thing most of the time. Communication was inexistent in her life as a child, and says she would lose herself deep into a book, and deal with her problems by herself. As mentioned earlier, she will not voice opinion and when asked if she would like to better her communication skills, she responded with a quick “yes”.

She emails and calls her son and youngest daughter frequently. P.L.’s ways of showing happiness is to keep mentally active like going on the computer and playing games. This would be nonverbal communication. She tells us she is usually happy all the times unless something bothers her. In addition, she believes that her husband does not notice when she gets upset. She also admits that she does not find holding her emotions back lead to greater distress.

When it comes to circular communication, P.L. avoids conflict to refrain from confrontation. She refrains because she claims it helps her deal with the situation. As mentioned earlier, she has difficulty voicing her opinion and trouble vocalizing emotions which can be a difficult time for her when confronted. P.L. feels she will yell and get mad if she wants to voice her opinion and know that it does not help by yelling.

Her problem solving strategies include thinking and reflecting. She will think on what she feels and how she will say what she want to say. When conflict arises, she leaves someone else to problem solve and mentions that she has always been a good listener. When asked what her roles were in her family, she replied being a mother, teacher, listener, and friend.

When it comes to influence and power, she is asked what she feels her responsibilities are as a mother, grandmother, sister, and wife. She replies that her role as a mother was to teach her children to be individuals. As a grandmother, she felt she had a big influence on the grandchildren, and says that she had the same relationship with her grandkids as with her own children. As a sister, P.L. says that she is distant from many siblings, always felt like a loner and was bullied. As a wife, she tells us she has the same love for him than with anyone else.

What she believes since she has learned from being diagnosed with MS is that she was relieved; the doctors had put a label on it and they would take care of it, if something had to be done. The most helpful information she has found out about dealing with MS is looking in a medical book she owns, as well as the Internet and information sheets her daughter would print. She was happy that a name could be put on her condition so that she knew what it was that she was living with. In addition, she believes that her belief in God has helped her cope during difficult times and claims that God helps her do all the things she wants to do and gives her the opportunity to go about her day every day.

Lastly, she believes that her and her husband’s message went across to the children. If there are arguments between family members, P.L.’s husband would be more likely to help resolve the issue or attempt to intervene. When asked if she thinks she has any influence on how close or distant her family is, she says that their love holds them together, and that it is carried on through the generations. She also enjoys that her family is in Cornwall, and that her children have their own lives.

Rolland’s Conceptual Framework

As Rolland (1987) states, chronic illnesses can be categorized according to four key dimensions that have an impact on the family system: onset, course, outcome, and degree of incapacitation. It is important to understand Rolland’s conceptual framework in order to identify where the person with a chronic illness is precisely situated on the two-dimensional matrix (Appendix B).

One must first understand the chronic illness. As mentioned earlier, P.L. suffers from multiple sclerosis. According to Hendrickson, Elms, and Shaw (2010), multiple sclerosis (MS) is a chronic disorder which 55,000 to 75,000 Canadians suffer from.

MS may affect vision, hearing, memory, balance and mobility. (Source: MS Society of Canada). There is an estimated 55,000 to 75,000 Canadians presently living with this disease (Source: PHAC).

? P.L. mentions that she will always be there for her children and the most important lesson taught that still remains, is to care for one another and everyone. ?

http://www.phac-aspc.gc.ca/cd-mc/ms-sp/what-quest-eng.php

http://www.mssociety.ca

Medical-Surgical Lewis book

Nurses and Families Wright book

Butler, J. F. (2008). The Family Diagram and Genogram: Comparisons and Contrasts. American Journal Of Family Therapy, 36(3), 169-180. doi:10.1080/01926180701291055

Weigel 2008

Communication is a vital part of the nurses role. Theorists such as Peplau (1952), Rogers (1970) and King (1971) all emphasise therapeutic communication as a primary part of nursing and a major focus of nursing practice. Long (1992) further suggests that communication contains many components including presence, listening, perception, caring, disclosure, acceptance, empathy, authenticity and respect. Stuart and Sundeen (1991, p.127) warn that while communication can facilitate the development of a therapeutic relationship it can also create barriers between clients and colleagues.

