Reflection on Difficulty in Communication
The following is a reflective account of an experience during my placement in critical care in which it was difficult to communicate with the patient.
During my placement in a critical care unit, I came across Rachel. Names and identifying information have been changed in order to abide by confidentiality guidelines set by the Nursing and Midwives Council (NMC, 2008). Rachel was brought in to the emergency room after being hit by a car while crossing the street. Suffering from a possible head injury, Rachel’s face was swollen and she could not speak. From the identification documents found on her, I saw that she was a tourist visiting from another country. I was not sure that she spoke the language, or what languages she could speak. Rachel was clearly distraught and scared. Though she could not speak and could hardly move, I could see the fear in her eyes. Before we could begin the necessary testing and examination, it was crucial that Rachel relax and that she knew where she was and what was going on. In addition, it was important to establish some form of communication in order to avoid medical complications and mishaps (Sutcliffe, Lewton and Rosenthal, 2004). The first thing I did was take her to a private, quiet room. In there, I tried to see whether she understood English. We used eye blinking as a form of communication, with one blink indicating a “yes” answer and two blinks indicating a “no”. It appeared Rachel could understand some English, so I proceeded to slowly and softly explain what had happened. Throughout the examination I could see that Rachel was frightened, and may not have any friends or family available to provide support. I could also feel that Rachel trusted me and that we were able to establish a rapport. When it was time to go for tests, I decided to accompany Rachel and hold her hand. I made sure to look her in the eye when I spoke; reassuring her that I was there and will take good care of her. Meanwhile, I asked the other staff to try and understand from the documents we found what language Rachel spoke and whether we could find an interpreter who could come in. After a few hours, an interpreter was found and came in to facilitate the continued medical care.
Involvement in an accident can be frightening and stressful for any person, especially in a foreign country with no friends or family around. Establishing nonverbal communication and empathizing with the patient were a crucial part of her overall medical care, as well as for relieving her stress and anxiety.
The use of reflective practices had been endorsed and promoted by professional nursing bodies such as the English National Board for Nursing (ENB) (James and Clarke, 1994). Guidance for professional conduct for nurses and midwives emphasizes the importance of listening to the patient and responding to their concerns and preferences. In addition, healthcare staff should provide information and advice in a way the patient can understand, so that they can make informed choices and decisions (NMC, 2008). One of the most prominent issues with which any trainee struggles, and to an extent will continue to struggle with throughout their career is 'ethics'. In essence, ethics refers to the explicit examination of moral aspects of human behaviour, and in regards to professional practice, ethics are concerned with the power imbalance between the service provider and recipient (Bond, 2000).
In an increasingly ethnically-diverse world, nurses must be culturally sensitive and competent. In addition, nursing practice consists of care that is holistic, addressing the physical, psychological, social, emotional and spiritual needs of the patient (Tuohy et al., 2009). To this extent, care plans must account for cultural diversity, as should nurse’s education include diversity training and exposure to a variety of cultures (Maier-Lorentz, 2008).
Communication can be impeded by a variety of factors, including cultural barriers and more importantly language barriers. A study of nursing practices in Australia had found that when treating a patient who does not speak the language, half of the nurses turn to an interpreter, while the other half either make do with non-verbal communication or otherwise do not make an effort to communicate beyond the bare essentials. Moreover, the study had found that when nurses employed empathy and willingness to make an effort to understand the patient, treatment outcomes were deemed as better by the patient and staff (Cioffi, 2003). A study in Ireland found similar results (Touhy et al., 2009). In a sense, in order for nurses to truly understand cultural diversity, they may need to imagine themselves working in a foreign country and what would help them cope (Magnusdottir, 2005).
Gibbs (1981; 1988) defined five stages for a reflective process. The first stage refers to the description of the event. A person should ask questions such as where were you; who else was there; why were you there; what were you doing; what were other people doing; what was the context of the event; what happened; what was your part in this; what parts did the other people play; what was the result (Jasper, 2003). In this case, I was in the critical care unit of a large hospital. Several other nurses were on duty and doctors. My patient was a female in her late 30’s who was wounded in a car vs. pedestrian accident. My role in this encounter was to provide initial care and examination, take patient’s history and provide necessary information to the attending physician.
