1 AUTHOR: SHADRACH DARE (2011) UNIVERSITY OF CAPE COAST DEPARTMENT OF NURSING This is a reflective report on the subject of nurse

patient communication based on a critical incident I observed during my second week placement as a student nurse in an obstetrics and gynaecological ward. The author will describe communication and the role the nurse has in this regard but emphasis has been placed on the incidence for the sole purpose of this assignment. Platzer (1997) identified that learning through reflection is more potent if there is an underlying framework that encourages a structural process to guide the act of reflection. In light of this, Gibbs 1988 reflective model (appendix 1) shall be used to reveal my strengths and weaknesses in the analysis and how they may be enhanced to improve professional training. However, the author shall merge some sub topics of Gibbs reflective model due to space constraints. In the concluding paragraph, the author will state how much he has gained from the experience and the structured reflection. The Dyadic Interpersonal Communication theory (appendix 2) has been adopted to help analyse the incident. Anonymity shall be maintained throughout this piece for the sake of confidentiality (NMC, 2008). Since the inception of the term critical incidence as a classification and training method by Flannagan in 1954, there have been varying definitions by several authors in the field of social, health and behavioural science of which nursing is a part. Fook & Cooper (2003) describe a critical incident as an episode of experience, not necessarily dramatic, which has significance for the observer. It is often an event which made you stop and think, or one that raised questions for you. According to Lassisi (2009) it is an incident which in some way has had a significant impact on your personal and professional learning. It may have made you question an aspect of your beliefs, values, attitude or behaviour. In the clinical setting, critical incidents may relate to issues of communication, treatment, culture, relationships and emotions or beliefs (Dadson, 2006).

2 AUTHOR: SHADRACH DARE (2011) UNIVERSITY OF CAPE COAST DEPARTMENT OF NURSING Description of the Situation This is an account of the incidence that has left an indelible snapshot on my mind, one which caused me to question the culture within which I grew up, an event that made me feel powerless but most importantly, one that has changed the way I talk to my patients. This incident is about a man, a husband and father to be that never was, who was invited to comfort his wife who had refused to be comforted despite the several therapeutic touches or advice a nurse could offer a patient. Her reason? She had lost her baby who had refused to breathe or cry like all babies do soon after delivery, just an euphemism of saying her baby had died, after going through the ordeal of pregnancy, endured the pains of labour but enjoyed the obstreperous cry of other babies on the ward. This man comes to the ward and instead of playing the role of a comforter to the wife, he busts into tears louder than his wifes because this is the second time he has been a disappointed father. A professional nurse trained in the Akan society in her attempt to comfort this man quotes the popular Akan adage benyin nsu meaning men are not supposed to cry but the man replies in rage dont tell me that because you dont know what I am going through. It is upon the popular cultural phrase used by the nurse that I base my analysis as I reflect on the incidence. Communication is a central theme in nursing (NMC, 2008). Balzer-Riley (1996) describes communication as a reciprocal process of sending and receiving messages using a mixture of verbal and non-verbal communication skills. Verbal communication is spoken, while non-verbal communication comprises forms of message sending such as facial expressions and or gesturing. Nurses depend upon their communicative skills to be able to understand and meet the needs of their patients. Some nurses are effective at this act and skill whilst others are not so effective (Fook & Cooper (2003). Statistics in the past has indicated that the majority of malpractice allegations about nurses do not stem from issues of clinical competence, but rather arise from problems in communication and inability to convey a sense