Within Healthcare, communication may be described as a transitional process that is dynamic and constantly changing (Hargie, Saunders and Dickenson, 1994, p.329). It primarily involves communication between the nurse and the patient. If the interaction is to be meaningful, information should be exchanged; this involves the nurse adopting a planned, holistic approach which eventually forms the basis of a therapeutic relationship.

Fielding and Llewelyn (1987) contend that poor communication is the primary cause of complaints by patients. This is supported by Young (1995) who reports that one third of complaints to the Health Service Commissioner were related to communication with nursing staff. Studies by Boore (1979) and Devine and Cook (1983) demonstrate that good communication actually assisted the rate of patient recovery thus reducing hospital admission times. This suggests that good communication skills are cost effective.

In this assignment, I have reflected on situations that have taken place during my clinical work experience. These situations have helped to develop and utilise my interpersonal skills, helping to maintain therapeutic relationships with patients. In this instance, I have used Gibbs’ (1988) reflective cycle as the framework for my reflection.

Gibbs’ (1988) reflective cycle consists of six stages in nursing practice and learning from the experiences.

Description of the situation that arose.

Conclusion of what else would I could have done.

Action plan is there so I can prepare if the situation rises again.

Analysis of the feeling

Evaluation of the experience

Analysis to make sense of the experience

My Reflective Cycle

Baird and Winter (2005) illustrate the importance of reflective practice. They state that reflecting will help to generate knowledge and professional practice, increase one’s ability to adapt to new situations, develop self esteem and greater job satisfaction. However, Siviter (2004) explains that reflection is about gaining self confidence, identifying ways to improve, learning from one’s own mistakes and behaviour, looking at other people’s perspectives, being self aware and making future improvements by learning from the past. I have come to realise that it is important for me to improve and build therapeutic relationships with my patients by helping to establish a rapport through trust and mutual understanding, creating the special link between patient and nurse as described by Harkreader and Hogan (2004). Peplau (1952), cited in Harkreader and Hogan (2004), notes that good contact in therapeutic relationships builds trust as well as raising the patient’s self esteem, often leading to the patient’s personal growth. Ruesh (1961), cited in Arnold and Boggs (2007), states that the purpose of therapeutic communication is to improve the patient’s ability to function. Therefore, in order to establish a therapeutic nurse/patient interaction, a nurse must possess certain qualities e.g. caring, sincerity, empathy and trustworthiness (Kathol, 2003) (P.33). These qualities can be expressed by promoting effective communication and relationships by the implementation of interpersonal skills. Johnson (2008) defines interpersonal skills as the ability to communicate effectively. Chitty and Black (2007, p 218) mention that communication is the exchange of information, thoughts and ideas via simultaneous verbal and non verbal communication. They explain that while verbal communication relies on the spoken word, non-verbal communication is just as important, consisting of gestures, postures, facial expressions, plus the tone and level of volume of one’s voice. Thus, my reflection in this assignment is based on the development of therapeutic relationships between the nurse and patient using interpersonal skills.

My reflection is about a particular patient, to whom, in order to maintain patient information confidentiality (NMC, 2004), I will refer to as Mr R. It concerns an event which took place when I was working on a surgical ward. Whilst there were male and female wards, female and male surgical patients were encouraged mingle. On this particular day, I noticed that one of the male patients was sitting alone on his bed. This was Mr R., a 64 year old gentleman who had been diagnosed with inoperable cancer of the pancreas, with a life expectancy of 18-24 months. He was unable to control his pain, and whilst some relief could be provided by chemotherapy, Mr R. had a good understanding of his condition and knew that there was no cure available. He was unable to walk by himself and always needed assistance even to stand up or sit down. Because of his mobility problems I offered to get him his cup of tea and I then sat with him as he was lonely.

