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Critical reflection of the use of therapeutic groups

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ā€œMental health nurses must use skills and knowledge to facilitate therapeutic groups with people experiencing mental health problems and their families and carers.ā€ (Nursing and Midwifery council, 2010a).

Reflection is a skill that can be used to help nurses improve care by having a better understanding of their self and their practice situations (Dolphin, 2012). Throughout our nurse training, we are encouraged to reflect as much as possible. The Nursing and Midwifery Council (NMC, 2010b) essential skills clusters teach that nurses must use reflection to maintain their personal and professional development. This assignment will be a critical reflection of my nursing practice focusing on the above domain from the Nursing and Midwifery Council standards of proficiency for pre-registration nursing education. Reflection is a vital to the development of and maintenance of competence (Paterson and Chapman, 2013).

For my reflection I will be looking at six critical incidents from my practice experience and analyzing how they have contributed to the achievement of my chosen standard of proficiency. Any patients or practice areas will not be mentioned by name to comply with NMC (2008) code relating to confidentiality. For my reflection, I will be using the model of reflection developed by Gibbs (1998) and will be referring directly to my own academic portfolio that can be found in the appendices of the assignment. Gibbs model incorporates six aspects of the reflection; description, feelings, evaluation, analysis, and action plan. The reflection begins with a brief description of the situation and a report of what I was thinking and feeling throughout the experience. Gibbs then suggest that I evaluate what was positive and negative about the experience and analyze what sense I can make of the situation. The reflection concludes with a suggestion of what else I could have done in that situation and what I would do if the situation were to arise again.

Placement 1
My first practice placement was at a day center for patients with chronic mental health conditions. Whilst on this placement I worked closely with a number of patients who had received a diagnosis of schizophrenia. Every week I would attend I music group with the patientā€™s where we would write andĀ record music for a relaxation CD. Feelings/thoughts

Prior to attending the group I had met some of the patients in the communal area of the center and my first impressions of the patients where how disabled they were by the negative symptoms of their conditions. Many of the patients appeared much sedated and some appeared to have problems with their dexterity. At this time I felt like the music group would simply be a way of passing the time and that the patients would not engage very well. I found however that when the patients attended the music group, they were more enthusiastic and where very talented on their respective instruments. Evaluation

This was my first experience of therapeutic group contact and it enlightened me to the potential benefits this type of contact can have for patients. This experience also highlighted to me that my preconceptions of a patient could be far from the reality and that I should not make judgments about a patientā€™s presentation until I have all the facts available to me. Analysis

Kern et al (1998) found observe that patients who suffer from schizophrenia, are generally slower than healthy adults on tasks that require fine motor speed. This would lead one to assume that patients would find the finer skills required for using instruments difficult. Overall, I found the experience to be a positive one, it gave me ideas for future practice and I engaged well with the patients in the group. Conclusion /Action Plan

To conclude, this experience has altered the way I perceive my first impressions of patients. I should not have made any assumption about the patientsā€™ abilities based on my first impression of them. After I reflected on this experience, I was able to engage in the group was praised by my mentor, who was happy to utilize my music experience for the group and reported that I engaged well with the patients (Appendix 1). If the situation arose again I would certainly attend the group with an open mind about the ability of the patients and not make any assumptions based solely on my first impressions of the patients.

Placement 2
The final placement of my first year of study was on an inpatient eating disorder ward. At the time the ward was treating a number of female patients suffering from anorexia nervosa. The treatment involved a strict diet plan with the purpose of increasing the patientā€™s weight to a state where they were not physically at risk. It also included psychological therapy in order to treat the underlying condition. Whilst on the ward I observed that the patients spent a lot of time in their room when they were not in the communal dining room for meals, so I attempted to engage them in some group activities. My choices for group activities where limited as the patients were not able to do any strenuous exercise that might further there weight loss. I asked the patients what kind of activities they would like to do and it was decided that they would like to do quiz every Friday evening. Feelings/thoughts

I found it difficult to engage some of the patients and a number of the patients came to the quiz but did not take part. Evaluation
Although some patients did not take part I do think they benefited from the group contact. This continued for the remaining 4 weeks of my placement and was due to continue after I left. What was good about the experience was that the patients chose their own activity and that it helped to reduce their isolation. It also gave me the opportunity to work autonomously. Which I had not yet had the opportunity to do as a first year student. Analysis

