Neonatal Hypothermia and Neonatal Sepsis: Nursing Case Study

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Introduction

Nursing profession is one of the most rewarded profession, and nursing neonates is highly challenging. Neonates are a specialised cohort of patients requiring an individualised approach in nursing care and the provision of a thermoneutral environment is a corner stone of neonatal care.The Marks-Maran and Rose’s (1997) reflective model and will guide my reflection and analysis of an experience gained in the special care baby unit. This reflective model has four parts: incident, reflective observation, related theory, and future action. In view of confidentiality and anonymity, the baby will be named Andy as per the guidelines determined by Nursing and Midwifery Council, 2018.


The Incident

In one of my shifts, I was tasked to care for baby Andy, 28+4 weeks at birth, weighing 1.240kg, delivered by emergency Caesarian section.  At the time of incident Andy is 8 weeks old with current weight of 1.960kg. Andy is admitted due to prematurity and chronic lung disease. Was nursed in a cot ,well thermoregulated and on Full enteral feeds. Knowing the history of Andy, I performed all the safety checks and prepared the plan of care.

During the mid afternoon it was noticeable that Andy was a bit sleepy, less active, neither woke up crying for feed nor cried during the cares. Andy looked lethargic which was quite unusual to him. I monitored his observations, comparing the baseline data,I noted that his temperature was 36.6 degree centigrade ,which was a decline from 37 degree centigrade. Heart rate was recorded between 110-110beats per minute and the respiratory rate was 62 breaths per minute. I dressed Andy well, covered him with a blanket and re assessed him as per unit guidelines.The temperature instability, reduced heart rate and level of activity prompt me to escalate this incident to the nurse in charge and the doctors. I ensured that parents were updated about the clinical condition of Andy.   Eventually the doctors informed the parents about the possibility of Andy having sepsis due to significant temperature instability. Bloods were taken in order  to rule out sepsis, Furthermore Andy was commenced on Intravenous antibiotic therapy.


Thoughts and feelings

When I was been allocated Andy, I thought it would be a straightforward plan of care.  Being aware of the history, I was quite confident that min is coping well with the baby. I was looking forward to prepare mum to room in the unit so that the transition to going home will be easier for mum and baby. Premature babies have poor thermal stability, that poses a greater risk for respiratory distress and hypothermia (Smith L.S ,2004). This incident made me confused with the signs and symptoms of hypothermia related to sepsis. I was also unsure if I need to escalate these findings for further management. This reflection sought to understand the clinical manifestation of hypothermia and sepsis and be assertive in decision making.




Related Theory


Cinar and Filiz (2006) explained that the ability to balance heat production and heat loss in order to maintain body temperature within a normal range is called thermoregulation.Thermoregulation or temperature control in the neonate is a critical physiological function that is strongly influenced by physical immaturity,  of illness and  environmental factors (Thomas, 1996). Furthermore Preterms have decreased capability to maintain homeostasis therefore are extremely vulnerable to body temperature variations.Neonates have decreased subcutaneous fat, a thin Epidermis , a greater body surface related to body mass and also the fact that the blood vessels being closer to the skin surface makes the infant vulnerable for temperature instability (SmithL.S, 2004). In addition newborns are especially susceptible to serious infections (McKenzie,1998).Small infants like Andy with large surface area in relation to body weight tends to loose heat rapidly therefore highly prone to acquire neonatal sepsis. Another reason for underdeveloped thermoregulation is due to the excessive heat loss, about four times more when compared to adults . This is primarily due to the lack of ability to generate heat from shivering, their hypothalamus can be slow to respond to the changes in temperature, and decreased brown fat deposits which is primary source of thermoregulation. (Lodewig et al,1998).Since Andy was born preterm poses a great risk for depleting brown fat stores. According to Çinar and Filiz (2006) neonatal hypothermia is defined as a drop of temperature below 36.5 ºC.

Managing Andy’s hypothermia was the prime objective. It is essential that neonates are nursed within their neutral thermal environment.Waldron and Mackinnon (2007),defined Neutral thermal environment as the environment or the air temperature which an infant with normal body temperature has a minimal metabolic rate and therefore minimal oxygen consumption. Robin knobel (2014) dictates that Neutral thermal environment can be maintained by using radiant warmers, incubators, heated mattress or by skin to skin contact. Radiant warmers increase convective and evaporative heat loss and insensible water loss but eliminate radiant heat loss. The major advantage of radiant warmer is the easy access it provided without disturbing the thermal environment (Bell,1983).with this view point Andy was put under radiant warmer.

Also heat can be lost due to environmental factors . The four ways that heat loss is most common are conduction, when skin comes in direct contact with cold surface; convection , involves heat loss from infant to cold air. Heat loss from radiation involves heat loss to other objects not in direct contact, and evaporative heat loss occurs when fluid evaporates from wet skin into the air(Ellis,2005).There could be a possibility that Andy might be on a wet nappy or a wet bed resulting in heat loss by evaporation. It could also be due to convective heat loss if he was exposed to cold air or left undressed. I noticed that any was nursed in a cot close to the window. Likewise the cold windowpanes could have contributed to heat loss due to radiation.Also conductive heat loss , if Andy was wearing cold clothes or was handled with cold hands. Vital signs were checked continuously to monitor for effectiveness of the interventions. If left untreated Preterm small babies are more likely to experience circulatory, respiratory, thermal and glycemic compromise (Petty.J, 2010).

On the other hand, Sepsis can be life-threatening for infants during the first year of life as a result of weak immune system or any other illness. Since Andy was born before term, prematurity could result in underdeveloped immune system making him prone to develop neonatal infections. Saez-Lopez , Guiral and Soto (2013 )states that Neonatal sepsis can be subdivided sepsis related to age and onset of symptoms .It includes Early-onset neonatal sepsis which occurs within 72 hours of life and late-onset neonatal sepsis at 4 to 90 days of life. Andy being  8weeks old , he could be classified under late- onset  sepsis. According to Brenda (2008), sepsis is more likely to occur in infants who have a low birth weight,Infants who were born with a low APGAR score or Infants whose mother has certain risk factors (such as a low socioeconomic status or premature rupture of the membranes) . In addition, clinical manifestation of neonatal sepsis usually include temperature instability, respiratory problems, apnea, feeding intolerance. However Andy presented with temperature instability , lethargy and poor feeding. According to Polin R.A(2009) the diagnosis of late-onset sepsis is more problematic. It is a high incidence disease, and unlike early-onset sepsis (which more commonly affects term and near-term infants), late-onset sepsis occurs in preterm infants like Andy who are hospitalized for extended periods of time . Since Andy was in the Neonatal unit for 8 weeks he was prone to develop late-onset sepsis. Davies (2012),discussed that neonatal sepsis is  diagnosed based on a combination of clinical presentation; blood CSF and urine cultures; the use of nonspecific markers, including C-reactive protein and procalcitonin (where available) and X-ray. Blood and CSF culture, urine microscopy,  blood cell count C-reactive protein and X-Ray was performed on Andy .

Infants with suspected late onset infection are typically treated with empiric broad spectrum antibiotics while blood culture results are pending (Rubin et al ,2002). A variety of diagnostic tests (complete blood count, acute phase reactants) are commonly obtained, and antibiotics are continued or discontinued based on the results of the laboratory testing, degree of clinical improvement and cultures.Empiric antibiotic treatment varies between neonatal intensive care units and countries. A Combination of glycocopeptide with cephalosporins is most preferred antibiotic regime. Andy received Vancomycin which is a glycopeptide antibiotic and cefotaxime as per the unit guidelines .Punnoose, et al. (2012), stated that antibiotics should not be used without a proven bacterial infection. The usage of broad-spectrum antibiotics in the neonatal intensive care unit is a serious issue, because it promotes the development of resistant flora, prolongs hospitalization and increases costs (Polin.R,2009).However, As stated by Stoll et.al(2002) late-onset sepsis remains an important risk factor for death among VLBW preterm infants and for prolonged hospital stay among VLBW survivor.Also Voller and Myers (2016) explains  that there’s an improved outcome for neonates with sepsis if there are a prompt diagnosis and management, thus, treating Andy with a diagnosis of suspected sepsis is indeed proper.  Strategies to reduce late-onset sepsis and its medical, social, and economic toll need to be addressed urgently.

To put it into a nutshell , The neonate’s susceptibility to temperature instability needs to be recognised and understood in order to appropriately manage and limit the effects of cold or heat stress (Smith, Alcock and Usher, 2013).Therefore maintaining the thermoneutral environment for sick and premature newborn infants is a key part of the nurse’s role on the neonatal unit as a abnormal temperature is strongly associated with adverse outcome.By choosing and using proper equipment for infant based on his condition and gestational age, we may be able to provide effective and efficient care. In addition nurses play curial role and prime position in the early recognition, diagnosis and treatment of sepsis thus contributing to reduced the morbidity and mortality rate .


Future Action

From this experience I am now more mindful of the importance of proper nursing assessment and ensuring that information is passed on to the doctors and staffs for effective implementation and management. It encouraged me to read more about Hypothermia and neonatal sepsis. I could have acted immediately considering the best interest of Andy. The insight that I have gained from this reflection improved my knowledge, skills and attitude towards neonatal  nursing. In future I aim to be more proactive in dealing with a situation and doing timely referrals.If in doubt I will approach the senior nurses if something appears different in terms of delivering nursing care.Furthermore, I will consider reviewing the history of the patient as this could be very helpful and be a basis of the plan of care. It is obvious that prematurity may cause many potential problems to the neonate so it is necessary as a healthcare professional to be able to foresee these challenges and be prepared for untoward incidents.


