Quality of Nursing and Diversity

Critically discuss how an understanding and application of the concepts of diversity, cultural competence and equality can help to improve the quality of nursing care in today’s diverse healthcare settings for a diverse service-user population
The Office of National Statistics (2014) displays how the population of Britain is becoming increasingly diverse due to migration, with 560,000 people migrating to Britain between March 2013 and March 2014; a significant increase from 492,000 people in the previous 12 months. Globalisation; which is the increasing integration of economies and societies has a profound effect on migration and health. For example the ease of accessibility of borders for services and trade removes the boundaries for migration and increases the production and marketing of products such as tobacco which have an adverse effect on health (Wamala and Kawachi 2007). The increasing movement of countries into the European Union (EU) also removes the boundaries to migration as the European commission state that individuals who hold European citizenship have rights to free movement and residency within the EU(EU 2014).

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The acceleration of globalisation and the growth in migration means the NHS have to care for an increasingly diverse service-user population who have a range of health needs which presents many issues and challenges for nursing care. Blakemore (2013) recognised how research by Macmillan cancer support found that patients from Black minority ethnic (BME) groups experience increased challenges and poor treatment compared to white British cancer patients; such as lack of compassion and poor and ineffective communication.
This is an example of how diverse groups can receive poor quality care and highlights the need for nurses to understand and apply the concepts of diversity, cultural competence and equality to evade this diminished care. This essay will explore, discuss and critique these concepts when looking at how they can improve the quality of nursing care in today’s diverse healthcare settings for a diverse service-user population.
Diversity is defined by Dayer-berenson (2014) as the ‘individual differences of the human race’ which should be ‘accepted, respected, embraced and celebrated by society’. The differences encompass many factors such age, religion, ethnicity and sexual orientation, all which shape an individual to be unique. This definition however fails to acknowledge that differences exist within each unique factor. For example in ethnic groups; where although common characteristics such as language and origin are shared, differences within the ethnic group still do exist such the extent to which the individual practices their religion, and the culture to which the individual identifies to (Henley and Schott 1999).
The National Health Service (NHS)(2011) expand on this definition by recognising that diversity includes ‘visible and non-visible’ differences. Recognition of this is important in clinical practice as non –visible differences such as values and beliefs will not be established unless nurses effectively communicate and assess there patients values, needs and prefences. This will prevent the assumption that all members of one ethnicity act as another as mentioned previously, and therefore avoid stereotyping. Henley and Schott (1999) recognise how stereotyping will result in inadequate nursing care as people distance themselves from those they see as different, causing them to have a lack of consideration and respect for the individual, thus diminishing care.
Furthermore, when assessing the values and beliefs of diverse patients, nurses must avoid holding an ethnocentric attitude. Ethnocentrism is when people identify their own cultural ways as superior to others, creating an attitude that any other beliefs and values are wrong. This leads to inadequate care as other diverse beliefs, values and therefore needs; will be rendered as insignificant and may be ignored (Royal college of Nursing (RCN) 2014). Ethnocentric behaviour however is not always recognised by the individual and is therefore difficult to challenge, as through socialisation into their own cultural values and beliefs a viewpoint of what is ‘normal’ and ‘appropriate’ is created. This viewpoint is then used to often negatively judge diverse cultures that the individual comes across (Henley and Schott 1999).
On the other hand Sharif (2012) views ethnocentrism as having a positive influence on healthcare in the United Kingdom. When looking at BME groups, South Asians are a high risk group for public health diseases such as cardiovascular disease, diabetes and chronic kidney disease. Sharif recognises the need for ethnocentric interventions to educate South Asian communities and to distinguish them as a group to further investigate the differences in epidemiology, pathophysiology and health outcomes.
This view is opposed by The Nursing and Midwifery Council (NMC)(2010) who state in their standards for pre-registration nurses that nurses must strive for culturally diverse nursing care by practicing as holistic, non-judgemental and sensitive nurses, avoiding assumption, recognising individual choice and acknowledging diversity. Therefore nurses must adhere to this code by avoiding stereotypical and ethnocentric attitudes which can be done through assessing and recognising patients as individuals. This will result in high quality care which is essential for a diverse service user population.
Respecting individual patient diversity results in respecting equality which is the elimination of discrimination and disadvantage through respecting the rights of individuals and promoting equal opportunity for all. Nurses working within an organisation must comply to the Equality Act 2010 which protects 12 diverse characteristics such as age, disability and religon from discrimation and disadvantage (Equality and Human Rights Commison 2014). In healthcare this is done through the implementation of policies and guideance, however Talbot and Verrinder (2010) highlight how equality policies can express the need for patients to receive equal care regardless of characteristics and background. This ignores personal choice and therefore disregardards individuality and diversity; producing poor quality care.
When looking at equality further nurses can promote equality through ensuring everyone has equal and full access to health care. It is recognised that BME patients have a poor uptake of healthcare services compared to white British patients for several reasons such as; language barriers, negative experiences and inadequate information (Henley and Schott 1999,Washington and Bowles et al 2008). Dayer-berenson (2014) however identifies that barriers to healthcare are not just due to racial factors but also socio-economic factors. Nimakok and Gunapala et al (2013) expand on this further by recognising that individuals from BME communities are more likely to be of poor socio-economic status than their white counterparts ; due to factors such as low income and poor housing quality. Nurses must therefore be in the position to promote equality through endorsing equal access to healthcare and complying to equality policies. This must be done whilist respecting individual patients and their diversity which produces culturally competenet nurses and thus high quality care for the diverse service user population.
Cultural competence is defined by Papadopolus and Tilki et al. (2003) as the act of respecting the cultural differences of patients in order to provide effective and appropriate care. This is a brief definition which fails to include all aspects of being a culturally competent practicioner, which arguably involves more than respecting cultural differences which will later be explored (McClimens and Brewster et al. 2014).
Leininger (1997) states that cultural competence is the goal of providing culturaly congruent, compent and compassionate care through holisticly looking at culture, health and illness patterns and respecting the similarities and differences in cultural values and beliefs.This definition fails to recognise that cultural competence Is never a completed goal but an ongoing process (Dean 2010), however it recognises the importance of looking at the similarties within cultures. This increases the nurses ability to understand and meet the patients full range of needs thus producing culturally competent care (Henley and Schott 1999).
Cultural competent nursing care is essential for enusuring high quality care in the increasingly diverse service user population, with The NHS stating that it provides a comprenhesive service for all regardless of background and characteristcs and In consideration of each individuals human rights. Respect for equality and diversity are two important aspects of The NHS`s vison and values as highlighted in this statement; and through culturally competent care these values can be achieved (McClimens and Brewster et al. 2014, NHS 2014).
Educating health care professionals on culturally competent care is therefore important with Hovat and Horey et al. (2014) looking at the effects of educational cultural competence interventions for healthcare proffesionals on healthcare outcomes. The review found that health behaviour such as concordance to treatment was improved however they also acknowledged that there quality of evidence was poor and that cultural competence is still a developing stratergy, therefore further research is needed to establish its effectiveness on healthcare outcomes.
Dayer-Berenson (2014) however, states how culturally competent care does produce positive healthcare outcomes and therefore high quality care as through culturally competent practice, cultural sensitivity can be developed. This will bridge the gap between the healthcare professional and the patient which allows the patient to feel understood, respected and supported.
There are various models which offer an understanding of cultural competence and a process for developing cultural competence to allow for high quality care. Campinha-Bacote developed the `The Process of Cultural Competence in the Delivery of Healthcare Services model’ in 1998 which looks at how the healthcare professional must work within the cultural context of the patient and ‘become’ culturally competent rather than ‘be’ culturally competent. Campinha-Bacote sees becoming culturally competent as an ongoing process which involves the constructs of cultural awareness, knowledge, skill, encounters and desire Campinha-Bacote (2002). When looking at cultural awareness; which is the process of the nurse exploring there own cultural and professional background and any bias towards other cultures, Dayer-Berenson (2014) agrees nurses need to be aware of there own culture so that they can step outside of it when necessary and care for patients only in terms of their needs. This will reduce misunderstandings and misjudgements and therefore failures in care, allowing for high quality care for the diverse service user population.
On the other hand this model has some weaknesses. When looking at the construct of cultural skill which Campinha-Bacote (2002) defines as the collection of relevant cultural data through cultural assessment in regards to the patients presenting problem, Leishman (2004) identifies some issues. Her study on perspectives of cultural competence in healthcare found that nurses do not agree that the personal beliefs and values of patients should be impinged upon as Camphinha-Bacote suggests in her model. Leishmans study found that this may impact the patients overall impression on the care they receive and that individual patient needs irrespective of culture should be the focus of care.
This view argues that patient centered care is favourable over cultural competence when caring for a diverse patient population . Patient centered care describes care which is centred around the individual and their needs with inclusion of families and carers in decisions about treatment and care (Manley and Hills et al. 2011). It is a philiosphy which is embedded at the forefront of all patient care, with a recent inquiry comminsed by the Royal College of General Practicioners (2014) emphasising the importance of patient centred care in the 21st century to meet the challenging and changing needs of patients; such as the increase in the diverse patient population.
Kleinmans explanatory model of illness offers an alternative approach for looking at cultural competence as it supports the delivery of person centred care. The model contains steps that the healthcare professional can use to communicate with their patients. The steps look at several issues such as; establishment of the patients ethnic identity and what It means to them, how an episode of illness can effect the patient and their family, what the illness means to the patient, and how a cultural competent approach may help or hinder the patients care (NHS Flying Start 2014 , Kleinman and Benson 2006).
By eliciting the patients and their families views and explanations of their illness the model allows for patient centred care. Also the cross cultural communication and recognition of any conflicts in values and beliefs which need negotiating produces culturally competent care (Hark and DeLisser 2009, Misra-Herbert 2003). The model has further strengths which also allow for high quality care as recognised by Kleinman and Benson (2006) who state that the model allows practicioners to set there knowledge alongside the patients own views and explanations which avoids an ethnocentric attitude. On the other hand the model is focused on the interaction between doctors and patients so it is therefore questionable as to wether this model can be applied to the nursing care of a diverse service user population (Misra-Hebert 2003).
The acceleration of globalisation and therefore increase in migration means that the NHS have to care for an increasingly diverse service user population. To give high quality nursing care to their patients nurses must understand apply the concepts of diversity, equality and cultural competence. This essay has shown how this can be done by ensuring their practice is underpinned by legal and ethical principles and through respecting the diversity of all through treating patients as individuals and avoiding stereotypical and ethnocentric attitudes. Respecting diversity can also endorse equality which nurses can also encourage through promoting equal access to healthcare for all. Finally nurses must be culturally competenet practicioners by respecting diversity and equality and through the implication of models although further research is needed as cultural competence is a developing concept with other principles such as patient centered care also being seen as essential in nursing practice.
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Professional Development in Nursing | Reflection

In order to enhance knowledge, skills, values and attitudes needed for a safe and effective nursing practice, this reflective piece aims to demonstrate the author’s commitment to the need for professional development contribution and personal supervision activities. Through leadership, peer support, supervision and teaching this account will further enhance the professional development and safe practice to others.
To achieve these aims, backed with supportive evidence, the author shall use a case study to enable him make discussions and debates. To maintain confidentiality, names of people and places mentioned in this account has been anonymised in accordance to NMC code of professional conduct (NMC, 2010).
During the mid-point of his final placement, Bruce was instructed by his mentor to assume the primary nurse role for 73 year old Alice who was detained in an inpatient psychiatric unit under section 3 of the Mental Health Act. Alice was diagnosed with Alzheimer’s disease dementia with a history of falls, self-neglect and aggressive behaviours toward staff and fellow patients. Following Alice’s CPA review, additional medication was prescribed to her after a mutual agreement between Alice, her family and the MDT as rapid deterioration in her mental state was a concern. CPA (2008) recommends that patients, family and carers should be involved in decision making in regard to their care plans. To promote medication adherence, NICE (2009) declares that, patients should be involved in decisions about prescribed medication to enable them to make informed choices. Bruce was not aware of Alice’s new prescribed medication because he had 2 days off from work.

