The Nursing and Midwifery Council (NMC) has set out at least four domains of competencies for entry to the register in Adult Nursing. In this brief, I will focus on the second domain of communication and interpersonal skills. Communication plays a crucial role in addressing the needs of the patients. Adult nurses are expected to communicate effectively, listen with empathy and advocate for their patients (Department of Health, 2012a, 2012b). Specifically, the Department of Health (Commissioning Board Chief Nursing Officer and DH Chief Nursing Adviser, 2012) has introduced the 6 Cs of nursing, which encompasses compassion in nursing practice. Compassion in care is only possible when patients feel that their nurses understand their feelings and show empathy (Chambers and Ryder, 2009). Communication is essential in helping patients articulate their needs (Hall, 2005). Similarly, poor communication could result to misunderstanding, anxiety for the patients and poor quality of care (Chambers and Ryder, 2009).
In this brief I will focus on the domain of communication and interpersonal skills since these form the foundation of my relationships with my patients. Developing my competency in this domain would help me identify both verbal and non-verbal messages of the patients and address their needs accordingly. Meanwhile, effective communication is needed when I communicate with my colleagues and other healthcare practitioners. A focus on my communication skills with my patients will be made in this reflective brief. Communicating effectively with my patients and other health and social care professionals would help improve the care received by my patients. Benner’s (1984) stages of clinical competence would be used to underpin my development from novice to competent. Gibb’s (1988) reflective model will be utilised to reflect on my experiences in the last three years from novice to competent.
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Professional Development from Novice to Competent Level
Reflective practice (Gibbs, 1988) allows healthcare practitioners to improve current practice by learning from incidents and one’s own experiences. Pearson et al. (2009) explains that one’s own experiences are another form of evidence in healthcare. With the focus on patient-centred care, the NHS (Department of Health, 2012b) has encouraged evidence-based care when addressing the needs of the patients. I will use Gibbs (1988) model in reflecting on my communication experiences in years 1 to 3. This model starts with a description of an incident followed by analysis, evaluation, conclusion and action plan.
An incident during my year 1 exemplifies how I developed my communication and interpersonal skills as a novice. I was assigned to the mental health ward and assisted an elderly patient with dementia who was admitted for pneumonia. During his first day in the hospital, my senior nurse performed a nutritional assessment and informed me that I should assist the patient during feeding time. This was consistent with the Patient Mealtime Initiative (PMI) (NHS, 2007) implemented in our ward. As a student nurse, I would be assist the patient to self-feed and make his environment comfortable and uncluttered. During mealtime, I talked to the patient and informed him that I would assist him in eating his food. He stared at the wall and did not respond. I gently asked him if he was ready to eat. When he turned to me, I informed him that he could now start eating. He only stared at his food and did not seem to understand my instructions. I placed the utensils near his hand so he could grab it and eat. When he did not respond, I asked him if he wanted me to help him eat. After a few minutes, he got his spoon and held it for a few minutes. I began to realise that he did not seem to understand my instructions so I started to place the spoon with food in his mouth and gently touched his chin to remind him to chew his food. My senior nurse passed by and informed that I have to put some pressure on the patient’s chin and make some chewing motions to help remind him that he needs to chew his food. It took me an hour to feed my patient.
On reflection, communicating with older patients with dementia could be a challenge. Most of these patients suffer from cognitive impairments, which make it difficult for them to communicate their feelings and concerns (NICE, 2006). A significant number of older patients with dementia who are admitted in hospital wards are underweight (World Health Organization, 2014). Jensen et al. (2010) explain that many of these patients have forgotten how to eat and chew their food while others lack cognitive abilities in understanding instructions on feeding. Hence, the National Institute for Health and Clinical Excellence (NICE, 2006) guideline on nutrition for older patients highlights the importance of assisting the patients during feeding. For patients in the advanced stages of dementia, the main aim of nutrition is to maintain hydration and comfort feeding. Meanwhile, some patients could also suffer from swallowing problems, making it more difficult to ingest food (Lin et al., 2010).
