Reflection on Commnication Stroke Patient

The assignment is based upon a critical incident that occurred in clinical practice. Dimond (2008) believes critical incidents allow nurses to explore and reflect on situations in clinical practice which are good or bad, which will help them to learn and recognise what, could have been done differently. Benner (1984) argues that nurses cannot increase or develop their knowledge to its full potential unless they examine their own practice. Using Driscoll’s (2000) model of reflection the main focus of this assignment is to discuss the communication skills used in the critical incident. This will include; definition of communication, the use of non-verbal and verbal communication skills, the barriers that affected communication with the patient and how these were overcome to return the patients autonomy.

Driscoll’s (2000) identifies three processes when a nurse reflects on practice. They are: ‘What’ (returning to the situation), ‘So What’ (understanding the context) and ‘Now What’ (modifying future outcomes). By applying Driscoll’s model of reflection it will enable me to link theory to practice. The Nursing and Midwifery Council (NMC, 2004), outlines the importance of reflection for nurses stating that it will enable nurses to learn and develop from their experiences in-order to be able to provide patients with necessary quality of care (Taylor, 2006). This reflective account will highlight the knowledge and understanding I have gained and how I intend to continuously improve my communication skills for future practice. As outlined in NMC Code of Conduct the patient’s real name will not be used to maintain his confidentiality (NMC, 2008).

Communication is about the reciprocal process in which messages are sent and received between two or more people (Charlton et al, 2008). The NMC stipulates that the communication skills of nurses must always be safe, effective, compassionate and respectful. They must communicate effectively using a wide range of strategies and interventions and make reasonable to ensure patients and their families experience effective communication (NMC, 2010, p24). Meddings and Haith-Cooper (2008) identified effective communication as being key to a successful relationship between patient and nurse. When a patient’s illness compromises this communication, this can leave the patient feeling anxious; unable to understand what is being said to them, or unable to express their needs and circumstances. The following incident identifies measures used to effective communicate to a patient.

WHAT
Mr. Brown a 70 year old man was admitted to the adult rehabilitation ward following a severe stroke which left him paralysed on his right side. Due to the stroke Mr. Brown had dysphasia (difficulty swallowing) and had difficulty speaking (aphasia of speech). Mr. Brown was completely dependent on nursing staff to help him with all activities of living (AL). I had been informed in handover that Mr Brown had not slept very well and was occasional aggressive with the night staff. I first approached and introduced myself and asked for his consent to assist him with his AL’s. At that time Mr Brown appeared blank and looked at me without any reaction, so I touch his hand and lowered myself to maintain good eye contact. He made several attempts to produce words but I could not comprehend or understand at the time what he was trying to say.

To respect Mr Brown as an individual (NMC, 2010) I waited for a moment for him to try and communicate to me. After a further attempt to communicate he realised I did not understand and became very frustrated and knocked over his bedside table with had a glass and his breakfast plate on it. A colleague upon hearing the commotion came into the room to offer assistance. I explained what had happened because it was necessary for me to develop a rapport with Mr Brown so that he could trust me. My colleague informed me that Mr Brown had a book on his bedside locker which had pictures and words in that he used to help him communicate to staff about common activities. Using the book Mr Brown became less frustrated as he was able to point out his needs and wishes and I was able to reply to let him know I understood. He would also tap the table to get my attention and used touch as a way to get me to understand what he needed. I felt that Mr Brown seemed relieved to be able to communicate his need to me and this helped develop a therapeutic nurse-patient relationship.

SO WHAT
When I entered Mr Brown room I felt confident in providing him care as I had witnessed cases where patient had experienced communication difficulties following a stroke. It has been estimated that approximately one third of stroke survivors experience communication problems (Ross, 2009). These include language impairments (aphasia) resulting in difficulties generating or understanding words, reading and/or writing. Aphasia appears to increase the risk of depression and nonverbal cognitive deficits (Parr, 2007). Impairments in the motor production of speech (dysarthria) affect speech intelligibility. The Stroke Association (2010) observed that patients with communication problems are at added risk of experiencing negative psychosocial consequences of stroke. When I entered Mr Brown’s room I wanted to give him my full attention when communicating to him so I closed his bedroom door to minimal distractions from sounds coming from the dayroom where the television was on.