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Upon return to work, Bruce volunteered to be the nurse in charge of the shift to enable him gain more confidence and build his leadership skills. Whilst Bruce was being supervised during the morning medication rounds as guided by (NMC, 2010). Alice noticed that there was a new medication so she asked Bruce purpose of the additional medication. Bruce could not confidently explain the purpose of the medication so he asked Dora his mentor who stood by to explain to Alice. Alice became extremely angry and agitated, hostile and physically aggressive towards Bruce accusing him of wanting to kill her however, staff intervened and managed to de-escalate the situation. NICE (2005) recommends that at the first signs of agitation or violent behaviour, staff should first try to calm the patient down using de-escalation methods.
Taking the above scenario into consideration one can say that Bruce acted proactively by volunteering to co-ordinate the shift. However, Bruce should have been more concerned to find out the outcome of Alice’s CPA meeting as her acting primary nurse. NMC (2008) asserts that the care of people should be your first concern, treating them as individuals and respecting their dignity. Since Bruce volunteered to coordinate the shift, he could have delegated some of the task i.e. medication rounds to other qualified nurses to enable him to catch-up with what happened at the ward during his absence. Delegation of task enables the team leader to be able to devote more time to those tasks that cannot be delegated. With more time available, the leader can invest time and energy into developing practice, improving standards and influencing decisions that affect their service (Garland and Sullivan, 2010).
It was a bad practice for Bruce to administer medication without knowing it purpose as a nurse. NMC (2010) affirms that, nurses must know the medicine’s therapeutic use, its normal dosage, side effects, precautions and contra-indications before administering it. Bruce should have checked the use of the newly prescribed medication in the British National Formulary (BNF) before administering it to Alice (NMC, 2010). Bruce could have also asked Dora about the purpose of the newly prescribed medication when he realised he was not familiar with it even before dispensing it into the pot for Alice. However, one can say that Bruce acted professionally by acknowledging his limitations and therefore asked Dora to explain the use of the newly prescribed medication to Alice. NICE (2009) recommends that as a good practice, nurses should provide patients with verbal and written information regarding their prescribed medication to promote medication concordance.
Bruce in a meeting with Dora identified the need for developing his medication administration and management skills and agreed on an action plan under his mentor’s supervision. Care Quality Commission (2013) affirms that supervision provides opportunity for staff to review their performance, set objectives in line with the organisation objective and service needs, and identifies training and continuing developing needs. Bruce further identified the need for research on medication administration, management and medication training all these shall be accomplished under the supervision of Dora. Bruce also has requested to be more involved in medication administration and did a research and found out that, patients must always understand the reason for taking a particular drug. NICE (2009) recommends that, at intervals agreed with the patients, staff should review patients’ knowledge, understanding and concerns about medicines, and patients view of their need for medicine because these may change over time.
Bruce had the opportunity to learn how to write CPA reports, tribunal reports and continued to build his confidence in writing plans of care and risk profiles by assuming the primary nurse role for Alice. Bruce also seized the opportunity by being the primary nurse to Alice to gain a better understanding of the MDT working. DOH (2004) ten essential shared capabilities recommends that professionals, patients, family and carers should work in partnership to provide quality care.
By volunteering to coordinate the shift gave Bruce the insight of the responsibilities and what to expect from a qualified nurse. Coordinating the shift enabled Bruce to research more about his leadership styles, improved on his communication and delegation skills and his management. Bruce also had the opportunity as the shift coordinator, to do an incident report about Alice’s physical aggression towards him under Dora’s supervision.
It can be argued that Alice was not supposed to behave that way however, she could forget about her CPA meeting and the newly prescribed medication because of the symptoms of her illness. Wrycraft (2009) declares that, typical symptoms of dementia are loss of memory, confusion and a change in personality, mood and behaviour.
NHS (2012) confirms that, common symptoms of Alzheimer’s disease include memory loss, especially problems with memory for recent events, such as forgetting messages, remembering routes or names, and asking questions repetitively.
Based on the above account, a nurse should always reflect and evaluate his or her practice then plan future practice areas for development.
 

Non-pharmacological Nursing Interventions Literature Review

5 METHODOLOGY
A literature review is defined as a critical analysis of a segment of a published body of knowledge through summary, classification, and comparison of prior research studies, reviews of literature, and theoretical articles.
In addition to that a literature review will be used for conducting the research. According to Fink (2010), literature review is an evaluative report that is a systematic, explicit and reproducible method for identifying, evaluating and synthesizing the existing body of completed and recorded work produced by researchers and scholars. In this literature review the main focus was to search the existing literature on non-pharmacological nursing interventions in order to be able to describe and analyze the similarities, differences, consistencies and inconsistencies and issues within the research topic.

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5.1 Inclusion and exclusion criteria
Inclusion criteria are characteristics that proposed subjects must possess in order to be integrated in the future study. On the other hand, Exclusion criteria are characteristics that help the researcher to eliminate subject from being integrated in the study. A clear comprehension of the inclusion and exclusion criteria ensures that the research yields accurate and genuine results (Fink 2010). The inclusion and exclusion criteria of this literature review are described below in table 1.
TABLE 1. Inclusion and Exclusion criteria

Inclusion criteria

Exclusion criteria

The research focused on the non-pharmacological nursing interventions of geriatric depression

The articles which are not related to the research questions.

Articles were limited from 2005 to present

Articles were not related to the studies and carried out before 2005.

The articles were in full text, abstract and within the keywords

The articles without full text, abstract and within the keywords

Languages used were English and Finnish.

The articles which were not in English and Finnish.

Evidence based research were used.

Articles that were not related to nursing and were not scientific.

4.3 Data collection
The research articles for the literature review were limited to a time frame between 2006-2015. The information was gathered using different computerized databases such as Ebrary, CINAHL, Ovid, SAGE Premier and Science Direct, to find scientific journals. Moreover web based publications such as WHO, kaypahoito and Terveyden ja Hyvinvoinnin Laitos were also used.
In addition to that numerous articles were gathered from well known scientific journals such as Journal of Advanced Nursing and Journal of Nursing Education. Keywords used in the search were focused on the research topic, they included Geriatric Depression, non-pharmacological interventions and Signs of geriatric depression. The key words and the time frame were combined in order to constrict the range of articles; the materials obtained for this study were in both English and Finnish.
4.4 Data analysis
The collected data will be analyzed through content analysis of the collected articles, journals and electronic web pages. All the collected data related to the topic will be divided into different groups to make analysis easy.
5 ETHICS AND RELIABILITY
High ethics will be maintained throughout the research process. I will also consider a good scientific conduct to ensure that the research is ethically acceptable. The authors in the references will be respected and thus referred accurately. The research project is about finding out the effectiveness of non- pharmacological treatment methods when dealing with geriatric depression. I plan to follow the set thesis guidelines of Centria University of Applied Sciences while carrying out my research. Reliability will be ensured by only referring to recent research materials available concerning geriatric depression. The articles and other materials will be obtained from reliable electronic sources and the school’s library databases to ensure that valid results are obtained that can be used in the future.
6 FINDINGS
6.1 Non-pharmacological nursing interventions
Physical Exercise
In a study by Park, Han and Kang (2014), it was found that regular exercise for older adults suffering from depression increased their social contact and improved their self efficacy. Physical activities also had inverse relationship with depression among the elderly. This meant that older adults engaging in physical exercises were found to have improved mental and physical health. (Lee, Brar, rush and Jolley 2014.)Regular physical exercises reduced depressive symptoms and anxiety associated with aging and other predisposing factors such as chronic ailments. In additional to that, older adults involved in physical activities ended up having some positive thoughts and opinions on their own aging process. (Park et al 2014.)
As a result of physical exercise physical exhaustion was also highly reduced as a result of improved cardiovascular activity, immune system and the endocrine system. These also translated to reduction of depressive symptoms and an improvement in psychological well being. (Tsang, Fung, Chan, Lee, and Chan, 2006). In another study by Stanton and Reaburn (2014), it was confirmed that aerobic and non aerobic exercises including outdoor walking and stationary cycles demonstrated a reduction in depressive symptoms among the elderly. Exercises were conducted three times a week for a total duration of twelve weeks. (Stanton et al 2014.)
Furthermore, regular physical activities among the elderly were found to improve their quality of sleep. Poor sleep quality and related sleep disturbances were attributed to in active lifestyles and repetitive daily routines, which further lead to cases of depression, anxiety, agitation, fatigue and daytime drowsiness. In a related article by Cheng, Huan, Li and Chang (2014), found that elderly people who engaged in physical activities such as the senior elastic band exercise reported improved sleep quality and significant decrease in depressive symptoms. In additional to that, Chen et al (2013) developed the wheelchair-bound senior elastic band (WSEB) exercise program, which granted the depressed older adults bound on wheel chairs an opportunity to exercise too. (Chen et al 2013.)
Cognitive Exercise
According to a study by Khatri, Blumenthal, Babyak and Krishman (2001), it was determined that physical exercise impacts positive effects on the cognitive functioning among elderly people suffering from depression. The study was carried out on two different groups of randomized participants: medication group and the aerobic exercise group. All the groups underwent the tests for duration of four months. In the medication group they received antidepressants while the exercise group underwent aerobic training. In addition to depression cognitive functions were also assessed, for example memory, executive functioning, concentration and psychomotor speed. Assessment tools used in the study included Beck Depression Inventory (BDI) and Wechsler Memory Scale (WMS). It was established that participants in the exercise group exhibited greater improvements in both memory and executive functioning than those in the medication group. Furthermore, the exercise group also showed better improvements in the Wechsler Memory Scale visual reproduction delayed recall scores. However there were no significant differences in the verbal memory and concentration. (Khatri et al 2001.)
Vasques, Moraes, Silveira, Deslandes and Laks (2011), found that despite physical exercise having significant effects on depression it also exhibited positive effect on the brain function. During their study neuropsychological tests were performed in the forms of Mini Mental State Examination (MMSE), the Digit Span Test (DST)and the Stroop Color-Word Test (SCW) to assess the cognitive functions of their elderly participants suffering from major depressive disorder. After the participants walking on the treadmill for half an hour cognitive tests were performed before, during, after and 10-15 minutes after the training session.
Similar cognitive tests were also performed on the control group but without exercise. There were no significant differences for both the control and the exercise group on the Digit Span Test. However in the Stroop Color-Word Test, the exercise group had improvements in their results when compared to the control group. The improvements were a clear indication that physical exercise had a positive effect on the cognitive functions of the depressed participants. (Vasques et al 2011.)
According to Nicholas et al (2006), nurses used Problem solving therapy to help patients with depression to improve their cognitive functioning. Individuals were assigned certain tasks to handle in the form of games which varied from cheap to hard. This helped the individuals to think in a structured way which in turn improved their cognitive functioning. In additional to that it helped relieve depressive symptoms. (Nicholas et al 2006; Haggerty 2006.)
Family Therapy
In another study by Tanner, Martinez and Harris (2014), to examine the functional and social determinants of depression on community dwelling older adults it was concluded that support from family showed an improvement in general functions and a decrease in loneliness. In additional to that, family support satisfaction scale (FSSS) was used on the older adults to assess satisfaction with support received. The instrument consisted of 13 questions constructed to investigate the participant’s satisfaction with the family support they received from family members. The participants were expected to respond with either agreement or disagreement. It was found that those participants who had higher support scores had decreased levels of depression.
Loneliness was also identified as one of the main causes of depression in addition to other predisposing factors. Older adults who were satisfied with the family support they received confirmed that it helped them cope with depression as well as chronic illnesses. (Tanner et al 2014).
Nurses were found to play a crucial role in helping elderly people dealing with depression developed as a result of social isolation or bereavement. It was discovered that leaving these psychosocial factors not dealt with it made it difficult to make a lasting or complete recovery. (Hughes 2005). Nurses were found to play an important role in guiding, supporting and encouraging elderly people dealing with depression to keep contact with their family members. (Parello 2012.)
According to a study by Merema (2014), it was found that older adults with good social network between them and their family members had higher levels of self esteem and self worth. In additional to that they were less likely to attempt suicide when compared to their counterparts with little or no social network at all.
Music therapy
According to a research carried out by Chan, Mok and Tse (2009), to determine the effects of music on depression levels in elderly people. The study was conducted on 47 elderly people (23 using music and 24 controls), majority of who were 75 and above. It was pointed out that music exerts psycho-physiological responses through influence on the limbic system. The limbic system is involved in our feelings of pleasure and emotions such as fear, anger as well as motivations. Therefore the limbic system is mostly affected by music rhythm as well as pitch and is also responsible for processing the music stimuli. It was found that music expends its effects through entertaining the body rhythms. In this context entertainment can be described as a tendency by two bodies locking together and vibrating in harmony. When an elderly person is going through a depressive phase they tend to experience mixed feelings of discomfort or agitation which in turn disrupts their body rhythms. The Body rhythms is disrupted through change in breath, blood flow and heartbeat which further lead to changes in blood pressure levels and oxygen saturation. (Chan et al 2009).
The music interventions used included four different types of music which included western classical, western jazz, Chinese classical and Asian classical. Each type of music was played for a duration of 30-min once per week for a duration of four weeks. The participants listened to the music without any interaction with the therapist. At the end of the study the depression levels of the experimental group had significantly decreased from form mild depression to normal levels. On the contrary there was no change in the depression levels for the control group within the four weeks. (Chan et al 2009).
Furthermore, the physiological measures monitored including systolic and diastolic blood pressure, heart rate and respiratory rate of the elderly in the experimental group had reduced significantly in comparison to those of the control group. The findings demonstrated the benefits music has on older people suffering from geriatric depression. Music had a soothing physiological and Psychological effect on the elderly suffering from geriatric depression. This also support that music has the capability of to resonate with the listeners feelings. (Chan et al 2009).
It was discovered that giving participants an opportunity to choose their music led to effective treatment. Chang, Wong and Thayala (2011), suggested that when the participants chose their own music it facilitated the entertainment process because the listener was in tune with their music of choice. The effects of music listening did not occur after one or a few sessions. In contrary to that, significant decrease in depression levels were reached after the participants had music listening sessions for a few weeks. In additional to that it was found that different kinds of music had similar effects on depressive symptoms among the elderly depending on the listener’s preference of music. (Chang et al. 2011).
Music therapy was found to reduce irritability, agitation, and problem behaviors in people with geriatric depression. In additional to that it was also found that music therapy improves the sleep quality of people dealing with geriatric depression. (Rice et al 2010).
Social activities
While going through recent randomized trials it was found that social activities were effective interventions which improved depression outcomes among the elderly. (Merema 2014.) Social activities were provided in form of recreational group events such as day meetings, group outings and visits from family. These social activities generated social interaction and support among the elderly. (Hsu and Wright 2014).
In additional to that it was found that through social activities the elderly were able to establish enduring relationships which in turn provided an effective method of reducing or limiting the severity of depression. It was also established that social activities improved the sleep quality and the cognitive functions of the elderly people. Social activities had a direct effect on the levels of loneliness faced by elderly people with depression. Furthermore it was discovered that depressed old adults felt much better when they were around other people. (Merema 2014.) Engagement in social activities was found to reduce cases of social isolation thus limiting worsening in the severity of depression. (Hsu et al 2014.)
In a study by Hsu et al (2014), it was indicated that meaningful and enjoyable social activities lead to a decrease in depressive symptoms among institutionalized elderly living with depression. Social activities that were interesting to the elderly dealing with depression showed a decrease in depressive symptoms. It was found that a large number participated in social activities in the institution due to the positive emotions they experienced or out of personal interest. (Merema 2014.) The reduction in depressive symptoms was as a result of the psychosocial mechanism which includes a positive feedback where there is an improved mood due to pleasant events. Surprisingly it was found that institutionalized depressed elders participated more in social group activities. The institutional environment offered them an opportunity to participate in activities that led to more positive mental attitude and a decrease in depressive symptoms. (Hsu et al 2014.)
 

