Essay: Service user in a supported living service (autism following MMR)

My reflection focuses on a service User in a Supported living service. I would call him John. In other for me to critically analyze and evaluate the role of a nurse in dealing with Complex communication situations, I would, first of all, give a background information on John. John was born with no medical concerns, as a baby, he was reaching his milestone earlier than expected. By the age of one, Jon was already walking, calling the names of his parents, counting 1 to 10 and singing letter A to E. At the age of 16 months, John was given an MMR and within 1 week John had stopped talking, John couldn’t count and John couldn’t recognize some of the members of his family. John’s parents noticed the difference and immediately raised concerns with the NHS. John was then put on a waiting list. One year later Jon was diagnosed with Autism. Johns parents were counselled about send education and the opportunities it offers. But within months it was quickly realised that there was no school in the country that could take care of John’s needs. Even as a young child all the primary schools couldn’t attend to John’s need and they were not equipped to deal with the situation. For example, John needed 5 hours to shower, he had OCD and wanted things to be done in a particular way. All switches on the wall had to be in a particular way.

John was more powerful than children twice his age and became extremely aggressive, hitting, biting, spitting , breaking items and self-harming. John was considered as one of the most challenging children in all of England and by the age of 10 he was put on a 5 to 1, by the age of fifteen John was put on 8 to 1. What has made things worse with John’s communication is that he has not improved since the age of 1 after he had the MMR. The things he knew at the age of 1 are the things he knows now as an adult. John is nonverbal and cannot communicate in sentences.

The fact that John had no education of any kind meant his communication became very limited. John’s communication and interaction is significantly below age-related expectation. John is nonverbal and he occasionally uses single words or seeks positive attention through eye contact, gestures and actions. John now requires a minimum of 5 support workers with him at all times. John has a limited sense of danger with little or no regards for his safety or that of others. The fact that he John is nonverbal and can’t communicate his feelings properly makes John extremely violent.

John has been diagnosed Autism Spectrum disorder, OCD, ADHD, and emotional behavioral Disorder.

I was the send educator for this support home of residence and on that particular night, I was working as the on-call manager. John normally has Porridge and yogurt every day at 19:30. John has a routine set from when he gets up in the morning till when he gets to bed. John remembers his routines an follows them always. When he has but because we had agency support workers, John’s routine change and his dinner was given to him an hour late. John received his food at 20:20. John was given a toast with hot chocolate. John was very anxious, restless and agitated, John started to say “yougyyy”, “youggy”, “youggy” which is a word for yogurt but staffs didn’t understand the message John was trying to pass across. Staffs inability to communicate effectively was the problem, so they carried on and gave John hot chocolate. As soon as they gave it to John, he smashed it on the floor, took his iPad and threw it on the floor, John started jumping and screaming, attacking staffs, he was throwing punches, spitting, kicking and when staffs tried to restrain John, he started to hit his head and face on the wall. John grew even more powerful as the restraint lasted for more than 2 hours. John was so full of rage he was spitting blood at the staffs while he was restrained. At this point the support workers became scared and they ran downstairs to get the nurse, while the others were calling for the police. At this time they Locked John in his room. John started to destroy, breaking the TV, DVD, play station, bulb, John was in a destructive mode, injuring himself in the process.

Straight away the Support workers went to get the nurse. She intervened promptly. The nurse quickly asked what happened. Where’s John? She was told what happened and she ran up the stairs to John room. She told the support workers to open John’s room and to be ready to restrain John again. While they did hold John, she took the lead, came over and engaged with John, looking at him and creating eye contacts with John. She was very calmed around him in the midst of all the aggression, there was already a two-way Dialogue happening even without them saying a word to each other.

John, what do u want? Look at me John and breathe, breathe, relax, relax she said, John was looking at the nurse, she then told John count 1 to 10 with me. John started to fight but he counted 1, 2, 3, 4, 5, she said breathe son, breathe, everything is fine. What do you want John? , John said “Yoggy yoggy” she said what flavour ? John said ” stabi, stabs” which is a word for strawberry flavour yogurt. She told one of the support workers, To hurry, get John his yogurt, and she said John you would have 2 today. Count with me, and John said 1, 2. The support workers quickly returned with 2 strawberry yogurt. She told them to stop the restraint and let John be himself. She said John here is your yogurt. John quickly calmed down,

Six male support staffs, all MAPA trained in the art of restrained, all 6 foot tall, weighing 100kgs plus, looking like WWE wrestlers couldn’t defuse a situation because of lack of communication and awareness. 1 nurse, 1 woman, communicating effectively with the service user, using her skills calm him down.

