This reflection will discuss the importance of the multi-disciplinary

team (MDT) and how they work with the client to promote
independence.The MDT within the mental health environment
generally comprised of psychiatrist, clinical psychologists, nurses,
occupational therapists and social workers, but other therapists
such as family therapists, psychotherapists, dietician and
counsellors mat also become involved in the care of the client
(Perkins &Repper 1998).
Multidisciplinary involvement is important within mental health
nursing as people with mental health problems have multiple needs,
so a variety of expertise is required to meet the needs of these
people (Darby et al 1999).Ovretveit, (1993) defined the MDT as a
group of practitioners with a wide variety of professional training
who regularly meet to provide a service to clients.Throughout this
reflection, the clients name and clinical setting will not be disclosed
as this would breach confidentiality (NMC 2004). For this reason the
client will be referred to as ‘Martin’.
The first stage of Gibbs (1988) model of reflection requires a
description of events.Martin is a 45 year old male, who is currently
at a mental health rehabilitation unit as he suffers from paranoia
schizophrenia. Paranoia results in episodes of delusions which can
be accompanied by hallucinations, perception disturbances and
auditory variety (BBC 2006). Schizophrenia is a psychiatric diagnosis
that describes a mental disorder characterized by expressions of
reality or by impairments in perceptions (BBC 2006).Martin was
brought into the rehabilitation unit as he suffered from chronic
delusions, which caused him to behave irrationally and destructive.
Before he was admitted into hospital, he was causing danger to
himself and others by setting objects on fire and was very paranoid
about objects in the kitchen. He felt that the instruments in the
kitchen were dangerous and always commented on the cooker and
oven being broken. This resulted in him being unable to prepare
himself food and eating fast food meals everyday.After spending 2
weeks in a mental health hospital he was transferred to a
rehabilitation unit, which he had currently been in for a month.The
MDT had to work together so Martin was able to overcome his fear
of the kitchen and able him to become independent.
I had the opportunity to observe a MDT meeting and participated in
the discussion about Martin. Throughout Martin’s time in the
rehabilitation unit, many of the MDT members individually spent
time with him.The consultant discussed with him any medical
problems Martin may be having and gave Martin a description of the
medication he had been prescribed and why it was essential they
were taken (Kirby et al .2004)The psychiatrist discussed with him
how he was dealing with the paranoia schizophrenia and gave
Martin a better overlook of his overall life and what he would be able
to achieve if he focused on trying to prepare meals. The psychiatrist
allowed Martin to discuss his feelings openly and concentrated on
whether his perception of cooking had changed over the month he
had been in the rehabilitation unit.
The occupational therapist also worked with Martin. The main role of
the occupational therapist is helping individuals with everyday tasks
to promote and maintain their independence and reduce the risk of
relapse (Burke 2006). The occupation therapist guided and
supervised Martin with his cooking which also gave them a chance
to bond and communicate, while preparing their meals (Taylor et al
2001).The dietician was also notified about Martins lack of ability to
prepare food. The dietician explained the risk of poor nutrition and
what affects it could have on Martin.
The social workers main duty was to help Martin cope with the
environmental aspect of his life, by giving him and his family
information about the ways to support him while in rehabilitation
and when he returns home. The social worker also advised Martin to
attend cooking groups so he could gain confidence in cooking. The
social workers also encouraged Martin to join more social
events/groups which would encourage social integration (Thompson
2006).
I am now going to enter into the second stage of Gibbs (1988)
model of reflection, which is a discussion about my thoughts and
feelings.I felt very comfortable and accepted within the MDT
meeting. The atmosphere was friendly and relaxed and the MDT
discussed Martin’s progress. I felt quite nervous in contributing to
the MDT discussion but felt as though I was Martins advocate and
was speaking out on his behalf, as I had gained a strong bond with
him. The MDT listened to my opinions and asked further questions
on how I felt he was progressing. The MDT communicated well with
each other and had Martin’s best interest in mind at all times. The
discussions about Martin were held until the best outcome was
achieved for him. This demonstrated the benefits and importance of
communication within a team and how all contributions within
meetings should be valued (Perkins & Repper 1998). I found it
extremely interesting to see a MDT in action and witness the
teamwork between different disciplines.
Evaluation is the third stage of the Gibbs (1988) model of reflection
and gives an account of the importance of MDT. There are many
positive aspects of this particular MDT as they all worked well