Importance of Communication in Nursing

Communication in nursing
 
Introduction
Communication in nursing is vital to quality and safe nursing care (Judd, 2013). There is evidence that continues to show that breakdowns in communication can be responsible for many medication errors, unnecessary health care costs and inadequate care to the patient (Judd, 2013). Several reports exist from the Institute of Medicine that stress the importance of good communication and its link to providing safe and reliable care (Judd, 2013). (Smith & Pressman, 2010). However, even nurses with the best communication skills can be challenged by difficult situations such as life threatening threatening illness or injury, complicated family relationships, and mental health issues, to symptoms such as unrelieved pain and nausea. How a nurse may respond during these situations depends on many factors. Each nurse brings their own history, culture, experience, and personality to a situation. Communication in the workplace can either be horizontal among workers at the same hierarchical level, vertical among workers in different hierarchical levels or diagonal amongst different workers in different hierarchical levels. All these kinds of communication are crucial in the work environment because work needs to be done and goals need to be met. A communication channel is made up of three components made up of the sender of the message (encoder), the channel of sending the message and the receiver of the message (decoder) (Anderson, 2013). For effective communication to be achieved, the encoder and the decoder must be able to understand one another. This paper will discuss some strategies which could be implemented to improve both written and verbal communication between nurses, health professionals and between patients and the health care team.

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Communication, a fundamental aspect of nursing, is a complex, continual transactional process that occurs between persons by which information, feelings, and meaning are conveyed through verbal and non verbal messages (Peereboom, 2012). It is crucial for nurses to identify communication strategies that should be put into consideration every time they are involved in conversations involving their line of practice. This is because clear and accurate communication strategies enable them to identify effective patterns in their interactions and in teaching themselves to improve their patient education techniques. Handover communication between practitioners may at times seclude crucial information and is even prone to misinterpretation. Such communication breakups and challenges can lead to intense mishaps in the continuity of health care, incorrect treatment, and potential harm to the patient in general (Memoire, 2007).
Simple strategies can easily impart critical information just by eye sight. For instance, nurses are able to communicate critical patient status issues like allergies and fall risk with color-coded patient identification wrist bands or stickers on their medical records, a seat belt or flag attached to a wheel chair, or any other objects which are easily identifiable by all medical practitioners (Joint contribution resources, 2005). The use of local jargon can also be avoided when making professional conversations because some words may portray a meaning that was not intended or is not readily understood by a large number of people.
Assimilation of the ISBAR tool is a strategy that has been really helpful in enhancing communication in the healthcare sector when used. Identifying yourself (I), availability of the situation (S), background (B), assessment (A), and recommendations (R) facilitates communication allowing each health practitioner to receive and give important information in a format that satisfies numerous communication styles and needs (Dixon et al., 2006). This tool should be adopted by everyone to improve communication is because this technique utilizes the use of one common language for passing on critical information without leaving out anything.
Another strategy that can be used to improve communication in healthcare centers is the Crew Resource Management technique which is both a communication and team building technique (ECRI, 2009). This strategy trains members of the healthcare sector to assert themselves respectively and be attentive when they are being spoken to and also encourages them to make use of briefings. Briefings are direct communications between physicians, nurses or other caregivers acting on patient status which includes sharing of important information at critical times, such as before the start of a procedure, at the change of shift and during normal patient rounds (ECRI, 2009).
COMMUNICATION BETWEEN PATIENTS AND THE HEALTH CARE TEAM
One stratergy that can be used to improve communication between patients and the health care team is the use of ‘The World Health Organization Surgical Safety Checklist’. This checklist is to be used in operating suites to ensure everyone involved with the patient including the patient understands what procedure they are having ad gives prompts to tick off so important information is not missed during handovers leading to reduced inpatient complications and death (Department of Health, 2010).
In addition to the patient, their family members or next of kin can also be included in the rounds further increasing the opportunity for direct dialogue which reduces the development of complications which arise as a result of miscommunication in the form of home care. It is important to note that if personal care by the family of the patient is not provided as requested by the medical practitioner, cohesive care is not accomplished and the opportunity to achieve patient care goals will not be met (O’Leary et al., 2010). Joint commission reports also indicate that health practitioners should also encourage patients to actively participate in their own care as a strategy to enhance communicational barriers (Stein, 2006). Successful interactions are always co-constructed, involving a constant interplay among the two parties. When the patient and the healthcare provider are comfortable with one another communicating becomes easy and more effective in the sense that the healthcare provider will be able to solve the needs of the patient.
COMMUNICATION BETWEEN HEALTH CARE DISCIPLINES
Communication between medical practitioners can greatly influence the general patients care outcomes. Medical practitioners are in the frontline to investigate and identify communication challenges and try to implement solutions that fit their line of duty. Some further research is also being carried out to evaluate potential solutions and more successful options (Rosenstein, 2005).
Creating a collaborative relationship between nurses and other medical practitioners is also another strategy that can help reduce communicational barriers and thus improve the general treatment of patients (Arora, 2005). With regard to Schmalenberg and Kramer (2005), “MD/ RN collaboration is reflected in reduced patient mortality, fewer transfers back to the ICU, reduced costs, decreased length of stay in hospitals, higher nurse autonym, retention, nurse-perceived high quality care, and nurse job satisfaction”. Larabee (2006) also found out that positive relationships between medical practitioners were a major contributing factor to improved nursing job satisfaction and retention. Positive collegial relationships therefore result from good communication, mutual acceptance and understanding, use of persuasion rather than coercion, and a balance of reason and emotion when working with others (College of Nurses of Ontario, 2009, pg. 7).
COMMUNICATION BETWEEN NURSES
A number of strategies have been set up to address communication issues among nurses. For instance, the implementation of unit based care teams places nurses and people like physicians close to one another thus increasing the chances of communicating effectively (Gordon et al, 2011). The introduction of compulsory bed rounds is also another strategy that has enabled nurses to reduce communication barriers and promote effective communication thus creating patient health satisfaction and general health care providers satisfaction in their duties.
The continuous flow of interruptions and multiple patient handoffs affect the ability of nurses and physicians to connect effectively, and establish a trusting and collegial relationship (Tschannen et al., 2011). The fact that the working environment of nurses and other medical practitioners is rather different also induces a number of communication barriers with regard to the intensity of activities on a normal working day (Burns, 2011).this could be improv4d by…
Communication challenges are recognized when set goals or achievements are not met or when there is great employee turnover. Technological advances have opened up communication across boundaries of different countries meaning that people with different languages, behaviors and culture interact with one another (Krizan, 2010).In the health care sector in particular, the most pertinent communication barrier is the inability for colleagues to interact physically as they are separated in different departments (Vignam, 2013). This lack of interaction minimizes the ability for team members to collaborate wholly in the sense that the ability to analyze body language and create a sense of energy among team members is null. This can be improved by…
Barriers
Barriers to communication that exist are the use of machinery and equipment that might malfunction and deliver the message later than expected thus reducing the urgency of information. In addition to this, these machines are not able to express aspects of speech such as tone thus making them a true barrier to effective communication. Language is also a major communication barrier in the case where colleagues do not speak the same language or where they have difficulty in articulating clearly in one common language. The use of local idioms, jargon and acronyms further complicates language and kills communication among team members who find certain words ambiguous (Lingard, 2005). A patient in a hospital setting usually sees more than one health care practitioner and specialist during their stay (Memoire, 2007). Handover communication between practitioners may at times seclude crucial information and is even prone to misinterpretation.
By improving communication among healthcare professionals the delivery of patient care improves and is saferStrong and effective nursing care is enriched and strengthened by good communication (2)
In Victoria, the direct cost of medical
errors in public hospitals is estimated at half a billion dollars annually [1]. Today, healthcare is
evermore complex and diverse, and improving communication among healthcare professionals
is likely to support the safe delivery of patient care.
References
Anderson, P., 2013. Technical communication, cengage learning, Canada
Arora V, Johnson J, Lovinger D. (2005) Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care
Burns, K. (2011). Nurse-physician rounds: A collaborative approach to improving communication, efficiencies, and perception of care. MEDSURG Nursing
Dixon, J., Larison, K., & Zabari, M. (2006). Skilled communication: Making it real. AACN Advanced Critical Care
College of nurses of Ontario. (2009), conflict prevention and management, Toronto, ON
ECRI. (2009), Healthcare risk control, 5200 butler pike, Plymouth meeting, PA 19462-1298, USA
Fernandez, R., Tran, D., Johnson, M., & Jones, S. (2010).Interdisciplinary communication in general medical and surgical wards using two different models of nursing care delivery. Journal
Of Nursing Management
Gordon, M., Melvin, P., Graham, D., Fifer, E., Chiang, V., Sectish, T., & Landrigan, C. (2011). Unit-based care teams and the frequency and quality of physician-nurse communications. Archives of Pediatric & Adolescent Medicine
Joint commission resources. (2005), issues and strategies for nurse leaders: meeting hospital challenges today, joint commission resources, Inc, USA
Krizan, A., Merrier, P., Logan, J., Williams, K., 2010. Business communication: Business communication series, Mason: USA: Cengage learning
Larabee, L., Janney, M., Ostrow, C. Withrow, M. Hobbs, G. Burant, C. (2007), predicting registered nurse job satisfaction and intent to leave, journal of nursing
Lingard L, Espin S, Rubin B. (2005) Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care
Memoire, A. (2007), communicating during patient hand over, patient safety solutions, vol 1
O’Leary, K., Thompson, J., Landler, M., Kulkarni, N., Hawiley, C., Jeon, J.Williams, M. (2010). Patterns of nurse-physician communication and agreement on the plan of care. Quality and Safety in Healthcare
Peereboom, K. (2012), facilitating goals of care discussions for patients with life limiting disease- communication strategies for nurses, journal of hospice and palliative care
Rosenstein AH, O’Daniel M. (2005). Disruptive behavior & clinical outcomes: Perceptions of nurses and physicians.American Journal of Nursing
Stein JS. (2006) Improving patient safety communication. Presented at: Philadelphia Area Society for Healthcare Risk Management; Mar 16; ECRI Institute, Plymouth Meeting (PA).
Schmalenberg, C. Kramer, M., King, C. (2005), excellence through evidence: securing collegial nurse physician relationships, journal of nursing administration
Schmalenberg, C., & Kramer, M. (2009). Nurse-physician relationships in hospitals: 20,000 nurses tell their story. Critical Care Nurse
Vigman, S., 2013. Global challenges: communication and culture: people issues in a global environment, workforce solutions review
Department of Health 2010
Promoting effective communication among healthcare professionals to improve patient safety 1-1-7
Retrieved from
http://www.health.vic.gov.au/qualitycouncil/downloads/communication_paper_120710.pdf
http://www.health.vic.gov.au/qualitycoun http://www.health.vic.gov.au/qualitycouncil/downloads/communication_paPromoting effective co
 

Leadership Styles in Professional Nursing

The health sector’s success relies mainly on the leadership of the nurses in command; this may be a nurse manager who is in control of a unit or a nurse executive who controls numerous units. To be able to successfully lead the others the nurses need to have the necessary leadership skills that will be employed to solve all the challenges (Mahoney, 2001). The effective leadership skills will be very useful in the decision making process in the health sector.