The nurse had to write an incident report which was sent to safeguarding. The police getting involved as John had a lot of injuries all over his body. John was not restrained properly and the support workers didn’t deal with the situation effectively or even read John’s care plan to see what he had for dinner and what time he goes to bed.

Introduction

Now that we know about John, we shall describe and critically analyse a complex communication situation that involved John, Support workers, the nurses, and the police. We shall look at the main role of nurses in support homes, while also paying particular attention to that of the nurses at John’s home of residence. In this passage would like to show what intervention took place, looking at what is meaningful and important in relation to the service users. I would show why Peplau’s theory of the interpersonal relationship between nurses and clients is very important. We shall look at why the interpersonal relationship was even more important in the case of John. We shall look at communication theories in nursing and see how Nappi training was used as an effective communication tool to provide John with the care, love, and support he needs. This review would indicate that communication skill is not only important to nurses but also to service users

We shall conclude by showing that nurses have a very important role to play in the lives of service users. I would give credit to the work done by Peplau to promote the development of nursing. This review would indicate that communication skills are not only important to nurses, but also to the service users and health care providers. We shall also reflect on John Herons 6 model of intervention. Herons six categories of intervention analysis were used by the Support adult living service to come up with a better solution of supporting John.

Communication is an integral part of life and human existence. Without communication, there may be no life on earth. Communications start from birth, it could be verbal, or nonverbal but it continues till death (Vertino, 2014)

Communication is important not only to transmit information and ideas but more importantly to promote human relations across the planet. According to Lambrini and Loanna (2014), nursing goes far beyond scientific knowledge; it requires effective interpersonal communication, technical abilities, and intellectual skills. The ability to effectively communicate with others is at the centre of every client care. One of the most important tools in improving patient care is effective communication between service users and healthcare providers. Service users are more likely to obey and follow their treatment regimes, when they feel close to healthcare providers, when they feel the healthcare providers communicate effectively well with them, understanding how they are feeling.

A complete human entails body, mind, and spirit, you cannot give more to service users when you don’t have much to give yourself. Moreover, Bach and Grant (2009) insist that nurses understanding of effective communications skills is one of the most important ways of achieving holistic and client-centered care. Lambrini 2014 concluded that, despite the importance of effective communication and interpersonal skills, the subject is not highlighted sufficiently in clinical training. Thus, the purpose of this paper is to explore and find out the importance of effective communication in health care service and the role of nurses. I believe that this paper would go a long way to contribute to and improve the quality of health care service and how effective communication could be used to deal with complex situations.

Nurses show their care to patients verbally (through speaking) and non-verbally through doing, acting, touching, and showing. The information could be verbal or nonverbal, they could be spoken or written, personal or impersonal, specific or general and even relationship oriented (Sheldon, 2004). Communication, when used properly, provides clear, accurate, consistent and easy nursing service, providing the satisfaction the patient needs while protecting the nurses, (Verderber 1998).

Before we continue we shall look at the role of the Johns night shift nurse. Nurses do provide the human touch in support adult living services, they are at the forefront of patient care. They are there to care for patients, interacting with them and supporting them.

She gets to work 19:00 and gets the handover from the day shift nurse. She briefs the support worker on what is expected of them for the night shift.

She goes to the medical room downstairs and gets John medication ready. She makes sure John gets the right medication.

She later goes to the office downstairs, doing all the medication counts and completing all the paperwork for the day, while John stays in the care of 6 support workers.

She does the observation for John every 30 minutes for the rest of the night, writing down every information, is he sleeping? Watching TV? Playing games, bedroom? toilet? What time did he do all of this? Any late medication or PRN gave? What time? What reasons?

In the morning she also gives a handover to the day staff informing them of how John was at night.

She returns home at 8:00 am in the morning.