References

  • Bell, E.F.(1983).‘Infant incubators and radiant warmers. Early Hum Dev’. 1983. 8(3-4) pp.351.
  • Çinar, N. D. and Filiz, T. M.(2006).‘Neonatal Thermoregulation’, Journal of Neonatal Nursing, 12(2), pp.69-74.
  • Marks-Maran, D. and Rose, P. (1997). Reconstructing Nursing: Beyond Art and Science. London: Balliere Tindall.
  • National Health Service/NHS (2017) Hypothermia. Available at: https://www.nhs.uk/conditions/hypothermia/ (Accessed: 26 December 2018).
  • National Institute for Health and Care Excellence/NICE Guideline (2017) Sepsis: recognition, diagnosis and early management. Available at: https://www.nice.org.uk/guidance/ng51/chapter/recommendations#risk-factors-for-sepsis (Accessed: 26 December 2018)
  • Nursing and Midwifery Council/NMC (2018) The Code. Available at: https://www.nmc.org.uk/standards/code/read-the-code-online/ (Accessed: 26 December 2018)
  • Polin, R.A. (2012) ‘Management of neonates with suspected or proven early-onset bacterial sepsis’, Pediatrics, 129 (5), pp.1006-1015.
  • Polin,R.A.(2009).’The Ins and Outs of Neonatal Sepsis’.Pediatrics,135(7),pp.2-3.
  • Punnoose, A. et al. (2012).‘Antibiotic Resistance’, JAMA, 308(18), pp.1934.
  • Roychoudhury.S and Yussef.k(2017).’Thermoregulation:Advance in preterm infants’.Neoreviews,18(12).
  • Rubin L.G,et al (2002).’Evaluation and Treatment of Neonates with suspected late-onset sepsis’.Pediatrics,110(4),pp.4-7.
  • Saez-Lopez E,Guiral E and Soto S.M(2013).’Neonatal Sepsis by Bacteria:A Big Problem for Children.,Clin Microbial 2(6),pp.1-4.
  • Simonsen K.A, Anderson-Berry A.L and Davies H.D(2014).’Early-onset neonatal sepsis’.27(1),pp.21-47.
  • Smith L.S.(2004).’Temperature monitoring in newborns:A comparison of thermometer and measurement sites’.12(5),pp.157-164.
  • Stoll B.J, Hansen N and Fanaroff A.A .et al.(2002).’Late onset sepsis in very low birth weight neonates’.Pediatric 110(2002),pp.285.
  • Tesini B.L.(2008).’Neonatal Sepsis’.Available at : https://www.urmc.rochester.edu/people/27205648-brenda-l-tesini.
  • Voller, S. and Myers, P. (2016) ‘Neonatal Sepsis’, Clinical Pediatric Emergency Medicine, 17(2), pp. 129-133.
  • Waldron S and Mackinnon R.(2007).’Neonatal Thermoregulation ‘.Infant 3(3),pp.101-103.
  • World Health Organization. (2003). Managing newborn problems: a guide for doctors, nurses, and midwives. Geneva: World Health Organization.

Also read: How to Write a Nursing Case Study Paper

Examining Models of Reflection on Leadership and Management

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“The final test of a leader is that he (sic) leaves behind him in other men the conviction and the will to carry on.”

[Lippmann , 1945]

The quote from Walter Lippmann above highlights a major part of what a leadership entails. The ability to inspire others to carry on with work once we have moved on or are not there to lead ourselves is a skill that many of us have to work hard to acquire. Being a leader is not as easy as it sounds. Sometimes a leader has to make unpopular decisions for the good of all. How this is achieved is also a skill that good leaders display.

The leadership styles in management also vary on the type of people that the leader works with. Some need the iron fist, others need the velvet glove. Leadership styles in management hinge on two things, the leader himself and the people around him. The leadership style which the leader chooses ought to ideally be the one which will help him extract the best out of the people around him. So having said that, here are the dominant leadership styles in management.. Good leaders are made not born. If the one have the desire and willpower, he can become an effective leader. Good leaders develop through a never ending process of self-study, education, training, and experience (Jago, 1982). While leadership is learned, the skills and knowledge processed by the leader can be influenced by his or hers attributes or traits, such as beliefs, values, ethics, and character. Knowledge and skills contribute directly to the process leadership, while the other attributes give the leader certain characteristics that make him or her unique.

Leadership and management are essential skill for all qualified healthcare professionals. when leadership comes to nursing, it is recognised that nurses  who have leadership capabilities can improve motivational levels of others in the work environment, this helps nurses to have a positive attitudes about their work, and to run their daily tasks and responsibilities more effectively. Treat the patients and other staff members with respect, and be able to reach personal goals and objectives. It involves an individual’s efforts to influence the behaviour of others in providing direct individualised one in that the primary responsibilities of the nurse and health care personnel’s in the delivery of nursing care. The process of leadership and management are based on a scientific approach called problem solving method. The function of these scientific method is to increase the probability of success for a nurse manager’s action, given the particulars of a unique environment. In a typical nursing environment, there are staff members, clients, managers, situational variables such as polices and norms, and material resources, there are unique science it would be impossible to find this exact environment in another place or time. The goal of nurses manager is to identify the environment’s resources and put them to work as a whole system in accomplishing goals and facilitating growth.

“Reflection involves describing, analysing and evaluating our thoughts, assumptions, beliefs, theories and action” [Fade 2005]

The educationalist and philosopher John Dewey developed his ideas on thinking and learning and focused on the concept of thinking reflectively, defining it as; ” Active persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends” [Dewey 1933.p 9]

He says reflective thinking as a thinking with a purpose and focused strongly on the need to test out and challenge true beliefs by applying the scientific method through deductive reasoning and experimentation. He implied the emotions and feelings are part of reflective thinking but , interestingly, this is not something on which he expanded. He made some important assumptions about people emphasising our tendencies towards quick solutions, tradition and ‘mental ruts’ and the pervading influence of culture and the environment upon our thinking. He also emphasised the need the need for thinking to be directly linked with action, demonstrating the pragmatic nature of his philosophy, and suggested that any thinking can be intellectual. Thus emphasising the importance of practical as well as the theoretical.

Reflection starts with the individual or group and their own experiences and can result, if applied to practice, in improvement of the clinical skills performed by the individual through new knowledge gained on reflection. Clamp (1980) noted that nurses’ attitudes largely govern how care is administered to their client and the commonest causes of poor care are ignorance and inappropriate attitudes. This process of reflection, if then related into practice, can assist the individual in gaining the required knowledge, leading to a potential improvement in the quality of the care received from that individual. The outcome of reflection as identified by Mezirow (1981) is learning. Louden (1991) describes in ordinary language reflection as serious and sober thought at some distance from action and has connotations similar to “meditation” and “introspection “. It is a mental process which takes place out of the stream of action, looking forward or (usually) back to actions that have taken place.

Reflective Practice

Reflective practice is associated with learning from experience, and is viewed as an important strategy for health professionals who embrace life long learning. The act of reflection is seen as a way of promoting the development of autonomous, qualified and self-directed professionals. Engaging in reflective practice is associated with the improvement of the quality of care, stimulating personal and professional growth and closing the gap between theory and practice.

Models of reflection

In the models of reflection, I would like to discuss about Gibbs Frame work for Reflection and Johns Model of Structured Reflection

â- 1.Gibbs Framework for Reflection (Linked with the core skills of reflection)

In that

Stage 1: Description of the event

Describe in detail the event you are reflecting on.

Include e.g. where were you; who else was there; why were you there; what were you doing; what were other people doing; what was the context of the event; what happened; what was your part in this; what parts did the other people play; what was the result.

Stage 2: Feelings and Thoughts (Self awareness)

At this stage, try to recall and explore those things that were going on inside your head. Include:How you were feeling when the event started?What you were thinking about at the time?,How did it make you feel?,How did other people make you feel? ,How did you feel about the outcome of the event? ,What do you think about it now?

Stage 3: Evaluation

Try to evaluate or make a judgement about what has happened. Consider what was good about the experience and what was bad about the experience or what did or didn’t go so well

Stage 4: Analysis

Break the event down into its component parts so they can be explored separately. You may need to ask more detailed questions about the answers to the last stage. Include:

What went well?,What did you do well?,What did others do well?,What went wrong or did not turn out how it should have done? .In what way did you or others contribute to this?

Stage 5: Conclusion (Synthesis)

This differs from the evaluation stage in that now you have explored the issue from different angles and have a lot of information to base your judgement. It is here that you are likely to develop insight into you own and other people’s behaviour in terms of how they contributed to the outcome of the event. Remember the purpose of reflection is to learn from an experience. Without detailed analysis and honest exploration that occurs during all the previous stages, it is unlikely that all aspects of the event will be taken into account and therefore valuable opportunities for learning can be missed. During this stage you should ask yourself what you could have done differently.

Stage 6: Action Plan

During this stage you should think yourself forward into encountering the event again and to plan what you would do – would you act differently or would you be likely to do the same?

Here the cycle is tentatively completed and suggests that should the event occur again it will be the focus of another reflective cycle

â- 2 Johns model of structured Reflection

. Chris John’s (1994; 1995) model arose from his work in the Burford Nursing Development Unit in the early 1990’s. He envisaged this model as being used within a process of guided reflection. His focus was about uncovering and making explicit the knowledge that we use in our practice. He adopted some earlier work by Carper (1978) who looked at ways of knowing in nursing. According to his model of reflection the ways of knowing are

Aesthetics – the art of what we do, our own experiences

• What was I trying to achieve?

• Why did I respond as I did?

• What were the consequences of that for the patient? Others? Myself?

• How was this person (people) feeling?

• How did I Know this?

Personal – self awareness

• How did I feel in this situation?

• What internal factors were influencing me?

Ethics – moral knowledge

• How did my actions match my beliefs?

• What factors made me act in an in-congruent way?

Empirics- scientific

• What knowledge did or should have informed me?

•

• References

• C Rodgers (2002) Teachers collage records: the voice of scholarship in education

• Elaine Lymne La Monica (1986) Nursing leadership and management: an experiential approach

• Chris Bulman Sue Schutz (2004) Reflective practice in nursing

• Gibbs G (1988) Learning by doing: A guide to teaching and learning methods. Oxford Further Education Unit, Oxford.

• Johns C (1995) Framing learning through reflection within Carper’s fundamental ways of knowing in nursing. Journal of Advanced Nursing 22 226-234

•

Explains the laws that relate to adolescent safety and health privacy in a school setting and provides historical background of the laws.

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Explains the laws that relate to adolescent safety and health privacy in a school setting and provides historical background of the laws.

CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED

Describe health and wellness issues specific to the adolescent population.

Does not describe health and wellness issues specific to the adolescent population.

Identifies but does not describe health and wellness issues specific to the adolescent population.

Describes health and wellness issues specific to the adolescent population.

Describes health and wellness issues specific to the adolescent population, including issues related to sexual activity and mental health.

Explain the laws that relate to adolescent safety and health privacy in a school setting.

Does not explain the laws that relate to adolescent safety and health privacy in a school setting.

Identifies laws that relate to adolescent safety and health privacy in a school setting.

Explains the laws that relate to adolescent safety and health privacy in a school setting.

Explains the laws that relate to adolescent safety and health privacy in a school setting and provides historical background of the laws.

Explain how privacy laws affect the school, student, and school nurse.

Does not explain how privacy laws affect the school, student, and school nurse.

Explains how privacy laws affect the school, student, and school nurse but the explanation is inaccurate or missing key elements.

Explains how privacy laws affect the school, student, and school nurse.

Explains how privacy laws affect the school, student, and school nurse, and provides a rationale of the benefits of the law.

Recommend evidence-based ethical strategies relating to health and wellness privacy communication by the school nurse.

Does not recommend evidence-based ethical strategies relating to health and wellness privacy communication by the school nurse.

Identifies evidence-based ethical strategies relating to health and wellness privacy communication by the school nurse, but does not clearly recommend strategies.

why do we love junk food so much when we know that it is unhealthy for us?

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why do we love junk food so much when we know that it is unhealthy for us?