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The senior nurse therefore has the control over all the activities involved which means that he/she must do it diligently and professionally at all times. They need to be visionary and have appropriate strategies to success; in addition they should be dynamic, motivated, and have the desire to achieve greater heights (Mahoney, 2001). This paper analyses leadership styles in professional nursing and how they can be applied to make the health sector effective and efficient. It reviews professional nursing literature that identifies the major leadership skills and gives a clinical application example.
Review of the Professional Nursing Literature
In leadership, the leader must aim at transformation where the nurses are motivated to transform the industry through proper morals and hard work. There are various leadership styles that can be applied by leader nurses; these include democratic or autocratic leadership. In this regard the nurses who lead can apply such styles depending on the situation and experience of the nurses. According to Cook (2001) in the article “The renaissance of clinical leadership” there are various factors that influence the style of leadership to be applied. They include, the external environment; the experience of the nurse involved the internal environment, and the understanding. He identifies four styles that nurses can use in their leadership and make it effective. The styles are connected to nursing care approaches and include; transactional, transformational, connective and renaissance.
In transformational leadership the leaders and subordinates are able to lift each other in their work to higher heights. This is mainly achieved through motivation and morality where they are both involved in whatever happens to one another (Cook, 2001). This is more like the democratic leadership where leaders seek the opinion of the subordinate nurses in the decisions they make. The nurses are able to carry out all their duties independently, without interference and to their understanding. They are however free to ask for assistance from others either the leaders or the colleagues in case they need any assistance. This means that the nurses are able to work efficiently and behave well due to the motivation, inspiration, individual consideration and intellectual stimulation (Cook, 2001).
Transactional leadership on the other hand pursues an autocratic leadership style where the nurses are under obligation to perform in view of the fact that they are paid to do so. The subordinates must take strict orders from the leaders; which they must obey without questions or comments. The leaders are able to further their own agendas, goals and whatever they see as effective. They do not take in to considerations the view of the subordinates viewing them as just workers to follow the orders given. The leaders supervise the subordinates very closely and are mainly on duty to ensure that every nurse arrived to their duty and has performed all the duties as per the instructions.
Thyer (2003) in the article “Dare to be different: transformational leadership may hold the key to reducing the nursing shortage” gives an account on the contribution of transformational leadership on the issue of nurse shortages that have been experience. On their part, health care has in many occasions been implemented under transactional leadership that has made nurses to quit and leave the industry (Thyer, 2003). This leaves a shortage in the profession as more continue to leave either for retirement or other well led careers. The nurses blame the system in the workplace which they say is dictatorial and does not bring fulfillment to their profession.
Transformational leadership on the other hand when applied will bring motivation and morality in the sector and thus retains more nurses and attracts more others. The nurses become visionary, creative, independent, and engaged in the making of decisions both at the in-patient and out-patient level and this brings fulfillment and individual association with their work. They are able to attach themselves to their work and make it more enjoyable through contributing to the decisions made. The transformational leadership also allows equality in terms of gender, race, and age; what’s more is that the nurses are able to contribute to the communication strategies that are needed in the health sector (Thyer, 2003).
Transactional on the other hand will erode the spirit of team work, communication and togetherness in the sector. In view of these facts, transformational leadership becomes an inspirational mode to attract better terms of reference in the job market and create a notion that inspires even scholars to join in.
Sellgren et al. (2006) in the article “Leadership Styles in Nursing Management: Preferred and Perceived” aimed to explore the leadership involved in nursing in regard to what managers and their subordinates view as important. It also aimed at exploring the opinions of the subordinates on their superiors’ performance in the work place.
The study was based on the leaders’ styles and their fundamental roles they have to play in their workplace and the view the subordinates have of those roles (Sellgren, et al. 2006). It is also based on the way the subordinates accept and follow whatever the leaders say and the motivation they get from the leaders; and the way they follow the goals and objectives of the manager for the purpose of quality.
Application of Clinical Example
When leaders apply the styles they are positive that they will achieve their objectives and whichever style they apply they are guided by the experience and situation. When leading nurses who are managing experience nurses they tend to apply transformational leadership since they know the nurses know their work and don’t need much supervision. In contrast when leading new registered nurses they may apply transactional leadership which will ensure they are supervised appropriately before they are acquitted with their duties (Mahoney, 2001). In situations where the leading nurses want to make decisions such as purchasing equipment then the transformational leader will seek for the opinion of the subordinates who will be able to give whatever they need to use and find comfortable and appropriate.
The major need for effective and efficient leadership is the success of the health system which requires that the leaders are devoted, strategic, and charismatic (Cook, 2001). In every decision they make they have to ensure that they are not derailed from achieving the final objective.
Conclusion
Leaders have the opportunity to apply any style they deem fit in achieving their goals and objectives. In addition they have the chance to apply one or both styles or change the style if they see one is not effective. No matter the style they apply or management decisions they make they must be able to ensure growth and sustainability in the health sector, where patients must be positive about everything happening in the sector. Job satisfaction for the subordinates’ nurses and the entire society of nurses also depends on the leadership style therefore the leaders should evaluate the style they will apply critically before implementation.
 

Communication Skills in Nursing

Communication is a vital part of the nurses role. Theorists such as Peplau (1952), Rogers (1970) and King (1971) all emphasise therapeutic communication as a primary part of nursing and a major focus of nursing practice. Long (1992) further suggests that communication contains many components including presence, listening, perception, caring, disclosure, acceptance, empathy, authenticity and respect. Stuart and Sundeen (1991, p.127) warn that while communication can facilitate the development of a therapeutic relationship it can also create barriers between clients and colleagues.