Upon analysis of the situation I can understand why the patients wanted to spend more time in their room as some of the patients were detained to the ward under section 3 of the mental health act 1983 and did not feel they needed any treatment. This disagreement with their treatment can often cause patients to disengage from any therapeutic relationship (Halvorsen & Heyerdahl, 2007). Dean et al (2008) discuss that patients that suffer from eating disorder, especially in an inpatient setting, are very resistant to service engagement. The patients also found meal times to be a very stressful time due to their condition so it is understandable that they would want some time to relax afterwards. Conclusion /Action Plan

I asked the patients after the quiz if they enjoyed it and wanted to continue it so I think they found the social time beneficial. Although the ward staff were to continue the quiz after my placement ended, I could have given the patients the responsibility and resources to arrange the quiz instead. If this situation were to arise again try harder to include all of the patients in the group or changed the activity occasionally instead of having the same activity every week.

Placement 3
My second year diversity of care placement with an early intervention in psychosis team. Whilst on this placement I had the opportunity to get involved with and on some occasions take the lead on occupational and leisure groups offered by the team (appendix 2). One of the groups was an exercise group that was conducted in a local public park. The group was only a small group containing only 5 of the 193 patients that the team had. Feeling

I found this to be a very small number when I considered that the potential patients for the team was at the time ages from 17-35 and I would expect to be fairly active. At first I thought that whilst beneficial to those who took part, the nurse who facilitated the group could better spend his time with a larger group of patients. Evaluation

I thought that the exercise group offered by the team was a great idea, as it attempts to tackle a number of the other issues associated with mental health conditions. A well-known adverse effect of antipsychotic medication is weight gain (Tardieu et al, 2003) and the exercise group tries to combat this issues. Analysis

Although there was only a small group of patients for the exercise group, one could argue that there is a reason for the other patients not attending. As suggested by Meaden et al (2012), patients who suffer from mental health problems may not be able or want to engage in mental health services. EvenĀ though this may be the case, it is the responsibility of the patientsā€™ care coordinator to encourage their engagement in therapeutic groups (NMC, 2010). Conclusion /Action Plan

Upon analysis of the experience I do not think I could have done anything different as it was merely an observation. I do feel like my attitude towards the situation would be different if the situation where to arise again.

Placement 4
My final second year placement was on an acute inpatient mental health ward. There was limited opportunity for group contact on the ward as many of the patients were acutely unwell. I did however have the opportunity to spend time in occupational therapy, who offered a number of group activities. One of the activities I was able to observe was the relaxation session. Feelings/thoughts

When I was told about the relaxation sessions, my first thought was that they would not work but I was told by a number of the patients that they found them very effective. After I took part in the relaxation group, I was very surprised about its efficacy. When taking part I found myself feeling relaxed and the patients appeared to find the environment very relaxing. Evaluation

What is good about this session is its application outside the branch of mental health. As suggested by Hazlett-Stevens and Bernstein (2012) the relaxation techniques can be learned and applied to other nursing disciplines and even outside of a clinical area. The skills learned in the relaxation session can be used at home with patientā€™s families. Analysis

Ahrens (2008) suggests that anxiety and depression can be caused by stress. She continues to suggest the active relaxation is an effective way to combat this. Relaxation sessions can also improve any sleep disturbances associated with mental health conditions (Bloch et al, 2010). This would reduce theĀ need for medication based interventions such as the use of hypnotic or benzodiazapines (De Neit et al, 2011). Conclusion /Action Plan

The experience in general was a good one, it taught me that I need to more open minded about the different varieties of therapeutic interventions available to clients. In the future I will try to experience or research other interventions before I judge them on their efficacy.