 

It an age old war between healthy food and junk food. When it comes to choosing between health foods and junk foods, junk food has always won the race! Whether we admit it or not, although we may start off our day with eating an apple, well end it with two to three slices of extra cheese pizza and coke. But why do we love junk food so much when we know that it is unhealthy for us? There are many reasons to which most of you will agree. 1. They are a pleasure to our taste buds. Do we get the same pleasure in eating a bowl of fruits that we get in a cheese burger? 2. Junk food is way tastier than healthy food. Yummy cheesy sandwich vs. a bowl of seasonal fruits; a war is going on in your mind.which one will you choose for your snack? Sandwich always wins. 3. Temptation plays a very important role when it comes to choosing junk food over healthy food. The melted chocolate dripping out of chocolate fudge is more tempting than an apple. 4. Another reason for junk food craving is the mood. It has been noticed that when you are overtly stressed you crave for sweet junk food like cakes, pastries, brownies or chocolates. But does junk food do any good to us? It may satisfy our taste buds and fix our hunger pangs to certain extent but what about the pounds of fat that is adding on your waistline? Lets check out the cons list: 1. Junk foods add to pounds and pounds of weight. Thats the reason why so many of us suffer from weight problem these days. 2. Have you ever thought about the nutrition factor? Do you really get any nutrition from these junk foods? You may say that the veggies used in burger and sandwiches are raw, may be just stir-fried. So what? What about the cheese and different sauces? The bread is grilled with quite a lot of butter too. All these oil and grease travels through your blood vessels blocking up your arteries gradually. The result being poor health after some years. 3. Fried junkies like chips, pakoras, french fries will satisfy to a great extent when eaten, but what about the nutrition. These foods being over-fried foods have left behind all the nutrition where it had been prepared. What you get is all grease and calories! 4. The high calories in junk food not only lead to absurd weight gain but also your ability to produce insulin weakens. Hence diabetes. And diabetes means more hunger, more junk foods. The list includes cookies, chips, biscuits, donuts and breakfast cereals. 5. All packet and fried foods are rich in trans-fat. This is the worst kind of fat that results in a number of chronic diseases. This type of fat is the main culprit for a variety of heart diseases. 6. Junk food being low in fiber content also results in high blood sugar and high cholesterol. 7. Junk food also contains added colors and preservatives, artificial sweeteners which might not be properly tested. 8. Pregnant women who feel hunger pangs quite frequently often indulge in a lot of junk foods like potato chips, ice-cream, candies, aerated drinks and what not. During pregnancy what you need most is a lot of nutritious food rich in proteins, calcium, minerals, vitamin and omega 3 fats. But these processed packet foods are generally high in trans-fat, calories, sodium and hydrogenated oils. Remember the food you are eating is affecting the growing fetus inside you as well. Moreover if you are suffering from high blood pressure, the sodium content in these foods will shoot up your blood pressure level which is not good for your baby. 9. Gorging continuously on junk foods will lead to a high BMI (body mass index). Doctors say that if your BMI is below 18.5, you are underweight, if it is ranging between 18.5 and 24.5, you have a normal weight, if it is between 24.5 and 29.5 you are overweight compared to your height, and if it is 30 and above, you are overweight; time to consult a doctor. So what do you think about junk food now? Are they worth eating? Absolutely not. But still we eat. and keep eating. Now that we know why not to…; It an age old war between healthy food and junk food. When it comes to choosing between health foods and junk foods, junk food has always won the race! Whether we admit it or not, although we may start off our day with eating an apple, well end it with two to three slices of extra cheese pizza and coke. But why do we love junk food so much when we know that it is unhealthy for us? There are many reasons to which most of you will agree. 1. They are a pleasure to our taste buds. Do we get the same pleasure in eating a bowl of fruits that we get in a cheese burger? 2. Junk food is way tastier than healthy food. Yummy cheesy sandwich vs. a bowl of seasonal fruits; a war is going on in your mind.which one will you choose for your snack? Sandwich always wins. 3. Temptation plays a very important role when it comes to choosing junk food over healthy food. The melted chocolate dripping out of chocolate fudge is more tempting than an apple. 4. Another reason for junk food craving is the mood. It has been noticed that when you are overtly stressed you crave for sweet junk food like cakes, pastries, brownies or chocolates. But does junk food do any good to us? It may satisfy our taste buds and fix our hunger pangs to certain extent but what about the pounds of fat that is adding on your waistline? Lets check out the cons list: 1. Junk foods add to pounds and pounds of weight. Thats the reason why so many of us suffer from weight problem these days. 2. Have you ever thought about the nutrition factor? Do you really get any nutrition from these junk foods? You may say that the veggies used in burger and sandwiches are raw, may be just stir-fried. So what? What about the cheese and different sauces? The bread is grilled with quite a lot of butter too. All these oil and grease travels through your blood vessels blocking up your arteries gradually. The result being poor health after some years. 3. Fried junkies like chips, pakoras, french fries will satisfy to a great extent when eaten, but what about the nutrition. These foods being over-fried foods have left behind all the nutrition where it had been prepared. What you get is all grease and calories! 4. The high calories in junk food not only lead to absurd weight gain but also your ability to produce insulin weakens. Hence diabetes. And diabetes means more hunger, more junk foods. The list includes cookies, chips, biscuits, donuts and breakfast cereals. 5. All packet and fried foods are rich in trans-fat. This is the worst kind of fat that results in a number of chronic diseases. This type of fat is the main culprit for a variety of heart diseases. 6. Junk food being low in fiber content also results in high blood sugar and high cholesterol. 7. Junk food also contains added colors and preservatives, artificial sweeteners which might not be properly tested. 8. Pregnant women who feel hunger pangs quite frequently often indulge in a lot of junk foods like potato chips, ice-cream, candies, aerated drinks and what not. During pregnancy what you need most is a lot of nutritious food rich in proteins, calcium, minerals, vitamin and omega 3 fats. But these processed packet foods are generally high in trans-fat, calories, sodium and hydrogenated oils. Remember the food you are eating is affecting the growing fetus inside you as well. Moreover if you are suffering from high blood pressure, the sodium content in these foods will shoot up your blood pressure level which is not good for your baby. 9. Gorging continuously on junk foods will lead to a high BMI (body mass index). Doctors say that if your BMI is below 18.5, you are underweight, if it is ranging between 18.5 and 24.5, you have a normal weight, if it is between 24.5 and 29.5 you are overweight compared to your height, and if it is 30 and above, you are overweight; time to consult a doctor. So what do you think about junk food now? Are they worth eating? Absolutely not. But still we eat. and keep eating. Now that we know why not to…

Reflective Practice in Nursing Communication

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This assignment looks at the study of theoretical reflection in conjunction with how effective communication skills can be developed to expand our knowledge. To achieve this I will explain what reflection practice is using

models of reflection

; evaluate theories of personal development – what they are and how they are used. Discuss how reflective practice benefits communication skills and in turn influence our knowledge of nursing care.

What is reflection?

In scientific terms reflection is seen as light, heat or sound striking a surface to give off a reflection (Darlene 2006). Reflection is also seen as philosophical understanding of how one can gain knowledge through experience and use different approaches to the same scenario (ref). Reflection can be described as; meditation, deep thinking and or giving careful considerations to possibilities and opinions of a given situation (Mcferran and Martin 2008).

The novel idea of reflection rose from a theorist John Dewey (1859-1952); his proposed view on reflection is described as persistent, active thinking and taking into consideration the supporting evidence that forms knowledge to the given situation. This theorist suggests that the person uses their mind and emotions to facilitate reflection (Bulman and Schutz 2008). This suggests that John Dewey describes reflective individuals has being open-minded, responsible and wholehearted (Vaugn and Leblanc 2011).

Dewey’s perception of reflection was a platform for many authors to elaborate on in terms of understanding reflective practice. Johns and Freshwater (2005) propose that health professionals should find the meaning of reflection through description rather than definition because to define reflection is to suggest the author has authority over its meaning. This in turn allows reflections models and frameworks to be used intuitively giving a more holistic approach, it can be subjective and purpose driven (Johns and Freshwater 2005).

Mann et al (2007) describes Schon’s (1983) view that reflection can happen in two ways: reflecting upon activities whilst they are happening called reflection in action (present reflection) and reflecting upon activities once they have happened (reflecting on the past). Reflection can also be seen as the engine that facilitates superficial learning into finding a deeper understanding that enables the practitioner to transform what is known to knowledge in action (Boud et al 1985 cited in

Rolfe et al

2011).

Reflection (Broad overview)

Describe some of the different theories and models of reflection that are available and how they are used. Explain how reflection can aid personal development.


Schon, reflection on and in action

– Models of reflection, Driscoll’s, Atkins and Murphy, Gibbs, Johns, Kolb.

Reflection Model and frameworks

There are many different models of reflection which seem to have similar philosophical theories attached to each approach. Rolfe et al (2011) asserts models are methodologies and frameworks are methods used to understand and give guidance on how use the chosen reflective model and models therefore are ontological this mean they have formal specifications for representing ideas and concepts that aim to improve personal growth and development.

Model’s of reflection developed by Schon and Argyris (1992) involves three elements: (1) knowing-in-action (2) reflection-in-action and (3) reflection-on-practice (Ghaye and Lillyman 2010). Ghaye and Lillyman (2010) have extrapolated Schon’s work to include knowing-in-action; they propose that practitioners ‘customise’ and ‘tailor’ their own knowledge or theories to the situation presented. Knowing in action is described further by Carper (1978) who identifies five approaches to knowing in action; empirical, personal, ethical and aesthetic knowing ( Newton and McKenna 2009).

Empirical knowing is the formation of knowledge organised into general laws and theories for the describing and predicting phenomena pertaining to nursing practice (Averill and Clements 2007). Empirical means of knowledge tends to seek out theoretical explanation which can be replicated and be publicly verifiable (Newton and McKenna 2009). Newton and McKenna (2009) further suggest that empirical knowledge can only be effective when it is interpreted within the context of given clinical situation and how it is assimilated into practitioners personal knowledge.

Personal knowing described by Carper (1978) is about finding out how much we know about ourselves when faced with clinical challenges and that health care professionals may not necessarily know about the self but do strive to know about the self. Newton and McKenna (2009) state that Caper (1978) does reiterate that it is difficult to master however it is an essential in understanding nursing care. Newton and McKenna (2009) suggest that personal knowing demands a deeper level of understanding and awareness to communicate and interact with ourselves and others. This type of knowing requires the nurse to be empathic, nurse attempt to do this by developing a personal yet professional relationship between the patients as opposed to viewing a patient as an object (Newton and McKenna 2009). Moral actions and ethical choices are intertwined with personal knowing to which Carper (1978) suggests presupposes personal maturity and freedom.

Ethical knowing is about the moral aspect of nursing that is concerned with making choices, making justifiable actions and judging outcomes (Newton and McKenna 2009). The main focus of ethical knowing is trained towards issues of obligations that would require rationalisation and deliberate reasoning (Carper 1992). Chinn and Kramer (2004) suggest that rational can be expressed through codes, moral rules and decision-making. Newton and McKenna (2009) assert that having knowledge of moral issues is not isolated to ethical codes of nursing disciplines for example the Code of Conduct written by the NMC (2010). Newton and McKenna (2009) assert that ethical knowing is only partly learnt through applying codes and moral rules but is more through experiencing situations that initiate reflection upon what is or has happened and how this affects patient care.