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Within Healthcare, communication may be described as a transitional process that is dynamic and constantly changing (Hargie, Saunders and Dickenson, 1994, p.329). It primarily involves communication between the nurse and the patient. If the interaction is to be meaningful, information should be exchanged; this involves the nurse adopting a planned, holistic approach which eventually forms the basis of a therapeutic relationship.
Fielding and Llewelyn (1987) contend that poor communication is the primary cause of complaints by patients. This is supported by Young (1995) who reports that one third of complaints to the Health Service Commissioner were related to communication with nursing staff. Studies by Boore (1979) and Devine and Cook (1983) demonstrate that good communication actually assisted the rate of patient recovery thus reducing hospital admission times. This suggests that good communication skills are cost effective.
In this assignment, I have reflected on situations that have taken place during my clinical work experience. These situations have helped to develop and utilise my interpersonal skills, helping to maintain therapeutic relationships with patients. In this instance, I have used Gibbs’ (1988) reflective cycle as the framework for my reflection.
Gibbs’ (1988) reflective cycle consists of six stages in nursing practice and learning from the experiences.
Description of the situation that arose.
Conclusion of what else would I could have done.
Action plan is there so I can prepare if the situation rises again.
Analysis of the feeling
Evaluation of the experience
Analysis to make sense of the experience
My Reflective Cycle
Baird and Winter (2005) illustrate the importance of reflective practice. They state that reflecting will help to generate knowledge and professional practice, increase one’s ability to adapt to new situations, develop self esteem and greater job satisfaction. However, Siviter (2004) explains that reflection is about gaining self confidence, identifying ways to improve, learning from one’s own mistakes and behaviour, looking at other people’s perspectives, being self aware and making future improvements by learning from the past. I have come to realise that it is important for me to improve and build therapeutic relationships with my patients by helping to establish a rapport through trust and mutual understanding, creating the special link between patient and nurse as described by Harkreader and Hogan (2004). Peplau (1952), cited in Harkreader and Hogan (2004), notes that good contact in therapeutic relationships builds trust as well as raising the patient’s self esteem, often leading to the patient’s personal growth. Ruesh (1961), cited in Arnold and Boggs (2007), states that the purpose of therapeutic communication is to improve the patient’s ability to function. Therefore, in order to establish a therapeutic nurse/patient interaction, a nurse must possess certain qualities e.g. caring, sincerity, empathy and trustworthiness (Kathol, 2003) (P.33). These qualities can be expressed by promoting effective communication and relationships by the implementation of interpersonal skills. Johnson (2008) defines interpersonal skills as the ability to communicate effectively. Chitty and Black (2007, p 218) mention that communication is the exchange of information, thoughts and ideas via simultaneous verbal and non verbal communication. They explain that while verbal communication relies on the spoken word, non-verbal communication is just as important, consisting of gestures, postures, facial expressions, plus the tone and level of volume of one’s voice. Thus, my reflection in this assignment is based on the development of therapeutic relationships between the nurse and patient using interpersonal skills.
My reflection is about a particular patient, to whom, in order to maintain patient information confidentiality (NMC, 2004), I will refer to as Mr R. It concerns an event which took place when I was working on a surgical ward. Whilst there were male and female wards, female and male surgical patients were encouraged mingle. On this particular day, I noticed that one of the male patients was sitting alone on his bed. This was Mr R., a 64 year old gentleman who had been diagnosed with inoperable cancer of the pancreas, with a life expectancy of 18-24 months. He was unable to control his pain, and whilst some relief could be provided by chemotherapy, Mr R. had a good understanding of his condition and knew that there was no cure available. He was unable to walk by himself and always needed assistance even to stand up or sit down. Because of his mobility problems I offered to get him his cup of tea and I then sat with him as he was lonely.
I would now like to discuss the feelings and thoughts I experienced at the time. Before I gave Mr R. his cup of tea, I approached him in a friendly manner and introduced myself; I tried to establish a good rapport with him because I wanted him to feel comfortable with me even though I was not a family member or relative. When I first asked Mr R. if I could get him a cup of tea, he looked at me and replied “I have asked the girl for a cup of tea, I don’t know where she is.” I answered “Well, I will see where she is and if I can’t find her, I will gladly get one for you Mr R”. In doing this, I demonstrated emphatic listening. According to Wold (2004, p 13), emphatic listening is about the willingness to understand the other person, not just judging by appearance. Then I touched MrR.’s shoulders, kept talking and raised my tone a little because I was unsure of his reaction. At the same time, I used body language to communicate the action of drinking. I paused and repeated my actions, but this time I used some simple words which I though Mr R. would understand. Mr R. looked at me and nodded his head. As I was giving him his cup of tea, I maintained eye contact as I didn’t want him to feel shy or embarrassed.
Fortunately, using body language helped me to communicate with this gentleman. At the time I was worried that he would be unable to understand me since English is not my first language but I was able to communicate effectively with him by verbal and non-verbal means, using appropriate gestures and facial expressions. Body language and facial expressions are referred to as a non-verbal communication (Funnell et al. 2005 p.443). I kept thinking that I needed to improve my English in order for him to better understand and interpret my actions. I thought of the language barrier that could break verbal communication. Castledine (2002, p.923) mentions that the language barrier arises when individuals come from different social backgrounds or use slang or colloquial phrases in conversation. Luckily, when dealing with Mr R. the particular gestures and facial expressions I used helped him to understand that I was offering him assistance. The eye contact I maintained helped show my willingness to help him; it gave him reassurance and encouraged him to place his confidence in me. This is supported by Caris-Verhallen et al (1999) who mention that direct eye contact expresses a sense of interest in the other person and provides another form of communication. In my dealings with Mr R., I tried to communicate in the best and appropriate way possible in order to make him feel comfortable; as a result he placed his trust in me and was more co-operative.
Evaluation
In evaluating my actions, I feel that I behaved correctly since my actions gave Mr R. both the assistance he needed and provided him with some company. I was able to successfully develop the nurse-patient relationship. Although McCabe (2004, p-44) would describe this as task centred communication – one of the key components missing in communication by nurses – I feel that the situation involved both good patient and task centred communication. I feel that I treated Mr R. with empathy because he was unable to perform certain tasks himself due to his mobility problems and was now refusing chemotherapy. It was my duty to make sure he was comfortable and felt supported and reassured. My involvement in the nurse-patient relationship was not restricted to task centred communication but included a patient centred approach using basic techniques to provide warmth and empathy toward the patient.
I found that I was able to improve my non-verbal communication skills in my dealings with Mr R. When he first mentioned having chemotherapy, he volunteered very little information, thus demonstrating the role of non-verbal communication. Caris-Verhallen et al (1999, p.809) state that the role of non-verbal communication becomes important when communicating with elderly people with incurable cancer (Hollman et al 2005, p.31)
There are a number of effective ways to maximise communication with people, for example, by trying to gain the person’s attention before speaking – this makes one more visible and helps to prevent the person from feeling intimidated or under any kind of pressure; the use of sensitive touch can also make them feel more comfortable. I feel that the interaction with Mr R. had been beneficial to me in that it helped me to learn how to adapt my communication skills both verbally and non-verbally. I used body language to its full effect since the language barrier made verbal communication with Mr.R. difficult. I used simple sentences that Mr R. could easily understand in order to encourage his participation. Wold (2004, p.76) mention that gestures are a specific type of non-verbal communication intended to express ideas; they are useful for people who have limited verbal communication skills.
I also used facial expressions to help encourage him to have chemotherapy treatment which might not cure his problem but would give him some relief and make him feel healthier. Facial expressions are the most expressive means of non-verbal communication but are also limited to certain cultural and age barriers (Wold 2004 p.76). My facial expressions were intended to encourage Mr R. to reconsider his decision with regard to chemotherapy treatment. Whilst I could not go into all the details about his treatment, I was able to advise him to complete his treatment in order to alleviate his symptoms.
Analysis
In order to analyse the situation, I aim to evaluate the important communication skills that enabled me to provide the best level of nursing care for Mr R. My dealings with Mr R. involved interpersonal communication i.e. communication between two people (Funnell et al 2005, p-438).I realised that non-verbal communication did help me considerably in providing Mr R. with appropriate nursing care even though he could only understand a few of the words I was speaking. I did notice that one of the problems that occurred with this style of communication was the language barrier but despite this I continued by using appropriate communication techniques to aid the conversation. Although it was quite difficult at first, the use of non verbal communication skills helped encourage him to speak and also allowed him to understand me.
The situation showed me that Mr R. was able to respond when I asked him the question without me having to wait for an answer he was unable to give. Funnell et al (2005, p 438) point out that communication occurs when a person responds to the message received and assigns a meaning to it. Mr R. had indicated his agreement by nodding his head. Delaune and Ladner (2002, P-191) explain that this channel is one of the key components of communication techniques and processes, being used as a medium to send out messages. In addition Mr R. also gave me feedback by showing that he was able to understand the messages being conveyed by my body language, facial expression and eye contact. The channels of communication I used can therefore be classed as both visual and auditory. Delaune and Ladner (2002 p.191) state that feedback occurs when the sender receives information after the receiver reacts to the message, however Chitty and Black (2007, p.218) define feedback as a response to a message. In this particular situation, I was the sender who conveyed the message to Mr R. and Mr R. was the receiver who agreed to talk about his chemotherapy treatment and allowed me to assist. Consequently I feel that my dealings with Mr R. involved the 5 key components of communication outlined by Delaune and Ladner (2002, p.191) i.e. senders, message, channel, receiver and feedback.
Reflecting on this event allowed me to explore how communication skills play a key role in the nurse and patient relationship in the delivery of patient-focussed care. Whilst I was trying to assist Mr R. when he was attempting to walk, I realised that he needed time to adapt to the changes in his activities of daily living. I was also considering ways of successful and effective communication to ensure a good nursing outcome. I concluded that it was vital to establish a rapport with Mr R. to encourage him to participate in the exchange both verbally and non-verbally. This might then give him the confidence to communicate effectively with the other staff nurses; this might later prevent him from being neglected due to his age or his inability to understand the information given to him about his treatment and the benefits of that treatment.
I have set out an action plan of clinical practice for future reference. If there were patients who needed help with feeding or with other procedures, I would ensure that I was well prepared to deal patients who weren’t able to communicate properly. This is because, as a nurse, it is my role to ensure that patients are provided with the best possible care. To achieve this, I need to be able to communicate effectively with patients in different situations and with patients who have differing needs. I need to communicate effectively as it is important to know what patients need most during there stay on the ward under my supervision. Whilst I have a lot of experience in this field of practice, communication remains a fundamental part of the nursing process which needs to be developed in nurse-patient relationships. Wood (2006, p.13) states that communication is the key to unlock the foundation of relationships. Good communication is essential if one is to get to know a patient’s individual health status (Walsh, 2005, p.30). Active learning can also help to identify the existence of barriers to communication when interacting with patients. Active learning means listening without making judgements; I always try to listen to patients’ opinions or complaints since this gives me the opportunity to see the patients’ perspective (Arnold, 2007, p.201). On the other hand, it is crucial to avoid the barriers that occur in communication with the patients and be able to detect language barriers. This can be done by questioning patients about their health and by asking them if they need help in their daily activities. I set about overcoming such barriers by asking open-ended questions and interrupting when necessary to seek additional facts (Funnell et al, 2005, p.453).
Walsh (2005, p.31) also points out that stereotyping and making assumptions about patients, by making judgements on first impressions and a lack of awareness of communication skills are the main barriers to good communication. I must not judge patients by making assumptions on my first impression but should go out of my way to make the patient feel valued as an individual. I should respect each patient’s fundamental values, beliefs, culture, and individual means of communication (Heath, 300, p.27). I should be able to know how to establish a rapport with each patient. Cellini (1998, p.49) suggests a number of ways in which this can be achieved, including making oneself visible to the patient, anticipating patients’ needs, being reliable, listening effectively; all these factors will give me guidelines to improve my communication skills. Another important factor to include in my action plan is the need to take into account any disabilities patients may have such as poor hearing, visual impairment or mental disability. This could help give the patient some control and allow them to make the best use of body language.
Once I know that a patient has some form of disability, I will be able to prepare a course of action in advance, deciding on the most appropriate and effective means of communication. Heath (2000, p.28) mentions that communicating with patients who have an impairment requires a particular and certain type of skill and consideration. Nazarko (2004, p.9) suggests that one should not repeat oneself if the patient is unable to understand but rather try to rephrase what one is saying in terms they can understand e.g. try speaking a little more slowly when communicating with disabled people or the hard of hearing. Hearing problems are the most common disability amongst adults due to the ageing process (Schofield. 2002, p.21).
In summary, my action plan will show how to establish a good rapport with the patient, by recognising what affects the patients’ ability to communicate well and how to avoid barriers to effective communication in the future.
Conclusion
In conclusion, I have outlined the reasons behind my choosing Gibbs’ (1988) reflective cycle as the framework of my reflection and have discussed the importance of reflection in nursing practice. I feel I have discussed each stage of the cycle, outlining my ability to develop therapeutic relationship by using interpersonal skills in my dealings with one particular patient. I feel that most parts of the reflective cycle (Gibbs 1988) can be applied to the situation on which I have reflected. Without the model of structured reflection I do not feel I would have had the confidence to consider the situation in any depth (Graham cited in Johns 1997 a, p.91-92) and I fear reflection would have been remained at a descriptive level. I have been able to apply the situation to theory; as Boud Keogh & Walker (1985, p.19) explain that reflection in the context of learning is a generic term for those intellectual and effective activities whereby individuals engage to explore their experiences in order to lead to a better understanding and appreciation. Boyd & Fales (1983, p.100) agree with this and state that reflective learning is the process of internally examining and exploring an issue of concern, trigged by an experience that creates and clarifies meaning in terms of self and which results in a changed conceptual perspective. However, I personally believe that the reflective process is merely based on each individual’s own personality and beliefs as well as their attitude and approach to the life.
Appendix
Mr R., a 64 year old gentleman, was an inpatient on a surgical ward. Earlier that day his consultant had directly informed him that he had inoperable cancer of the pancreas with a life expectancy of 18-24 months. Some relief might be offered by chemotherapy, but there was no cure. Mr R. was understandably shocked, but had suspected the diagnosis. At that time he remained in the care of the specialist nurse. Later in the day, as I was passing through the ward, I notice Mr. R. alone on his bed.
Prescriptive
A prescriptive intervention seeks to direct the behaviour of the client, usually behaviour that is outside the client-practitioner relationship. My first intervention was to open the conversation and demonstrate warmth. I provided information myself and gave Mr R. the choice of staying on his own or engaging with me. By shaking Mr R.’s hands I was attempting to provide reassurance and support as well as communicating warmth in order to reduce his anxiety and promote an effective nurse-patient relationship.
Practitioner: Hello Mr. R, I am one of the nurses here this morning with Dr. M. Is there anything I can get you or would you rather be on your own? (Shook hands).
Mr. R: NO, I remember you from this morning, come and sit down. I’ve asked the girl for a cup of tea, I don’t know where she’s got to.
Practitioner: Well give me a minute and I’ll bring you one in. Do you take sugar?
Mr. R: I suppose I shouldn’t, then why worry. Two please.
Practitioner: (Returning with a cup of tea) Here we are, don’t blame me if it’s horrible, I got it from the trolley. (I smiled at Mr.R. and tried to establish eye contact, then sat down in the chair next to him).
Mr. R: Thanks, that’s just what I need.
2. Informative
An informative intervention seeks to impart knowledge, information and meaning to the patient. My intention was to reinforce the nurse-patient relationship by smiling and attempting to establish eye contact as well as using facial expressions to put the patient at ease and establish a good rapport. By making Mr. R a cup of tea it created a pleasant response in a time of crisis.
Practitioner: Jane (specialist nurse) was here this morning, what did you think about what she had to say?
Mr. R: Oh yes she was very nice, mind you I’m an old hand at this, I looked after my wife when she had cancer.
Mr. R: She was riddled with cancer, but we kept her at home and looked after her. She could make a cracking cup of tea (Mr.R. smiles)
Practitioner: (smiles and nods) When did she pass away?
3. Confronting
A confronting intervention seeks to raise the client’s consciousness about limiting behaviour or attitudes of which they are relatively unaware. By meeting the patients’ needs at that time I felt the urge to continue to show a display of warmth and develop the relationship further.
Mr. R: It will be two years next month that she died.
Practitioner: You must miss her.
Mr. R: There’s not a day goes by that I don’t talk to her. Goodness knows what she would make of all this, it’s brought it all back.
4. Cathartic
A cathartic intervention seeks to enable the client to discharge/react to a painful emotion – primarily grief, fear and/or anger. Mr. R spoke emotively and angrily by using such words as ‘riddled’ and ‘cancer’. He spoke loudly and angrily with congruent non-verbal cues.
Practitioner: Has what you’ve been discussing with Jane reminded you of your wife’s death?
Mr. R: Yes, (patient covers his face with his hands).
Practitioner: What is it about what you’ve heard that is worrying you, do you think you can tell me?
5. Catalytic
A catalytic intervention seeks to elicit self-discovery, self direct living, learning and problem solving in the client. Mr. R had a broad scope in which to discuss any concerns he may have had, but his response only concerned his wife, not him as his wife was the one who suffered from cancer.
Mr. R: (Pause)………..I’m an old hand at this and I don’t want any of that chemo.
Practitioner: What is it about the chemotherapy you don’t like?
Mr. R: My wife had it and we went through hell.
Practitioner: You went through hell
Mr. R: The doctors made her have the chemo and she still died in agony.
6. Supportive
A supportive intervention seeks to affirm worth and value of the client’s person, qualities, attitudes and actions. It is done to encourage the client to say more and to explore the issue further. Support is provided by non-verbal means like giving warmth, supportive posture and maintaining eye contact. I wanted to convince Mr. R that I was interested in what he had to say and help him believe that he was worth listening to – that his opinions really mattered.
Practitioner: Do you think the same thing will happen to you?
Mr. R: Yes, that’s the one thing I’m worried about.
Practitioner:.em, if I’m honest with you chemotherapy treatment is not a subject I know a lot about. (Pause), would you like to see the specialist nurse again? She can go over things with you and explain your options.
Mr. R Well if she doesn’t mind, I’m just not sure the chemo will be worth it.
Learning outcomes
From this experience, I have learned the importance of:-
Practice in accordance with the NMC (2004) code of professional conduct, performance, when caring for adult patients including confidentially, informed consent, accountability, patient advocacy and a safe environment.
Demonstrating fair and anti-discriminatory behaviour, acknowledging differences in the beliefs, spiritual and cultural practices of individuals.
Understanding the rationale for undertaking and documenting, a comprehensive, systematic and accurate nursing assessment of physical, psychological, social and spiritual needs.
Interpreting assessment data to prioritise interventions in evidence based plan of care.
Discussing factors that will influence the effective working relationships between health and social care teams.
Demonstrating the ability to critically reflect upon practice.
 

Theories of Psychological Care in Nursing

The best definition of psychosocial care is found in the National Council for Hospice and Specialist (2000) which describe it as “concerned with the psychological and emotional wellbeing of the patients and their families/carers, including issues of self-esteem, insight into an adaption to their illness and its consequences, communication, social functioning and relationships”. Psychosocial care theory differs from theory of biomedical care in that the former uses the holistic approach (Sheldon, 1997 and Oliviere et al, 1998) or the diseases, psychology, social and spiritual health of patients whereas the latter care only for patients’ physical ill-health. Furthermore, the biomedical model predicts poorer health outcome, psychological distress and poorer daily function, more days spent in bed, and more health professionals visit and surgeries (Sheridan & Radmacher, 1992). Keywords used will be defined to facilitate understanding.

