Examplars
Critical nursing incidents where you made the difference
Helen Calabretto
School of Nursing, University of South Australia, SA
PP: 186 - 188
Article Text
Reflections of psychiatric rotation
Natalie Heazle, nursing student
Have those of you have never worked in a mental health setting ever considered what it might be like? As part of my nursing course, I was required to complete a placement in a psychiatric setting. As a third year nursing student, I had become more confident in the nursing role however I was concerned about working on a psychiatric ward because I didn't know what to expect. I had many preconceived fears about the clients and the general atmosphere of the ward. I was no longer in a familiar environment and I was very unsure of my abilities as a nursing student. My comfort zone was slipping away. Other students didn't help, in fact they sometimes made the situation all the more terrifying as they appeared to be so confident and relaxed on the ward.
My anxiety levels made me forget everything that I had ever been taught, or so it seemed. What was I supposed to say to mentally ill clients? How would I say it? My tutor was very understanding and encouraged me to take one step at a time. Eventually with the support from both my tutors and peers, I worked up the courage to approach a female client. We conversed normally until halfway through the conversation when she started to cry. I panicked, I didn't know what to do. Nothing was needed, as she walked away. My second attempt ended in much the same way. At the end of the first day, I felt mentally exhausted, and I was wished that I could return to the comfort zone of previous clinical placements.
The following day I started chatting with a group of clients who included me in their conversation and I felt both accepted and at ease. Following this group interaction, a male client approached me and initiated a conversation. We talked about simple things and I found myself feeling more relaxed. Over the next few days, I established a therapeutic nurse-client relationship with this man, and while both of us talked, I did most of the listening. During the time I spent with this client, he discussed his reason for hospitalization. At first I was a little taken aback and a little frightened of the intensity of his revelation, since he was talking to me on a very trusting and personal basis. However, I reminded myself that it was he who had chosen to self-disclose and the only pressure which existed was that which I put on myself. Taking a deep mental breath, I listened attentively. We attended groups and workshops and our therapeutic relationship was strengthened. This attention and trust made me feel very special as I discovered an improvement in my communication skills.
As the rotation progressed, I felt my confidence and skills growing although I realized I still had (and have) a great deal to learn. My tutor also commented on my improved performance. I led a support group and also participated in many group activities. I was able to relate to the staff on a professional level and interact comfortably with the clients. Social stigmas attached to the mentally ill drastically alter the perceptions of any individual. This was true in my own case initially, as I found my expectations were affected by those myths. My current beliefs are more accurate and I find it unfortunate that social stigmas can alter society's viewpoint. This particular placement enhanced my communication skills which will be useful in all nursing settings and although it was relatively traumatic, I believed I learnt a great deal from the experience.
To drink or not to drink
Juliette Horrocks RN DipAppSci(N Adm) RenalCert
Clients suffering from early chronic renal failure are encouraged to drink large amounts of fluid in an effort to maintain optimal renal function for as long as possible. As their disease progresses, however, they may need to curtail their intake to prevent fluid overload with its attendant problems. The need to sustain a fluid restriction indefinitely continues when clients whose renal failure becomes end-stage are maintained by either haemodialysis or continuous ambulatory peritoneal dialysis. For those reasons, it is important that clients receive appropriate education regarding fluid management.
The control of restricted fluids is comparatively easy for hospitalized clients but becomes far more difficult for them to visualize when they go home. Cups and glasses vary in size and writing everything down is not a nuisance but, as nurses are well aware, easily forgotten! As clinical nurse consultant of a renal unit, I have had numerous discussions with clients about the whys and wherefores of fluid restriction and, especially initially, the need for it at all. It became apparent that people needed a simple but effective way to manage their fluid intake so that it did not impinge more than necessary on their lifestyle. They also needed to be able to easily recognize whether or not they were succeeding in their attempts to take responsibility for the managing this aspect of their care.
During fluid maintenance education sessions with clients, it became obvious that an information sheet outlining what had been discussed, would be a useful adjunct to their own notes. It would also be something to which they could refer in future. After several attempts and with input from other nursing staff and clients, which was greatly appreciated, I developed a single sheet for clients to use. This is written in a question (supposedly from a client) and answer form, and is written in lay terms. A brief excerpt follows.
Why must I measure how much I drink?
As your kidneys are no longer working properly and so cannot get rid of large amounts of fluid, it is very important that you control how much you drink. If you do not do this, fluid will accumulate in your body and cause serious problems, for example high blood pressure (hypertension), swollen ankles, difficulty with breathing and even eventually heart failure.
How can I measure how much I drink?
The easiest way to do this is to buy a plastic jug which has clear markings in 100 ml steps up to 2 litres. First thing in the morning, put water into the jug up to your fluid allowance and then, as you have a drink, pour out and throw away the same amount. If you prefer, you can start with an empty jug and then pour a similar amount in each time you drink. If you go out, perhaps for lunch, remember to tip out (or add) the amount of fluid you have drunk when you come home.
To complete this information sheet, there are two other questions. One provides information to assist clients to assess whether they are managing their fluids properly, and the other outlines indicators that fluid management is incorrect or may need adjustment and the consequent need to seek medical advice.
This sheet has been given to clients for their use and comments and judging by their expressions of appreciation it has been well worth the effort involved in its preparation. Not only is it obviously useful but its simplicity is a major factor in the readiness with which it is accepted. One thing of which I was very conscious was the need to use language which anyone could understand but to avoid any impression of 'talking down' to the users. Indications so far are that I have achieved this, which is pleasing.
In discussing the format of the information sheet with clients, I was reminded, as so often during my nursing career, of how much our clients have to teach us and that education is a two-way process. I am also very thankful that I do not have to cope with the bane of fluid restriction!
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