The second step includes an evaluation of what feelings arose, including questions such as how you were feeling when the event started; what you were thinking about at the time; how did it make you feel; how did other people make you feel; how did you feel about the outcome of the event; what do you think about it now. Meeting Rachel, I felt compassion and could understand her anxiety. I remembered what it is like to be in a foreign country and could only imagine how scary it would be to be in a hospital setting with injuries, all alone. I also remembered the NMC guidelines on communication with patients and giving them a feeling of respect and control (NMC 2008). To this extent I tried to give Rachel as much control as possible, including asking her permission to move to another room or to perform an evaluation. Though we could not communicate verbally, I used nonverbal communication such as gestures and looking in her eyes.
The third step includes an evaluation of the situation- what was good or bad about the situation or experience. I think that despite not knowing whether she completely understood what I was saying and despite the evident language barriers, I was able to reassure Rachel and help her feel that she is not alone.
The fourth step according to Gibbs is analysis, breaking the event down to smaller components and asking more detailed questions such as what went well; what did you do well; what did others do well; what went wrong or did not turn out how it should have done; in what way did you or others contribute to this (Wikstrom, 2012). This fulfills the essence of reflective practice according to Gibbs- “the capacity to reflect on an action so as to engage in a process of continuous learning” (Gibbs 1989, p. 21). I think that in this situation, it may have been better to invest efforts in finding out Rachel’s language and finding an interpreter at the beginning. At that moment I felt that the most important thing was to reassure her and try to calm her. By taking her to another room and explaining what had happened, I delayed the search for an interpreter.
The fifth and concluding step includes a detailed an honest conclusion, developing insight into one’s own actions and the manner in which they contributed to the situation. The final step which in fact completes Gibbs’ ‘cycle’ is devising an action plan, assessing what can be done should the situation occur again.
Learning goals in nursing education should abide by the SMART outline. They should be Specific, Measurable, Attainable, Relevant and Time-limited (Bovend'Eerdt, Botell and Wade, 2009). Following my experience and reflection upon it, there are several steps I can take in order to implement an action plan preparing for future experiences. This includes having the numbers of interpreters on hand, identifying the person to whom I can turn for advice and assistance in any given shift. In addition, I need to be minded to what is best for the patient as a whole, and try to look at it from an objective point of view, putting my feelings aside. My empathy for Rachel may have caused me to choose to spend more time with her rather than search for an interpreter.
References
Andrews, G. J., Brodie, D. A., Andrews, J. P., Hillan, E., Gail Thomas, B., Wong, J. and Rixon, L. (2006). Professional roles and communications in clinical placements: a qualitative study of nursing students’ perceptions and some models for practice. International Journal of Nursing Studies, 43(7), 861-874.
Bond, T. (2000) Standards and Ethics for Counselling in Action.London: Sage. 2nded.
Bovend'Eerdt, T. J., Botell, R. E. and Wade, D. T. (2009). Writing SMART rehabilitation goals and achieving goal attainment scaling: a practical guide.Clinical rehabilitation, 23(4), 352-361.
Cioffi, J. (2003). Communicating with culturally and linguistically diverse patients in an acute care setting: nurses’ experiences. International journal of nursing studies, 40(3), 299-306.
Council, N. M. (2008). The Code: Standards of conduct, performance and ethics for nurses and midwives. London: NMC Available at: http://www. nmc-uk. org/aArticle. aspx.
Gibbs, G. (1981) Teaching students to learn: A student- centered approach. Open University Press, Buckingham.
Gibbs, G. (1988) Learning by doing: A guide to teaching and learning methods. Further Educational Unit, Oxford Polytechnic, Oxford.
James, C. R. and Clarke, B. A. (1994). Reflective practice in nursing: issues and implications for nurse education. Nurse Education Today, 14(2), 82-90.
Jasper, M. (2003). Beginning reflective practice. Nelson Thornes.
Maier-Lorentz, M. M. (2008). Transcultural nursing: Its importance in nursing practice. Journal of Cultural Diversity, 15(1).
Magnusdottir, H. (2005). Overcoming strangeness and communication barriers: a phenomenological study of becoming a foreign nurse. International nursing review, 52(4), 263-269.
Sutcliffe, K. M., Lewton, E. and Rosenthal, M. M. (2004). Communication failures: an insidious contributor to medical mishaps. Academic Medicine,79(2), 186-194.
Tuohy, D., McCarthy, J., Cassidy, I. and Graham, M. M. (2008). Educational needs of nurses when nursing people of a different culture in Ireland.International nursing review, 55(2), 164-170.
Wikström, B. M. (2000). Nursing education at an art gallery. Journal of Nursing Scholarship, 32(2), 197-199.