Gibbs( date) Driscoll(dates)and Kolb ( date)all conjured reflective models which are each similar to one another; they are all cyclical – reveals that learning through reflection about what is or what has happened is continuous cycle. Gibbs et al (1988) model please see appendix 1 (a)

Do you know of any other models that perhaps don’t take on such a cyclical approach… consider the work of Chris Johns, Mezirow, Boud et al also…. How do they compare and contrast with each other? Why might one model of reflection suit one situation or context better than another?Think about which models promote single loop or double loop learning if you can.

Reflective practice (Specific)

Give an overview of how reflection is used in nursing. Explain its relevance to nursing and how and when it is used. Explore the concepts of reflective practice and critical incident analysis.

Introduce use of reflection for personal development. CPD, self regulation. Identify the different situations where reflection can be used. Skills V critical Incidents – what is a critical incident.

Reflective practice is seen has using reflective techniques to improve, maintain change in clinical procedures and influence guidelines to encourage greater safety of patients in all areas of health organisations (Bulman and Schutz 2008).

Health care organisations in the UK have undergone and still continue to undergo changes to how it is regulated (Rolfe et al 2011). The emphasis is largely associated with increasing patient safety and risk reduction (Rolfe et al 2011). The four main bodies in the UK; Royal College of Nursing (RCN), Nursing Midwifery Council (NMC) and General Social Care Council (GSCC) and General Medical Council (GMC) which are concerned with the controlling, training and regulating of the healthcare system in UK (Rolfe et al 2011).

Evidence-based studies have taught the NHS and regulatory bodies how to change practices and procedures to create better outcomes for patients, they have also encompassed further development for staff to promote a better use of resources through continuing professional development CPD (Ghaye and Lillyman 2010). An example of this could be the pressure sore nurses taking on the responsibility of giving guidance to non-specialist nurses to take care of patients with such conditions. This could not have been achieved if it was not for reflective thinking being part of the learning process (ref).

How do we use reflective practice within our day to day practice? Consider the approaches that mentors take when supporting students, look at the principles involved in preceptorship and clinical supervision…

Communication skills (Application)

Discuss and analyse how reflection can be utilised to improve your communication skills in practice. Explore how and when you would use it. What practical steps would you take and what resources would you utilise and why.

Link reflection in and on action to communication situations – giving information (in), breaking bad news (on), then use of journals, models, writing, peer support.

Conclusion

Sum up

You have made a solid start at this assignment so far and have introduced many ideas which are relevant to the topic. These themes now need to be explored in greater detail . You have a slight tendency to introduce theoretical concepts ( not all of which are uncomplicated) without fully explaining their meaning…. Take care to avoid this as just mentioning them does not mean that you understand them and we will be looking for evidence of understanding. You also need to pay attention to your sentence construction as there are several poorly constructed sentences noted so far…. Make sure that when you lift them from the text you have referred to , that you do adapt them to make sense in the context that you are trying to use them. I would like to have a look at this piece when it has been developed a bit more. You are definitely heading in the right direction though and overall have made an effective start.

Analysis of Nurse-Patient Interaction

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Environment

Physical environmental factors that may influence communications among patients and nurses include lighting, humidity, space within contact partners, place, comfort and conditions of private space, and disruptions like noise and confidentiality level (Daly, 2017). My partner and I went to the Stenberg College campus and asked the receptionist if we can use a room for our video. The room we got was conducive for effective communication, it is warm, comfortable and had chairs equal in height and a table with the right distance when I and my partner are interacting. Also, a private room will ensure our clients’ privacy as they will not be worried that someone might hear their information. Moreover, the room has adequate lighting and free from any disturbance. As per Stans, Dalemans, Roentgen, Smeets, and Anna (2018), clients and care providers reflected that a peaceful and calm environment in conversations without distractions is relevant as noise makes it hard for clients to focus on what the discussion is about. Furthermore, background noise hindered the capacity of nurses to hear their clients. The clients believed that if the conversation took place in an atmosphere where they felt relax and comfortable, it allowed them to express themselves (Stans et al., 2018). Through this, it is crucial for us nurses that we provide an environment wherein our clients can freely state how they feel, think and show their emotions.


Process Recording


Link:



https://youtu.be/2tAAs7OSlfc


NURSE TECHNIQUES (VERBAL/NONVERBAL)
CLIENT VERBAL


(NONVERBAL)


NURSE’S THOUGHTS AND FEELINGS CONCERNING THE INTERACTION
ANALYSIS OF THE INTERACTION
ALTERNATIVE RESPONSES
“Hi Good morning! My name is Hannah. I’ll be your counselor for today.”

“How would you like me to call you?”

“Hi, Pinky nice to meet you.”

Nonverbal: Relaxed and open posture, leaned forward, smiling and soft tone of voice.

“Hi”

“Pinky”

“Nice to meet you”

The client has an open and relaxed posture, smiling and nodding.

I realized that it is always crucial to introduce ourselves as this will give them a good impression at the beginning of the session. It is always nice to start a conversation with a positive attitude. By asking their name preference is a way of showing our respect. In this phase, this is where we create a good relationship with our clients to have effective communication for them to be more comfortable in sharing their information. This is the orientation phase, as per Peplau (1997), as helpers this is where we start to build trust and educate our client about the intent and meaning of our discussion and the time required (as cited in Arnold & Boggs, 2011, p. 91).

In this part of the conversation, we should develop rapport and trust with our clients because they will be more at ease in sharing information. Moreover, utilizing our nonverbal cues will also give a positive impression to our clients as they may feel that we are interested in listening to them.

As per Balzer-Riley (2017), clients may feel valuable and worthwhile when they receive respect (p. 77).

I should have shaken her hand to be more welcoming and it is also a sign of warmth.

A handshake or gentle touch is a way of showing respect (Balzer-Riley, 2017). For some people, handshake comes naturally especially if they meet new people.

“How would you like our room?”

“Did you like the private room?”

“Oh, ok!”

“Ahh. That’s good.”

Nonverbal: Smiling with hand gestures, used a soft tone of voice.

“Very nice, I like the view. Uhm, especially the weather is better. It’s cold and I’m sorry I’m a little bit under the weather. I’ve been battling with cough and colds for the past couple of days.”

“But I’m getting better.”

The client was smiling, relaxed and open posture with hand gestures.

I felt like it is important to consider the environment, as this will make our clients feel more relax and comfortable. Having a personal space will help our clients’ to be more open and direct in sharing their information about the changes that they plan for themselves. As per Arnold and Boggs (2011), securing our client’s privacy is a form of respect (p. 39). Also, for a meaningful discussion, we have to make sure that the client is protected, free from any distraction and noise (Arnold & Boggs, 2011, p. 178). This means that our client will be more open and comfortable in sharing information.

Additionally, I should be careful in using closed-ended questions. As this is used to quickly acquire information from our client (Arnold & Boggs, 2011, p. 183).

I should have said: “How do you find this room? Do you find it comfortable?”

I wanted to ask this question for me to know about my clients’ level of comfort and perception about the private space.

The nurse demonstrates humility, empathy, and respect every time they pay attention to the environment to maintain a good nurse-client relationship (Arnold & Boggs, 2011, p. 91).

“Before we start, we went over it beforehand. I want you to go over it again and then you can sign.”

Nonverbal: Leaned forward, relaxed and open posture, smiling.

“Hmm.”

“There you are.”

The client was nodding, appears relaxed.

I felt the need to explain the importance of confidentiality as the client will feel safe and secure. After asking her to go over the consent form, I was glad that she willingly signed the consent. As per Heery (2000), we have to ensure our clients that their personal data is confidential and secured (as cited in Arnold & Boggs, 2011, p. 91).

Also, we have to inform the client that the information gathered will be discussed with other health care providers (Arnold & Boggs, 2011, p. 91). It is important that we are telling our clients our goal and the purpose of the conversation.

I should have also explained that “This session is strictly confidential. However, our instructors Debbie and Maureen will be watching the video. But I assure you that your privacy is secured.”
“So, to start, I am here to listen for whatever you wanna share, with whatever you wanna change in your life at this moment.”

“So, feel free to start.”

“Yes”

While the client was talking, I also used silence to give her enough time to freely share her feelings.

Nonverbal: Relaxed and open posture, nodding, smiling, and with hand gestures.

The client replied: “Hmm.”

“So, I know that this is the second session. Uhm, coz the first one I know I talk to you about, my eating pattern and how the change of my lifestyle from the past year that I have enrolled in the nursing program. So, we know that it is an online course I’ve been sitting in my desk for a long time I don’t pay attention as to the amount of food I eat. So, basically stress-eating and my diet is, I’m Asian so we love rice. Uhm, and my family is such a foody. Me and my husband were, that’s our common past time like we love to dine out go out to eat and we just love food. Coupled with that, it makes me feel good if I eat at the side while reading. Uhm, and that has horrible effect with my weight. So, I really gained weight from the past year that I stopped working up to the present and I wanted to change that and reverse into a healthier lifestyle. Ah, mainly because of again for health reasons and number two I wanna have sustainability in terms of doing that long hours of shift. As we know that for nurses, we do 12 hours.”

The client appears relaxed, with hand gestures. She has a soft tone of voice.

I felt that when we give assurance to our clients, they will be more at ease in sharing personal information about themselves. Informing them that we are there to listen with them will make them feel that they are important and that someone is showing interest and giving them full attention. Also, in this part, I was just attentively listening to her. I remained quiet and I tried not to distract or interrupt her. This is the working process wherein the client addressed specific and more challenging problems and emphasizes self-management and self-direction in promoting clients’ wellness (Arnold & Boggs, 2011, p. 94).

Also, this is where the partnership or collaboration between the helper and the client. The collaborative essence of MI means that our own expectations as well as our client are addressed and controlled (Miller & Rollnick, 2013, p. 16).

As per Egan (2014), empathetic listening is unselfish as helpers have to set their own issues aside in order to be completely with their clients (p. 82). I believe that in this part I was able to show my client that I am interested in listening to her message and she has my full attention.

Additionally, in this part, the client was exercising her right to freely express herself and her choice of changing something in her lifestyle. As per Miller and Rollnick (2013), recognizing the freedom of choice of our client usually decreases hostility and can promote improvement (p. 19).

I should have also mentioned that “This is a non-judgmental environment and feel free to share whatever you are comfortable to share.”

“So, from our previous session before, I believe you mentioned that you wanted to go aqua therapy like swimming. Can you tell me about it?”

Nonverbal: hand gestures, relaxed posture, smiling and use a soft tone of voice

“Yes.”

“That’s a very good question.”

“We tried one session. It’s actually more of, me inquiring for the client that I support with, then I ended up being curious. So, my sister and I went in for a drop-in session. It was good, it’s a low impact exercise. Ahh, the flip side there is that after we did the aqua therapy, we went out to eat. So, it’s just like carbs in carbs out and then vice versa. So, it’s really me surrounding all the people that I love. And this people that I love also love food so it’s a challenge and it’s how to… I recognize that I have to break that cycle.”