I would now like to discuss the feelings and thoughts I experienced at the time. Before I gave Mr R. his cup of tea, I approached him in a friendly manner and introduced myself; I tried to establish a good rapport with him because I wanted him to feel comfortable with me even though I was not a family member or relative. When I first asked Mr R. if I could get him a cup of tea, he looked at me and replied “I have asked the girl for a cup of tea, I don’t know where she is.” I answered “Well, I will see where she is and if I can’t find her, I will gladly get one for you Mr R”. In doing this, I demonstrated emphatic listening. According to Wold (2004, p 13), emphatic listening is about the willingness to understand the other person, not just judging by appearance. Then I touched MrR.’s shoulders, kept talking and raised my tone a little because I was unsure of his reaction. At the same time, I used body language to communicate the action of drinking. I paused and repeated my actions, but this time I used some simple words which I though Mr R. would understand. Mr R. looked at me and nodded his head. As I was giving him his cup of tea, I maintained eye contact as I didn’t want him to feel shy or embarrassed.

Fortunately, using body language helped me to communicate with this gentleman. At the time I was worried that he would be unable to understand me since English is not my first language but I was able to communicate effectively with him by verbal and non-verbal means, using appropriate gestures and facial expressions. Body language and facial expressions are referred to as a non-verbal communication (Funnell et al. 2005 p.443). I kept thinking that I needed to improve my English in order for him to better understand and interpret my actions. I thought of the language barrier that could break verbal communication. Castledine (2002, p.923) mentions that the language barrier arises when individuals come from different social backgrounds or use slang or colloquial phrases in conversation. Luckily, when dealing with Mr R. the particular gestures and facial expressions I used helped him to understand that I was offering him assistance. The eye contact I maintained helped show my willingness to help him; it gave him reassurance and encouraged him to place his confidence in me. This is supported by Caris-Verhallen et al (1999) who mention that direct eye contact expresses a sense of interest in the other person and provides another form of communication. In my dealings with Mr R., I tried to communicate in the best and appropriate way possible in order to make him feel comfortable; as a result he placed his trust in me and was more co-operative.

Evaluation

In evaluating my actions, I feel that I behaved correctly since my actions gave Mr R. both the assistance he needed and provided him with some company. I was able to successfully develop the nurse-patient relationship. Although McCabe (2004, p-44) would describe this as task centred communication – one of the key components missing in communication by nurses – I feel that the situation involved both good patient and task centred communication. I feel that I treated Mr R. with empathy because he was unable to perform certain tasks himself due to his mobility problems and was now refusing chemotherapy. It was my duty to make sure he was comfortable and felt supported and reassured. My involvement in the nurse-patient relationship was not restricted to task centred communication but included a patient centred approach using basic techniques to provide warmth and empathy toward the patient.

I found that I was able to improve my non-verbal communication skills in my dealings with Mr R. When he first mentioned having chemotherapy, he volunteered very little information, thus demonstrating the role of non-verbal communication. Caris-Verhallen et al (1999, p.809) state that the role of non-verbal communication becomes important when communicating with elderly people with incurable cancer (Hollman et al 2005, p.31)

There are a number of effective ways to maximise communication with people, for example, by trying to gain the person’s attention before speaking – this makes one more visible and helps to prevent the person from feeling intimidated or under any kind of pressure; the use of sensitive touch can also make them feel more comfortable. I feel that the interaction with Mr R. had been beneficial to me in that it helped me to learn how to adapt my communication skills both verbally and non-verbally. I used body language to its full effect since the language barrier made verbal communication with Mr.R. difficult. I used simple sentences that Mr R. could easily understand in order to encourage his participation. Wold (2004, p.76) mention that gestures are a specific type of non-verbal communication intended to express ideas; they are useful for people who have limited verbal communication skills.