together as a team with the same goal in mind. The team discussed
the different options available and all the problems that may arise.
The MDT have to consider the current state of a client and if the
change in lifestyle would benefit him in the long-term. The
advantage of a multidisciplinary team approach is that all
professionals work together by collecting the facts and by bringing
information together, to obtain a complete view of the possible
problems of each individual patient. In doing this they are able to
make sure that the appropriate range of treatment is given (Onyett
2003).The MDT can have a large impact on the client’s life and can
change their long-term way of living.Although, one of the major
disadvantages of the MDT is that they work individually, therefore
there can be a lack of direction, unclear goals and poor leader ship
(Darby et al 1999) if effective communication between the team is
not achieved. This could affect the care Martin given and postpone
his discharge from the rehabilitation unit.Essential communication is
vital in MDT as it allows the team to gain an understanding of how
the client is coping and if the transfer from the mental health
hospital to the rehabilitation unit benefited him.
Stage four of Gibbs(1988) is an analysis of the event. If I had not
given my opinion on Martin’s care, he may not have benefited from
the MDT as much as he did. Contributing in Martins care meant that
I was able to inform the other members of the MDT about his
progress. I felt I did this well as I gave a description of his emotional
state and how he was progressing with preparing food in the
kitchen. The MDT appreciated me speaking about Martin, as they
were able to identify new targets for him to achieve, so he would
constantly be working towards reaching independence.
In conclusion, stage five of the Gibbs (1988) models, it is clear to
see from the MDT meeting that effective leadership and good
communication between members of the team is vital to ensure
there is a clear understanding of Martin’s outcomes (Taylor 2001).
The MDT has to be equipped with all the information to overcome
Martin’s individual problems (Taylor 2001). The team working
together forms the basis of mental health nursing and can influence
the success or failure of the care and treatment that Martin may
receive (Kirby 2004). The MDT has the potential to achieve positive
outcomes for Martin, and give him the opportunity to reach
independence.
The final stage of Gibbs (1988) model is the action plan. If I found
myself in this type of situation again, I would be more confident in
discussing about the clients and their needs thus participating more
within the MDT meeting. I have learnt from this situation that good
teamwork and communication between each other is vital (Taylor
2001). I have gained a better understanding of the multidisciplinary
team, and how the outcomes of these meetings can affect Martin
and his family’s quality of life, which will help me to think very
carefully about the decisions I make concerning client care in the
future.
References
BBC ,2006, Schizophrenia, BBC news, Available from:[Online]:
http://news.bbc.co.uk/go/pr/fr/-/hi/health/medical_notes/1079451.st
m[Accessed: 20th August 06]
Burke.L, 2006, Occupational therapists, [Online] Accessed from:
http://www.occupationaltherapists.com/[Accessed: 2nd September
06]
Darby, S. Marr, J. Crump, A Scurfield, M (1999) Older People, Nursing
& Mental Health. Oxford: Buterworth-Heinemann.
Gibbs.G 1988, Learning by doing. A guide to teaching and learning
methods, oxford polytechnic, Oxford
Kirby.S, Hart.D,Cross.D,Mitchell.G, 2004, Mental health nursing:
Competencies for practice, Palgrave, Hampshire
Nursing&Midwifery Council, 2004, NMC Code Of Professional
Practice: Standards for conduct, performance and ethics, United
Kingdom
Onyett, S. (2003) Teamworking in Mental Health. Bristol: Palgrave
Macmillan.
Ovretveit, J. (1993) Co-ordinating Community Care: multidisciplinary
teams and care management. Buckingham. Open University Press.
Perkins, R. Repper, J. (1998) Dilemmas in Community Mental Health.
Oxon: Radcliff Medical Press Ltd.
Taylor.C, Lilis.C, Lemone.P, 2001, Fundamentals of nursing: the art
and science of nursing care, 4th edn, Lippincott, Philadelphia
Thompson.N, 2006 , Anti-discriminatory practice 4nd edn. Palgrave
Macmillan, Basingstoke
The therapeutic relationship can be between two people. It is a
relationship that is establish to meet the patient’s needs and
therefore, it is client centered. I felt the need to develop therapeutic
relationships with the client’s so that they could feel they could put
their trust in me, also that I was there to listen and talk to them not
just care for them. My final placement was an elderly rehabilitation
ward which help the patient’s to adapt to changes in their life
circumstances. The ultimate goal is to maximise the social well
being of the individual and enabling them to regain their maximum
quality of life and the rehabilitation involved all the individuals’ daily
activities. I was not sure what to expect from this placement as it
was my first experience of working on an elderly rehabilitation ward,
as my first placement before was on a surgical ward. During my first
days on the ward I found it very different as the patients needed
more assistance with their activities of living, such as mobility when
transferring and their hygiene needs.