The client was smiling, nodding and with hand gestures. Also, she used a normal tone of voice.

I felt that it is important for me to know continued her plan of exercising and I wanted to know her feelings and emotions when she engaged herself in this activity. Asking open-ended questions is critical in moving forward, empowering and planning a transition to progress (Miller & Rollnick, 2013, p. 33).

An open-ended question is used so that our clients will speak about their situation and think about it and also, it helps integrate the important aspects of our clients’ experience (Arnold & Boggs, 2011, p. 182). This is something that we should use rather than close-ended type of questions. In this part, I was asking my client to tell me more about her experience about her chosen activity.

I should have also asked: “Tell me about the changes that you experienced from our last session.”

“How was your experience about aqua therapy?”

“Was there a change from your plan previously and up to this day?”

“Ah, ok!”

Nonverbal: nodding, relaxed posture, smiling, kept eye contact, use a normal tone of voice.

“Here and there, I’d say.”

“So, I’ve been battling with colds and cough and you know when you’re not feeling well you have that inclination to eat healthier. Uhm, so, my husband would cook something for me, it’s always chicken soup with some nice vegetables and I cut down with a little rice, but I don’t know if even that would make some significant impact as to my weight. But I recognize that really the changes of the amount of food intake and carbs that’s something I have to work on. I’d say it’s very minimal but I hope that I’ll reach that point that I’ll be able to overcome these challenges.”

The client giggled, she has an open and relaxed posture, also, while talking she used hand gestures.

I felt that I need to know my clients’ feelings about her set plans. I am glad that she recognizes the importance of eating healthy foods and that she is willing to take the challenge of losing weight and be more healthy foods. In this part, I asked a close-ended question just for me to clarify if the client experienced change from her previous plan. Even though I used this type of question my client seems to be so open and freely sharing her experienced.

Moreover, I realized that I should have used open-ended questions to enhance more my skills. An open question is one that allows an individual to think a little before answering and offers plenty of space to respond (Miller & Rollnick, 2013, p. 62).

I should have said: “What is the difference in your plan before and the plan that you have right now?”

“What motivates you to pursue your plan?”

“I’m glad that you are recognizing that.”

“Was there a plan or are you planning of doing something to change your eating habits? Like, let’s say are you setting up a diet plan?”

Nonverbal: Hand gestures, relaxed posture. Maintained eye contact.

The client nods after I said this.

“Right, I’ve heard about meal preps. My sister-in-law she’s into keto diet and she’s been really watching her diets and she’s into exercise, yoga and all that. And I see how she did a good job as she maintained her weight and everything. So, she shared to me some good food choices like instead of rice change it to quinoa or make a cauliflower fried rice. These are things that we’ve tried and it’s actually good. I enjoyed the cauliflower fried rice. But when I asked my husband, the funny thing is that I recognize, when I asked my husband how he prepared it, of course there is tons of butter and all that. So, I don’t know if that would even help. But psychologically I know that that’s a better option than rice. So, those are things that I would like to start off but it’s really hard.”

The client was smiling, with hand gestures, appropriate eye contact.

I felt that my client needs commendation to let her know that someone acknowledges her plans. However, I also felt her, it is really hard to lose weight as much as I wanted to share some of the diet plans that I have tried, I just don’t want to divert the focus of our conversation and my diet might not work for her as she has her own preference. I am well aware of the importance of asking open-ended questions. I know that the more I practice it will be easier for me to use for my future clients.

The closed question is requiring a quick answer and restricting the individual’s response (Miller & Rollnick, 2013, p. 63). Even though I used this type of question my client seems comfortable and she is still open in sharing data about her plans.

Instead of asking closed questions. I should have asked: “What is your dietary plan?”

“Tell me more about your eating habits, what type of food that you eat?”

“Good for you, that you are considering to change your eating habits.”

“Sounds like you’ve got a good plan there.”

“So, in the next two weeks when you come back here, what are the things that you would like to share about the changes that happened to you from the past?”

Nonverbal: maintained eye contact, relaxed posture.

After stating this the client was smiling and nodding.

“I’ll probably commit to myself like regardless if I have my sister with me or not. I’ll try to go to the recreation centre. I’ll try to commit myself at least to do once a week of aqua therapy coz that’s a low impact exercise that won’t hurt my knee or my ankle given my weight. I’ll try to do that I’ll let you know how I feel about it. I know myself well more than anyone else but I’ll let you know if I’m struggling. But it’s good to take this out of my chest and have somebody to talk too. The fact that I recognize that there is a need for me to change my lifestyle. I think that’s a good start.”

The client kept eye contact, nodding, smiling.

In this part, I realized that she is really willing to attain her goal of losing weight. Also, I can feel her dedication to push through her plan of exercise and be more physically active. An important MI skill is reflective listening. Effective reflective listening keeps the individual speaking, thinking and exploring (Miller & Rollnick, 2013, p. 34).

Reflective comments often enable individuals to listen and focus on the emotions and thoughts they share (Miller & Rollnick, 2013, p. 34). I believe that reflection is necessary for our client for them to engage more themselves in the conversation.

I should have also stated that: “Sounds like your sister-in-law influenced to continue your plan of losing weight and eat healthier food.”
“That’s a good plan.”

“So, Pinky just to sum up everything  So, you’re planning to lose weight, you’re trying to cut back you’re eating habits like from carbs, you’re planning to do exercise like you said aqua therapy and trying out new exercises just for you to lose weight and think more about your health.”

Nonverbal: hand gestures, open and relaxed posture, kept eye contact.

The client was nodding replied: “ah-huh,”

smiling, relaxed posture and maintaining eye contact.

I felt the need that I have recognize her so that she will feel that she is doing something right.

In this part, there is always a hesitation on my part as I might not interpret her message correctly. Thus, I felt good that my client validated it through her nonverbal cues and respond appropriately.

To affirm is to accept and appreciate what is great, including the intrinsic worth of people as human beings, and to understand and support our client (Miller & Rollnick, 2013, p. 64). This skill is relevant in our practice as this will boost our clients’ confidence and it motivates them to be more positive in their plan of change.

Moreover, summaries are important observations that bring up many things an individual has stated (Miller & Rollnick, 2013, p. 66). I believe that I was able to get the gist of my clients’ message.

Also, reflecting and summarizing is shedding light on the perspective of the client encouraging them to explore more (Miller & Rollnick, 2013, p. 66).

I think that I should have said: “Just to be clear, you are planning to lose weight by cutting back you stress-eating habits and you are planning to come up with a dietary plan and you are willing to engage in the aqua therapy exercise as you want to be live a healthier life.”
“Ok! So, next week once we gonna come back here again I hope that you will have the plan that you told me.”

“So, yeah! We are done for today see you next week then.”

Nonverbal: Hand-shake, smiling nodding, normal tone of voice, demonstrated an open and relaxed posture.

The client was smiling, replied: “Ok! Thank you, Hannah.” She was also, nodding and maintained eye contact, with an open and relaxed posture. I felt that I was able to meet her expectations and I responded to her appropriately and I was able to get the core of her message and I gave her enough time to speak without stressing her out.

I felt the need to tell her that I am going to see her for follow-up, for me to be able to know if she follows her plans and continues to pursue her goal.

This is the termination phase of the interaction process. It is vital to be open to how long a therapeutic interaction should last. During the collaboration, termination might be indicated and clients should be notified well in advance of forthcoming end date (Arnold & Boggs, 2011, p. 97). I should have asked my client about her feelings and thoughts about our conversation and I think that I have to consider my clients’ points of view regarding the outcome of our interaction.

I should have also asked: What are your insights about our conversation? How are you feeling right now?

Summary

This activity measured my ability to demonstrate the skills we learned and we need to acquire. During the activity, I think I was able to portray the role of a nurse in my conversation with my client. Also, I was able to get the key message of my client regarding her plan of changing her bad eating habits into healthier food, be more physically active and lose weight. In our interaction process, I was able to establish rapport and gained the trust of my client. I used minimal responses to ensure that my client was at the center of our communication process. Minimal signs encouraged client trust in exchanging personal data (Arnold & Boggs, 2011, p. 184). Moreover, in our conversation, I am well aware of the importance of SOLER as this will help in the flow of a good discussion. I was also able to demonstrate my listening skills and show my respect and genuineness with my client by responding to her in an appropriate way. Furthermore, this activity helped me realize the things that I still need to work on.

Additionally, the highlight of this activity is to exercise our ability in using the spirit of MI and OARS skills for effective motivational interviewing. As per Miller and Rollnick (2013), OARS skills are essential mechanisms for mutual understanding in the communicating process (p. 62). This means that I have to practice more to improve my skills as this is relevant for me to utilize in our upcoming clinical placements. I know that I have used open-ended questions, reflection, and summarization before but I still need to exercise it more so that I will gain enough confidence and be more knowledgeable when I deal with my future clients’. Moreover, in this activity, I have used a few close-ended questions but I am well aware that I should focus more on using open-ended questions for me to get more information from my client. I plan to enhance more my skills so that I will be more prepared in our upcoming clinical placements. Overall, this activity helped me recognize the things that I still have to learn and I intend to fulfill this goal for me to be able to provide good therapeutic communication and be more skillful in motivational interviewing.

References

  • Arnold, E. C. & Boggs, K. U. (2011).

    Interpersonal Relationships: Professional Communication Skills for Nurses (6



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    Edition).

    St. Louis, MO: Elsevier
  • Balzer-Riley, J. (2017).

    Communication in Nursing (8



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    Edition)

    . St. Louis, MO: Elsevier
  • Daly, L. (2017). Effective communication with older adults.



    Nursing Standard (2014+),




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  • Egan, G. (2014).

    The Skilled Helper: A Problem-Management and Opportunity-Development Approach to Helping (10th ed.).

    Belmont, CA: Brooks Cole
  • Miller, W. R. & Rollnick, S. (2013).

    Motivational Interviewing: Helping People Change (3



    rd



    edition).

    New York, NY: The Guilford Press
  • Stans, S. E. A., Dalemans, R. J. P., Roentgen, U. R., Smeets, H. W. H., & Anna, J. H. M. B. (2018). Who said dialogue conversations are easy? the communication between communication vulnerable people and health‐care professionals: A qualitative study.



    Health Expectations,




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Population-Based Nursing Care

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Population-Based Nursing Care

Order Description

Discuss your role as an advocate and healthcare leader in promoting positive social change as a scholar-practitioner to improve the health of vulnerable populations in your community.
•In your current practice and as a health leader in your community how will you collaborate with other healthcare providers to promote the health of your community (especially in childhood obesity)

Protecting the Public and Maintaining Care Standards: The Nursing and Midwifery Council

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With reference to adult nursing, discuss how the Nursing and Midwifery Council seeks to protect the public and maintain care standards.