Communication is a very important human quality, It is important for everyone to not only communicate but to communicate effectively. For communication to effectively fulfil its objectives, the focus should be laid on its core, especially in nursing practice (Bringer, 1997). For a nurse-patient relationship to blossom, the two parties would have to understand each other. Effective communication can only be successful when there is a two-way dialogue between patients and health care provider, where both sides to speak and listen to each other’s without interfering, both ask questions to gain a better understanding, as they express their opinions. (Boykins, 2014). This is why it is important that there’s an agreement between verbal and nonverbal communication.
A stated by Lambrini and Loanna (2014), words convey only a part of a message that’s being communicated. Attitude, gesture, and tone convey the other aspects of communication. Evans (2003) also noted that non-verbal communication happens without people even realising, nonverbal communication is basically a continues process. Listening attentively, smiling and even sitting at the same height as the service user could enhance a two-way dialogue, thereby making the communication to be effective. Bringer (1997). These are all techniques the nurse did when talking to John, she showed great ability to listen to what he wanted, she was very calm around him, she looked at him in his eyes creating a bond and making him feel like he could trust her, while the support workers were relying solely on muscle.

There was more intervention done by management of John’s support living residence when they saw the incident report. Herons six categories of intervention analysis were used by the firm to come up with a better solution of supporting John and his need. What is this intervention based on? according to heron, they are based on the fact that a practitioner provides their clients with services. What is the motivation of the practitioner when making these interventions? What are their intentions? These are the questions Heron had in mind when he came up with these interventions.

• Authoritative
  • Prescriptive: aims to show that you have more control over the behaviour of a client, telling them in some sort of a commanding way regarding what needs to be done.
  • Informative Interventions aims to provide useful and credible knowledge to the client.
  • Confronting Interventions aims to raise the client’s awareness on certain behaviours and attitude they didn’t know
• Facilitative:
  • Catalytic. Aims to come up with problem-solving skills. Fresh ideas to make this better.
  • Cathartic Aims to explore the feelings of the clients. Aims to understand the client better from an emotional point of view.
  • Supportive: aims to encourage the client. Showing that they are valuable. Giving clients positive feedbacks.

The aim of these interventions is to improve understanding and interactions between practitioners and clients.
To understand how we are interacting with people. It is also aimed at supporting practitioners, so they understand their clients better. Giving them all the right tools to be successful. I would like to do some more reflection on what the management did following John’s complex communication incident.

All support workers were sent to do Nappi training. Non Abusive Psychological and Physical Intervention. This was aim at informing the staffs more about John, helping the staffs to detect triggers. Helping the staffs to intervene when John is anxious, so that he doesn’t become agitated, disruptive and destructive. Nappi provides behavioural de-escalation techniques to staff.

NAPPI is more psychological and restraint avoidances, so there are fewer chances of staffs and service users getting injured.
John was also introduced to a picture chat which was used as a communication tool between John and the support workers.
John was also provided with a pleasure box, so he could have his private moments. Like most adults, it is relaxing for John to have these moments and he feels much better and relax after.

This study has helped us discover existing knowledge and understanding of effective communication skills. This would help nurses improve their communication as well as improve their confidence and self-ability to notice and react to patient needs (Bramhall, 2014)

In order for us to fully understand this study, we need to look at

1. The limitations of effective communication in nursing practice?
2. What influence does effective communication have on the patient-nurse relationship?
3. How to improve and develop effective communication in nursing practice?

Communication in nursing practice has got several limitations. Environmental factors such as Staff support, noise, water, privacy, light, workload and time (Stockmann, 2005) The lack of basic necessities could hinder patients from opening up and talking with the nurses freely. Low staff support and job pressure could also hinder nurses from communicating effectively due to the high workload. Long working hours could lead to fatigue and the lack of freshness could prevent effective communication. The fact that nurses are busy and the amount of noise inwards could prevent a two-way dialogue.

Personal characteristics such as emotional problems, hidden agenda, and poor self-esteem could prevent nurses from communicating effectively with clients. There are loads of secured units where nurses have been scared of approaching their clients. Maybe they lack of confidence could represent a communication problem. Maybe the fear of getting attacked could prevent nurses from creating that bond with service users.

The language barrier could be a problem, this is very common in hospital wards with clients of all background and some of them can’t say a word or two in English. How do nurses communicate effectively in such circumstances?
Physical or mental illnesses could prevent effective communication. If clients are in experiencing physical pains or depression, they won’t communicate effectively with nurses.

What influence does effective communication have on patient-nurse relationship?