However the ward did use the same model of care on the ward as
my last placement which was the Roper, Logan and Tierney
activities of living model. This helped as the purpose of this model of
nursing is to provide a framework mainly for nurses to plan and
individualize nursing for those interventions which are related to the
patient’s activities of daily living. Roper et al (2002, p434) states
that living could be described as an amalgam within the activities of
daily living and the way in which the activities are carried out by
each person contributes to individuality in living.

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In both of these placements I have interacted with a large number
of patients, all of whom have been admitted for a variety of
difference reasons. This involves me admitting these patients, their
overall care during their time either in hospital or in other care
centres right up to their discharge.

When I first started on the ward I was a little bit concerned when
meeting patients when other staff were present as I thought that I
was in the way and I would be unprepared when asked to do
anything or answer any questions that the patient may ask, as the
other staff seemed so professional. Prior to starting each of my
placements I attended classes which involved how to act
appropriately around the patient’s and other members of the team
in which I was working and it was to prepare us for our practice
placement, but when you get out in practice and are faced with the
real thing it is much different.

I knew this was something I needed to overcome and as I started to

settle in and understand the routine of the ward the easier it
became. Freshwater et al (2005, p101) suggests the nurse patient
relationship can be viewed as a major therapeutic tool of effective
patient care. McHugh Schuster (200, p7) sates that communication
plays an important role in the therapeutic relationship. Clark &
Bridge (1998, p2) suggest that forms of communication such as
asking questions, allowing patients to express their feelings, or
reassuring patients by means of touch will also result in important
patient care, and increase patient satisfaction and well being.
Nichols (cited in McQueen 2000, p723-731) also suggests that the
nurse is the central figure in the patient care and is best placed to
provide much of the psychological care and this demands good
interpersonal skills to form a therapeutic relationship with patients
and to communicate more effectively with relatives and other health
professionals.

Communication covers a wide range of things including touch, play,

and enthusiasm. Touch is important as it showed that I was listening
to the patient’s, touch can mean different things, and it is a silent
language of non verbal behaviour. Touch is an affectionate way of
transmitting warmth. Whilst I was on the ward an example of touch
would be when patients are upset or anxious I would maybe hold
their hand or give them a comforting hug. Not all patients are
comfortable with using touch but I knew the boundaries with each
individual patient.

Another non verbal communication skill could be silence giving both

the patient and the nurse time to reflect upon prior or future events
in the patient’s care. Although it is important that the patient’s
needs are still met and that the focus is still on them. Therefore it is
important that the nurse involves the patient through other means
of communication which again could be through touch or play.

There are many ways of forming a relationship and gaining the trust
and respect of the patient and I had to work out the different things
that make a good therapeutic relationship. Hinchliff et al (2003,
p102) states there are a number of important elements that make a
good therapeutic relationship, but it is important to make clear that
a therapeutic relationship is a formal relationship between a medical
professional and patient. The Nursing and Midwifery Council (2004)
maintains that at all times nursing staff must maintain appropriate
professional boundaries in the relationships they have with patients
and clients.

The NMC (2004) states that the nurse must recognise and respect
the role of the patient/client as partners in their care and the
contribution they can make to it. This would be the phase of
identification in Peplau’s (1988) model of the nurse patient
relationship. Peplau (cited in Hinchliff et al 2003, p130) views the
nurse patient relationship as passing through four phases
orientation, identification, exploitation and resolution, with
identification being when the patient finding out more about the
reason for health care and the people who can be relied upon for
help and advice and how the patient can become more involved in
their own care.

In this piece of reflection I did not have to obtain consent from

patients as I generalised and have not discussed individual cases.
However confidentiality is of major importance whilst confirming a
patient and it is essential that informed consent is valid as each
patient has the right to keep their caring need private. Riley (cited
in Cutcliffe et al 2005, p304) suggests that therapeutic relationships
are about patient’s disclosure of personal and occasionally painful
feelings with the nurse at a calculated emotional distance near
enough to be involved but objective enough to be of help. Neal
(cited in Hinchliffe et al 2003, p102) states that confidentiality and
trust are two sides to the same coin and trust is another important
attribute to the therapeutic relationship as the patient will place
their trust in the nurse.

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This element is important as in the nurse patient relationship the
patient is in a vulnerable position. People become vulnerable
whenever their health or usual function is compromised. This
vulnerability increases when they enter unfamiliar surroundings,
situations or relationships. Older patients and those with dementia
are especially vulnerable. I felt on the placement the patient’s could
put their trust in me as when taking personal information from
patients I would ensure to the patient in the early stages of the
relationship that information provided is treated as confidential, but
will be shared on a need to know basis, with others involved in the
delivery of their care.

Even something as simple as when I put a patient on the commode

and I inform them I will be back to check on them in five minutes I
always return straight away as I told them and if I was tied up I
would ask one of my colleagues to check on them this helps to
maintain their trust in me.

