Reflective practice has been recognised by health care professionals as an essential tool to link theory to practice, which can help us learn from our experiences (Jasper 2003a). During my first placement I experienced an incident that a struggled to deal with because I did not understand the condition that the patient had. By using a reflective model I am going to revisit this incident with the intention of learning from it to improve my future practice. There are many reflective models that I could have used, such as John’s Model of Structured Reflection, but the reason that I decided not to was because John’s (2004) reflects on uncovering the knowledge behind the incident and the actions of others present, which I felt was not suited to my chosen incident. The reflective model that I have chosen to use is Gibb’s Reflective Cycle (1988), as I feel that this is a simple model, which is well structured and easy to use at this early stage in my course. Gibbs (1988) will help me to explore the experience further, using a staged framework as guidance.

Description – what happened?

I was assisting an elderly patient that had Parkinson’s disease, with her drink. It was my second shift and I had not had much contact with the patients on the ward, but I felt confident enough to assist this patient as I have previous experience of care. I was holding the cup for the patient whilst she was sucking the fluid through a straw, but she was struggling as she wasn’t sucking hard enough. She became distressed, and said that I was stopping the fluid from coming out of the straw and being evil towards her; even trying to kill her! I was shocked by her accusations but thought that there must be a logical explanation, so I stayed with her, reassuring and assisting the best I could, as I didn’t want her to see that I was distressed. I then left the ward and immediately went to seek advice from my mentor.

Feeling – what were you thinking and feeling?

Initially, at the time my feelings were for the patient, as I was concerned that my actions had caused her to feel threatened, but I didn’t understand why. I felt embarrassed by her comments, and doubted myself, as this was a simple task so how could I get it wrong? I began to feel tearful, but then quickly reminded myself that there must be a reasonable explanation.

Evaluation – what was good and bad about the experience?

I felt happy and confident to assist the patient. I referred to the Nursing & Midwifery Council (NMC) code in my head and recalled that I should gain consent before offering to assist them NMC (2008), which she agreed. The patient appeared quite and I thought it would be nice for her to have some interaction, and to also feel at ease with a student nurse caring for them.

The downside was that the patient felt that I was being nasty to them. It also made me doubt myself and the care that I was providing. I was also in a bay area, so other patients would have heard their comments. Would they then look at me differently, and not trust me to care for them too?

Analysis – what sense can you make of the situation?

The patient had no recollection of what she had said to me and since the incident she has made these comments to other staff, which has put me at ease and made me realise that I had done nothing wrong. My mentor explained that a patient with Parkinson’s can often behave like this as they develop dementia, which Noble (2007) also confirms. Since the incident I have read about Parkinson’s and am now aware that the patients expressionless face Netdoctor (2008), also made her comments appear more confusing and aggressive.

Conclusion – what else could you have done?

I could have asked my mentor before assisting the patient what the disease was like, so that I was prepared. I did ponder about calling over another member of staff, which may have helped me to understand that the patient had a condition that was making her act this way, but I didn’t want to appear incapable of doing my job.

Action Plan – what would you do if this situation arose again?

I am now more prepared for any future patients with this disease as I have researched it. I will take the time to talk to them, to make sure they are at ease with me, before providing any care. If they appear distressed I would get another member of staff to help me to reassure them.

From my reflection it is clear to me that learning through reflective practice and being able to identify, and understand, my skills and abilities in both theory and practice are crucial for me to be able to act as a professional practitioner (Jasper 2003b). It is also important that I look at, and be honest about, the strengths and weaknesses that I have. So that I am able to identify these I have produced two Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis’, one for theory (Appendix A), and one for practice (Appendix B). I am now going to explore these further, identifying the main areas that I feel are important to me, and my future development.

My SWOT analysis for theory identifies my strengths, as a whole, as being very organised with my preparation for the work I have to undertake, with strong determination and motivation to succeed. (Appendix C) is a reflection that I wrote after completing my 1st week in university and demonstrates these qualities towards the course. It was important for me to realise that enrolling on a professional university course would mean that I became an independent learner, who must have strong organisational skills in order to succeed (Burns & Sinfield 2008a). I believe that from my preparation this is a very strong strength that I have developed.