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The theory of psychosocial care has the following components; firstly, psychology deals with the way the patients use their conscious and subconscious (Freud) is dealt with their emotions, which is their feeling fine tuned throughout their lifespan development, to be aware of their different moods. Then their self-esteem, the patients perceived their self-worth, value themselves, self-respect and self confidence (Barry, 1992 & Niven, 2006), should be respected, hence, make them more confident and themselves. Scherer (2005) referred to emotion and self-esteem as behaviour forming strategies and
Emotions are intensified feelings or complex patterns of feelings that one experience when the patients found themselves in a strange environment, giving their intimate information to people they just met moments ago. Nursing professional should respect patients as a person by so doing will make them feel more confident in themselves or raising their self-esteem. Therefore, self-esteem is ones feelings regarding the patients self-worth, values oneself, shows self respect or self confidence Scherer (Barry, 1992 & Niven, 2006). (2005) referred to emotion and self-esteem as part of cognition or psyche. The cognitive approach is to let the patient talk about his feelings as most that we do is controlled by our unconscious mind, we have to listen carefully to what the patient is saying (Freud). Moreover, we should ensure that information being given by the nurses is understood by the person (Smith et al, 2003). We should praise the patient if he has done something good.
The patients’ social environment is important for their care as the nursing professionals must understand the supporting mechanism they have and those that needs to be put into place. In doing so one has to understand their need for equality and sensitivity that are required to care for patients from different ethnic and cultural background. The family being a component of the social jigsaw and it is important to involve them as long as the patients have given their consent. One has to be aware of confidentiality when talking about the patients’ information even to family. Research has shown that the involvement of families/carers greatly improve the psychological aspect of the patients’ rehabilitation (to put references). Social class again research has shown that patients coming from social class 3 access medical help faster than those living in social class 1. Therefore, this will affect their healing process if they are staying in an overcrowded and damp or living alone and have no family support. If they are staying in a rough area of the Borough therefore they are afraid to go out. Their culture is important as it is their core values and beliefs they have within their society. Environment is important to know if they are staying near a busy and noisy road. Their religion is important especially when it comes to food. The psychological and social aspects of the patients are one of the two elements in psychosocial care. Spiritual health refers to the possession of a belief in some unifying force that gives purpose or meaning to life or to a sense of belonging to a scheme of existence greater than merely personal, is another dimension of psychosocial care.
The nursing practice is based on warmth, acceptance, genuineness and empathy and by moving our focus away from the illness to that of the patients (Baughan & Smith, 2008), not forgetting to maintain privacy and dignity whilst talking to the patients (Faulkner, 2000) by getting the patients consent and their confidential preserved. Talking, caring, listening and supporting patients are qualities that nursing needs in forming good relationships with patients. Nurses should provide care that is focused on patients and tailored to their individual needs. Words like trusts, empathy, listening and compassion spring to mind. Nursing uses therapeutic comforting touching with confidence, not denying patients’ information, discussing the problem in a clear and understanding manner, being honest and have empathy not sympathy are useful tools to enhance the nursing practice. Subsequently, through therapeutic communication (Peplau, 1952) it built trust and confidence between the nursing professionals and the patients. Moreover, without the proper use of therapeutic communication, which is achieved through touch, silence and humour (where appropriate), listening to their narratives, not being judgemental, being considerate, respect their confidentiality and dignity as a person are important skills. The patients are able to reveal intimate details of their psychological and social health which inform the nursing professionals of better ways to support the patients towards the road to long lasting recovery. Therefore, Allen voiced the opinion of Wright (2004) “too posh to wash” that bad communication limits the extent that psychosocial care can be effectively given to patients.
This will be achieved by using therapeutic communication (Peplau, 1952) through explaining clearly what is being done, touching, silence and humour and listening carefully to what the patients are saying without interaction and being judgmental. Furthermore, they expect to be given the right information when needed, not in jargons but in an understandable language. This is the platform from which one can use to get the correct information from the patients.
Caring can be defined as involving concern, empathy and expertise making things better for others and is based on compassion (Smith, 1992; Eriksson, 1994 cited by Barry, 1994; Niven, 2006);). In view of the caring nature of the nursing professionals the patients are willing to (offered) information that they will not do so to other people (including their families/carers)…into their confidence therefore could have intimate knowledge than other medical professionals may not be able to tease out. This is possible by listening attentively to what the patients are saying without interruptions, to emphatise () with the
In return the patients expect that they are given the right information at the right time in a way that they understood. Their self esteem is ones feeling regarding their self worth, values oneself, show self respect or self confidence (Barry, 1992 & Niven, 2006). It can be improved through group support, forming realistic expectations, maintaining physical health, examining problem and seeking help e.g. limit smoking and alcohol.
Empowerment ranged from giving patients information and helping them to understand, cope with and take control of their disease to psychological support them, rapport-building, reassurance, empathy and promoting self-esteem.
The points raised so far is giving the reader a theoretical view of the way psychosocial aspect of care is relevant to nursing practice
Stress and coping are concepts that will be used as reference to bring theory into practice observed whilst on the ward. Stress is defined as an interaction between an event in a person’s life which is perceived as placing considerable demands on him and their response to coping with it. Therefore, the transactional model (Lazarus & Folkman, 1984) of stress and coping is appropriate to further expand the stress being felt by the patient. A transactional model of stress is when a patient is confronted with, does that event present any threat to him at the time, and if not then he does not perceive the event as stressful. However, if it does whether he experiences stress will depend on his secondary appraisal and if he has the necessary resources, such as personal, social, financial support and/or hardiness; is sufficient to allow him to cope effectively with the stressor. Moreover, he may not perceive himself to have sufficient resources available to deal with the problem and as result he will experience a response that one would refer to as a stress response.
It will also relate the concept to nursing practice
Self-efficacy according to Bandura () is when the patients believe that they can successfully connect with and execute a specific behaviour
X, a 65years old Caucasian male, married with two children, was admitted to hospital suffering with excruating abdominal pain. He has been diagnosed a week ago with lung cancer due to his heavy smoking, 15 cigarettes a day, increased to more than 20 after the death of his wife. His children said that he X constantly said that he wants to go and meet his wife wherever she might be. He is not eating properly and recently has been drinking heavily. He has low self-esteem and sometimes cries. Whilst helping him to shower daily the nurse was able get more information, he does not want to go a hospice or a care home like his children are saying. He wants to stay and die in his family home. Moreover, apart from his children he does not have any relatives staying close by. He is afraid of dying
 
Therefore, he is not caring for himself and not eating properly. was admitted to the ward after he was diagnosed with advanced lung cancer. Psychosocial care states that the patients’ psychological and social factors are taken into consideration when assessing them. The ward is busy though Wright (2004) stated that nurses are too busy to talk to their patient, it is not the case here each patient is treated as an individual and they are listened to without being judgemental. Moreover, the opinions of the patients’ families/carers are listened to and information is shared with them after getting the consent of the patients due to confidentiality legislation. Mr. X
 
Lists of References
Allen D. (2009) Nurses are only effective as their communication skills. Nursing Standard. 23 (28) 28-29.
Baer P.E., Garmezy L.B.; McLaughlin R.J., Pokorny A.D. and Wernick M.J. (1987). Stress, Coping, Family Conflict, and Adolescent Alcohol Use. Journal of Behavioural Medicine 10, 5, Pages 449 -466.
Bandura A. (1978). Reflections on Self-Efficacy. Advances in Behavioural Research and Therapy 1, Pages 237-269.
Bandura A. & Locke E.A. (2003). Negative Self-efficacy and Goal Effects Revisited. Journal of Applied Psychology. 88, 1, Pages 87-99.
Barry P.D. (1996). Psychosocial Nursing: Care of Physically Ill Patients & their families. (3rd Edition) Philadelphia: Lippincott-Raven publishers.
Colder C.R. (2001). Life Stress, Physiological and Subjective Indexes of Negative Emotionality, and Coping Reasons for Drinking: Is there Evidence for a Self-Medication Model of Alchol Use? Psychology of Addictive Behaviours. 15, 3, Pages 237-245.
Faulkner A. (2000), Effective Interaction with Patients. London: Churchill Livingstone.
National Council for Hospice and Specialist (2000). What do we mean by ‘psychosocial’? London; March 2000 Briefing No. 4.
Niven N. (2006). The Psychology of Nursing Care (2nd Edition) London: Palgrave MacMillan.
Oliviere D., Hargreaves R., Monroe B. (1998) Good Practices in Palliative Care: A psychosocial perspective. Aldershot: Ashgate Publishing Ltd.
Scherer K.R. (2005). What are emotions? And how can they be measured. Social Science Information. 44 (4) 695-729.
Sheldon F. (1997) Psychosocial Palliative Care: Good Practice in the care of the dying and bereaved. Cheltenham: Stanley Thornes (Publishing) Ltd.
Sheridan C.L. & Radmacher S.A. (1992) Health Psychology: Challenging the Biomedical Model. Chichester: Wiley
Smith A. (2009) Exploring the legitimacy of intuition as a form of nursing knowledge. Nursing Standard. 23 (40) 35-40.
Smith P. (1992). The Emotional Labour of Nursing. Basingstoke: The MacMillan Press Ltd.
Summers L.C. (2002) Mutual Timing: An essential Component of Provider/Patient Communication. Journal of American Academy of Nurse Practitioner. 14(1) 19-25.
Wilson V. (2004). Supporting Family carers in the community setting. Nursing Standard. 18, 29, Pages 47-53.
Smith said that intuition is a valuable source of knowledge though it could be difficult to put into words as there is little empirical evidence…
Self-esteem refers to one’s sense of self-respect or self-confidence. It is how much one likes oneself and values one’s own personal worth as an individual.
Self-esteem can be improved in several ways: Support groups; Completing required tasks; Forming realistic expectations, Taking/Making time for you ; Maintaining physical health; Examining problems and seeking help
External influences are those factors that we do not control, such as who raised us.
The family influences include family upbringing.
Healthy, nurturing families produce more well-adjusted adults.
Dysfunctional families may produce confused adults who have a harder time adapting to life.
Influences of the greater environment include safety, access to health services and programs, and socioeconomic status.
Internal factors include hereditary traits, hormonal functioning, physical health status, physical fitness, and other selected elements of mental and emotional health
(Definition) It can be improved through support group, forming realistic expectations, maintaining physical health, examining problem and seeking help limit smoking and alcohol.
He was assessed by the nurse after he gave his consent whereby information about his past and present illness, demographic and his activity of daily living was recorded on the assessment form. The nurse recorded the reading of his vital signs such as pulse, respiratory, temperature, O2 and heart, taking the vital signs at all time Mr. X dignity was not abused. Patients records are confidential information and can only be access by the nursing and medical professionals working with the specific patients.
Respondents found it very hard to cope with watching their partner’s suffering, and not knowing how to deal with it. In this situation the nurse’s role should include giving information and educating patients and partners, as well as offering support. Information should be accessible throughout the course of the illness, and needs to cover physical and emotional issues (Northouse and Peters-Golden, 1993).
Self-efficacy :Learned helplessness is a response to continued failure where people give up and fail to take action to help themselves.
 

Explaining the Nursing NMC Code of Conduct

(A.) A code of conduct is a set of customary principles and expectancy that are considered binding on anybody who is member of a certain group.
Nursing and midwifery practice in the United Kingdom are bound by a set of precepts and standard that set the least requirements for anyone wishing to practice nursing or midwifery within England, Scotland, Wales, Northern Ireland and Island. There is a more advance set of ethical and behavioural pattern that all nurse and midwife working in the United Kingdom must follow (NMC 2008).This is maybe the most important of the pattern set by the regulatory body for nurses and midwives as it comprises the ethical and moral codes that they are expected to obey. The code applies to anyone in the register; nevertheless the importance and need for codes of practice and conduct goes beyond nurses and midwives and their everyday contact with patients.
Even when not on duty, they must still stick to the principles and values comprising the code, especially as they directly connected to the women and people that they have been in their care. An example of this is respecting your client confidentiality.
There are no much difference in the NMC code of conduct United Kingdom and that of Nigeria. In the aspect of treating people equally without prejudice and discrimination, all humans are equal and must be treated kindly and with respect.
Confidentiality is another important part of the code of conduct which states that sharing of information is not right except in the case where the person is at risk of harm or in compliance with a court case.
In writing of inform consent one must ensure that the client is of legal age which is 18years in Nigeria. In a situation where the client is under aged, the parent or next of kin signs the informed consent on his or her behalf.
A nurse should maintain boundaries in a professional by not accepting gift, favours because it might be interpreted as an attempt to gain special preference.
A nurse should avoid careless, malpractice and abuse while providing care to client.
Clients do have a right to know about their conditions.
A nurse should be accountable to the public at all time by helping to protect the public against harmful dangers and agents.
As a nurse one must be ready to implement global health initiatives and participate in national and international conferences.
(B.) Be aware that the rules of obtaining consent apply equally to those who have mental illness. Under mental health act it is very important that clients are checked under statutory powers, knowing the conditions and safeguards needed for giving care and treatment without consent.
(C.) An area of the code that I am interested in is the area of informed consent. In Nigeria a clients legal age that allows him or her to sign informed consent is 18 years and above but in a situation where the client is under aged, the guardian or next of kin can sign the informed consent on his or her behalf. While in the United Kingdom, if the client is (a minor) under the age of 16,it becomes a complex case because it is believed that they are not matured enough to have a superior power of discernment and reasoning to make decision. This is a more similar case with that of Nigeria. Buts the difference is that, in Nigeria even if the client is 16 or 17 years and with parental responsibility the client will still not be given the opportunity to sign an inform consent. However the explicit wish of a minor should be thought about by an investigator, there are gillick competent minors that are able of consenting in their own right to treatment procedures, given that, in the view of the professional concerned, they had gotten the nature of the treatment she is going to have and its potential advantage and disadvantage and were adequately mature intellectually and emotionally to make a judgement.