Chambers (cited in Cutcliffe et al 2005, p308) states that empathy is

also an important feature to the therapeutic relationship and
suggests empathy is the ability to recognise and understand the
patient’s feelings and point of view objectively. According to Riley
(cited in Cutcliffe 2003, p93) empathy expressed verbally conveys
caring, compassion and concern for patient’s but never implies that
the nurse can fully experience patients feelings, also listening is an
important element as it is critical to hear what the patient is saying,
verbally and non verbally. Smyth (cited in McQueen 2000, p723-
731) suggests that our personal experiences can make a
contribution to their emotional work and ability to empathise and by
reflecting on personal experiences nurses may be better able to
identify with patients.

Whilst I was on placement and listening to the patients concerns

and worries, using qualities mentioned by Hinchliff el at (1998,
p225) of care, concern, compassion and respect I explained that it
was a natural reaction to feel nervous and unsettled and this helped
to lesson their underlying anxieties. In order to be genuine it was
necessary to be honest and put some of my own feelings into the
situation like getting into their shoes and trying to see things like
emotions and experiences from their perspective where possible.

Chambers (cited in Cutcliffe 2005, p308) states that therapeutic

relationship differs in terms of focus, length, depth and degree of
closeness, regardless of this; they need to be grounded in respect
for the patient. Getting the message of respect to the patient can be
done in a number of ways as part of the therapeutic relationship like
making sure that all conversations take place in private, whilst the
doctors are doing ward rounds being present, listening and
validating material that is disclosed. Honesty and genuineness play
a key role in conveying respect, even when the information shared
may be difficult for the patient. The NMC (2004) states that respect
in the general sense recognises the worth of a patient irrespective
of gender, age, race, disability, sexuality, culture, religion, economic
status or personal beliefs.

Whilst on placement I had to be aware of the aspects of treatment

in respect of race and religion. This can be seen through
communication, religious beliefs and special dietary needs. Each
person has a right to be treated in a way their religion dictates. An
example of this is through the dietary need for Muslims in the hallal
way of preparing meat for hospital meals. Other patients may also
have special dietary needs such as patients with diabetes.

Much of nursing is on a one to one basis and is intimate of nature.

Dignity is a major issue to many patients and should be respected
at all times when working on a ward or other health care situation.
Windang & Fridlund (2003 cited in Cutcliff et al 2005, p81) states
that dignity mainly comprises as seeing the whole person, being
respected and being seen as trustworthy. I have respected the
dignity of others by understanding the need for respect and privacy
due to the patient’s personal feeling and religious beliefs. In building
a therapeutic relationship I had not really considered the
environment for doing so. Birrell et al (2006, p43) state how
important it is that sensitive issues are discussed in side rooms or
an area with an element of privacy and not just at the patient’s
bedside.

Although when talking to patient’s privately I drew the curtains

around the bed I still had to lower my voice so that other patients
could not hear our conversation which was particularly difficult if the
patient had hearing difficulties. On reflection I now realise that I
should have found a quite room in which to discuss private matters
with patients or waited until the bay was quieter or when the other
patients were busy or out of the room.

The main purpose to this reflection has been to show the difference
between a normal everyday relationship and a relationship between
a medical professional and a patient. In a nurse – patient
relationship as the NMC (2004) states there is a duty of care. This
expresses itself, especially in a hospital setting. One of the
important elements of nursing is establishing a therapeutic
relationship. Until I had considered Gibb’s cycle I had not really
thought about the elements that make up a therapeutic
relationship. These I now appreciate include verbal and non verbal
communication, such as touch, humour, compassion and listening
appropriately to the patient and it id further shaped by the concepts
of power, trust, respect and intimacy.

Professional interpersonal skills arise from a variety of experiences

whilst engaging with patients, relatives, colleagues and other health
welfare practitioners. Egan et al (1995, p1) suggests that
interpersonal skills refer to those interpersonal aspects of
communication and social skills that professionals use in direct
person to person contact. In looking back I feel as though I have
developed my interpersonal from a normal everyday relationship to
that in a medical setting.

I have learnt how to listen and talk to patients, staff and family
members for me as a first year student this was a daunting task at
the beginning but I felt I developed this and my confidence come
from personal experience. I would hope in the future to develop
further interpersonal skills and help patients in what ever setting I
find them. I need to make all patients feel equal and attend to all
their needs in privacy and with dignity and cooperate with their
individual needs separately.

In the future and having the knowledge gained through this piece of
reflection I

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References

Birrell, J., Thomas. D., Jones. C.A. (2006) Promoting privacy and
dignity for older patients in hospital. Nursing Standard, Vol 20; No,
18 Middlesex: RCN Publishing Company.

Bridge, W. and Macleod Clark, J. (1998) Communication in nursing

care. Chichester: Wiley

Chambers, M. (1998) Interpersonal mental health nursing: research

issues and challenges. Journal of psychiatric and mental health
nursing 5: 2003-211. Cited in Cutcliffe, J. and Mckenna, H. (2005)
The essential concepts of nursing. London: Churchill Livingstone.