3 AUTHOR: SHADRACH DARE (2011) UNIVERSITY OF CAPE COAST DEPARTMENT OF NURSING of care (Schofield, 2003). The pregnant woman who has lost her baby and the family of that pregnant woman can face many dilemmas ranging from a physical, psychological and psychosocial domain (Berlo, 1960). Nursing, being an interactive skill, requires the nurse to be able to communicate effectively with the patient and family. The inability to communicate can hamper this very crucial relationship as posited by Dadson (2006). Analysis of feelings From the time the woman got unto the delivery suite till the time her husband came in and even beyond to this time as I write out this assignment, a series of feelings ran through me. Initially, I felt disturbed, like all other nurses on the ward, as the woman screamed in agony and aghast when I saw her husband wail on the corridor of the ward for I did not understand why a man should cry like a baby. Finlan (2006) describes crying as a very effective way to free the soul for the heart tranquillity. Some people yell with suffer and pain, and other people stop breathing and they cant control it when crying. Scientists explain that the yells and all that people do are caused by long time passed from the last time of crying till the present one (Flores, 2010). Flores (2010) continues to state that a heavy cry is followed by a sense of joy, calm, pleasure and relief with oneself. I felt worried as the woman ceased not to cry so I approached the scene to render the necessary help I could offer. I rubbed her back gently as the staff nurses also comforted her. but all these were to no avail. Patterson (2009) identifies back rubbing as a component of non verbal communication and Myles (2006) describes back rubbing as a therapeutic way of going through distress including loss. I felt frustrated as the woman ceased not to cry despite the numerous therapeutic touches so I followed a nurse out of the room to advise the husband to help comfort his wife. There I was surprised, yet engulfed by a sense of pity for the man as I saw him swimming in a pool of tears. Subconsciously, I realised I was trying to remember the last time I cried like that.

4 AUTHOR: SHADRACH DARE (2011) UNIVERSITY OF CAPE COAST DEPARTMENT OF NURSING Statistics shows that women cry four times more than men because they secrete 60% more of prolan and they need to eliminate this through crying (Flores, 2010). Ashie (2009) argues that this is not true; rather men hide when crying due to cultural standards. From the Akan perspective, it is said that a man is not supposed to cry (Arthur, 2001). The nurse as African as she was, told the man that men do not cry as the man replied in anger that you have no idea of what I am going through. Then, I felt speechless, as I wished to know the right words to say to this man to comfort him but as I found none, I stood closer to him and leaned against the wall with my eyes blinded with tears yet stirring at him. I kept mute and watched him cry his heart out because I knew not of what to do. I was taken aback when after about 10 minutes of intensive crying the man approached me and asked with a husky voice nurse, how shall we go about it now. You can only imagine how wide my smile was when the young man who in just about 15 minutes ago wouldnt listen to anybody willingly sought advice. Sincerely, I feel uncomfortable as I look at my practice from a critical perspective yet I am amazed as I come to the realisation of how I felt throughout the incidence. Gibbs (1988) states that the act of reflection will assist you in the process of revealing new perspectives but it could be uncomfortable for the student. Evaluation/ Analysis of experience From the dyadic interpersonal theory, it can be seen that the encoder (nurse) had a clear and just intention of comforting the man but her aim was not well processed, analysed, decoded and thus comprehended by decoder (man) and this resulted in undesired response (Berlo, 1960) because her attitude was inappropriate. The content of the nurse message though culturally acceptable, the situational context of grieving and emotional and physical state of the man were intense. Mathews (1983) states that communication is strongly dependent on the culture, the social status, and reciprocal relationships of the participants.

5 AUTHOR: SHADRACH DARE (2011) UNIVERSITY OF CAPE COAST DEPARTMENT OF NURSING Poor communication leads to heightened anxiety and depression, poor psychological adjustment, ineffective coping, hopelessness and reduced quality of life (Fogarty,1999; Ong & De Haes, 2000) and all these were evident from the rage out of which the man replied. Fottler & Swan (1992) encourage the concurrent use of non verbal and verbal communication techniques is a more effective way of sending information. I believe that should the nurse have touched the man gently and spoke the same words, showed a more empathic attitude rather than standing at a distance, the man would have felt better. One may argue that this is not true but it is evident that as I stood closer to the man without saying a word but keeping eye contact, though ignorant of its implications, he felt better a few minutes thereafter. Bults (2005) identified that the time one spends in talking to patients in distress as an essential component of the intervention process. Conclusion/ Action plan Good communication skills are essential for health care providers, and are important in nearly all aspects of nursing. Developing greater confidence in how I communicate will lead to patients having greater trust in me as their nurse. Improving my skills in this area will also make me more effective in discussing cases with colleagues, and in participating in teams when necessary. This incident made me realise that I can communicate effectively and confidently once I do not allow the situation overwhelm my emotions. It demonstrated to me that in order to make progress or create positive change you must think outside your cultural setups. Overall, this incident has had a positive impact on both my studies and on the development of skills needed in my future career. I feel that I will be confident in dealing with patients and more effective in communicating with patients in distress should a similar situation rise. It is an undeniable fact that communication is so primary in nursing such that it cannot be overlooked or swept under the carpet in anyway whatsoever such that without it