The weaknesses that I have identified in my SWOT analysis for theory, that I feel will affect my grades in the future if they are not improved are referencing, revision technique and exceeding the word limit on assignments. I feel that these are weaknesses because they are new to me and as a mature student I have been outside of academic study for some time. (Appendix D) for example, is my feedback from my 1st assignment and shows how I have been penalised one grade point for exceeding the word limit. I will need to look at these weaknesses more closely and plan to improve them overtime, as Burns & Sinfield (2008b) have commented, it takes time and practice to be a good student; we are not just born that way.

My SWOT analysis for practice shows my strengths as wanting to help people, being determined to succeed, my willingness to learn and valuing people. These are all good qualities of a being a successful and professional nurse (NMC 2008). I have always had a caring nature and I am very determined to succeed and be successful in what I choose to do. (Appendix E) is a reflective journal that I wrote after my second week in placement and clearly highlights my strengths in practice. I feel that during my time as a student nurse I will build on these strengths even more.

I have identified my weaknesses in practice, from my SWOT analysis, as communicating with difficult patients, showing emotion and aseptic technique. (Appendix F) demonstrates how I found it difficult to communicate with a patient because I did not understand her condition. It was also difficult for me not to take her behaviour to heart and show emotion at the time, it is clear that this is an area I need to build on for the future. I also need to practice my aseptic technique as I feel very unsure of the whole process, but need to be able to get it right as it will protect me and the patient from contamination (Dougherty & Lister 2008).

According to Bulman & Schutz (2008), nursing requires effective preparation so that we can care competently, with knowledge and professional skills being developed over a professional lifetime. One way this can be achieved is through what Schon (1987) refers to as technical rationality, where professionals are problem solvers that select technical means best suited to particular purposes. Problems are solved by applying theory and technique. However, Bulman & Schutz (2008) argue that this is failure to educate and for us to learn from practice and develop thinking skills. I would agree with them, as I learn best from practical experience, and build on it to improve my skills. With this is mind, I am now going to focus on my weaknesses, in both theory and practice, and state how, when and why I plan to improve on these.

Theory Weaknesses

Weakness Identified

Referencing – This is very new to me and when writing my 1st assignment I found that it took up much of my time, as I struggled with it.

Revision Technique – According to Cottrell (2008a), reading through notes over and over is a pitfall with revision. This is the strategy that I would normally use.

Exceeding the word limit on assignments – I must take more care with this as on my 1st assignment I was penalised for it.

How I Plan to Improve

Referencing – To practice writing out references from different sources.

Revision Technique – I have decided to use the advice of Cottrell (2008a) and produce index cards that ask me questions relevant to my chosen subject. I will also produce a timetable in order to manage my time.

Exceeding the word limit on assignments – I will count the words manually and make sure that I do not use the whole +10% again so that I am in danger of being penalised.

When I Plan to Improve

Referencing – When I receive my feedback from my 1st assignment I will use the comments on my referencing to guide me.

Revision Technique – I will start preparing my index cards immediately and plan my timetable to start after submission of this assignment.

Exceeding the word limit on assignments – This is the next assignment that I will hand in so I will make sure that I adhere to the word limit.

Why I Plan to Improve

Referencing – Referencing plays an essential part within my writing Gimenez (2007), so correct use and structure of references will improve my grades.

Revision Technique – Improving my revision technique will mean that I am more relaxed before an exam, and will help me to achieve better grades (Cottrell 2008a).

Exceeding the word limit on assignments – Adhering to the word limit as Cottrell (2008b) suggests, will improve my grades in future assignments.

Practice Weaknesses

Weakness Indentified

Communicating with difficult patients – On my 1st placement I experienced a patient that had communication difficulties which I found difficult to deal with.

Showing emotion – I am a very sensitive person and feel anxious that I will get upset in front of a difficult patient, or a patients family at an inappropriate time, e.g. patient death.

Aseptic technique – In practice I need to get this procedure right, but I do not feel 100% confident with it at present as I have not had much practice with it.

How I Plan to Improve

Communicating with difficult patients – I will observe as much as possible my mentor, and other nurses communication skills.