Cutcliffe, j. and Mckenna, H. (2005) The essential concepts of

nursing. London: Churchill Livingstone.

Egan, G. 1998) The skilled helper: a systematic approach to

effective helping 5th ed cited in Ellis, R.B., Gates. B, Kenworthy. N.
(eds.) (2003) Interpersonal communication in nursing. Theory and
practice 2nd ed. London: Churchill Livingstone.

Freshwater, D. and Johns, C. (2005) Transforming nursing through

reflective practice. 2nd ed. Oxford: Blackwell.

Hinchliff, S., Norman, S. and Schober, J. (eds.) (2003) Nursing

practice and health care. 4th ed. London: Aronold.

Jasper, M. (2003) Reflective practice. Foundations in nursing and

health care. Cheltenham: Nelson Thornes.

McHugh Schuster, P. (2000) Communication the key to the

therapeutic relationship. Phiadelphia: F.A. Davis Company.

Neal, K. (2003) Nurse patient relationships cited in Hinchliff, S.,

Norman, S. and Schober, J. (eds.) (2003) Nursing practice and health
care. 4th ed. London: Aronold.

Nichols, K.A. (1993) Psychological care in physical illness. 2nd ed.

London: Chapman & Hall. Cited in McQueen, A. (2000) Nurse patient
relationship and partnership in hospital care: The journal of clinical
nursing. Vol 9 (5), 723-731.

Nursing and Midwifery Council. (2004) The NMC code of professional

conduct: standards for conduct, performance and ethics. London.

Peplau, H. (1998) interpersonal relationships in nursing. New York:

Putman. Cited in Hincliff, S., Norman, S. and Shober, J. (eds.) (2003)
Nursing practice and health care. 4th ed. London: Aronold.

Riley, J. B., Kelter, B.R, Schwecker, L.H. (2003) Communication: cited

in Cutcliffe, J.R. and McKenna H.P. (2005) The essential concepts of
nursing. London: Churchill Livingstone.

Roper, N., Logan, W. and Tierney, A. (2001) The Roper - Logan -

Tierney model of nursing: Based on activities of living. Edinburgh:
Churchill Livingstone.

Widang. I, Fridland, B. (2003) Self respect, dignity and confidence:

conceptions of integrity among male patients. Journal of Advanced
nursing. 42: 47-55 cited in Cutcliffe, J.R and McKenna, H.P (2005)
The essential concepts of nursing, London: Churchill Livingstone.

Smyth, T. (1996) Reinstating the person in the professional:

reflections on empathy and aesthetic experience. Journal of
advanced nursing 24 (50), 932-937. Cited in McQueen, A. (2000)
Nurse patient relationship and partnership in hospital care: The
journal of clinical nursing. Vol 9 (5), 723-731.

In keeping with NMC guidelines, all names and locations have been
changed, to protect the identity of the individuals involved.
However, it must be stated that individuals who work with the client
groups may recognise the individuals concerned, due to the
information provided. In this respect, it is not always possible to
completely protect the individuals concerned; however, it is also the
duty of other professionals concerned to remember their own
responsibilities regarding protecting the client’s rights of privacy and
dignity.

The purpose of this essay is to reflect upon a critical incident that

took place on the first of my specialised placements, which, in my
case, was mental health. To achieve this, I will use the reflective
cycle (Gibbs 1988) cited by Palmer et al (1994). I will start by
giving an outline of my placement. For reasons of confidentiality,
(UKCC 1992), the client's name will be changed to `Clive'. I shall
then discuss the critical incident; by providing details of what took
place and when; this will lead on to details of what I found the most
satisfying and what troubled me about the incident. I shall finish by
relaying what I believe I have learned from the incident.