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In high schools in the United Kingdom, consent is important to the appropriateness of treatment and school nurses must have a sound consent before he or she can lawfully go on with treatment for a child. For children who are very young who do not have the power to make consent for treatment, the school nurse will depend confidently on the consent of someone acting on the power of a person with parental responsibility.
As a child rows with age the law permits them to make consent to treatment decisions where they have the power to do so. School nurses can go on with treatment plan and advice if the child is seen or considered to be gillick competent.
Right to consent is not subject to individual will or judgement without restriction set at puberty: it is a must by the school nurse who must be comfortable that the child is old enough to fully understand the consequences of the particular decision they are making. The more complicated the decision, the greater the maturity and intelligence needed to reach ability, as there will be a lot for the child to understand.
School nurses will need to be comfortable with the child to fully estimate the difficult issues that needs to be considered before they can safely go on that the child has power to consent to treatment.
In a case were the child is asking for treatment and counselling in relation to sexual activity such as contraceptive, then the nurse must also be sure that they are acting to protect the child and they meet the need of the sexual offences Act 2003.This is best achieved by recording the treatment and counselling given in line with Lord Fraser’s guidance in Gillick V West Norfolk and Wisbech AHA (1986)
School nurses must keep their patients medical needs confidentially. This duty is draw from their legal, pertaining to and professional sense of duty and requires that as a rule they will not open patient information.However, the need to share information with others is vital to help deliver necessary care and protection of patients. While not proper disclosure is never welcomed, always using the duty of confidence as an excuse never to share information can lead in poor care and even bad report. School nurses must look at each case on its merits. Whenever needed the consent of the patient should be gotten before disclosure.
Disclosure of patient information without consent is allowed in the public interest or where regarded by law and it is important that school nurses carefully balance the overall need for confidentiality against the needs and welfare of the patient that might need the information to be shared with necessary source.
(D.) The sufficiency of informed consent is a vital part to consider when caring for patients.Weisz & Melton (1995) describes informed consent as one of the most debateable issue in health care. This debate becomes even more important in adolescents health care. Informed consent is a technical issue and often does build legal and ethical concerns for the adolescent, parents or legal guardian(s) of the adolescents (Sturman, 2005)
The legal and ethical connections associated with informed consent are very complicated and present challenges for those finding treatment and those delivering care (Anderson, 2005) an example was when a 16 year old girl walked into the hospital where I worked as a registered nurse in Nigeria and said she was pregnant and wanted to terminate the pregnancy. She was asked to go and call her parents or guardian to come and sign an informed consent for her before any form of pregnancy termination will be done. She walked up to me thinking probably I could help her out as a young nurse but rather I recognised my responsibility and up held the code of conduct which states that clients who are under aged; not above 18 years should be with a next of kin or parents to sign an informed consent.
(E.) If it was in the United Kingdom, I would have acted differently because once a child gets to the age of 16; he or she is believed in law to be capable to give consent for themselves for their own medical, dental or surgical procedures. Meaning the young girl would be treated as an adult. Although it is still best practice to advice capable children to involve their parents in decision making. Where confidentiality is involved i must keep her privacy, unless I can justify disclosure on the grounds that I suspect she would likely suffer consequential harm. I would however ask her to involve her parents, unless I see it was not in her best interest to do so.
(F.) The four Nursing and midwifery council domains are: Competent midwifery practice, Professional and ethical practice, developing others and self and realizing quality care through appraisal and research. As a registered nurse I took personal responsibility for my actions, those I forgot to do and been accountable for any action I take. I could make sound decision while handling the case of my young client in respect of my personal professional development; practice within the range of view of my personal professional capability and extended this scope as needed.
Working with minors, a registered nurse should have capability and confident in giving the basic aspect of care. This gives the client and parents more confidence. This confidence and capability strengthens the foundation by ability and practical skills in the area of child growth, communicating with minors and their family members.
This self awareness for nurses working with minors needs to be able to give support, educate them and help them understand what they should do and why, to make decisions about treatment choice and to be able to assist themselves meaningfully to their own care. A registered nurse must recognize their emotions, quality of feeling at a particular time and drives. They need to understand how these emotions produce effect on others and their performance. This self awareness requires strict inquiry into their personal thoughts and experiences. It required carefully weighed analysis of their feelings and how these emotions drive ideas and behaviours.
We humans always have automatic reactions to certain interpersonal stimuli. This reverse movement may result from deep-seated suppositions that have taken root over time. Best example of an automatic reaction can be seen when watching group of cows going out to pasture. For unknown reasons, the cows always follow the same path. Humans also create symbolic cow paths in their rejoinder to certain situations, thoughts and emotions. The registered nurse needs to know his or her cow paths in other to raise their self-ability and have self-reliance in situations fraught with the various emotional responses found in health care.
REFERENCE LIST
Christina, M. (2009). Midwifery regulations in the United Kingdom. In: Diane, F and Margaret, C Myles textbook for Midwives. 15th ed. London: Churchill Livingstone Elsevier. P83.
DOH. (2010). Seeking consent; working with children. Available: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4067204.pdf. Last accessed 16th May 2011.
Janet, F. (2010). Evolution of clinical nurse specialist role and practice in the United State. In: Janet, F and Brenda, L Foundations of clinical nurse specialist practice. New York: Springers publishing company. P18
NMC, UK. (2008). The code; Standards of conduct, performance and ethics for nurses and midwives. Available: http://www.nmc-uk.org/Documents/Standards/The-code-A4-20100406.pdf. Last accessed 10th May 2011.
NMC, Nigeria. (2005). Code of professional conduct. Available: http://www.nmcnigeria.org/standards.php. Last accessed 10th May 2011.
Nick.B (2009). Legal and ethical issues relating to medicinal products. In: John, G and PFD’Arcy The textbook of Pharmaceutical Medicine. 6th ed. London: BMJ Publishing Group Limited. P354.
NMC, UK. (2004). Standards of proficiency for pre-registration nursing education. Available: http://www.nmc-uk.org/Documents/Standards/nmcStandardsofProficiencyForPre_RegistrationNursingEducation.pdf. Last accessed 16th May 2011.
NMC, UK. (2006). Allegations; Warwick, Diana 78A3956E. Available: http://www.nmc-uk.org/Hearings/Hearings-and-outcomes/May-2011/Charges-WarwickDiana/. Last accessed 14th May 2011.
NMC, UK. (2010). Feedback about the guardians. Available: http://www.nmc-uk.org/General-public/Older-people-and-their-carers/Feedback-about-the-guidance-/. Last accessed 12th May 2011.
NMC, UK. (2008). Advice for nurses working with children and young people. Available: http://www.nmc-uk.org/Nurses-and-midwives/Advice-by-topic/A/Advice/Advice-on-working-with-children-and-young-people/. Last accessed 16th May 2011.
Roberson, AJ. (2007). Adolescent informed consent: ethics, law and theory to guide policy and nursing research. Journal of Nursing Law. 11 (4), P191-P192. (Accessed 14th May 2011)
Griffith, R. (2008). Consent and children:the law for children. British journal of school nursing. 3 (6), p284.
Mark ,A. (2008). School nurses and consent:duty of confidence. British journal of school nursing. 3 (8), 380.
 

Concept of Care and the Nursing Metaparadigm

Caring is a core element in nursing even yet it remains elusive to the entire nursing metaparadigm. All nurses as required by their profession must be caring. For it is through caring that nursing derives its uniqueness and contributes significantly to health care (Thorne, Canam, Dahinten, Hall, Henderson, and Kirkham, 2002). This is not only the patient as an individual but the family and community as well. Further as the nursing profession continues to take on some of the roles of physicians, it is important to differentiate the profession from that of physicians. Caring seems an obvious component of nursing yet does not feature in the nursing metaparadigm for a number of possible reasons. First, there is a possibility that caring was perceived to be synonymous to nursing. It is true there is little understanding and agreement on what the term refers to. Again, a focus on caring was perceived to delimit the nursing territory (Thorne, Canam, Dahinten, Hall, Henderson, and Kirkham, 2002). The variability of care makes scientific inquiry almost impossible. It is indeed true that medicinal treatment alone can guarantee healing. This however, becomes tricky with the aged, frail people and those suffering from chronic diseases. These groups of persons need care.

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According research and experiences recorded by nurses; once patients are well taken good care of, it helps boosts their chances of recovery. This is because sickness, even when traced from traditional societies, was perceived to interact with environment, family, community, spirit and the individual persons. The better an individual feels the greater are his or her chances to respond positively to treatment. This good feeling can be provided by the nurse who establishes confidence, a bond and trust with the patient. Caring is therefore an important concept that needs to feature in the nursing metaparadigm. Without this concept nurses may not be well able to execute some of their duties successfully.
Concepts and Metaparadigms
Concept refers to terms that define phenomena occurring either in thought or nature (McEwen and Willis, 2006). Concepts normally contain some attributes which help to distinguish them. Since the formulation of concepts employs the use of words, concepts can be broadly be categorized as either concrete or abstract. The former can be perceived by the common senses and include concepts such as universe, passion, ground, which are symbolic and a representation of phenomena. On the other hand abstract concepts include love, anger, passion etc. All these terms are particular to an entity and for that matter descriptive in nature. Concepts can be formulated using a single word, two words or a phrase (McEwen and Willis, 2006). Examples of single word concepts include death, fear, anxiety etc. The concepts with two words can take the form of mutual agreement, self-fulfillment etc. There are concepts which take the form of a phrase such as user-friendly services, environmental conscious behavior, poor service delivery etc. There are many concepts in different disciplines which help to differentiate one from the other. For the reason purpose of systematic study of nature, it is important to come up with concepts that are clear (Duncan, Cloutier and Bailey, 2007). This becomes a stepping stone that gives researchers and scholars a grasp of reality. It also makes the study of phenomena easier. Also in order to communicate meaning clearly to readers there is need for scholars to avoid ambiguity. This means that every time a term is used in a particular context, scholars must endeavor to define it to ensure proper interpretation.
On the other hand metaparadigms define a discipline and set the boundaries with other disciplines. It gives the discipline a global perspective which is useful for the practitioners of the discipline to observe phenomena within their parameter (Van Wyk, 2005). In most cases it comprises a range of major concepts which act as its defining elements. These concepts within a metaparadigm act as limitations or boundaries of the discipline. Again, metaparadigm not only defines a discipline but also outlines its concerns. For instance in nursing metaparadigm we have four concepts which include environment, person, nursing and health. These concepts in general help to define nursing metaparadigm and set it apart from other disciplines or professions for that matter. A clear line is therefore able to be drawn between nursing and physician practice. This is possible because of the different metaparadigms.
Evidence to Support Position
Historically there are four concepts in the nursing metaparadigm which have been used to describe the context and content of the nursing profession. As much as the four concepts; health, environment, person and nursing continue to be embraced in the nursing fraternity, they have been a number of challenges and proposals being experienced and given as alternatives (Schim, Benkert, Bell, Walker and Danford, 2007). The nursing metaparadigm however, continues to be recognized by all professions in the field. Apart from the four components the concept of caring continues to be a contentious issue. For a long period caring has been ignored since it could not be subjected to scientific inquiry, measured and its impact determined (Thorne, Canam, Dahinten, Hall, Henderson, and Kirkham, 2002). In many instances the ability to cure by use of scientific means through medicinal treatments alone renders the role of caring obsolete. This however, does not apply to those who are weak, aged and suffering from chronic diseases (Castledine, 2009). These ones have to be cared for in order to boost their recovery process.
Even with the many perceptions and definitions there seem to be an agreement on the components of care. The major focuses of these components are the physical, emotional and psychosocial requirements of the patients (Castledine, 2009). The patient needs to be cared for and in this case the staff is concerned primarily with giving care and little attention is given to end results. For this reason there is need to understand care in a far more refined manner compared to the traditional view of the same (Van Wyk, 2005). It is important for the care givers to be compassionate with those receiving care. The level of concern with the health of patients makes nurses not only to experience whatever the patient is going through but give hope and assurances or recovery. The nurse can also offer assistance in areas where the patients is unable to perform. There are also specific conditions and situations which call for care from the nurses. These problems may be social or medical. Most importantly care much aim at the preservation of a patient’s dignity (Castledine, 2009).
According to research carried out to examine how students perceive stories shared by nurses, researchers found out the views of four students which centered on the care as developing of trust (Adamski, Parsons and Hooper, 2009). The stories told by nurses tended to encourage as well as make one student gain confidence to undertake similar experiences. This student in particular went into mimicking the behavior of the nurse such as the use of non-verbal communication thus leading to desirable results. In this way it became apparent to the student that through experimenting with some of the ways demonstrated and practiced by nurses, one could actually make a bond with patients. There is much excitement and one is encouraged to go and try it out with the patients.
The view of another student tended to perceive a great percentage of caring resulting from being open to patients and at the same time listening attentively to what they say (Adamski, Parsons and Hooper, 2009). This student emphasized the need to concentrate on the patient while withholding ones judgment. In this way the student perceived caring as being manifested in a number of ways but most importantly it was channeled towards trust and establishing a bond with the patient (Adamski, Parsons and Hooper, 2009). Similarly, the same student craved for a mentor who would be instrumental to help her gain confidence, learn to care and see to an improvement of her nursing practice (Adamski, Parsons and Hooper, 2009). It is true that the care shown to patients makes them feel good about themselves. The nurse should therefore endeavor to improve these skills in order to be successful in executing duty.
Moreover, it is important for nurses to exhibit confidence, communicate effectively, respect and be available always to attend to a patient’s needs. This is a tall order which requires the nurse to be comfortable in a number of situations (Rayman, Ellison, Holmes, 1999). The only way to achieve this is through experience and to allow exposure to a number of situations. These experiences are gained from a number of places. Similarly, it was noted by the student that caring involves being able to stay current on nursing practices, ability to prioritize and doing what is right (Adamski, Parsons and Hooper, 2009).
The concept of caring comprise of various attributes. These attitudes are essential to nursing as a whole. They include attitude, action, variability, relationship and action (Brilowski and Wendler, 2005). Nursing as a profession pays much attention to relationship between nurse and patient. This relationship is initiated by the former with the intention of taking action. It is a relationship that calls for cooperation and respect from both parties. The patients require such a relationship for assistance as most of them are not able to care for themselves. In some cases the relationship has been perceived to be a form of friendship as there is concern and affection for one another (Rayman, Ellison and Holmes, 1999). The nurse being the initiator and most active in the relationship is a companion in the client’s journey towards recovery. In order for this relationship to be fulfilling there must be intimacy, trust and responsibility. The nurse has the responsibility to develop a trusting relationship which comes with patience, openness, love and sincerity. Proximity to the patient is vital and important for the development of intimacy and trust.
Since the nurse is in a professional relationship with the patient then all responsibilities are at facing to that direction. The person who is receiving care must be assured of well- being through responsible actions shown by the nurse. Professional care givers therefore need to act in the most current and knowledgeable manner towards their clients (Khademian and Vizeshfar, 2008). In this mission there are guided by professional ethical codes. For instance their conduct must be of high standard and also their decision making must be guided by principles of practice.
In conceptual analysis of care there must be action exhibited by the nurse towards the patient. This is not only performing some activities for the patient but also ensuring one’s presence at all times. The care giver sees the need of an individual and more than wiling to respond to these needs in a professional manner (Khademian and Vizeshfar, 2008). It is important for instance for the nurse to be interested in the patient as a human being worthy of respect and dignity. It is from her that the nurse will start to exhibit care for the patient. The most obvious of this kind of care is physical. In this case some actions that would make patients feel good about themselves. These actions may include a rub on the back, assisting the patients in and out of bed, chair, dressing and undressing etc. In some cases the nurses will have to assist female patients to do their hair and even apply make-up (Brilowski and Wendler, 2005). All these ensure that the patients feel good about themselves. They feel their live has not simply stalled due to sickness but someone is more than willing to see them recover and carry on with the day to day life.
A caring nurse must also exhibit a caring touch. As much as the action might seem small, its significance is great. It is a form of non-verbal communication important to establish rapport between the two and changes the perceptions of the patient towards the nurse. Actions such as holding hands, gently stroking the hair are some of the actions that cement the relationship between the nurse and the patient.
The physical presence of the nurse is important just like emotional presence. The nurse must not only shares time and space with patients but also listens actively (Brilowski and Wendler, 2005). There is need to be a part of the family and share their fears, hopes and aspirations. It is important at this time for the family and the patient to be assured that they are not alone. A nurse may seat by the bedside of the patient telling stories and contributing to whatever the family have to offer. It is simply the feeling of togetherness and appearing like one family. This is a holistic and genuine engagement of the two parties that helps build on trust and confidence.
Caring as a concept varies in different circumstances, people involved and the environment at large (Daniels, 2004). Variability in care is therefore another way to describe the changing nature and fluidity of caring. For this reason the more a nurse practices care giving to patients the more experience gained. It is therefore expected of the nurse to offer care corresponding to environment and nature of the patient. There is need to understand that patients are different and need assorted care and attention.
Importance to Nursing
The introduction of the concept of care in nursing metaparadigm will help reduce emotional labor that always accompanies giving of care among nurses. In the work place nurses normally have emotional regulation which is likely to lead to emotional exhaustion or burn out (Huynh, Alderson and Thompson, 2008). In any organization and in nursing profession in particular it is vital that workers be able to feel their emotions and be aware of the personal costs associated with the services they give to patients. It is important to note that emotional exhaustion of the nurses can come as a result of a number of factors including depersonalization of the patient. As an attribute to care, variability must be taken into consideration such that patients are treated as individuals (Brilowski and Wendler, 2005). This cannot be easily achieved if the nurse has not been oriented on some of the principles of care. His or her individuality must be taken into account.
Caring gives nursing its uniqueness hence the reason for nurses to be directly involved in care giving. In the modern health care however, the role of care giving is remotely executed by the nurse. For instance it is common for support staff to aid in care giving while under the supervision of a nurse (Clifford, 1995). In this case the role of the nurse is reduced to that of a supervisor and therefore contact with the patient is reduced. The all important link between the nurse and the patient is cut. This makes treatment to be a long and complicated experience for both the nurse and the patient.
In defining nursing as a formalized manner of giving care then it becomes easy for the nurses to respond to the needs of patients with compassion. There will be little or no pressure at all for the nurses to fulfill demands that are farfetched from nursing. Their activities as care givers will be guided by the need to respond to health care. The available resources will therefore dictate the activities of the nurses (Clifford, 1995).
Through the experience gained in caring for the patients, nurses feel empowered and become mush tolerant of uncertainty. Since an individual is able to connect with the patients, it becomes easy to respond to their needs (Daniels, 2004). In addition the satisfaction gained through work is increased as the nurse becomes energized and passionate about work. It is for the same reason that the nurse is able to empathize with the patient. The nurse is close to the patient and attends to all demands being made, it quickens the recovery progress. The patient is not ashamed to communicate and share deep feelings. On the other hand the nurses are well able to experience the illnesses thus increase their understanding. In this way it becomes easier to attend to similar cases in future.
Care education is also essential in nursing profession more so preparing nurses for care in their profession. As much as the theory of care differs greatly from the life experiences in the field; still the need to get the education is vital. Once the students have gotten the knowledge in school it will help change their attitude and more importantly give them a clue of what to expect in their work. This knowledge is essential for preparation and also in laying down a framework for the nurses such that they are aware from the onset what is entailed in their profession (Clifford, 1995). In addition the knowledge is important for the sake of contemporary practices in health care and gives insight to the future of nursing.
For a long time nursing as a profession has been misunderstood and portrayed negatively. The inclusion of caring in nursing metaparadigm is important in the creation of a good public image for the nurses and the profession. Once the public has a good image upon a profession it helps boost recruitment and also change the nurses’ attitudes towards work (Takase, Maude and Manias, 2006). The nurses will also improve on their self-image which largely contributes to performance in the job.
Conclusion
There is still much debate on whether or not the concept of caring should be included in the nursing metaparadigm. In the nursing profession this concept continues to be controversial. The reason for this controversy is the fact that nurses continue to give care despite the concept being ignored. This may appear simply as an ignored concept but in reality it has been and remains part and parcel of the nursing profession. In fact there are those who have equated nursing as a whole to caring. In this case caring seems to have been a metaparadigm of nursing alongside health, person, and environment. In the modern health care, nurses have delegated the role of care to subordinate staff while maintaining the role of supervisors. As much as the nurse is still in control, there is lack of attachment with the patient.
The public opinion of nursing is far from impressive as most of the people are ill informed about the profession. The majority tend to think nursing to be synonymous to caring. The nurse is perceived as a subordinate to the physician, receives instructions from the doctors, earns less salary etc. All these are stereotypes most of which emerge from the tradition role of the nurse as a care giver. This caring is understood casually with little understanding of the profession. It is for the same reason that people feel they know quite well the role of the nurses. For this matter they are ready to judge on the delivery of services. It is important for the nurse to be respected, seen to be compassionate, concerned and competent.
The importance of caring is not only confined to the nurses but the family and the patient as well. Most importantly however, is the fact that caring will help increase the rate of healing and health thus lighten the work of the nurses. It is significant to all involved in the entire process of healing as it reduces anxiety and fear for both the family and patients. In this way it helps to empower the patient, give comfort, hope, security and self-esteem. Eventually, nurses are able to enjoy their work. This is as a result of the nurse being perceived differently by the patient thus boosting morale. Caring should therefore be incorporated in the nursing metaparadigm since it will be a major boost to the profession. The nurses will feel good about their profession as they are trained, gained experience and able to develop a relationship with patients.
 

