Boyd and Fales (1983) suggest that critical reflection is the difference between whether an individual repeats the same experience several times therefore developing proficiency in one behaviour or if the person can learn from an experience in such a way that the individual becomes more open to change and development.
By using reflection as a tool, many advantages can be gained in the development of nursing care. It is suggested that by encouraging nurses to reflect upon nursing situations, in order to promote the nurse’s professional development there will be by a process of growth better nursing care for the patient’s (Gustafson and Fagerberg , 2004).
This essay presents a reflective overview of an experience that took place during my clinical placement with the Accident and Emergency Psychiatric Liaison Team and will focus specifically on my experience with a patient who attended the department with an anxiety disorder.
I will use the Levitt-Jones (2007) narrative framework to underpin this essay and also aim to demonstrate and implement the Specific Capabilities in Practice (SCiPs) during this reflective process.
It is important at this point to review the principles of confidentiality, as detailed by the Nursing and Midwifery Council (2008), when providing information about a patient’s care it is important to maintain confidentiality. Therefore the patient will be referred to as Jane (not her real name) for the purpose of this essay.
Jane attended the Accident and Emergency department complaining of tightness in her chest, nausea, feelings of dizziness and a dry mouth. She was examined by the medical team who found no underlying physical cause for these symptoms.
During the medical assessment process it was disclosed by Jane that she had been prescribed medication for an ‘ anxiety disorder’ by her GP. It was with this knowledge that Jane was referred to the Psychiatric Liaison Team for a mental health assessment.
My mentor had suggested that I go and introduce myself to Jane and let her know we would be coming to complete a mental health assessment once her blood results had come through and she had been classified as ‘ medically fit’.
I approached the bed area where Jane was and noted the curtains were partially pulled round the bed, as I approached the bed area round the curtain I started to introduce myself and explain about the mental health assessment, however I was unable to finish my introduction and explanation as Jane shouted ‘ go away, get out, I want you out’.
At this time I am aware I froze, uncertain as how to proceed as this was not what I expected, Jane again stated that she wanted me to ‘ go away’ so I turned and walked away from the bed area and returned to my mentor to report what had just occurred.
My mentor advised me that we would wait for Jane to be cleared medically and then she would go and speak to Jane about what had just occurred; my mentor suggested this would give Jane time to calm down and give us an opportunity to request any past psychiatric records.
Whilst I was waiting for a fax from Jane’s GP, I was pre-occupied with what had happened and wondered if Jane’s reaction was because she had some kind of issue with me, my appearance or what I was wearing. I also questioned if Jane did not want student nurses involved in her care or if she had issues about having a mental health assessment.
I also ran through, over and over, what I had said and how I had said it; was I too loud? Did I startle her by coming round the curtain unannounced?
My mentor returned to the office after having spoken discreetly with Jane and disclosed to me that as I approached Jane she was in fact experiencing a panic attack and she had become agitated and shouted for me to leave as she was worried ‘ I would think she was mental’ and ‘ couldn’t bear the thought of a stranger watching her have a panic attack’.
I had felt relieved and some of my own anxiety was reduced when this information was handed over to me as I had become convinced I had done something wrong to provoke this reaction from Jane; however my mentor suggested that Jane was now willing for me to complete the mental health assessment.
During the course of the assessment I was able to identify some key points that required some further exploration with Jane and my mentor encouraged me to sit with Jane and talk through our suggested treatment plan and plan of care.
Jane disclosed that her anxiety symptoms had started several months ago following the death of her cousin in a road traffic accident, initially they had been mild but as time had gone on things had got a lot worse.
In addition to the symptoms of anxiety Jane had described she also during the course of our assessment identified experiences that could also be defined as symptoms of depression; these included; loss of appetite, early morning waking and low mood.
The GP records that had been faxed over indicated that an anti depressant had been prescribed for Jane (Citilopram) months ago but she disclosed she had not taken this on a daily basis as she thought it was ‘ just to help when she was really bad’.
It is reported that despite an increase in the prescribing of anti depressants compliance with antidepressants by patients has been described as ‘ a major problem’ (Pampallona et al, 2002).
This can be attributed to many reasons including; fear of dependence, concern of social stigma and also the prescriber giving unclear instructions about how and why the medication should be taken (McMullen and Herman, 2009).
Jane had stated that she did not know why she had been given and anti depressant for anxiety and that she was not aware that she should take it every day. Jane also expressed concern that she was going to become addicted to the anti depressants and that she would not want to stay on them for any longer than a couple of weeks.
I aimed to reassure and educate Jane by telling her that Citilopram; although a medication from the anti depressant family also, had properties that would treat her symptoms of anxiety and panic. The benefits would only be felt if the medication was taken every day and only after at least a period of 3 to 4 weeks should any benefit be highlighted (NICE, 2009).
I was also able to inform Jane that it is recommended that treatment with anti depressants should continue for at least six months, even if she was to feel better, to ensure the chance of relapse and re emergence of symptoms is reduced (NICE, 2009).
Jane stated her GP had told her the medication was to make her feel better but not much more information about how often and for how long she should take it, Jane indicated she would now take it every day and see if it helped her.
At the end of the assessment Jane thanked me for my help and again apologised for ‘ snapping at me’.
I felt it was important to end the assessment with both myself and Jane feeling the issue was resolved so that our relationship could move so I empathised with her that she was having a very difficult time and her response was understandable in the context of what was happening to her at that time.
Berg and Hallberg (2000) suggest that caring for people with mental illness demands an intensified presence, not allowing one to glide away, close the door or just disappear.
On reflection I felt that although initially anxious and self critical of my initial interaction with Jane, I was tempted not to return to complete the assessment with my mentor, however I was glad that I did so that a relationship could be established and the outcome became more positive for myself and most importantly for Jane.
I was able to spend some time a week later with my mentor and we discussed the outcomes from Jane’s assessment.
Initially I had felt unwilling to proceed with the assessment and admitted to my mentor that I had felt very anxious about Jane’s initial reaction to me. My mentor identified she was aware that I had personalised Jane’s response and that I had questioned myself at length about what I had done wrong.
My mentor was able to advise me that although it is essential for nurses to reflect on their interactions with patient’s, it is also important to attempt to obtain balance in the reflective process; which on this instance I had initially failed to do. I had become so focused on what I could have done wrong this was not balanced with what other factors may have influenced the patient’s reaction.
Hem and Heggen (2003) suggest that an important element for mental health nurses was to recognize personal vulnerability in order to survive and develop professionally.
The interaction with Jane did make me feel vulnerable; however by spending time with my mentor and by resolving the issues with Jane by understanding the reasons behind her behaviour, I feel that have further developed my skills and self awareness when delivering patient care.