I also used facial expressions to help encourage him to have chemotherapy treatment which might not cure his problem but would give him some relief and make him feel healthier. Facial expressions are the most expressive means of non-verbal communication but are also limited to certain cultural and age barriers (Wold 2004 p.76). My facial expressions were intended to encourage Mr R. to reconsider his decision with regard to chemotherapy treatment. Whilst I could not go into all the details about his treatment, I was able to advise him to complete his treatment in order to alleviate his symptoms.

Analysis

In order to analyse the situation, I aim to evaluate the important communication skills that enabled me to provide the best level of nursing care for Mr R. My dealings with Mr R. involved interpersonal communication i.e. communication between two people (Funnell et al 2005, p-438).I realised that non-verbal communication did help me considerably in providing Mr R. with appropriate nursing care even though he could only understand a few of the words I was speaking. I did notice that one of the problems that occurred with this style of communication was the language barrier but despite this I continued by using appropriate communication techniques to aid the conversation. Although it was quite difficult at first, the use of non verbal communication skills helped encourage him to speak and also allowed him to understand me.

The situation showed me that Mr R. was able to respond when I asked him the question without me having to wait for an answer he was unable to give. Funnell et al (2005, p 438) point out that communication occurs when a person responds to the message received and assigns a meaning to it. Mr R. had indicated his agreement by nodding his head. Delaune and Ladner (2002, P-191) explain that this channel is one of the key components of communication techniques and processes, being used as a medium to send out messages. In addition Mr R. also gave me feedback by showing that he was able to understand the messages being conveyed by my body language, facial expression and eye contact. The channels of communication I used can therefore be classed as both visual and auditory. Delaune and Ladner (2002 p.191) state that feedback occurs when the sender receives information after the receiver reacts to the message, however Chitty and Black (2007, p.218) define feedback as a response to a message. In this particular situation, I was the sender who conveyed the message to Mr R. and Mr R. was the receiver who agreed to talk about his chemotherapy treatment and allowed me to assist. Consequently I feel that my dealings with Mr R. involved the 5 key components of communication outlined by Delaune and Ladner (2002, p.191) i.e. senders, message, channel, receiver and feedback.

Reflecting on this event allowed me to explore how communication skills play a key role in the nurse and patient relationship in the delivery of patient-focussed care. Whilst I was trying to assist Mr R. when he was attempting to walk, I realised that he needed time to adapt to the changes in his activities of daily living. I was also considering ways of successful and effective communication to ensure a good nursing outcome. I concluded that it was vital to establish a rapport with Mr R. to encourage him to participate in the exchange both verbally and non-verbally. This might then give him the confidence to communicate effectively with the other staff nurses; this might later prevent him from being neglected due to his age or his inability to understand the information given to him about his treatment and the benefits of that treatment.

I have set out an action plan of clinical practice for future reference. If there were patients who needed help with feeding or with other procedures, I would ensure that I was well prepared to deal patients who weren’t able to communicate properly. This is because, as a nurse, it is my role to ensure that patients are provided with the best possible care. To achieve this, I need to be able to communicate effectively with patients in different situations and with patients who have differing needs. I need to communicate effectively as it is important to know what patients need most during there stay on the ward under my supervision. Whilst I have a lot of experience in this field of practice, communication remains a fundamental part of the nursing process which needs to be developed in nurse-patient relationships. Wood (2006, p.13) states that communication is the key to unlock the foundation of relationships. Good communication is essential if one is to get to know a patient’s individual health status (Walsh, 2005, p.30). Active learning can also help to identify the existence of barriers to communication when interacting with patients. Active learning means listening without making judgements; I always try to listen to patients’ opinions or complaints since this gives me the opportunity to see the patients’ perspective (Arnold, 2007, p.201). On the other hand, it is crucial to avoid the barriers that occur in communication with the patients and be able to detect language barriers. This can be done by questioning patients about their health and by asking them if they need help in their daily activities. I set about overcoming such barriers by asking open-ended questions and interrupting when necessary to seek additional facts (Funnell et al, 2005, p.453).

