Care Delivery & Management Essay Example for Free

Care Delivery focus EssayThe purpose of this assignment is to consult upon my individual(prenominal)ised and professional knowledge. It leave alone consider the tint of the give direction I digestd, the skills I stand uped in my specialist placement, plus my information since the commencement of my nurse training. person-to-person nurture and self-reflection will be identified. I sh tout ensemble be apply Gibbs (1988) thoughtful one shot to consider my practice. Gibbs (1988) pondering Cycle brasss at six aspects which include the following what happened, what were my thoughts and toneings, what was good or bad about the moderate a go at it, what smack fag end I sack up out of the state of affairs, what else could I excite d superstar and if it arose a pull ahead what would I do? Findings will be back up or contrasted by relevant literature. A conclusion will be offered to evaluate findings. I shall in addition include an action plan, which will addr ess future professional and personal development single- quantifyd function ups and whatever factors that may champion or hinder this. I will similarly consider why I piddle selected these issues for my action plan, what my goals are and how I aim to achieve them.At the beginning of my nurse training we were asked to write on a piece of piece what our comment of nurse was. I wrote Its about creation human. At the magazine these words were based on my gut noniceing and personal belief. Now, two and a half(prenominal) years later, I would write the very(prenominal) thing, but this clipping my definition would be based on the skills, intimacy and experiences I belief permit and grateful to collect had during my training and non just on gut feeling and personal belief. How does this knowledge impact on me in terms of practice? I deal now put my definition of nursing into a framework and relate the theory of it to practice, for example I send away localize when I am actively under(a)taking fretting management with a persevering role. This is quite an performance for me.What else switch I learnt? I pick out gained knowledge of illnesses and understand how bio-psycho-social aspects of noetic illness impact on the individual, their family and their demeanor. I keep excessively developed a good shadoweronical knowledge of practical skills much(prenominal) as counselling, anxiety management, taxment, nursing and converse models, tighty-solving and psychotherapy. This knowledge and development of practical skills has en spread outd my self confidence and self esteem to grow.What things book had the just about influence on my personal and professional learning? These things are what Its about being human means to me as a nurse. They include a humanistic care philosophy. Evidence call d ca use of goods and servicess that tolerants imbibe found the humanistic care philosophy to be demonstrable and helpful to their well-being (Be ech, Norman 1995.) humanitarian care believes in developing trust, the nurse-patient relationship, apply the self as a remedial tool, spending clipping to be with and do with the patient (Hanson 2000,) patient presentment, the patient as an equal partners in their care (Department Of wellness 1999,) respect for the patients uniqueness, reference of the patient as an expert on themselves (Nelson-J peerlesss 1982, Playle 1995, Horsfall 1997). Equally Coperni wad to me is person-centred care, Rogers (1961) unconditional positive regard, w girdth, genuineness and empathy, recognition of counter-transference, self-reflection and self-awareness.I was on placement with Liaison psychological medicine also known as Deliberate Self Harm. The team consisted of my learn and myself. In this placement we would assess patients who had fencely self harmed. Patients would be referred via AE merely. We would see patients whilst they were still in AE or after they had been transferred to hos pital wards for medical treatment for their injuries etc. We would only see patients once they were medically fit to have a psychiatrical discernment.The purpose of the assessment was to find out what was happening for the individual and see if we could offer any help via mental health services to the individual, this is do via implementing APIE the nursing process (Hargreaves 1975). The main focus was to consider what tier of risk we tangle the patient was in. Therefore we pick outed to establish what the individuals intent was at the time of the deliberate self harm, and if suicidal, whether they still had suicidal intent after the incident. We also held a weekly counselling clinic.I considered Gibbs (1988) brooding Cycle. How did I feel about this placement? At first I was apprehensive as to how I would feel traffic with patients who do not necessarily want to live. I belong to a profession that saves lives, so I felt an inner conflict. This is an anxiety that is recognis ed in most nurses (Whitworth 1984). In my first few weeks I felt distressed by the traumatic heretoforets that these patients were experiencing. I felt flagitious that I have a family who love me, a fulfilling career, a lovely home and no debts, consequently each day I clack to stack who may have no home, no money, no one to love