FUNDAMENTAL APPROACHES TO NURSING
 INTRODUCTION
This is a reflective essay that focuses on practice experience in an alternative nursing field. This essay will examine the care delivery given to patients in line with the four domains of nursing as prescribed by the Nursing and Midwifery Council (NMC). However, for this essay, focus shall be on communication and interpersonal skills and how it impacts on the physical health care of one of the service users.

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My experience at a learning disability support facility will be used an am alternative nursing field. This essay will reflect on my experience, the effectiveness of the organisation in delivering care to service users. Upon reflection, I will identify things that I could have done better, what the organisation could have done better and how it can be improved and used in future practice.
Gay and Kirkland asserts that critical self-reflection is the way various individuals analyse past situations and occurrence, with the aim of criticizing and reviewing those events for better understanding which can lead to change in thought or behaviour (Gay and Kirkland, 2003). Consequently, critical self-reflections enable professionals to be more aware of their presuppositions and challenge their established patterns of how they think and react to circumstances (Mezirow, 1990; Jarvis et al, 2003). This reflective essay will illuminate the concept of communication and its impact on delivering care in learning disability.
Furthermore, in this critical reflective essay, the Driscoll’s reflective model will be utilised in organising and analysing my reflections into the three stages; what? so what? and now what? (Driscoll, 2007). Using the Driscoll model, what? will describe the events and my reaction thoughts, so what? will analyse my reactions, critically analyse my experience, why I am writing the reflection and that of others involved and finally, now what? will explain what I learnt and what the action plan is, what the organisation can improve on ,what the learning outcome means for my future practice. In this essay, the confidentiality requirements as enshrined in NMC code (NMC 2015) will be followed, consequently, fictitious names will be used to represent patients and staff.
Communication and interpersonal skills are essential nursing skills and it is very pivotal to care delivery. communication and interpersonal skills can either make or mar a situation based on how it is done. NMC (2018), posits that all nurses must build partnerships and therapeutic relationships through safe, effective and non-discriminatory communication.
Communication is more than the flow of information. Keyton opines that communication is the process of transmitting information and common understanding from one person to another (Keyton, 2011). However, communication can be ineffective if the messages are not clearly understood after transmission. Effective communication requires an understanding of the information passed by the sender to the receiver.
Effective communication can be defined as reciprocal and interactive process whereby sender and recipient have responsibilities to ensure that a message has been received and understood, communication is incomplete until the loop is closed, (Hugman, 2009). In other words, communication can be said to be ineffective if the transmitter of the message has not received evidence from the recipient that message was received and clearly understood.
Morrissey and Callaghan posit that for communication to be effective, mental health nurses must be competent in using basic communication tools. That is, knowing the required skill, when to use it, the reason for the using it and the ability to transfer skills for interaction purpose (Morrissey and Callaghan, 2011).
Communication and interpersonal skills are very crucial to therapeutic interventions. Interpersonal skills are the means and tone of communication delivery. Interpersonal communication has been described as the way we utilize our skills to interact with other people (Donnelle and Naville, 2008). In learning disabilities settings, communication is a process whereby individuals interact, using symbols to create and interpret various meanings (Wood, 2004).
Communication effectiveness is not the only crucial part in communication, communication style is also important in nursing process and therapeutic interventions. There are two categories of communication styles, verbal and non-verbal. During my alternative field placement, I realise how important both verbal and non-verbal communication are to care delivery.  Silverman et al, (2005) asserts that it is imperative to recognise a patient’s verbal gestures in their facial expression, eye contact, body position and so on.
Consequently, we need to be aware of our individual non-verbal cues as they can either make or mar the achievement of the interactions or engagement. Non-verbal communication skills are essential in nursing care, supporting people with severe learning difficulties the crucial resources required is the nurses face, voice and body, therefore understanding the non-verbal cues is greatly essential when caring for people with profound learning difficulties, (Chambers 2003; Hannon and Clift, 2011).
Communication and interpersonal relationship in learning disability is quite different from the one in the general care settings and this is due to different types of need. Learning disability has been defined as a lifelong condition which could have occurred during prenatal, perinatal or postnatal or as a result of damage to the brain before age eighteen, thus affecting the person’s ability to learn, communicate or do everyday things (Hannon and Clift, 2011). Various authors have identified communication as one of the major issues when it comes to providing and receiving care in learning disabilities. Royal college of nursing (2006) also corroborates this by stating that for people with learning disabilities to have equal access to primary and secondary health care, communication skills has to be effective and information has to be accessible.