Nurses also feel more confident to do their jobs because they feel the trust of the patients. It’s been noted that effective communication improves patients medication adherence, as patients are more willing to follow medical advice from the nurse, they are more willing to cooperate because trust is built between the patients and the nurses. (Sheldon,2013)

There is also evidence of less medication error from nurses when trust is created between the nurses and the patient (Smith, 1992))
Patients generally feel secured and satisfied, with greater ability to trust the nurses due to effective communication. The level of pain and depression reduces as patients feel safe. Patients usually recover quicker when they feel safe (Bash, 2009)

How to improve effective communication in nursing? So that complex communication situations can be solved.

Conclusion

This study review shows the importance of effective communication in nursing and how that could be used in dealing with complex communication circumstances. After looking at communication theories and interventions, the results indicate that effective communication is of great importance to patients as they feel secure and satisfied, they fee positive due to Therapeutic communication. Nurses also feel more confident about carrying out their roles in dealing with complex communication circumstances.

References

• Bach, S. and Grant, A. (2009) Communication and Interpersonal Skills for Nurses. Great Britain: TJ International Ltd.
• Boykins, A. D., (2014) Core communication Competences in Patient-centered Care. The ABNF Journal. Volume: 25. No. 2. Pp 40-5
• Bramhall, E. (2014) Effective Communication skills in nursing practice. Nursing Standard. March 3 December. Vol. 29. No. 14. Pp. 53-59.
• Brinkert, R. (2010) A literature review of conflict communication causes, costs, benefits and interventions in nursing. Journal of Nursing Management, Vol. 18, Pp. 145- 156
• Casey, A., and Wallis, A. (2011) Effective communication: Principle of Nursing Practice E. Nursing Standard. April 13 2011. Volume 25 no 32 pp 35-37.
• Casey, A., and Wallis, A. (2011) Effective communication: Principle of Nursing Practice E. Nursing Standard. April13 2011. Volume 25 no 32 pp 35-37.
• Ennis, G., Happell, B., Broadbent, M. and Reis-Searl, K (2013). The Importance of Communication for Clinical Leadership in Mental Health Nursing: The Perspective of Nurses Working in Mental Health. Mental Health Nursing. Volume 34, No. 11. Pp. 814-819
• Epstein, R. and Street Jr, R. (2011) The Values and Value of Patient-Cantered Care: Annals of family medicine. vol. 9 no 2, pg. 100 – 103. University of Rochester Medical Center.
• Groves, W. (2014) Professional Practice skills for nurses. Nursing Standard Vol. 29 No.1, Pp: 51-59.
• Haber, J. (2000) The psychiatric Nursing legacy of a legend. Journal of the American Psychiatric Nurses Association Vol. 6. No.2 Pp:56-62
• Lambrini, K. & Loanna, V. P. (2014) Communication in Nursing Practice. Professional Paper. Mater Socio-med. Vol. 26 No.1 Pp: 65-67
• Peplau, H. E. (1992). Interpersonal relations: A theoretical framework for application in nursing practice. Nursing Science Quarterly, 5, 13-18.
• Peplau, H. E. (1991). Interpersonal relations in nursing. New York, NY: Springer.
• Peplau, H. E. (1997) Theory of Interpersonal Relations. Nurse Science Quarters
• Stockmann C. A literature review of the progress of the psychiatric nurse-patient relationship as described by Peplau. Iss Mental Health Nurs 2005;26(9):911–19.
• Sheldon, L. K. (2013) Establishing a Therapeutic Relationship Communication for Nurses: Talking with Patients (third edition). Jones & Bartlett Learning
• Shipley, S. D. (2010) Listening: A Concept Analysis. Nursing Forum Volume 45, No.2, Pp 125-134
• Smith, P. (1992) The Emotional Labour of Nursing. How Nurses Care. Macmillan Education, Basingstoke.
• Wright Rose. (2012) Effective communication skills for the “caring” Nurse.
• Burnard P. & Morrison P. (1988) Nurses’ perceptions of their interpersonal skills: a descriptive study using six categories inter-vention analysis. Nurse Education Today 8, 266±272.
• Lucas S., Jones A. & Glover D. (2000) Implementation problems. Nursing Times 96, 49±52.
• Martin T. (1992) Psychiatric nurses’ use of working time. Nursing Standard 6, 34±36.