6 AUTHOR: SHADRACH DARE (2011) UNIVERSITY OF CAPE COAST DEPARTMENT OF NURSING holistic nursing remain a pious hope. Nurses ought to be adroit communicators, combining both verbal and non verbal communicative skills. Crying is an effective way to free the soul for the heart tranquillity. Like Spartacus differed from the global perception that gods are immortal as he said in his famous play 100 Spartans that in war gods bleed, I differ from the popular Akan saying that men are not supposed to cry and throw my weight in favour of Flores (2010) when he says that a man before becoming a man is a human and humans cry. In fact if there is only one thing you can do in this world before you die, then my advice to you is to cry, no matter your gender.

7 AUTHOR: SHADRACH DARE (2011) UNIVERSITY OF CAPE COAST DEPARTMENT OF NURSING Appendix 1 Gibbs (1988) Reflective model

Description What happened? Action plan If it arose again what would you do? Feelings What were you thinking and feeling?

Conclusion What else could you have done?

Evaluation What was good and bad about the experience? Analysis What sense can you make of the situation?

Appendix 2 The Dyadic Interpersonal Communication Theory Berlo (1960) describes the dyadic interpersonal communication as a dynamic interactive process that comprises a source or sender (encoder). The aim of the sender is to be understood by another person (decoder). The decoder processes, analyses, decodes and comprehends the message. The recipient responds to the message based on her interpretation of the message. Communication occurs within a context influenced by the situation, the message content, attitude, perception and the emotional and physical state of the sender and recipient. Berlo places great emphasis on dyadic (communication between two people) communication, therefore stressing the role of the relationship between the source and the receiver as an important variable in the communication process. It is for this reason that this

8 AUTHOR: SHADRACH DARE (2011) UNIVERSITY OF CAPE COAST DEPARTMENT OF NURSING theory is adopted for this analysis because the incidence under critique involved 2 people- a nurse and a patient. References Atkins, S. & Murphy, D. (1994). The professional nurse and regulation. Journal of PeriAnesthesia Nursing. 18(3), 160-167. Baker, C. (1996). Reflective learning. Journal of Nursing Education 35(1), 19-22. Balzer-Riley (1996) as cited in Atkins & Murphy (1994). The professional nurse and regulation. Journal of PeriAnesthesia Nursing. 18(3), 160-167. Berlo, D. (1960). The process of communication. An introduction to theory and practice. New York: Holt, Rinehart & Winston. Dadson, B. (2006). Risk, communication and health psychology. London: Open University Press. Finlan, K. (2006) Counseling for patients with cancer. British Medical Journal 297, 727-729. Fogarty, L. (1999). Can 40 seconds of compassion reduce patient anxiety? Journal of Clinical Oncology. 17(1), 371-379. Fook, D. & Cooper S. (2003). The professional nurse and regulation. Journal of PeriAnesthesia Nursing. 18(3), 160-167. Flannagan, S. (1954) as cited in Atkins, S. & Murphy, D. (1994). The professional nurse and regulation. Journal of PeriAnesthesia Nursing. 18(3), 160-167. Flores, A. (2010). Risk, communication and health psychology. London: Open University Press.

9 AUTHOR: SHADRACH DARE (2011) UNIVERSITY OF CAPE COAST DEPARTMENT OF NURSING Ghaye, T. & Lillyman, S. (1997) Learning Journals and Critical Incidents. 35(2), 1418. Gibbs, G. (1988). Learning by Doing: A Guide to teaching and learning methods. UK: Oxford Lassisi, L. (2009). Ethics and issues in contemporary nursing. United States of America: Delmar Thompson Learning Nurses and Midwives Council- Ghana. (2008). Code for Professional Conduct. Accra, Ghana: Author. Ong, L. & De Haes, J. (2000). Doctor-patient communication and cancer patients quality of life and satisfaction. Patient Education Counselling. 41(2), 145-156. Platzer, E. A. (1997). Communication training for health professionals who care for patients in distress: a systematic review of effectiveness. Supportive Care in Cancer. 12, 692700. Schofield, P. (2003). Psychological responses of patients receiving a diagnosis of cancer. Annals of Oncology. 14(1), 48-56.