The hospital ward environment is also new to older patients with dementia and might trigger anxiety and fear (Lin et al., 2010). Since patients are in unfamiliar surroundings with unfamiliar people, they might express their fears and anxieties through aversive behaviours (NICE, 2006). It is shown that nurses react negatively to aversive behaviours of older patients with dementia (Jensen et al., 2010). On reflection, the incident taught me to be more patient and to understand both verbal and non-verbal messages. It took some time for me to realise that I have to feed the patient since he appeared confused. I was also unprepared on how to communicate with an older patient with dementia. As a novice nurse, my feelings and apprehensions are normal and are also shared by other nurses (Cole, 2012; Murray, 2006). Best and Evans (2013) have shown that nurses feel unprepared to communicate and care for older patients with dementia. On reflection, I should continue with my professional development by joining training and seminar on how to communicate with older patients with dementia and address their nutritional needs. When faced with a similar situation in the future, I am better prepared and would not need more supervision from senior nurses on how to communicate with older patients with dementia and address their needs. For instance, I am now aware that these patients have difficulty verbalising their needs and I have to be sensitive of non-verbal cues and interpret aversive behaviour as possible signs of distress, anxiety or fear (Best and Evans, 2013).
The second incident occurred during year 2 in my placement in the Urology Department. At this stage, I already considered myself as an advanced beginner (Benner, 1984). I was assigned to care for a 45-year old male patient who was admitted due to testicular pain. I introduced myself to the patient and informed him that I was part of a team that would be caring for him during his hospital admission. I noticed that he was uncomfortable communicating with a student nurse and asked for a more senior nurse. I gently informed him that my senior nurse was supervising other student nurses and he was left to my care. I tried to communicate and noticed that he had difficulty with the English language. I asked him if he needed a language interpreter. Once an interpreter was identified and assisted me with communicating with my patient, I noticed a change in his behaviour. He began to open up and was willing to take his prescribed medications. I slowly understood that he was anxious about his condition and wanted a male nurse with the same ethnic background to be his nurse. When he realised that most of the nursing staff are composed of female nurses, he began to accept me as his nurse.
On reflection, this incident illustrates the importance of taking into account individual differences and using communication strategies to understand the patient’s needs. Specifically, I became aware that he had difficulty with the English language. The act of getting an interpreter greatly improved our communication. One of the competencies stated under communication states that nurses should be able to use different communication strategies in order to identify and address the patient’s needs (Nursing and Midwifery Council, 2010; National Patient Safety Association, 2009). It was apparent that the patient was self-conscious that a female nurse was addressing his needs. It is shown that a patient’s perception about his condition is also influenced by their cultural beliefs and ethnicity (Department of Health, 2012b). He was uncomfortable that a female nurse was providing care when he was suffering from testicular pain. However, the patient shares similar ethnic background as the interpreter and only became comfortable when the interpreter assured him that he could trust me. I realised that patients with different cultural background could be anxious about their treatment and might have difficulty communicating.
On evaluation, I felt that I was able to address the immediate language barrier gap by getting an interpreter to help me communicate with the patient. My experiences during my first year in placement with patients who have different ethnic backgrounds and have difficulty expressing themselves in English helped me prepare for this situation. As Benner (1984) stated, nurses develop competency through experiences. I felt that I have improved on my communication skills and have achieved the advanced beginner level during year 2. Being sensitive to the communication needs of my patient is also consistent with the 6 Cs of nursing (Commissioning Board Chief Nursing Officer and DH Chief Nursing Adviser). In this policy paper, nurses are encouraged to show compassion in caring through effective communication.
On analysis, I could have improved my communication skills by learning how to communicate with patients with different cultural beliefs about human sexuality. The patient was shy that a female nurse is part of the healthcare team managing his testicular pain. As part of my professional development and action plan, I will participate in training and seminars on how to communicate about health issues, such as testicular pain, that are considered sensitive and may carry some cultural taboo.