Walsh (2005, p.31) also points out that stereotyping and making assumptions about patients, by making judgements on first impressions and a lack of awareness of communication skills are the main barriers to good communication. I must not judge patients by making assumptions on my first impression but should go out of my way to make the patient feel valued as an individual. I should respect each patient’s fundamental values, beliefs, culture, and individual means of communication (Heath, 300, p.27). I should be able to know how to establish a rapport with each patient. Cellini (1998, p.49) suggests a number of ways in which this can be achieved, including making oneself visible to the patient, anticipating patients’ needs, being reliable, listening effectively; all these factors will give me guidelines to improve my communication skills. Another important factor to include in my action plan is the need to take into account any disabilities patients may have such as poor hearing, visual impairment or mental disability. This could help give the patient some control and allow them to make the best use of body language.

Once I know that a patient has some form of disability, I will be able to prepare a course of action in advance, deciding on the most appropriate and effective means of communication. Heath (2000, p.28) mentions that communicating with patients who have an impairment requires a particular and certain type of skill and consideration. Nazarko (2004, p.9) suggests that one should not repeat oneself if the patient is unable to understand but rather try to rephrase what one is saying in terms they can understand e.g. try speaking a little more slowly when communicating with disabled people or the hard of hearing. Hearing problems are the most common disability amongst adults due to the ageing process (Schofield. 2002, p.21).

In summary, my action plan will show how to establish a good rapport with the patient, by recognising what affects the patients’ ability to communicate well and how to avoid barriers to effective communication in the future.

Conclusion

In conclusion, I have outlined the reasons behind my choosing Gibbs’ (1988) reflective cycle as the framework of my reflection and have discussed the importance of reflection in nursing practice. I feel I have discussed each stage of the cycle, outlining my ability to develop therapeutic relationship by using interpersonal skills in my dealings with one particular patient. I feel that most parts of the reflective cycle (Gibbs 1988) can be applied to the situation on which I have reflected. Without the model of structured reflection I do not feel I would have had the confidence to consider the situation in any depth (Graham cited in Johns 1997 a, p.91-92) and I fear reflection would have been remained at a descriptive level. I have been able to apply the situation to theory; as Boud Keogh & Walker (1985, p.19) explain that reflection in the context of learning is a generic term for those intellectual and effective activities whereby individuals engage to explore their experiences in order to lead to a better understanding and appreciation. Boyd & Fales (1983, p.100) agree with this and state that reflective learning is the process of internally examining and exploring an issue of concern, trigged by an experience that creates and clarifies meaning in terms of self and which results in a changed conceptual perspective. However, I personally believe that the reflective process is merely based on each individual’s own personality and beliefs as well as their attitude and approach to the life.

Appendix

Mr R., a 64 year old gentleman, was an inpatient on a surgical ward. Earlier that day his consultant had directly informed him that he had inoperable cancer of the pancreas with a life expectancy of 18-24 months. Some relief might be offered by chemotherapy, but there was no cure. Mr R. was understandably shocked, but had suspected the diagnosis. At that time he remained in the care of the specialist nurse. Later in the day, as I was passing through the ward, I notice Mr. R. alone on his bed.

Prescriptive

A prescriptive intervention seeks to direct the behaviour of the client, usually behaviour that is outside the client-practitioner relationship. My first intervention was to open the conversation and demonstrate warmth. I provided information myself and gave Mr R. the choice of staying on his own or engaging with me. By shaking Mr R.’s hands I was attempting to provide reassurance and support as well as communicating warmth in order to reduce his anxiety and promote an effective nurse-patient relationship.

Practitioner: Hello Mr. R, I am one of the nurses here this morning with Dr. M. Is there anything I can get you or would you rather be on your own? (Shook hands).

Mr. R: NO, I remember you from this morning, come and sit down. I’ve asked the girl for a cup of tea, I don’t know where she’s got to.

Practitioner: Well give me a minute and I’ll bring you one in. Do you take sugar?