Showing emotion – I will use reflective models to make sense of what has happened, and also discuss it with my mentor.

Aseptic technique – I have asked my mentor if I can practice this procedure as much as possible.

When I Plan to Improve

Communicating with difficult patients – Each time I am on placement I will plan to improve my skills in communication.

Showing emotion – I will start to use reflective models in my practice now so that I have experience of using them ready for when an emotional situation happens.

Aseptic technique – During the rest of my time in my 1st placement I plan to practice this so that I am comfortable with it by the end of my 1st semester.

Why I Plan to Improve

Communicating with difficult patients – As a student nurse, and in line with the NMC (2008), I should make the effort to meet patients communication needs to provide the best care that I can.

Showing emotion – I want to appear professional to patients and their family, however I do agree with Scott (2008), that sometimes we should not be afraid to show emotion as a nurse, as long as we maintain our professional image at the same time.

Aseptic technique – The correct use of aseptic technique will protect myself and the patient from healthcare associated infections (Hart 2007). It will also prevent infections from being spread around the rest of the ward, which could harm other patients.

I have clearly demonstrated that by using a reflective model as a guide I have been able to break down, make sense of, and learn from my experience during my 1st placement. So that I could identify my strengths and weaknesses in both theory and practice easily, I found that the use of a SWOT analysis provided a good framework to follow. I have then built on this by producing a development plan that focuses on my weaknesses and how, when and why I plan to improve on them. I will now begin to work on these, the main reason being of course, that I am determined to be a competent, professional nurse in the future.

As the United States enters one of the worst drug crises in its history, children and adolescents are being prescribed mediation at younger and younger ages and at faster and faster rates (Vitiello, 2012). The use of antipsychotic medication in the treatment of various disorders in both children and adolescents has been on the rise despite the strong side effects affiliated with these medications and the controversy surrounding diagnosing young children with psychiatric illnesses. This paper will look at the high level of variability that accompanies diagnosing children with psychotic disorders as well as the rates of prescriptions for non-psychotic conditions and the implications of using such medications at young ages.

The issue that is important to the discussion surrounding antipsychotic prescription rates for children is the ambiguity that accompanies the diagnostic criteria for psychiatric illness in children and adolescents. Currently, the boundaries for diagnosis are unclear and between health professionals and there is a lack of consistency in how to consider the presentations of psychotic disorders in the developmental trajectory. Unlike with adults who have lived longer and who have had longer time to establish their “normal” functioning it becomes difficult to discern developmental issues of behavior and conduct with the symptoms of mental illness. How does one establish that the belief that a monster is at the bottom of the stairs is a delusion as opposed to a normal childhood worry?

The difficulties in forming a consensus about the epidemiology of childhood schizophrenia has to do with the rarity of the disorder, hindrances in describing symptoms due to developmental constraints in children as well as the difficulty of discerning childhood experiences present in normal developmental trajectories from abnormal psychopathological symptoms (e.g. fantasies from delusions) (Russell, 1994). Childhood-onset schizophrenia (COS) is marked by the manifestation of psychotic symptoms before the age of 13. Schizophrenia is rarely diagnosed until adulthood (Gochman, 2011). When comparing prevalence rates, in the United States, 1 in 40,000 children are diagnosed with schizophrenia when compared to 1 in 1,000 adults (Gochman, 2011). The conversation surrounding this disorder centers on if schizophrenia with onset in childhood is clinically different from schizophrenia with a later onset. Additionally, little research has been conducted from a longitudinal perspective on the stability of this diagnosis over time. Prognoses for children with schizophrenia are worse than adults (Gochman, 2011). In a study conducted looking at the clinical presentation of child-onset schizophrenia, auditory hallucinations were found to be the most common symptom present in the sample, all of which were hearing voices (Russell, 1994). Most of these voices were also found to be negatively-centered with violent content such as “shut up” as opposed to positive or affirming content. About 37% of the sample also endorsed visual hallucinations. In the sample, 63% of children suffered from delusions with no singular classification being predominant. The complexity of the delusions was found to vary by age and often times the delusions seen in children with schizophrenia reflect a child-like theme not seen in adults with the disorder (Russell, 1994). A large portion of the sample was also found to have met the criteria of disorganization that is marked by illogical thought or speech patterns. This study also found a large instance of comorbid psychopathology in the subjects such as attention deficit hyperactivity disorder (ADHD), depression, dysthymia and bipolar disorder, whose incidence in childhood is also controversial and will be discussed further in the paper. The issue for determining the age of onset of COS, or when behavioral symptoms first emerge, is that it is highly dependent on subjective interpretation of the symptoms based on interviews with children and parents. The average age of onset found by the paper was determined to be 9.5 years, with a confidence interval being from 4.9 years to 13.3 years.