The third incident happened during year 3, in my placement in the surgical ward for orthopaedic patients. At this stage, my previous experiences in communicating with patients during year 1 and 2 have helped me develop important communication skills. These included recognising non-verbal messages, understanding how culture influences my patients’ perceptions of nurses and the care they receive. Culture plays a crucial role in how patients place meanings on the words and symbols I use when communicating (Funnell et al., 2009). Apart from culture, I realised that the patient’s own perceptions of the illness and pain they are experiencing could also influence the quality of our communication.
In the incident, I was assigned to assess the level of post-operative pain of a patient after surgical operation. He was a 32-year old male and was unable to communicate even after four hours of surgery. I tried to communicate with him to help assess his level of pain. Since he could not verbalise his level of pain, I used the visual analogue scale (VAS) to identify the level of pain. On analysis, I felt that I have done the right thing and have fulfilled one of the competencies under the domain of communication. Specifically, the NMC (2010) states that nurses should be able to use different communication strategies to support patient-centred care. The use of the VAS helped the patient articulate his level of pain. The VAS is often used as a tool in healthcare practice when assessing the patient’s level of pain. This tool is reliable and has been validated in different settings (Fadaizadeh et al., 2009). On analysis, my personal experiences in the last three years helped me become acquainted with current guidelines on pain assessment. It also helped me identify a simple but valid and reliable tool in assessing patient’s level of pain.
Pain perception in post-operative patients is highly subjective and could be influenced by several factors (Gagliese and Katz, 2003). These include age, gender, prior pain experience, medications and culture (Lavernia et al., 2011; Grinstein-Cohen et al., 2009; Gagliese and Katz, 2003). Regardless of the factors that influence pain, nurses should be able to assess the patient’s pain accurately and communicate with the patient strategies on how to control pain (Clancy et al., 2005). Hence, communication is crucial in ensuring quality post-operative care. On reflection, I was aware that the patient has difficulty communicating. Hence, choosing a more complex tool in assessing pain could add to more distress and anxiety for the patient (Gagliese and Katz, 2003). I realised that choosing a simple assessment tool helped calm down the patient since I was able to deliver care appropriately.
On reflection, I would follow similar procedures in the future. However, I would improve my knowledge on pain assessment by participating in pain education nursing classes in university or in the hospital where I am assigned. This would form part of my continuing professional development and action plan. Abdalrahim et al. (2011) argue that nurses with high knowledge on patient education are more likely to accurately assess patient pain, leading to earlier relief and management of the patient’s pain. However, Francis and Fitzpatrick (2013) express that despite high levels of knowledge on pain management, there are some nurses who have difficulty translating this knowledge into actual practice. One of my roles as a nurse in an orthopaedic surgical ward is to manage post-operative pain of my patients. Failing to manage pain could lead to chronic pain, longer hospital stays and poorer health outcomes (Grinstein-Cohen et al., 2009). I also realised that effective communication with patients is needed to ensure that the patient’s needs are addressed.
In conclusion, the three incidents portrayed in this reflective brief demonstrate how I evolved as a nurse practitioner from novice to competent. Specifically, my communication skills have developed from year 1 until Year 3. In the first incident, I had difficulty communicating with older patients with dementia. Beginner nurse practitioners have no experience in the situations they find themselves in. This was true in my experience with the older patient with dementia. It was my first time at communicating with a patient with cognitive impairment and feeding him. I lacked confidence in carrying out the task and only improved after several meetings with the client. However, in year 2, my communication skills improved. For instance, I was able to immediately identify the needs of the patients by depending on verbal cues and non-verbal messages of the client. I was able to get an interpreter and communicate with him. However, I also realised that I still need to improve by participating in classes and training on how to communicate effectively with patients with different ethnic background.
Finally, in year 3, I was now more competent in communicating with patients. Even when the patient in post-operative care could not communicate, I was aware that he was in pain. I was also able to use an appropriate assessment tool that is consistent with the guidelines in our hospital. I realised that I possess more confidence in communicating with the patient and identifying his needs. My previous experiences in communicating with different groups of patients helped me become competent in identifying the needs of the patients. Importantly, care was delivered promptly since I was able to appropriately assess the level of pain of the patient. All these three experiences show that I could hone my skills in communication. My communication experiences in nursing will help me become more competent and ready as a future nurse registrant.
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