My placement was in a day hospital, caring for elderly people with

mental health problems. According to Griffith (1988), community
care should support people who are affected by problems including
mental illness and mental handicap. The clients attended the unit
throughout the week, giving their carers a much needed break.
Research shows that four out of five older people who have mental
health problems are cared for at home, (Gearing 1990). Levin
(1983) stated that caring for someone with mental health problems
twenty-four hours a day leads to total exhaustion.In the unit, there
were three trained mental health nurses, one occupational therapist
and one nursing assistant. Care within the unit was based on
Roper's nursing model, and the twelve activities of daily living,
which are communicating, breathing, eating and drinking,
eliminating, personal cleansing and dressing, controlling body
temperature, mobilising, working and playing, expressing sexuality,
sleeping and dying. As a model, this concerns the idea that, if the
client has some type of health problem involving these twelve
activities, then they require the needs of a trained nurse. The unit
also worked with evidence-based practice in their treatment.
Evidence-based practice is where current practice procedure can be
evaluated and questioned upon how effective it is and whether it
can be changed to improve treatment.
The unit combined a holistic and client-centered approach which,
according to Rogers (1951), will assist the client to reach his/her
full self. The client's well being was taken into consideration, which
included their social, physical, psychological and spiritual needs.
Each client was under the care of a named nurse and underwent an
initial assessment over a six to eight week period, which involved
multi-disciplinary participation, consisting of a community
psychiatric nurse, psychiatrist and a social worker. According to
Naidoo & Wills (2000) Mental Health nurses work with people who
are mentally ill and ensure that they are able to cape. The unit used
therapy as a means of treatment and this involved the use of a
living dog, which wandered around the unit, and the clients
interacted with it. Sylvester (1988) stated that, `nearly half the
households in Britain own a pet, so they are a normal part of life far
many people'. Therapy methods used included reminiscence. The
use of reminiscence is to develop and aid the client value their
memories, (Coleman 1986). Other therapy methods were set within
a multi-sensory environment. This is where clients can handle
interactive toys involving microchip technology. This play-based
activity promotes considerable attention, participation and
commitment (Pulsford et al 1999). I discussed with my mentor the
possibility of some of these and other activities being demeaning to
clients of this age group. We managed to come to a mutual
understanding between ourselves over these activities, that the
clients enjoyed partaking in the activities and none of them refused
to do so. The critical incident itself happened during the second
week of my placement, over a period of two days. On the first day,
after the clients had arrived, we started to serve them cups of tea
or coffee. When I approached Clive, he asked if he could speak to
me. I sat beside him and he began telling me that he had had a bad
dream, which had really upset him, he said had never felt like this
before following any other dream he ever had. He also mentioned
he had never felt as low in life as he did at that present time. We
spoke for about five minutes and I told him I would mention it to
someone, which I did, though no action was taken at that time. The
following day; I was discussing my placement with my mentor
when, as the clients began to arrive, the ambulance crew came to
report that Clive did not wish to come to the unit and appeared very
upset and agitated. My mentor arranged for someone to go and see
him. Later that day, Clive arrived at the unit, very well presented,
but very quiet. Following lunch, I spoke to him and he asked if he
could have a talk with me. I took him through to the dining room
and Clive began by telling me he wanted to talk to someone, as
something was bothering him, but he was not quite sure what it
was. He began his story by telling me about his past, and how ill his
father had been and all about his mother and how well educated
and how respected she had been. He also told me how his father
would collapse for no apparent reason. Then Clive started telling
about his war-time experiences as a Prisoner Of War at the hands of
the Japanese and how he enjoyed this part of his life, as he never
caught any of the illnesses and enjoyed being able to help others
who were ill. Clive kept referring back to his mother. It appeared to
me that he looked up to her and always tried to equal her
achievements. Again, Clive repeated to me that he never felt as low
in his life as did at that present time. He once again referred to his
father, who, he told me, committed suicide and it was Clive who
found him. He continued referring back to his mother and
comparing himself and his achievements to hers and how he could
not measure up to her. I attempted to reassure him that he had his
own merits that he should be proud of ,I brought to his attention
the fact of his achievements in the war and how he helped others
who were less able to cope than he was. Clive appeared to take
notice of this, as he said he had never thought of it that way before.
It was interesting to note haw he kept referring to the past. Sndyer
(1987), cited in (Kegan and Evans 1998), stated that, `our
knowledge of self acts as a guide in helping us choose our actions,
the situations we meet, and the relationships we enter'. According
to Hinchliff el al (1998), depression is focused entirely in the past
and the patient's complaints of physical pain. Clive also mentioned
about his knee giving him pain and trouble.