When he tried to communicate with me I naturally began to empathise with him because I started to fully comprehend the affect the stroke had on his ability to speak. Being able to empathise with the patient according to Nazarko (2009) is critical to the communication process, as it not only helps the nurse to accept the patient on their own terms, but also sometimes to ‘tune in’ to emotions and thoughts of which they are not fully aware. I feel understanding Mr Brown illness increased my ability to communication with him. Likewise, as I empathise I used nonverbal cues to indicate that I understood and was listening to him. Miller (2002) suggests that the non-verbal component of communication is an essential element of communication as it is five times more influential than the verbal aspect (Sully and Dallas, 2010). In nursing situations when there is a barrier to effective communication, non-verbal forms of communication such as active listening, touch, eye contact and facial expressions are commonly used to create a connection with the patient.

In this incident, I established eye contact and used appropriate touch, which Arnold (2007) states is the universal language of caring as it shows support and indicated to Mr Brown that I was offering reassurance and that I was listening impartially and without prejudice. Being a good listener and not talking over Mr Brown was important because his ability to hear was still intact and he could still communicate but just not as effectively as before. When communicating back to Mr Brown I was made a conscious effort to talk and act respectfully and in an adult manner and used language terms without nursing or medial jargons which I found encouraged him to converse with me. The NMC (2010, p2) states ‘You must share with people, in a way they can understand, the information they want or need to know about their health’.

Likewise, as nurses we have a duty to recognise when other communication support is needed and know how to obtain it (NMC, 2010, p.24). I feel Mr Brown became irritated and frustrated because he was trying to draw my attention to the communication book on his bedside locker. Even though, I showed no emotion and dealt with the situation professionally, I realised that being aware of the communication book before I entered Mr Brown’s room would have enabled us to establish a much quicker rapport at the start. Charlton et al. (2008) believes knowing the patient and building rapport aids better communication. Equally, I become conscious that trying to listen to what Mr Brown was saying was not the best way in which to understand his needs and looking out for his hand movements and facial expressions became more of a priority. The Stroke Association (2010) emphasises that verbal communication is not the only way nurses can effectively communicate with a patient after a stroke.

Use of visual aids such as pictures, word lists, drawings, writing and gestures can facilitate the comprehension of a person with aphasia and encouraging that person to use the same will help facilitate his/her expression (Stroke Association, 2010). After my colleague intervened I was able to use the communication book to return Mr Brown’s autonomy. He was able to express his wishes and needs which enabled me to provide him with the appropriate care and response. I was also self-aware of what my body language was relaying to Mr Brown. Pease and Pease (2004) found body language as a strong indicator of a nurse’s engagement and interest in the communication process with patients. This suggest even if I was saying the right things’ to Mr Brown the message might be lost if my body language suggests I was thinking something very different. Removing all formal barriers such as negative facial expressions and crossed arms and having an open posture and leaning in when he tried to point to a word in his book or talk to me had a positive effect on our communication (Maguire and Pitceathly, 2002).

NOW WHAT

Overall, this experience has helped me realise that communication difficulties can be distressing (Sully and Dallas, 2010) and frustrating (Ross, 2009) for patients following a stroke. Therefore, it is important for me to have a clear understanding of how the illness can affects the patient’s ability to effectively communicate. Hence, I plan to research and identify communication barriers with the stroke client and how to overcome them (Nazarko, 2009). Likewise, I have also learnt to be more self aware of my own interactions with stroke patient’s and being positive and flexible in my approach.

I also realise that it is possible to communicate with people at all stages of stroke using the ABC of communication (Maguire and Pitceathly, 2002) avoid confrontation, be practical, clarify the person’s feelings and offer comfort. In clinical practice I recognize my limitations and will continue to develop my ability to solve problems which may (but not exclusively) include open communication with mentors and other members of the multi-disciplinary team. If a similar situation arose I would revisit Mr Brown case to help consider if other options are more appropriate. This will prepare me for the varied and unpredictable situations that are often the norm in the nursing profession.

Conclusion
In conclusion, this assignment has reflected on the importance of effective communication skills. Communication is a highly complex process and these skills need to be continually practiced, as every client we meet, is an individual and so is their situation. Effective communication need’s knowledge of good verbal and non-verbal communication techniques and the possible barriers that may affect good communication. There is a plethora of published literature, credible studies and guidelines regarding the necessity for competence in the key skills of effective communication in the provision of high-quality, patient-centred care. I feel that the approach and result in this instance was satisfactory. As nurses, it is incumbent on me to be cognisant of the need to develop these skills and capitalise on every opportunity.