Placement 5
My first placement of my third year was with an adult community mental health team. Whilst I was on my placement I had the opportunity to participate in and facilitate a mindfulness group with the teamā€™s clinical psychologist. Mindfulness based cognitive therapy is a group therapy aimed at changing the way patients view their life experiences and is indicated in the treatment of recurrent depression (Collard, Avny & Boniwell, 2008). The majority of the group suffered from bi-polar disorder and has experienced recurrent depressive episodes. Feelings/thoughts

During the session I found it surprising how easily the patients appeared to find it to talk about their traumatic events. Although the patients found it easy to discuss their issues openly, I did feel like I was intruding on the group as I had not had any time to build a therapeutic relationship with the patients. Evaluation

The highlight of the experience was how little involvement the psychologist had in the group, she simply facilitated the other patientā€™s discussions which I thought was a useful technique. As suggested by white (2000), a group therapists job is to build cohesiveness in the group to allow for open discussion between patients. The group gave patients an opportunity to talk to others who have experienced depression, this can be helpful to patients (Todd as cited by National Health Service, 2011). Analysis

Upon analysis of the session, the group appeared to have built a good therapeutic relationship with the psychologist and with each other. AsĀ suggested by Taube-Schiff et al (2007) there is a positive relationship between group cohesion and recovery. As suggested by van Gestel-Timmermans et al (2012) groups that are predominantly peer led, have a positive effect on recovery. Although this group was facilitated by the clinical psychologist, she had very little involvement and the group was mostly patient led. Conclusion /Action Plan

Although the psychologist simply facilitated the group, she did encourage me to involve myself in the discussion which I could have done more. If the opportunity to take part in a similar group would arise, I would engage myself more in the discussion and would research mindfulness techniques beforehand as it is not a therapy I am familiar with.

Placement 6
In my most recent placement I returned to the early intervention team I had visited previously in my second year. The group I had the opportunity to facilitate on a number of occasions was the music group. I had taken part in the music group on my previous visit to the team but I had never led the group. Many of the patients who attended the group where the same patients who attended the previous year. Unlike the patients in my first placement, these patients had not played an instrument before. Feelings/thoughts

The amount that the patients had progressed in terms of skill with the instrument and overall confidence was evident from the first session and I felt surprised by this fact. Many of the patients I had seen in community mental health patients had been under services for most of their life and where unlikely to fully recover. The fact that the patients under the early intervention team had improved so much in the space of a year improved my confidence in the service offered. Evaluation

This experience allowed me to see the progression of the patientsā€™ recovery and highlighted to me the therapeutic benefits that groups such as the music group can have. The patients had improved both in skill and in confidence since I last attended the group a year previous. As suggested by Clarke etĀ al (2009), recovery does not simply include relieving symptoms, goals and skill learning can help to increase wellbeing. Analysis

Analysis of this experience gave me the opportunity to not only see the benefits of group activity, it also gave me a chance to see how confidence and skill learning can aid recovery. Reynolds and Oā€™Hanlon (2011) suggest that recovery so something that must be tackled holistically, incorporating overall health and social wellbeing. Conclusion /Action Plan

The experience made me realize that given the opportunity, early intervention is the team I would most like to work with when I finish my nurse training. I donā€™t think that I would do anything differently if the situation arose again, however research into the benefits of therapeutic group contact may help me with my future practice in developing my own therapeutic groups.

In conclusion the importance of group therapeutic contact has not always been clear to me. I have not always had full confidence in my own abilities and this has led to me struggling to engage the more acutely unwell patients in group interventions. My early perceptions of nursing in mental health had been very clinically orientated focusing mainly on medical treatment.

Over the course of my nurse training I have experienced placements that has allowed me to observe and analyze the benefits of these groups to clients. I have seen how clients progress over a time as a result of attending therapeutic groups. I have a better understanding of the holistic approach that nurses must take in order to encourage and facilitate full recovery of health and quality of life. After my most recent placement, I now feel like I have the confidence to engage patients in these groups and also facilitate the organization of the groups myself. Word Count: 2722