Gearing et al (1990) also state that depression is common in old

age. Clive did not manage to tell me what was troubling him, but he
said he felt better for having talked to me. I will now discuss why
the event was important to me and what I found most satisfactory
about it. Listening to Clive describe his thoughts gave me a sense of
being able to do something important and attempt to help
someone, if only to listen to what they had to say. I also felt more
confident in the discussion we had; I believe this was due to the
interpersonal skills we covered in college. I found myself putting
into practice what we had covered, to the best of my ability at this
stage of my training. I still have limitations as to what I can
achieve. However, I did find myself asking open-ended questions, as
well as paraphrasing what Clive had told me. I attempted to
reassure him of his own self-worth as I saw it, and his
achievements during the Second World War, pointing out that this
was a good quality and something he should be proud of. It was a
nice feeling to hear Clive mention that this made him feel better
and that it was nice of me to point that out to him., as he said he
had never thought of it like that before. The most satisfactory part
of the incident was that, through my conversations with Clive and
the way I interacted with him and advised him, I felt that I had
helped Clive think about this own life, if only a little, and I also
believe it enabled him to get things of his chest. Kegan and Evan
(1998 p12) state that `counseling helps people constructively to
resolve personal problem(s) that may be long-standing or acute'. It
encouraged me that he trusted me enough to want to confide in me
and I may have been able to provide him with a little support. Some
aspects of this incident troubled me. Although Clive appeared to
enjoy our discussion, it troubled me that no other staff appeared to
have the time to talk to him and told me that it was nothing he had
not said before. Kogan and Evans (1998) argue that, if nurses give
clients reassurance as a meaning of avoiding underlying concerns, it
may do little to help the client. When I questioned Clive what it was
that was bothering him, he was unable to remember. In our
discussion, I referred to the fact: that he did not wish to attend the
unit that day. Clive was not able to recall the fact that he did not
wish to attend; in fact, he went on to say that there was no reason
what he should not want to come, as everyone here treated him
nicely. I asked him if he knew what the unit was for and what the
people who worked in the unit were there to do. Clive was unable to
tell me. He never asked me to explain and I did not feel as though it
was my place to tell him. Other aspects that troubled me were not
being able to help Clive more than I could, other than to keep
reassuring him of his own self¬-worth. I would then mention our
conversation to another member of staff, who might be able to offer
him more help. It also troubled me that, even though I did mention
it to his named nurse, as far as I am aware, no record was made of
it. I believe that there was a lack of communication from the trained
staff towards Clive, to help him come to terms with his current
problem in life. I believe I have learned from the incident and have
developed communication skills. People with mental health
problems have other physical illnesses as well. In Clive's case, this
would be the knee, which he complained about. According to his
case notes, he was also finding increased difficulty with his hearing
and his walking and he was becoming increasingly forgetful. One
needs to look into people's past history to gain a fuller
understanding of what is troubling them at present and take this
into account when assessing them far treatment. As Gearing et a1
(1990) state, a person's past life is unique to them. I now believe I
have gained a better knowledge of people with mental health
problems, despite being on the placement far only two weeks. I
went into the placement not knowing what to expect, but with an
open mind. I left realising that elderly people with mental health
problems have often led normal active lives and many have, in their
youthful years, provided inspiration to others, be that from
teaching, working with others or, in Clive's case, helping people less
able to cope than himself. Further discussion with my mentor
included the way in which clients were treated. For example, when
we laughed during a conversation, were we laughing at them'? This
was something we had discussed in college. The conclusion reached
was that everyone enjoyed this kind of interaction and it offended
no one, especially the clients. In fact, many of then benefited from
this sort of interaction. In future, I will be more aware of people
with mental health problems and look at them with a holistic view,
considering what they may have gone through, it is only through
placements like this, that one can gain a fuller knowledge of all
aspects of nursing.© Robert Sidwell 2005

Coleman, P. G. (1986) Ageing and Reminiscence Process. Wiley,

Chichester.

Gearing, B. Johnson, M. Heller, T (Eds) (1990). Mental Health

Problems in Old Age. Open University Press, Milton Keynes.
Griffiths, R. (1988) Community Care: Agenda for Action. A report to
the secretary of state for social services. HMSO, London.
Gibbs (1988) The Reflective Cycle, cited in Palmer, A. Burns, S.
Bulman, C. (1994) Reflective Practice in Nursing. London, Blackwell
Science. Cited in Reflective Portfolio Handbook {2001} St. Martin's
College, Lancaster.
Kegan, C. Evans, ,T. (1998) Professional Interpersonal Skills for
Nurses. Stanley Thornes Ltd, Cheltenham
Levin, E. Sinclair, T. Gorbach, P. (1983) The Supporter of Confused
Elderly Persons at Home. Extract from the main report. National
Institute of Social Work, London. Cited in Mental Health Problems in
Old Age (book 2) (1990). The Open University Press, Milton Keynes.
Naidoo, J. Wills, 3 (2000) Health Promotion Foundation for Practice
2nd Edition. Bailleire Tindall, London.
Rogers, C. (1951) Client Centered Therapy. Constable, London.
Roper, N. Logan, W. Tierney, A. (1988) Learning To Use The
Process of Nursing'. Churchill Livingstone, Medical Division of
Longman Group UK Ltd, Edinburgh.
Snyder; M. (1987) Public Appearance and Private Realities: The
Psychology of Self Monitoring. Freeman, New York. Cited by Kegan,
C. Evans, J. (1998) Professional Interpersonal Skills for Nurses.
Stanley Thornes Ltd, Cheltenham
Sylvester, J. (1988) Animal Crackers. Nursing Standard June 1
Volume 4 Number 3 pp28-29 1988.
Pulsford, D. Conner, I. Rushforth, D (1999) Does Play Journal Of
Dementia Care. Sep/Oct 1999 pp 15-16.