Mr. R: I suppose I shouldn’t, then why worry. Two please.

Practitioner: (Returning with a cup of tea) Here we are, don’t blame me if it’s horrible, I got it from the trolley. (I smiled at Mr.R. and tried to establish eye contact, then sat down in the chair next to him).

Mr. R: Thanks, that’s just what I need.

2. Informative

An informative intervention seeks to impart knowledge, information and meaning to the patient. My intention was to reinforce the nurse-patient relationship by smiling and attempting to establish eye contact as well as using facial expressions to put the patient at ease and establish a good rapport. By making Mr. R a cup of tea it created a pleasant response in a time of crisis.

Practitioner: Jane (specialist nurse) was here this morning, what did you think about what she had to say?

Mr. R: Oh yes she was very nice, mind you I’m an old hand at this, I looked after my wife when she had cancer.

Mr. R: She was riddled with cancer, but we kept her at home and looked after her. She could make a cracking cup of tea (Mr.R. smiles)

Practitioner: (smiles and nods) When did she pass away?

3. Confronting

A confronting intervention seeks to raise the client’s consciousness about limiting behaviour or attitudes of which they are relatively unaware. By meeting the patients’ needs at that time I felt the urge to continue to show a display of warmth and develop the relationship further.

Mr. R: It will be two years next month that she died.

Practitioner: You must miss her.

Mr. R: There’s not a day goes by that I don’t talk to her. Goodness knows what she would make of all this, it’s brought it all back.

4. Cathartic

A cathartic intervention seeks to enable the client to discharge/react to a painful emotion – primarily grief, fear and/or anger. Mr. R spoke emotively and angrily by using such words as ‘riddled’ and ‘cancer’. He spoke loudly and angrily with congruent non-verbal cues.

Practitioner: Has what you’ve been discussing with Jane reminded you of your wife’s death?

Mr. R: Yes, (patient covers his face with his hands).

Practitioner: What is it about what you’ve heard that is worrying you, do you think you can tell me?

5. Catalytic

A catalytic intervention seeks to elicit self-discovery, self direct living, learning and problem solving in the client. Mr. R had a broad scope in which to discuss any concerns he may have had, but his response only concerned his wife, not him as his wife was the one who suffered from cancer.

Mr. R: (Pause)………..I’m an old hand at this and I don’t want any of that chemo.

Practitioner: What is it about the chemotherapy you don’t like?

Mr. R: My wife had it and we went through hell.

Practitioner: You went through hell

Mr. R: The doctors made her have the chemo and she still died in agony.

6. Supportive

A supportive intervention seeks to affirm worth and value of the client’s person, qualities, attitudes and actions. It is done to encourage the client to say more and to explore the issue further. Support is provided by non-verbal means like giving warmth, supportive posture and maintaining eye contact. I wanted to convince Mr. R that I was interested in what he had to say and help him believe that he was worth listening to – that his opinions really mattered.

Practitioner: Do you think the same thing will happen to you?

Mr. R: Yes, that’s the one thing I’m worried about.

Practitioner:.em, if I’m honest with you chemotherapy treatment is not a subject I know a lot about. (Pause), would you like to see the specialist nurse again? She can go over things with you and explain your options.

Mr. R Well if she doesn’t mind, I’m just not sure the chemo will be worth it.

Learning outcomes

From this experience, I have learned the importance of:-

Practice in accordance with the NMC (2004) code of professional conduct, performance, when caring for adult patients including confidentially, informed consent, accountability, patient advocacy and a safe environment.

Demonstrating fair and anti-discriminatory behaviour, acknowledging differences in the beliefs, spiritual and cultural practices of individuals.

Understanding the rationale for undertaking and documenting, a comprehensive, systematic and accurate nursing assessment of physical, psychological, social and spiritual needs.

Interpreting assessment data to prioritise interventions in evidence based plan of care.

Discussing factors that will influence the effective working relationships between health and social care teams.

Demonstrating the ability to critically reflect upon practice.