In this article, the speaker will start by addressing the Nursing and Midwifery Council (NMC)’s key roles , which they seek to protect patients and service users as well as improve standards of care across the UK. The author would address briefly when the

NMC

regulations were first created, changes made to the regulations since they were first written, their priorities and the code of practise they laid out for which adult nurses would obey throughout their daily practise. The writer should address the CQC and discuss this body’s priorities and intent. We will then go on to explain what the procedure is for securing a position in the path of a nursing degree: what is required of them in their daily duties, together with mandatory preparation and practise lessons, during their degree and before they can enrol with the council and apply for their PIN number. The author will also discuss the value of secrecy and how privacy is to be considered when using social media, as well as what the protocols are if confidentiality is violated or the rules are overlooked. I will then conclude this assignment by drawing up a summary of all what was discussed throughout this assignment.

During the time of 1984 the United Kingdom central council (UKCC) created the first code of conduct for midwifes, nurses and health visitors which was the first-time high expectations for professionals in practice. This was created to ensure the public are protected through standards of care and inform them of the standard of professional conduct that is expected of them whilst they are being cared for. (Brooker and Waugh, 2013) The regulatory body for nurses and midwives in the United Kingdom is the nursing and midwifery council (NMC). The NMC was first established under the 2001 Nurses and Midwifery Order and opened in 2002 with the primary purpose of protecting the public. (Thewlis of the year 2003). It has since been republished with revisions to the legislation in 2008 and again in 2015. The body’s role is to protect the public by setting standards of practise, education, mandatory training and performance to allow nurses and midwives to deliver the best quality of health care during their careers. These are the expectations that could be required from practitioners by patients and members of the public while being cared for. (NMC, November 2015). The aim of the code is to advise the nurses and midwives registered with the Nursing and Midwifery Council of their expected standard of professional behaviour in their daily practise as well as to inform the public, employers and other professionals of the standard of behaviour they would expect from a registered practitioner. (Waugh and Brooker, 2013).

How does the nursing and midwifery council regulate “We set the standards of education, training and conduct that nurses and midwives need to deliver high quality healthcare consistently throughout their careers, We ensure that nurses and midwives keep their skills and knowledge up to date and uphold the standards of their professional code” (

https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-old-code-2008.pdf

)

Although the NMC is responsible for regulating the quality of licenced practitioners, they are not responsible for regulating hospitals and other treatment facilities such as nursing homes and residential homes. This is also referred to as the CQC’s position of the Care Quality Commission. The CQC is a statutory health and social care authority. Their goal is to guarantee that health and social care agencies in England provide all service users with secure, efficient, caring and high-quality care and to enable such facilities to change if they are found to have shortcomings and inconsistencies with their activities. To do this, the regulators of the Care Quality Commission go to hospitals, care homes and other nursing facilities to audit and monitor the care provided to ensure that they meet the basic quality and safety requirements. Researchers then publish their findings and provide these programmes ‘ quality reviews to help people determine where they want treatment. (2016 CQC).

Once an adult nurse has trained the task of delivering patient care over the age of 18. Upon certification and after obtaining their PIN number from the Nursing and Midwifery Commission, they will work in hospitals as well as other care facilities such as a home for people, care centres and nursing homes. It is important to re-register and refresh the PIN every three years. (The 2016 NMC). Until registering with the NMC, students are required to undergo mandatory training sessions. (The RCN, 2015). Mandatory training is mandatory training,’ according to the Royal College of Nursing (2015), which is decided by an agency to be necessary for the safe and efficient delivery of services. This method of education is aimed at reducing operational risks and following local or national priorities and standards of state. Some of these workshops may include avoidance of illnesses, instruction on how to insert and extract a catheter, advise on whistling, embracing basic life, and defending vulnerable adults. They can also take additional classes upon graduation to specialise in a specific area such as cancer care, women’s health, accident and emergency, critical care, nurse education, medical counselling, or nursing at work. (2015). (RNC).

All of the UK’s nursing programs are aimed at providing healthy, competent, qualified and caring providers who can provide appropriate evidence-based treatment. (Waugh and Booker, 2013). Anyone applying for a nursing degree is first sent through an application process that involves an interview to be sure they have the principles and qualifications they need to become a nurse. We also need to undergo an occupational health test and pass a criminal record check in order to be considered eligible for a potential nurse’s job.

Brooker and Waugh (2013) reports” Adult nurses are primarily responsible for health promotion and holistic treatment for physically ill and disabled people with high addiction rates in hospitals and community settings.” The code developed for adult nurses has the same values that exist within the discipline in all other areas. It is crucial for a nurse to provide efficient healthcare to be conscious of and have a good understanding of the medical meanings and values of their own and others. (Waugh and Booker, 2013). While practitioners, all registered nurses are personally responsible for their work for their acts and omissions and must always be able to justify their actions. Whether regarding their personal life or in their professional practise, they should always behave lawfully. (Waugh and Brooker, 2013).

A vital part of their daily duties is for nurses and other health professionals who are licenced with the NMC under privacy policies and procedures in the workplace. Every day, adult physicians, midwives and other clinicians receive information about the conditions, medications, history and care of patients. Such information should be kept private and should not be shared or spoken of without permission. The word privacy applies to patient data to Price (2016). He or she entrusts it to the nurse for safekeeping once the patient has exchanged personal information. This data is the person and is not constantly monitored by patients. Patients could be left exposed to information shared with nurses. The right to privacy is an expansion of the privacy clause. It is no less important as information is shared and it still reflects the individual. Even after their death, honouring and preserving the patient’s data remains an obligation. The RCN (2015) reported that” Confidentiality not only covers things like the treatment and prognosis of a patient / client.” In other words, it could also provide personal information like name, age and address of their house.

A guidance on how to use social media respectfully when relating to privacy is also included in the Nursing and Midwifery Council code. It is important for a nurse to preserve integrity and be responsible for what they choose on social networking sites to post and publish. We should not post any of these pages with pictures or patient information or their treatments and diseases. (NMC, November 2015). In doing so, they automatically faced being deleted from the register and their PIN number was permanently removed from the register. Same with any other situation that violates secrecy or goes beyond the regulatory body’s regulations. In a case of them breaching confidentiality which may lead to the nurses or the professionals being struck off as wells as being taken to court.

In this assignment, the writer discusses the key roles of the regulatory body of the Nursing and Midwifery Council, addressing the Council’s primary purpose when it was first formed, reforms that have been made and how they seek to protect the community and improve standards of care throughout the United Kingdom. The writer listed what is required of them in their daily practise and throughout their career as an adult nurse’s duty; whistle being recorded with the NMC. She also spoke about the required education that an adult nurse is supposed to undergo before they can apply to the council for their PIN number as well as any additional training that they can receive afterwards. The writer has talked about the importance of privacy while using social media and the dangers of violating secrecy or looking at the NMC’s regulations. With respect to all the information provided in the main body, I am sure that patients and service users could become at serious risk of wrongdoing without the regulations defined by the regulatory body. The criteria agreed by the council of nursing and midwifery give the public peace of mind in the understanding that their rights are being respected and that they can be handled with faith as well as by well-trained and qualified health practitioners.


References

  • Booker, you know, C. And Waugh, you know, A. (2013) Medical foundations: principles of clinical nursing. 2nd ed: Mosby / Elsevier, pp3-143, Edinburgh.
  • Who we are Care Quality Commission (CQC) (2016) Who we are? Online]. Cqc.org.uk. From January 8, 2017]. Available at: < http:/www.cqc.org.uk / content / who-we-are>.
  • Network on Nursing and Midwifery (NMC) (2015) Guidance on the conscientious use of social media. Online]. NMC.org.uk. From 7 January 2017]. < https:/www.nmc.org.uk/globalassets/siteocuments/nmc-publications/social-media-guidance.pdf > is available at:
  • Nursing and Midwifery Council (NMC) (2015) Code: Professional requirements for nurses and midwives in training and behaviour. NMC. Nursing and Midwifery Council (NMC) (2016) Check your registration. Online]. Nmc.org.uk. From January 8, 2017]. Valid at: < https:/www.nmc.org.uk / registration / staying-on – the-register / renewing-your-registration/>.
  • Price, B. Price. (2015) Confidentiality of the client. Nursing Style, pp. 50-57, 29(22), [ online]. From January 8, 2017]. < http:/journals.rcni.com / doi / full/10.7748/ns.29.22.50. e9579>.
  • Royal College of Nursing (RNC) (2015) Become a nurse | Royal College of Nurse. The Royal College of Nursing, [online]. [Accessed 5 January 2017]. Available at: .
  • Royal College of Nursing (RNC) (2015) Confidentiality. First Steps, [online]. [Accessed 7 January 2017]. Available at: .
  • Nursing and Midwifery Council (NMC) (2015) Guidance on using social media responsibly. NMC.org.uk, [online]. [Accessed 7 January 2017]. Available at: .
  • Nursing and Midwifery Council (NMC) (2015) Our role. Nmc.org.uk, [online]. [Accessed 4 January 2017]. Available at: .

Exercise for Balance in the Elderly | Research

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CHAPTER 1


INTRODUCTION

The ageing process is considered as a biological reality, and which cannot be controlled by human being. It is dynamic in nature. The beginning of the old age is about 60 or 65 years and it is equivalent to retirement age. According to the developed countries, old age means at the point when the active contribution is no longer possible

(Gorman et al., 2007).

As a natural part of aging, physiological and psychological changes can occur and it can affect the lifestyle and health of old age people. Most of the older adults commonly affected by the problems like osteoarthritis, osteoporosis, fractures, diabetes, hypertension, poor vision, hearing impairment, cardiovascular diseases, COPD, poor kidney function, cancers, urinary incontinence, anxiety, depression and balance problems.

(Nabili,2010)

One of the leading health concerns, in case of elderly is falling and which is related to balance Problems.

(Cochrane library)


.

Balance problems and falls are common, and falls can occur due to impaired balance among elderly

.

Worldwide, the number of persons over 60 years is growing faster than any other age group. In the middle of the 20

th

century 14 million people were in the age group of 80 years or older. By, 2050 it will be about 400 million in world wide. Approximately 28-35% of people over the age of 65 fall each year, and this proportion increases to 32-42% for those aged more than 70 years. 40% elderly people living in long term care setting experienced recurrent falls during each year and it is high as compaired to community older adults. Falls may lead to, increased dependence, loss of autonomy, confusion, immobilization and depression.

(WHO).

According to the centre for control of diseases and prevention (CDC) , one in every 3 adults over the age of 65 falls each year. Walking difficulty and poor balance are common impairments in old age group and which is the high risk for falling. In 2011American geriatric society recommended that all adults aged 65 or older should screen for falls. (

Shubert, 2011).

Falls can occur in all age groups especially in older adults. The prevalence and incidence of falls more commonly occurs after the age of 65 and (30-60) percentage in annually. As compaired to men, women are more prone to get falls. A study was conducted in Cape Town of South Africa to identify the risk factors of falls. The subjects were selected randomly aged more than 65 years. Total number of samples was 837 from different groups like whites, black Africans and Indians. The study result shows that, incidence of falls was high in women and prevalence of falls was different for different groups. (

Kalula, 2010)

The risk factors for falls are mainly Gait disturbance, muscle weakness, Dizziness, postural hypotension, visual Impairment, and syncope, use of an assistive device, visual deficit, arthritis, impaired activities of daily living, depression, and cognitive impairment.