There have been issues surrounding comparing the presentation of child and adult-onset schizophrenia due to the variance of the samples to represent the populations. Regardless, preliminary studies have shown that the distribution for delusions and both visual and auditory hallucinations are similar for both of these populations. These symptoms in younger populations, however, can give rise to multiple, alternative diagnoses by professionals which plays into the idea of the unclear boundaries surrounding this disorder in children. COS is commonly misdiagnosed as an autism spectrum disorder or a different type of developmental disorder (Bartlett, 2014). According to a study looking at the difficulties diagnosing children with schizophrenia the clinical rating scales are in place for diagnoses have “limited usefulness …when used to screen severely ill, medicated children with psychoses” (Gochman, 2011).

Bipolar disorder in children is also accompanied by controversy as the manifestation of its symptoms occurs at this critical period of development where behavior and mood patterns can be somewhat erratic. The accompanying rollercoaster of emotions in adolescence and the sporadic nature of mood in childhood can be difficult to distinguish from hypomania or volatile mood swings. In order to be diagnosed with the disorder, it must be found that the symptoms and the malfunctioning in emotion regulation must be significantly impairing. What was formerly known as pediatric bipolar disorder is now diagnosed as disruptive mood dysregulation disorder (DMDD) which is characterized by intense temper tantrums and abrupt mood swings as well as periods of hyperactivity followed by lethargy (American Psychiatric Association, 2013). There appears to be great overlap in the presentation of bipolar disorder and other disorders such as ADHD and so the detectable features of this disorder often become masked. As a consequence of this, the prevalence rates of this disorder become difficult to determine (Copeland, 2013). The heavy comorbidity of psychiatric illnesses in youth who are prescribed antipsychotics may reflect the “degree of diagnostic uncertainty in children and adolescents with behavioral health problems” (Penfold, 2013). To conclude, the validity of diagnosing young populations is highly unknown and so the use of antipsychotics to treat these disorders becomes muddled in this controversy as now the question becomes, “what illnesses are these treatments actually being used for?”

Antipsychotics are divided into two classifications according to their development, first-generation antipsychotics (FGAs), otherwise known as “typical” antipsychotics and second-generation antipsychotics (SGAs) or “atypical” antipsychotics. FGAs are marked by their side effects that often affect motor ability and can be marked by restlessness, contractions, inability to move muscles or repetitive, involuntary movements (Seida, 2012). To contrast, SGAs are thought to have less severe side effects in terms of motor impairment but can be accompanied with significant weight gain, the development of diabetes as well as elevations in blood sugar and cholesterol levels (Seida, 2012). Increased motor impairment with SGA treatment has been seen at higher doses, however. According to one study, there appears to be no difference in efficacy between these two types of antipsychotics in pediatric populations with psychotic disorders (Fraguas, 2011). Despite this finding however, SGAs have been prescribed at higher rates in children and adolescents as opposed to FGAs. The perceived safety of using these newer antipsychotics can be attributed to the increased use rate trends. These drugs also do not need to closely be monitored for neurotoxicity such as with lithium or antiepileptic medication (Vitello, 2012). This creates an image of feasibility of use and acceptability for the use of SGAs and the transition of these medications for treating non-psychotic disorders (Olfson et al., 2006).