Furthermore, it is imperative that a person-centred care is used in delivering care to patients with learning disability. Carnaby stated that communication chart tools are one of the numerous examples of person-centred tools that can be utilized in managing communication needs (Carnaby, 2011). Communication chart is a critical tool that is essential when an individual do not communicate with words, the chart shows how communication through behavioural cues (Carnaby, 2011).
Communication tools reduces the stress level of both the carer and the service users because ordinarily patients with learning disability find it harder to communicate and understand, (Dawkins 2013). I was opportune to experience this in a learning disability support home that I went to, this learning disability home provides care for adults between the ages of 22 years to 34 years of age[1].
These service users had various types of learning difficulties and I observed that they also have various physical health issues. One particular experience with one of the service users stood out the most for me during my placement, Jack is a patient[2] who is diagnosed with cerebral palsy, he has mobility issue and he was profoundly deaf. Furthermore, Jack has a massive wound on his back. On my first day I was introduced to all the service users including Jack and was informed that I would be supporting Jack that day.
Staff told me Jack has limited communication skills and I would have to use sign language to communicate with Jack. Also, staff added that Jack understands and recognises body language and non-verbal communication. Therefore, I had to be careful with my body language so as to not be misunderstood by jack. 
My first meeting and trying to work with Jack was hard on me, this was because he was receptive, he did not want me to support him. However, he was more comfortable communicating and accepting support from other member of staff which he was more familiar with.  I reacted to his actions positively by giving my best smile and kept on working on my sign language (Makaton).
However, on the second day, Jack was warmer towards me and smiled when he saw me which I considered a positive development. After shadowing the staff with jack for a period of time, he was more open and trusting with me and would often request that I watch films on his iPad with him. Due to Jack’s wound, it was care-planned to have his vital signs checked regularly in a bid to detect any if any infections. Jack’s vital observation signs has to be done at least six times a day, this is also due to the fact that he cannot verbalise if he is in pain or feeling a change in his temperature. Jack verbalises his pain or distress through physical aggression towards people and things around him.
On a particular day, while I was recoding the general observation for other service users, I stopped by to check Jack in his bedroom and found that he was biting his tv remote control. I called for assistance with the buzzer. Another member of staff came around and we were able to verbally de-escalate him. After he became calmer, staff requested me to check his vital sign.  I got the vital signs toolbox, went into Jack’s room to do the assessment. However, when I walked in, I observed he appeared weak and was breaking out sweats. I had washed my hands earlier in the clinic and I put the gloves on in Jack’s room. I did Jack’s vital signs, which included temperature, blood pressure, pulse and respiration.
 I got the tympanic membrane thermometer out and asked Jack using the sign language if he was alright with me doing his temperature. Jack consented by raising his thumb up to me.  Using a non-touch technique, I took Jack’s temperature by tilting his head to the side a little bit for easy access into his ear canal. I placed the thermometer in her ear and once I heard the auditory signal, I checked the thermometer and his temperature read 38.5 degrees Celsius.
 I disposed the use cap on the thermometer using the non-touch technique and recorded the reading. The other staff member was communicating with Jack for distraction whist I was doing the checking his vital signs. Immediately, we contact the emergency services and we got out Jack’s communication chart and showed him the doctor’s image.
He consented to going to the hospital for treatment, staff stayed with Jack till the paramedics came and he was escorted to the hospital. I also observed that the staff who escorted Jack to the hospital went with a hospital passport and his object of reference chart.
Communication is an important skill which has to be done concisely and effectively. There are verbal and non-verbal communication style. Consequently, we must be pay attention to our non-verbal communication as it requires high self -awareness (Sheila and webster, 2014). Our non-verbal communication communicates our attitudes and feelings which can sometimes be perceived wrongly or misunderstood by patients, colleagues or members of the public.  Self-awareness helps us to understand our needs and that of the people around us and this can be achieved through emotional intelligence.
Emotional intelligence is an individual’s capacity to accurately perceive, understand, reason about, regulate emotions, and to apply information to facilitate thought and achieve goals, (William et al, 2017). Considering that my job requires a lot of interpersonal relationship and teamwork, emotional intelligence is required to enable me to thrive and perform optimally.