Reference List
Ahrens, J. (2008). Relaxation to combat stress. Australian Nursing Journal, 16(4), 44. Bloch, B., Reshef, A., Vadas, L., Haliba, Y., Ziv, N., Kremer, I., & Haimov, I. (2010). The effects of music relaxation on sleep quality
and emotional measures in people living with schizophrenia. Journal of Music Therapy, 47(1), 27-52. Clarke, S., Oades, L., Crowe, T., Caputi, P., & Deane, F. (2009). The role of symptom distress and goal attainment in promoting aspects of psychological recovery for consumers with enduring mental illness. Journal Of Mental Health, 18(5), 389-397. Collard, P., Avny, N., & Boniwell, I. (2008). Teaching mindfulness based cognitive therapy (MBCT) to students: The effects of MBCT on the levels of mindfulness and subjective well-being. Counselling Psychology Quarterly, 21(4), 323-336. De Niet, G., Tiemens, B., van Achterberg, T., & Hutschemaekers, G. (2011). Applicability of two brief evidenceā€based interventions to improve sleep quality in inpatient mental health care. International Journal of Mental Health Nursing, 20(5), 319-327. Dean, H., Touyz, S., Rieger, E., & Thornton, C. (2008). Group motivational enhancement therapy as an adjunct to inpatient treatment for eating disorders: a preliminary study. European Eating Disorders Review, 16(4), 256-267. Dolphin, S. (2013). How nursing students can be empowered by reflective practice. Mental Health Practice, 16(9), 20-23. Gibbs, G. (1988) Learning by doing: a guide to teaching and learning methods. Oxford: Further Education Unit. Halvorsen, I., & Heyerdahl, S. (2007). Treatment perception in adolescent onset anorexia nervosa: Retrospective views of patients and parents. International Journal Of Eating Disorders, 40(7), 629-639. Hazlett-Stevens, H., & Bernstein, D. (2012). Relaxation. In W. T. O’Donohue & J. E. Fisher (Eds.), Cognitive behavior therapy: Core principles for practice (pp. 105-132). Hoboken, USA: Wiley. Kern, R. S., Green, M. F., Marshall jr, B. D., Wirshing, W. C., Wirshing, D., McGurk, S., Marder, S. R., & Mintz, J. (1998). Risperidone vs. haloperidol on reaction time, manual dexterity, and motor learning in treatment-resistant schizophrenia patients. Biological Psychiatry, 44(8), 726-732. Meaden, A., Hacker, D., Villiers, A., Carbourne, J., & Paget, A. (2012). Developing a measurement of engagement: The Residential Rehabilitation Engagement Scale for psychosis. Journal Of Mental Health, 21(2), 182-191. doi:10.3109/09638237.2012.664301 Nursing and Midwifery Council. (2008). The Code – Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: Nursing and Midwifery Council. Nursing and Midwifery Council. (2010a). Standards for Pre-registration nursing education. London: Nursing and Midwifery Council. Nursing and Midwifery
Council. (2010b). essential skills clusters and guidance for their use. London: Nursing and Midwifery Council. Paterson, C., & Chapman, J. (2013). Enhancing skills of critical reflection to evidence learning in professional practice. Physical Therapy in Sport, 14(3), 133-138. Doi: 10.1016/j.ptsp.2013.03.004. Tardieu, S., Micallef, J., Gentile, S., & Blin, O. (2003). Weight gain profiles of new antiā€psychotics: Public health consequences. Obesity Reviews, 4(3), 129-138. Taube-Schiff, M., Suvak, M. K., Antony, M. M., Bieling, P. J., & McCabe, R. E. (2007). Group cohesion in cognitive-behavioral group therapy for social phobia. Behaviour Research and Therapy, 44(4), 687-698. Doi: 10.1016/j.brat.2006.06.004 Todd, P. (2011). Depression support groups. Retrieved from http://www.nhs.uk/Conditions/stress-anxiety-depression/Pages/Depression-help-groups.aspx Reynolds, T., & O’Hanlon, L. (2011). Recovery-focused practice in mental health services. Mental Health Practice, 14(7), 25. Van Gestel-Timmermans, H., Brouwers, E., van Assen, M., & van Nieuwenhuizen, C. (2012). Effects of a peer-run course on recovery from serious mental illness: a randomized controlled trial. Psychiatric Services, 63(1), 54-60. White, J. R. (2000). Depression. In J. R. White, A. S. Freeman (Eds.), Cognitive-behavioral group therapy: For specific problems and populations (pp. 29-61). American Psychological Association. Doi: 10.1037/10352-002

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