The FDA has approved four atypical antipsychotics for pediatric bipolar disorder and schizophrenia however antipsychotics are used less often for psychotic disorders and more for other problems. In a study looking at pediatric use of antipsychotics, these medications have been increasingly prescribed “off-label” to treat behavior problems such as defiant disorder or conduct disorder, ADHD and sleep disorders in children (Penfold, 2013). The American Psychiatric Association in its recommendations has explicitly stated that antipsychotics should not be prescribed to treat “behavioral and emotional symptoms of childhood mental disorders.” According to a paper looking at the trends for prescription rates, there has been a “twofold to fivefold increase” for the use of antipsychotic medication in preschool children (Harrison, 2012). In the United States, from 2004-2005 the use of antipsychotics in individuals under 19 constitutes 15% of total antipsychotic use. This is an 8% increase from 1996-1997 (Domino and Swartz, 2008). Not only are the rates of antipsychotic prescriptions in pediatric populations increasing but there have also been significant increases in the rates of mood and anxiety disorders, psychoses, developmental disorders, and disruptive behavioral disorders in younger populations (Paus et al., 2008).

A factor in the increase in antipsychotic use for the treatment of emotional and behavioral problems in children can be attributed to the conceptualization of these problems from a medical perspective and the necessity of pharmacological intervention as the appropriate treatment. This phenomenon is reflected in the fact that the rates for all types of psychiatric medication and not just antipsychotics have seen increases in the past 20 years (Vitiello, 2012). This increase may contribute to an “environment of acceptability” for prescribing adolescents antipsychotics and decrease the preventative stigma that may hinder the use of these medications for this population. Additionally, in the U.S. there is limited availability of mental health treatment as well as access to inpatient services and thus the widespread availability of antipsychotics and their ability to stabilize patients could account for the rise of antipsychotics (Case et al., 2007).

Antipsychotic medication is noncurative and thus an individual with schizophrenia remains on antipsychotics for the duration of their life to stabilize the symptoms of their illness. The weight gain associated with SGAs persists throughout the entirety of treatment (Vitiello, 2012). Because child-onset schizophrenia occurs earlier in life and is thought to have worse prognoses than adult-onset schizophrenia, these individuals remain on medication for longer durations and this exposure could be implicated with higher mortality rates (Arango, 2004).  Some studies have shown that children, when compared to adults, have a higher sensitivity to the metabolic side effects of SGAs and the extrapyramidal effects of FGAs (Correll et al., 2006). With regards to weight gain, children gain proportionately more weight and gain that weight at a faster pace when compared to adults on the same medication (Correll and Carlson, 2006). Adolescents have a heightened susceptibility to the psychological adverse effects of antipsychotics as well (Arango, 2004). This is due to this particular stage of life where adolescents are particularly vulnerable because of their physical development and the sensitivity to the perception of peers (McCracken et al., 2002). Individuals who are on SGAs and experience weight gain may feel socially isolated or further stigmatization as a result of adverse effects on medication. This social rejection can also have profound effects due to adolescents’ heightened desire to fit in and for acceptance from their peers.

The abundance of the use of antipsychotic medications for treating a wide breadth of conditions in pediatric populations has outpaced the research to support the efficacy of these medications long-term. According to an article in Pediatric Health Care, younger populations have an increased likelihood of being on multiple psychotropic medications with 80% of preschoolers being prescribed another psychotropic medication in addition to their antipsychotic (Olfson, 2015). The side effects of medications can also be exacerbated when those drugs share common effects. This means that there are potentials for exacerbations of side effects in children which can have an immense influence on their behaviors as well as physiology. There is rapid brain development during puberty and adolescence however little review on the cognitive effects of antipsychotics or research on the long-term effects on brain development (Aman et al., 2012). The implications of this are profound as off-label prescription rates could continue to rise despite a dearth of knowledge of long-term consequences and thus populations of children could continuously be exposed to serious adverse effects that have life-long consequences.

It can be concluded that further research needs to be conducted in order to fully understand the implications of medicating children with antipsychotics for behavioral or emotional disorders. More data needs to be conducted on other intervention methods that can supplement pharmacological interventions such as cognitive behavioral therapy (CBT) or other forms of psychological therapies that don’t have such severe side effects. Overall, more support for inpatient and outpatient mental health services to promote accessibility for treatment with specialists can potentially counter the over-reliance on antipsychotics as a way to treat behaviors rather than the underlying illness.

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