This also assisted me in understanding the importance of following Jack’s care plan about monitoring this temperature. It is essential to measure and record body temperature of patients regularly with precision as it serves as a useful indicator of any change in the clinical conditions of patients (McCallum and Higgins, 2012). Consequently, an incorrect measurement of body temperature could lead to a late detection of pressing illness or alternatively an unnecessary septic which could lead to a fatality (El-Radhi, 2013). Sepsis is an example of such fatalities, Sepsis is a condition where the chemicals in the blood stream meant to fight infection triggers inflammatory responses throughout the body, hence attacking the body organs (Hammett, 2017). However, the pathophysiology of sepsis is not fully yet understood as more research are ongoing (Barbero, 2018).
Furthermore, temperature is taken in order to establish a baseline, observe difference from normal rate, post operations, seriously ill patients and patients that are susceptible to infections (Jones, 2016). Body temperature can be measured in various part of the body, for example the forehead, ear (tympanic), armpit (axilia) and the mouth (Smith and Robert, 2011). However, oral temperature can be affected by eating and drinking of cold things by the patient (Dougherty and lister, 2011).  When the oral cannot be used the axilia is also suitable. Environmental factors and surface temperature could also affect the accuracy of body temperature and should consequently be taken into consideration when monitoring body temperature (Jevon, Ewens and Pooni, 2012; and Mains et al, 2008). Using the tympanic route for temperature measurement can also be unreliable and inaccurate due to wrong technique, wrong size of probe cap, patient’s position and ear wax.
The body temperature can either be high or low and they all fall within various ranges. When the body cannot maintain or regulate the homeostatic/normothermic state and loses too much heat, it is said to be hypothermic (Jevons et al, 2012). While hyperthermia is the prolong increase in the core temperature which can be above 38 degrees, it can also be referred to as pyrexia (Williams and Hopper, 2015). The importance of temperature measurement has been highlighted and emphasised however, temperature measurement is still often overlooked in care delivery (Andrew and Nolan, 2006).
In the managing Jack’s physical health, the staff developed a person-centred care plan for him, also there was proper record of his risks and what to do in case of emergency. These fulfils the NMC code (2015) which provides that risk and/or problems should be identified and communicated to colleagues and other professionals who use the record have all the information they require. It was because of the person- centred plan I was able to identify that Jack was distressed as he was aggressively biting the TV remote.
In addition, there was also a person-centred communication tool for jack, for instance he had his own objects of reference chat which assists carers in identifying and meeting his desired needs. Jack also has a hospital passport; this will also assist other carers and interprofessional to deliver appropriate care for him. Furthermore, I observed that Jack was allowed to make his own informed decision about everything, ranging from what to eat, what to wear, going out and so on.
Communication amongst staff was great and every member had necessary information about all the service users at all times. Teamwork is very crucial as it helps in proper circulation of important information, this was evident in the home. In this experience, I had to learn how to communicate effectively with Jack with the support of the team. Working with team and able to manage the situation with Jack depicts good and effective teamwork. Furthermore, we were able to make quick decision as a team when he needed urgent care.
Conversely, I felt the home could have given me more time for me to familiarize myself with Jack’s routine and also for Jack to get used to seeing me around. Also, the organisation could improve on how they induct new staff.
In conclusion, communication is very crucial to nursing care and delivery. Effective communication is important effective communication (verbal and non-verbal) helps in building therapeutic relationship as well as delivering quality care to patients. This reflective essay gives me more insight into the importance of body temperature management, its measurement and its impact on patient’s health. Also, the importance of temperature cannot be underplayed in care delivery, it plays a huge role in detecting prognosis and in turn reduce avoidable fatalities. 
This reflective essay enabled me to identify things to improve upon, particularly in relation to my communication skill, I need to learn some basic sign language (Makaton). I also learnt how empowering it is when patient’s independence is promoted and how important it is for nursing staff to develop competencies in identifying individual needs. Going forward, I will use what I have learnt in my practice and I will continue to learn, improve and research in the areas listed, so I can use it in my future practice.
Reference

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[1] This is not the exact age range due to maintaining confidentiality as prescribed by the NMC.
[2] This is a fictious name, in order to maintain confidentiality