(WHO, 2006)

As age increases, individuals experience decreased strength and balance, which is a risk factor for falls. Balance is the ability to maintain an upright posture during dynamic and static tasks. Maintaining balance requires interactions between central and peripheral factors.

(Knerl, 2009)

Balance problems are commonly reported by elderly people. Good balance has been associated with independence in daily activities. Deterioration in balance may leads to reduced physical activities and fear of falling. Balance assessments serves several purposes, such as quantitative, description of ability, monitoring subject’s progress overtime and evaluating the effectiveness of intervention.

(Sihvonen,2004)

For old age people 65 or older, in 2010 the total direct medical cost was 30 billion dollars due to fall injuries and by 2020 it is expected to be about 54.9 billion. Implementation of effective intervention could reduce the health care costs of fall related injuries

.(CDC)

From the Health Day News, exercise programme means to prevent falls in the seniors, but according to new review it says that exercise programme helps to prevent injuries also. Balance training has been identified as one of the top 10 worldwide in the fitness industry. In 2008 Physical activity guidelines for Americans recommend that balance exercises for 3 days in a week was effective for active and inactive elderly aged more than 65. Gait and balance disorders are common in elderly. As a health care team, physicians or nurses have the responsibility to ask about the previous history of falls. Due to the lack of standardized measures,evidence for the effectiveness of balance training is limited. Yet the exercise and physical therapy are included in effective options for gait and balance.


NEED FOR THE STUDY

With the exponential growth in older population, exercise is a key target(WHO,2002) and it is a subset of Physical activity that is planned , structural and repetitive and it is considered to be the important rehabilitation programme to improve the functional ability of old age people

(Cochrane library).

Dr.Nick cavil says that “A people get older and their bodies decline in function, physical activity helps to slow that decline. In older adults reduced balance is associated with, decreased physical functioning and increase risk of falling. This review analyses the effect of exercise on balance in older adults.

(Cochrane editorial unit

). In 1960’s an astronaut called John Glenn disqualified from his service, because he experienced balance problems during his working. Then after the rehabilitation programme, at the age of 77, he performed well.

As per Indiana University, exercises that speedup swaying that may help to forestall balance problems in later. For the exercise programme safe environment is recommended, for that first step, to acquire sufficient fitness and Self-confidence. Gait balance training is effective, in clinical balance outcomes in elderly. These interventions are probably safe.

(Howe, 2011).

One in every 3 adults over the age of 65 falls each year . Balance is critical when it comes to avoiding falls at any age. Balance exercise improves strength and flexibility on both sides of the body, not only do they reduce the risk of sips , trips, and falls but also increases the likelihood that seniors will be able to recover balance or reduce the injuries . After 50 years of age , begins to lose 10% of our strength per decade of life , which leads to balance problems. Balance exercise help to reduce the decade of life.

(CDC).

A study to evaluate the effectiveness of an enhanced balance training programme to improve the mobility of older adults with balance problems. The study was conducted in Bromley Hospitals NHS Trust general hospital; the design adopted for the study was prospective singled blind randomized controlled trial. The subjects participated in the study were 199.The interventional group received balance training programme and control group received physiotherapy. The outcome measures were Berg balance scale,Frenchay Activities Index (FAI), Falls Handicap Inventory (FHI), and European Quality of Life questionnaire were measured regularly at 6,12 and 24 weeks.Both groups showed improvements. (Intervention: 22.5-16.5 seconds, P =.001; control: 20.5-15.8 seconds, P =.054). As by conclusion, the results shows that exercise programmes had an effect on balance among elderly. (Steadman, et.al 2003)

Older adults can improve their quality of life by participating in balance exercises. Their by they can improve their mobility and get fit. The researcher says that as age increases, there is a chance of losing muscle mass and strength. Exercise programme helps to improve the postural alignment in sitting and standing position. Many of the older adults, admitted to the hospitals due to decreased balance problem and it results in falls related injuries, so the investigator reveals that exercise programme helps to reduce the falls by improving balance among elderly. According to American journal of epidemiology 30% of community – dwelling seniors /citizens will experiences falls at least once a year due to balance problems. so, as a health care professionals we are responsible to make out the solution.

During cinical posting in medical and surgical ward in KMCH, the investigator came across so many persons with fall related injuries due to balance problems, and most of them were in the age group of more than 60.So in order to reduce the rate of falls and to improve the balance the researcher selected the exercise programme as an intervention for elderly people.


STATEMENT OF THE PROBLEM

Effectiveness of exercise program on balance among elderly in selected old age home at Coimbatore

.


OBJECTIVES


Objectives of the study were to

  • assess the balance score among elderly.
  • determine the effectiveness of exercise programme in improving balance scores.
  • identify the association between the balance scores with selected demographic

and clinical variables of elderly people.


OPERATIONAL DEFINITIONS


Balance:-

Ability of an individual to maintain the line of gravity of a body within the base of support with minimal postural sway during different activities such as bending forward, transfer and closing eyes.


Exercise programme:-

Systematically planned programme for the old age people to improve the balance, of 5 exercises namely sit to stand, heel to toe walk, one leg stand, sideways walking and step up.


Elderly:-

Both male and female in the age group of 60-80 years.


HYPOTHESIS

There is a significant improvement in balance following exercise programme among elderly.


ASSUMPTIONS

Balance impairments are important risk factor for fall.

Balance impairments are higher in elderly people.


CONCEPTUAL FRAMEWORK

A conceptual frame work in nursing is the backbone, on which the nursing research is built. A theoretical explanation of the phenomenon or problem and serves as the basis for the formulation of research hypothesis. The conceptual framework adopted for this study is wiedenbach’s Theory, (1970) which is established by Ernestinewiedenbach, who was early nursing leader. Wiedenbach focuses on individualizing care for each patient. This is done by assessing the individual needs of each patient, so the nurse knows when to step in and help the patient.


Central purpose

Central purpose of this study is to improve the balance among elderly people.


Prescription

The investigator plan the prescription that will fulfil the central purpose (improve the balance among elderly).Thus the investigator, selected the method, exercise programme for elderly people, and which is considered to be the effective measure of improving the balance.


Realities

Agent – investigator

Recipient – elderly people with decreased balance

Goal – improvement in balance

Means – provision of exercise (make them to do)

Frame work – old age home.


Identification

This includes identification of balance problems among old age people and also importance of exercises and its effects to improve the balance among elderly.


Ministration

Provision of exerciseprogramme (balance exercise) for elderly with balance problem.


Validation

Evaluation of the effectiveness of exercise programme on balance with the use of berg balance scale

Benefits of Postnatal Debriefing

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215133

POSTNATAL DEBRIEFING STILL VALUED BY WOMEN

Introduction

Providing debriefing for women in the postnatal period is believed by many midwives to help women to adjust to their childbirth experiences, and to help reduce postnatal psychological morbidity. The evidence base is equivocal in relation to the efficacy of these kinds of interventions, which are typically delivered by midwives in clinical practice.

This essay will review several pieces of research relating to postnatal debriefing associated with the psychological distress and potential post traumatic stress disorder associated with childbirth. It will look at the quality of evidence available and discuss some of the parameters of the arguments surrounding the provision of postnatal debriefing, listening and counselling services. It will also make recommendations for practice in relation to this kind of provision, and in relation to future research.

Discussion

Lavender and Walkinshaw (1998) carried out a randomised trial of a postnatal ‘debriefing’ service provided by midwives, to see what effect it had on psychological morbidity after childbirth. The authors comprise one midwife and one obstetrician, and the midwife has a postgraduate degree, suggestive that they have the skills to carry out and report on such a study. Using a randomised trial design is aimed at filling an apparent gap in the research at the time of the study, in relation to this area of practice (Lavender and Walkinshaw, 1998). This study was carried out “in a regional teaching hospital in northwest England, and used a sample of “one hundred and twenty postnatal primigravidas”, who were “allocated by sealed envelopes to receive the debriefing intervention (n 4 56) or not (n 4 58).” (Lavender and Walkinshaw, 1998 p 215). The study involved the collection of baseline intrapartum and demographic information in order to assess a wide variety of variables in the study (Lavender and Walkinshaw, 1998).

The intervention is described as follows:

“ Women randomised to the intervention participated in an interactive interview in which they spent as much time as necessary discussing their labour, asking questions, and exploring their feelings. One research midwife, who had received no formal training in counselling, conducted the interviews, which lasted between 30 and 120 minutes, the duration being guided by the needs of the respondent. Hospital notes were available throughout the interview so that direct questions could be answered. No interview schedule was defined, since the interviews were respondent led.” (Lavender and Walkinshaw, 1998)

This approach raises several points. To being with, it is positive that there is such transparency in explaining the intervention, even if the intervention is brief, because it allows the reader to understand the nature, it aids replication, and it demonstrates the lack of specialist knowledge required to perform the intervention. Secondly, it shows that a research midwife, who was not a counsellor, was carrying out the intervention. And thirdly, it demonstrates a woman-focused, midwifery-oriented approach, in that the interviews were respondent led and the length was not limited. Such an approach reflects midwifery philosophies which makes the article useful for midwifery practice.

Lavender and Walkinshaw (1998) used an established data collection instrument,

the Hospital Anxiety and Depression (HAD) scale, which was administered by postal

questionnaire 3 weeks after delivery. Using an established data collection instrument adds strength to the study, but there is a small amount of unreliability about postal questionnaires, because there is never any guarantee that they are filled out by the person they are sent to. Using the pre-tested scale allowed the authors to compare the proportion of women in each group with anxiety and depression scores of more than 10 points, using odds ratios and 95% confidence intervals, both of which are acceptable statistical applications for these data. The 95% response rate ensured a good sample size (Lavender and Walkinsahw, 1998), although the study would have had even more statistical significance if it could have been carried out across more than one site. The benefits of this intervention were established by the study, but the authors raise some concerns, including concern at the high levels of morbidity detected, and question whether using the chosen scale was appropriate for measuring psychological morbidity after childbirth (normal or abnormal) (Lavender and Walkinshaw, 1998). This study is limited now by its age, and by being superceded by more recent studies.

Kershaw et al (2005) carried out a prospective randomised controlled trail with two arms, which compared debriefing methods after birth which were aimed at reducing fear of future childbirth. As can be seen, this studied a more specific intervention, in relation to a very specific outcome, rather than measuring psychological morbidity per se. This would make it more applicable to specific aspects of practice. This study was also carried out in one site, and the authors provide details of the hospital site, which this author would question due to the issue of confidentiality. Kershaw et al (2005) focused on mothers whose first birth was an operative delivery, and gained ethical approval. More details about the ethics of this study would have enhanced its quality. Kershaw et al (2005) provide their inclusion and exclusion criteria, but do not discuss controlling for other variables. They also use a pre-established measurement tool to assess the fear of childbirth experienced by the study participants (Kershaw et al, 2005). They do subsequently present demographic information, and they use a range of suitable statistical tests, explaining the significance of these, which makes it easier for the novice reader to begin to assess the quality of the data analysis. This again was a debriefing intervention carried out by midwives in the postnatal period (Kershaw et al, 2005).