Tilley, Stephen. (Ed)(] 997), The Mental Health Nurse, Views of

Practice and Education. Blackwell Science Ltd, Oxford.

Norman, I. Redfern, S. (1997) (Eds) Mental Health care for Elderly

People. Churchill Livingstone. New York.
Claridge, G. (1987) Origins of Mental Illness. Basil Blackwell,
London.

Linda Broderick currently a HCA within the network has taken

a keen interest in communication with the patients. As part of
her NVQ Linda wrote Reflection on communication in the
intensive care unit, which has recently been published in the
HCA magazine. Well done Linda! keep up the good work.

REFLECTION ON COMMUNICATION IN THE INTENSIVE

CARE UNIT
This reflection, using Gibbs reflective cycle, describes a
challenging communication issue in Intensive Care.

Description
A patient was admitted to the Unit from another ITU, she
spoke no English and had a tracheostomy. Within thirty
minutes we managed to find a healthcare professional within
the hospital who could speak Italian, to explain to the patient
that she was in hospital, quite safe, that her daughter had
been informed and would be arriving in about an hour. When
the daughter arrived, she was able to relay the patient’s
preferences and needs which we decided to not only record in
her notes but to also make a list which was kept on the desk
by her bed to make it easier for staff involved in her care. The
daughter also wrote down lots of useful questions in both
Italian and English, enabling us to try our hand at a bit of
Italian and for the patient to point to any of the questions she
wished to ask us. We also went on the internet and found
some useful words we were able to use.

Feelings
I was aware of how frightening it must be for the patient who
was ill, had a tracheostomy and was surrounded by people
who she did not understand. At times I felt quite useless when
she was trying to talk to me and I had no idea what she was
saying. I could only hold up the questions her daughter had
provided and hope it was something on there that she wanted,
then I would feel really pleased for her if it was and I could
provide what it was. On occasions, when no matter how hard I
tried I could not understand what the patient was trying to ask
me, I would ask a colleague to see if they could understand
what the patient was asking. I am pleased to say that between
us, we always managed to work it out.

Evaluation
The good thing about the situation, was that it really
challenged us and everyone did really well. Also the more we
got to know the patient, the easier it became. On one
occasion, when an x-ray machine was wheeled into her room I
noticed a look of fear on her face. Realising we had no means
to explain an x-ray, I mimed to her that I was holding a
camera and taking a photo and mimed a square on my chest.
She immediately understood that we wanted to take a ‘photo
of her chest’ and she smiled at me and nodded.

On another occasion, we explained to her that we needed to

change her position. She understood and acknowledged it was
alright for us to do that. However, after putting the pillow
behind her back, her facial expression and the fact she made
attempts to remove the pillow told us she did not want the
pillow there. We removed it and her expression then told us
we had done the right thing.

The bad thing about the experience was the frustration you
feel when you are trying to understand what the patient is
telling you and you can only imagine the frustration the
patient must feel when, unlike us, she has nobody to help her
try to ‘work it out’. It also made me realise how a situation
could so easily become ‘unsafe’ when a person cannot tell you
in detail how they feel. When verbal communication is so
limited, it is so important to look for body language and
expression if you are to meet this patient’s needs.

When a male nurse was taking care of her and I went to assist
with her personal care, she understood and agreed to a wash
but made it clear she did not want the male nurse to do it by
pushing him away. I asked if she wanted me to do it by
miming a wash and pointing to myself she nodded and looked
relieved that I was going to do it.

Analysis
The language barrier and the tracheostomy provided two
communication challenges with this patient. However,
whatever the communication challenge, you can overcome it
to a degree, certainly enough to communicate with someone.
Non verbal communication becomes even more important in
these situations. We had a Spanish nurse who looked after her
when on duty which worked well as they understood quite a
bit of each other’s language and the patient enjoyed her
company.

Having internet access by the bedspace was very useful to

quickly look up words too.
The patient’s daughter was invaluable but we had to be careful
we did not breach the patient’s confidentiality in how we used
the daughter to interpret.

Conclusion
I don’t think any more could have been done. The patient was
happy during her stay and everyone made a good effort to
ensure that communication was not only questions and
answers. Our attempts to speak Italian made her laugh a lot
and she liked us to tell her about ourselves, such as if we had
children. We told her the day and the time and many other
things. The patient made it quite clear if she liked or disliked
someone by a simple brush of the hand or holding your hand.

Action Plan
If the situation arose again, I would feel more confident in
trying to learn a bit more about whatever language I was
dealing with. There are many sites on the internet and I would
certainly use that more. I know I could also contact an
interpreter as well.