Reflection on Self Development in Mental Health Nursing

The Nurse Association (ANA) (2003) defines nursing as the promotion, protection and improvement of health and abilities, stopping of illness and injury, relief of suffering through identification, medical care and support in the care of individuals, families, societies and citizenry (Nancy, 2001 p.2).Generally nursing is liable to the society for providing quality, economical as well as improving the care rendered. Hence, nurses are responsible for their patients’ standard of health.

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The area of practice I would like to develop in this regard is mental health. The World health Organisation (WHO) (2009) defines mental health as a state of well-being where all individual notices his or her own potential, can cope with normal stressful events of life, can be fruitful and productive, and is able to contribute meaningfully to his or her society.
For a person to live happily and meaningfully in life, mental health is important as well as physical health. Inadequate mental health can interfere with keeping meaningful relationships, having a sense of fulfilment in one’s self, work and ability to perform in daily activities of life. Mental illness can obstruct one’s interest in sleep, food and sexual contact.
How we cope with life situations, the way we think and feel can be defined as mental health. By description mental health could be defined as a state of well-being which enables one to be fruitful, being able to live in peace with other people, adjusts to alteration and been able to handle difficult situations.
Health conditions marked by alteration or abnormalities in mood, thinking or behaviour (or a mixture of the three) that causes discomfort or impair functioning is known as mental disorder. Giving a lot of definition without going into thorough details is difficult. One huge reason that is partly responsible for the difficulty in defining mental health, mental disorder and mental illness is the differentiation between mental and physical health which is largely pretended. Our ability to think, feel and respond is governed by our brain. The brain needs constant supply of oxygen and nutrients like any other organ in the body because it can also be damaged by thyroid issues, tumours and physical trauma. Mental health and physical health are interweaved (Linda, 2010, p.334).
STRENGTHS AND WEAKNESSES ANALYSIS OF MY CURRENT KNOWLEDGE BASE ON MENTAL HEALTH
My main tool as a mental health nurse is caring for the elderly living with dementia. As a mental health nurse I show compassion for the people I am dealing with by showing care towards them. Regrettably, there is still some stigma attached to mental illness. Combating this and helping the individuals and their families deal with it is the key part of my job. The danger of violence is often associated with this branch of nursing and one of the special skills required is to spot a build-up of tension and defuse it.
Dealing with the behaviour and human mind is not an exact science. The job of helping people back to mental health is every bit as valuable and satisfying as caring for those with a physical illness. Showing professional compassion in my field of practice as a mental health nurse is a very important strength that I possess. For true care to take place feeling compassionate and empathetic towards a stranger is a must; a good feedback feeling is set into motion by doing this. Feelings are important in a human’s life. I will say compassion is strength because it is a very important ingredient in nursing profession. Compassion is more than just showing pity or concern; and some dictionary definitions indicate that compassion is part of caring because it involves suffering with the person (Moya, 1992 p 5).
As a mental health nurse, it is my duty to understand how to care for the elderly with dementia because their cognitive and affective states are conflicting. Now my experience with the elderly does not appear to me differently put myself into the private world of my patient and this is what empathy and care requires. Moya (1992, p 8) suggested that though as mortals we may find true empathy hard to practice because true empathy is only possible among archangels.
My weakness on my current knowledge based on this area unfortunately is lack of Confidence which is evident in certain instances. Public speaking, presentation and demonstration of procedures to nursing assistance plague me. It is one thing to be nonchalant and laid back when speaking with your family and friends, but in a professional environment the whole mood and interpretation of things changes. It all comes down to one thing, the amount of self -esteem that i have and i am willing to exert.
CLEAR STATEMENT FOR PERSONAL KNOWLEDGE
Snow (1991, pp. 195-197) identifies compassion as pain, sorrow or grief for someone else. Emotions help me focus my moral actions. From my personal knowledge as a mental health nurse, compassion should be totally added in my concept of care. Furthermore the role of a Registered nurse is to improve the health and well-being of the people. My aim in focus is to strive for moral height because I have the opportunity as a nurse to give attention to the pain and suffering of my patients (Ferrel, 2005, p. 86), with a workable process in leadership and putting more compassion in practice.
Putting compassion into nursing care is really not an easy task as it involves a lot of work. How this will be achieved is by involving in a compassion program for qualified nurses; going into wards that are already selected for excellence in compassion. In addition getting myself in an NHS Lothian centre for compassionate care which is also called the ”beacon ward” where patients can be asked what we the nurses are doing right and tell us how can improve health (2008) puts it as bottling the magic formula and sharing it. The beacon ward will involve me using an “all about me” sheet which patients will fill when admitted. This form is not about their medical conditions; about how they will love to be addressed and who is important to them. This gives me an opportunity to look at people values and beliefs.
DEVELOPING KNOWLEGDE IN THIS AREA
My professional role and expectation from my clients as a mental health nurse is to win trust and establish contact with my clients. They find it difficult to gain trust and build good relationships with professionals in this field. In achieving this, competence is needed.
What is competence? Spencer & Spencer (1993) describe competency as the ability to realize organizational goals. It involves skills, attitudes and knowledge. These” soft skills” are vital in this area of practice. Developing my knowledge in mental nursing will enable me be a better nurse and gain a higher level of competency. Registered mental health nurses are regularly faced with clients who stay away from care. They involve patients with severe personality and behavioural disorders, older people living with dementia.
Nursing and Midwifery Council (2002) Professional code of conducts describes situations where my professional role as a nurse is needed to be put into practice as regards competence. Throughout my year of practice I must keep my knowledge and skills up to date. Taking part in learning activities that will develop my performance and competence.
In order to practice competently and professionally i must possess the knowledge, skills and abilities needed for lawful effective and safe practice without supervision. I must know the things that I am capable of doing and only accept those procedures and practice that I am competent at.
If an area of practice is above my level of competence or outside my area of specialty I should call for help and supervision from a competent practitioner except otherwise.
SMART CHART DETAILING HOW I WOULD ACHIEVE MY GOALS
My goals, when adequately structured can be achieved in a means elaborated below using a SMART CHART. Extension (2008) stressed that SMART goals will enable one achieve relevant actions and goal; they further explained SMART is an acronym for goals that are: Specific, Measurable (Mutual, Motivated), Attainable, Relevant/Realistic, and within a specific Timeline. Clearly stated, my goals are:

Improvement in the area of my level of competence as a mental health nurse
Ability to win patient trust
Develop my level of confidence
Broaden my level of knowledge in mental nursing

S

My goals are limited to my area of improvement and strengths particularly related to my area of specialization which makes it specific

M

These goals serve as a driving force to my striving for excellence in mental health nursing

A

A right move in attaining or achieving these goals is by the embarking on my current programme in the University which has boosted my assurance of being a figure head in the nursing profession.

R

My goals are still in line with my first degree and profession hence its relevance in to my career and to the improvement of patient status. The Nursing and Midwifery Council has embarked on nurses self-development training programmes which my goals conform to.

T

Putting into utmost consideration my level of adaptation to the health system of the UK and my academic pursuit, my goals are already being actualized and is an on-going process of development till my career is over because learning is a continuous process and knowledge is acquired on a daily process.