However, unlike the previous study, this one differed because the debriefing was held on two separate occasions, and sessions were held at home (Kershaw et al, 2005). Another significant element of this study was that the midwives involved received training in critical incident stress debriefing (Kershaw et al, 2005). The authors justify their study as follows:

“ In this study fear of childbirth and post-traumatic stress were measured rather than maternal depression and general health. It was decided not to measure maternal depression as research has

suggested this is frequently associated with factors not related to childbirth. Women were allowed sufficient time to debrief, sessions lasted up to an hour and a half.” (Kershaw et al, 1508).

This shows some strengths, including a focus on specific psychological features, rather than on general health and depression, which can be difficult to assess. Although the authors state women were allowed sufficient time for the session, this study does not reflect the kind of midwifery philosophy that the Lavender and Walkinshaw (1998) study did. The findings from this study do not support the use of this particular intervention in this particular population.

“The findings of this study demonstrated in the short term no significant difference in the WDEQ fear of childbirth scores and IES emotional distress scores. These findings show community-led debriefing is not proven to be of any value in reducing women’s fear of childbirth following an operative

delivery.” (Kershaw et al, 2005 p 1508).

However, this study may not be the last word on this kind of intervention, and there are limitations, including the focus only on women who had operative deliveries, focusing on one site, and in the intervention itself. Maybe the nature of the intervention, and the training provided for midwives, was limited. The authors agree that a longer-term evaluation might show different results (Kershaw et al, 2005). It might be that the data collection tool was inappropriate, as with the previous study. However, this study, as with the previous one, does establish the usefulness and facility of midwives providing postnatal support of this kind. Kershaw et al (2005) show that midwives identified those women who would be needing debriefing, but this author would argue that midwives are not experts in mental health, and limiting debriefing to those identified by midwives as at higher risk might miss important cases. Reading between the lines of this study seems to imply that this intervention is valued by midwives and by patients, despite the findings of the statistical analysis.

Small et al (2000) carried out a randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth, again, focusing on women who are viewed as potentially at higher risk of mental health morbidity postnatally. This study was carried out in a large maternity teaching hospital in Melbourne, Australia, unlike the previous two studies, which were carried out in the UK. Small et al (2000) had a sample of 1041 women who had given birth by either caesarean section (n = 624) , by assisted vaginal delivery using forceps (n = 353) or vacuum extraction (n = 64), and these women were randomised to the intervention group or the control group (Small et al, 2000). The sample size was statistically calculated for significance, which is a strength of the study. The methodology is clear and the randomisation process described. The intervention “provided women with an opportunity to discuss their labour, birth, and post­delivery events and experiences” (Small et al, 2000 p 1044). Although there is a woman-centred focus in this study, only 1 hour maximum was allowed for the discussion, which this author would suggest is a severe limitation of this intervention in relation to woman-centred debriefing. The midwives were not trained but described as experienced and skilled. The main outcome measures were “maternal depression (score >13 on the Edinburgh postnatal depression scale) and overall health status (comparison of mean scores on SF­36 subscales) measured by postal questionnaire at six months postpartum” (Small et al, 2000 p 1044). Again, established scales are being used to lend strength to the study.

Small et al (2000) found that “more women allocated to debriefing scored as depressed six months after birth than women allocated to usual postpartum care (81 (17%)

v

65 (14%)), although this difference was not significant (odds ratio = 1.24, 95% confidence interval 0.87 to 1.77)” and “they were also more likely to report that depression had been a problem for them since the birth, but the difference was not significant (123 (28%)

v

94 (22%); odds ratio = 1.37, 1.00 to 1.86).” (p 1043). According to this study, the authors demonstrated that midwife led debriefing following operative births was not only not effective in reducing maternal morbidity (in particular, psychological morbidity), at the six month point after delivery, but that it may have been a contributing factor to emotional health issues for certain women (Small et al, 2000). This author would suggest that it might be the nature of the intervention that is the issue here, because it was provided in hospital, soon after birth, and may not have been particularly woman-centred. Cultural differences between Australian women and UK women cannot be ruled out; neither can cultural differences in models of care and practice.

Priest et al (2003) carried out a randomised single-blind controlled trial, stratified for parity and delivery mode, to test whether critical incident stress debriefing after childbirth reduces the incidence of postnatal psychological disorders, also in Australia, in two maternity hospitals. They had a large enough sample size, consisting of 1745 women who delivered healthy term infants between a specificed time period, with 75 allocated to the intervention group and 870 to control group (Priest et al, 2003). Again, the study design is transparent, and the randomisation process clear. As with the previous study by Small et al (2000), the intervention was carried out soon after delivery, but this intervention consisted of an individual, standardised debriefing session based on the principles of critical incident stress debriefing. The intervention is described briefly, and it is stated that the midwives were trained in the intervention (Priest et al, 2003). However, the intervention itself and the training is not really described in great detail, which affects replication of the study. The intervention is based on theories which are not specifically developed for childbirth trauma, but that have been adapted, and this may be a weakness. As with the other studies, recognised outcome measures are used.

Priest et al (2003) found that “there were no significant differences between control and intervention groups in scores on Impact of Events or Edinburgh Postnatal Depression Scales at 2, 6 or 12 months postpartum, or in proportions of women who met diagnostic criteria for a stress disorder (intervention, 0.6% v control, 0.8%;

P

= 0.58) or major or minor depression (intervention, 17.8% v control, 18.2%; relative risk [95% CI], 0.99 [0.87–1.11]) during the postpartum year. Nor were there differences in median time to onset of depression (intervention, 6 [interquartile range, 4–9] weeks v control, 4 [3–8] weeks;

P

= 0.84), or duration of depression (intervention, 24 [12–46] weeks v control, 22 [10–52] weeks;

P

=0.98).” (p 544).

This leads to the conclusion that this single session of midwife led, specific debriefing was ineffective as a means of prevention of postnatal psychological disorders (Priest et al, 2003). While the authors conclude that the intervention had no ill effects (Priest et al, 2003), this author finds these findings significant in their lack of support for the intervention, and would suggest, again, that it may be the nature of the intervention that is leading to these kinds of results.

Gamble et al (2005) carried out a randomised controlled trial to assess the effectiveness of a counselling intervention after a traumatic childbirth, based on a midwife-led brief counselling intervention for women deemed at risk of developing symptoms of psychological symptoms postnatally. This was a smaller study group, with only 50 in the intervention group and 53 in the control group, and the intervention was also provided as face to face counselling within 72 hours of birth, as with the previous study, but also had a telephone counselling session at between four and six weeks postnatally (Gamble et al, 2005). The allocation/randomisation process is described, but the midwife was not blind to the randomisation, which may represent a potential source of bias. Established data collection scales were used as with all the previous studies: “Edinburgh Postnatal Depression Scale (EPDS) , Depression Anxiety and Stress Scale-21 (DASS-21) , and Maternity Social Support Scale (MSSS)” (Gamble et al, 2005 p 13). Gamble et al (2005) measured the following outcome measures: posttraumatic stress symptoms, depression, self-blame, and confidence about a future pregnancy. Gamble et al (2005) provide great detail about the underpinnings of the therapeutic intervention, and there is a midwifery/woman-centred focus to the intervention (and, by association, to the study). Gamble et al (2005) found their intervention to be effective in reducing symptoms of trauma, depression, stress, and feelings of self-blame.

All of these studies fall within the scope of good standards of evidence for practice, but find marked differences between studies in relation to efficacy and non-efficacy of interventions. There may be a number of reasons for this. Only one study suggests potential negative effects of this kind of intervention, but this was not conclusive and warranted further investigation. However, the literature around this subject does seem to predominantly suggest that such interventions are useful for women following birth. Axe (2000) suggests that women can use such support to help them cope with the difference between their expectations and experiences of birth. Robinson (1999) argues for the increasing occurrence of post traumatic stress disorder following traumatic childbirth, and suggests that this is under-diagnosed and represents a significant maternal morbidity which needs addressing, a suggestion also found by Ayers and Pickering (2001). Creedy et al (2000) state that “posttraumatic stress disorder after childbirth is a poorly recognized phenomenon,” and that “women who experienced both a high level of obstetric intervention and dissatisfaction with their intrapartum care were more likely to develop trauma symptoms than women who received a high level of obstetric intervention or women who perceived their care to be inadequate” (p 104).

Therefore, the focus on debriefing may not be the only way forward to improve psychological morbidity – there may be a need for research to explore ways of reducing the trauma that occurs in the first place. Czarnocka and Slade (2000) suggest that there may be opportunities for prevention of post traumatic stress and psychological morbidity after birth, through providing care in labour that enhances perceptions of control and support. One study demonstrates that negative experiences of interactions with maternity staff can contribute to psychological morbidity (Wijma et al, 1997).

Kenardy (2000) suggests that it is the nature of the debriefing that may be ineffective in those studies that have found such results. Gamble et al (2002) also suggest that the kind and timing of the debriefing warrants further investigation. Hagan et al (1996) did not find any reduction in psychological morbidity following this kind of intervention. Alexander (1999) suggests that some of the problems may be linked to the lack of clarity and understanding that exists about these processes, which are neither necessarily formal psychological counselling nor a simple sharing session.

Yet there does seem to be some indication that these kinds of supportive therapies are found to be useful by women and by midwives. Westley (1997) describes providing women with the opportunity to talk about their birth experiences, and have their questions answered, as useful, a finding supported by Smith et al (1996), Phillips (2003), Inglis (2002), Dennett (2003), Charles (1994), Charles and Curtis (1994), Baxter et al (2003), and Allott (1996). Certainly, a range of literature established post-traumatic stress disorder as a potential and/or real psychological morbidity for women having had a baby (Ayers and Pickering, 2001; Creedy et al, 2000; Laing, 2001; Menage, 1996; Robinson, 1999; Ballard et al, 1995; Crompton, 1996). Psychological debriefing interventions may be effective in preventing or managing post traumatic stress disorder in a range of situations (Rose et al, 2004), but there would seem to be some dangers inherent in some of the interventions found in the literature (Kenardy, 2000; Madden, 2002).

Conclusion

It would appear from the randomised controlled trials analysed here that while some evidence supports postnatal debriefing as a means of reducing psychological morbidity, significant evidence shows no correlation between postnatal interventions of this kind and improved emotional health outcomes. However, anecdotal evidence and other literature suggests that midwives and women find some benefit from opportunities to talk about their childbirth experiences. Some of these simply allow women an opportunity to talk and to ask questions about what happened to them. This leads to the conclusion that such interventions require much more research, preferably research which includes detailed, qualitative evaluations of interventions, and interventions which are specifically designed for this client group. However, this author would also recommend that such interventions be provided, as they are not proven to do harm in the majority of studies, and represent a woman-centred approach to good midwifery care.

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