Example 1
This is an extract from a student's reflection on a patient with dementia and her encounter with a care support worker.
I was feeding a patient who was in bed and had been very ill. In the bed next to her was another patient who had dementia (Mrs M). Mrs M was able to mobilise using a Zimmer frame quite safely and independently (she had no history of falls), although she was quite slow Mrs M was often disorientated of place and time and was slightly deaf. On this particular occasion she had begun quietly talking to herself and had expressed concern that her children needed picking up and that she would have to go and collect them. As I was in the middle of feeding someone who often declined to have anything to eat and was malnourished, I felt my priority was to make sure she had as much to eat as possible before she fell asleep again. For this reason, I didn’t go over to Mrs M and didn't want to address her by loudly speaking over the patient whom I was feeding at the time.
Mrs M stood up and started to arrange some of her belongings on the bed. At this point a care support worker (CSW) had arrived and stood close to Mrs M with her arms crossed. The CSW frowned and asked Mrs M what she was doing. Mrs M said that she was getting ready to go and pick her children up. The CSW told Mrs M that her children did not need picking up and that she was confused. The CSW told Mrs M to sit down. Mrs M raised her voice and insisted that her children needed collecting, and that she would have to do it as there was nobody else. The CSW told Mrs M that she couldn't leave and needed to stay on the ward so the staff could look after her. Mrs M then went on to express frustration that no-one would listen to her and that she was being kept prisoner against her will. The conversation soon became a repetitive cycle and continued for several minutes.
Mrs M became more animated as the conversation went on. I said to the CSW "you've tried, maybe just leave it now". She turned to look at me and frowned, and continued to exchange words with Mrs M, disagreeing with everything she said. The situation had become quite uncomfortable, both for myself and other patients in the bay, who had looked at me expressing disapproval for what was happening. I said again to the CSW, "I think maybe you should just leave it, you're winding her up". The CSW strongly objected to my comment by saying I didn't know what I was talking about. She said to me: "Who do you think you are telling me what to do?" The CSW continued to verbally express to me how inappropriate she regarded my comment. The CSW asked me what I would do differently that would be so much better. I said "I wasn't saying I could have done better, all I meant was sometimes it's better to just leave things to calm down and come back later". She then left the bay; still speaking at me very loudly as she left.
When I finished feeding the patient I spent some time talking to Mrs M. After she had calmed down I continued with the remaining tasks I was yet to complete: shaving two male patients. After this I shared my negative feelings with another student nurse. I then found a quiet room and wrote down what had happened and how I was feeling. I also spent the rest of the shift avoiding the CSW. When I finished the placement several weeks later I raised concern by discussing the experience with my link lecturer and academic advisor.
I experienced a number of negative emotions during and after this event. I was saddened, disappointed and annoyed at the CSW for not having any patience for Mrs M. I believe the CSW treated Mrs M with a lack of respect and failed to put her well-being first. I felt a degree of anger towards the CSW for having a lack of self-awareness and seemingly being unwilling to consider the effect of her actions or adopt an alternative approach. I was also angry on behalf of Mrs M who didn't have her concerns validated or her needs met. I felt that her dignity had not been preserved as she was made to feel foolish. After my attempts to improve the situation had failed. I also felt helpless to change what was happening, I was frustrated at having such little power or respect as a student nurse. My self-esteem had taken a big hit too. Furthermore I felt shaken up and was highly stressed.
After the adrenaline in my system had worn off I started to look at what happened under a new light. I did this by trying to appreciate things from not only Mrs M's point of view but also the CSW's. This was an attempt at positive reframing although it resulted in partial self-blame; an emotion-based (coping) strategy (Burgess et al. 2010). Another emotion-based coping strategy I used was to verbally vent to someone else. I tried to lessen the negative feelings associated with the challenging issue, after I had failed to change what was happening. Burgess et al. (2010), report that venting is a highly effective vehicle for stress reduction. Although this study is specific to an ICU setting, the significance of the findings on coping strategies are relevant to the wider field of nursing, as it relates to stressful situations in general.
Finally, I exhibited some avoidance-based behaviour by distracting myself from the stress I was feeling afterwards with other tasks. To some extent I was denying it had happened to me as I avoided further contact with the CSW. The fact that I was on my own in confronting the CSW added to my list of stressors. Vedhara et al. (2000) report that social support throughout a potentially stressful time can help reduce the amount of stress experienced by the individual. I further tried to alleviate my stress by writing about what had happened. As well as being a useful coping strategy, writing about such incidences also promotes self-awareness (Rungapadiachy 1999).
Although I didn't feel I'd witnessed unsafe practice, I read the guidelines on caring for the older person (Nursing and Midwifery Council 2009) and felt I was right to raise the concern. After then reading the NMC (2010) guidance on raising and escalating concerns, I decided to raise the concern with my link lecturer. I felt unable to do this until I had completed the placement, however, as I feared it would have a negative impact on my relationships with the staff and remaining time on the ward. Such reluctance of students to report bad practice is illustrated in a study by Bellefontaine (2009). This qualitative study involves semi-structured interviews with six student nurses on clinical placements. Four main themes were identified in the analysis which contributed towards students not speaking out: the student-mentor relationship; actual or potential support provided by both the practice area and university; students' own personal confidence and professional knowledge base; and fear of failing clinical placements. Bellefontaine acknowledges that there is limited evidence but estimates that the types of worries experienced by myself are extremely common among student nurses on placement.
Rungapadiachy argues that an ability to act appropriately on what one finds is the result of developing high levels of self-awareness. Self-awareness is fundamental to good nursing practice. According to Jack and Smith (2007), ‘being self-aware enables us to identify our strengths and also those areas that can be developed’ (p.40). The awareness we have about ourselves continuously shapes our future development and requires us 'to stand outside of ourselves, reflect on ourselves and evaluate our intra- and interpersonal elements' (Rungapadiachy 1999, p.20).On reflection, I could have been more assertive with what I said to the CSW, avoiding the criticism "you’re winding her up". Since examining this incident I have become more aware of how I may be perceived by others. I believe this will strongly enhance my future practice. I will continue to give more of a consideration to how I am approaching a challenge. I would like to have been able to calmly give an example of an alternative approach to the CSW. At the time I was unaware of the evidence concerning communication that exists. This has highlighted to me the importance of always researching the subject area of a placement. This way you can give your concerns a stronger voice by supporting them with firm evidence.
After conducting research for the purpose of this assignment, I have also considered that my personality may have an effect on my ability to cope. I have discovered that I successfully approach a challenging situation with a predominantly problem-based approach, although I could develop a tendency to deal with the emotions that arise as a result of the threat, rather than deal with the threat itself. For this reason I must engage in regular reflection and self-evaluation in order to monitor my stress levels and how I am coping. I need to work on being more assertive, particularly with my choice of words. It is important that I learn how to communicate concerns in a non-threatening and non-personalised way. I also need to be more vocal when I am experiencing stress, and seek social support at an earlier stage if possible, instead of or in addition to venting about it afterwards.'
Adapted from Bulman and Schutz 2013
QUESTION: What is your take home message from the tutorial today