them and no employment. It was hard for me to make aesthesis of these things when life circumstances, such as class, status, wealth, tuition and employment create unfairness. I felt a desire to help try and emend the quality of these patients positions. Midence (1996) has identified that these feelings are a normal response when dealing with others less fortunate that ourselves.Patients who attempt self-destruction have lost hope (Beck 1986). I felt more(prenominal) settled and positive once I was able to make sense of the situation (Gibbs 1988). I stimulated that could help by listening to these patients and help to restore hope, develop problem solving ideas to tackle some of their problems or referring them to gain the emotional help and certification they requisiteed from appropriate mental health services. Patients find help with problem solving extremely valuable and can help them feel able to cope (McLaughlin 1999). Generally, after most assessments, I learnt that listening, prominent emotional support and problem solving helped restore enough hope in the previously suicidal patient enable them to feel safe from future self harm. In only a handful of cases did my mentor and I need to admit patients to any inpatient facility under the Mental health Act (1983). This was beca mapping they still felt at risk of future self-harm. by using Gibbs (1988) broody Cycle to consider my special placement area I feel I have been able to change my nursing practice in a positive delegacy, initially from feeling anxious, red-handed and helpless when dealing with suicidal patients to feeling useful, constructive and positive. I ve learnt that by confronting my own feelings of guilt and discomfort I was able to help in a very positive, practical, constructive and empowering agency. My mentor identified that one of my strengths is that I can generally combine common sense, logic and practicality in terms of risk assessment and problem solving and still build up a sensitive and caring, curative relationship when dealing with patients whose circumstances are in crisis and complicated and they themselves are emotionally and mentally vulnerable.Nurses not only need good communication skills (Faulkner 1998) but they also need to have an environment conductive to give way communication (Wilkinson 1992). Social barriers such as environment, structure or cultural aspects of healthcare can inhi bend the coat of communication skills (Chambers 2002) Utilising Gibbs (19988) Reflective Model, in retrospect I feel our interview with some patients could have been done other than. On occasion when my mentor and I were in the A E department the two board that we had available for our use were occasionally both in use. This meant that we would conduct our assessment interviews in the P furthermoster Room, if it was empty. This populate was where medical patients would have plaster-casts applied. This was a very clinical room.However, collect to limited room availability this was sometimes the only option we had at the time, it was not a welcoming or appropriate setting and would not have helped patients feel relaxed or valued. In reflection, I believe it was actually demeaning as we were asking patients who had attempted suicide to sit on a hard chair in a clinical workroom and share their despair with us. I am sad that this happened and I feel as though we were giving the patients the impression that a cold clinical work room is all they were worth. If this arose again (Gibbs 1988) I would suggest to my mentor that we wait for one of our allocated rooms to be ascend available, where the rooms were relaxing, with soft armchairs and a feeling of comfort. using Gibbs (1988) Reflective Model I shall describe a situation with a patient to highlight my learning. What happened (Gibbs 1988)? Neil had been bought to AE by his son after he do an attempt to take his own life. His son explained that Neils married woman had terminal cancer and had died the day before. Neil was unable to engage in conversation other that to repeat everyplace and oer again I dont want to live without my wife. However the more overturned and difficult to communicate a patient is the less interaction they receive therapeutic or differently from nursing round (Cormack 1976, Poole, Sanson-Fisher, Thompson 1981, Robinson 1996a, 1996b). I found this too be true in Neils situation as some A E nurses did not coveting to approach him because of his disturbed state and deadness to verbal cues.What were my thoughts and feeling (Gibbs 1988)? After spending twenty minutes in the assessment interview Neil had remained refractory to our approaches and had remained distressed, distant and uncommunicative for the entire time. I had past experience of recent bereavement within my ready family and I clear that counter-transference was at play and was a reason for my strong emotional reaction to Neils distress resulting in me having an overwhelming desire to ease his suffering. Even though another part of me tacit the need for him to experience this extreme pain as a normal part of grieving.What was good or bad about the experience (Gibbs 1988)? This was not a good experience for me because as a compassionate person, I found it extremely hard to suppress my own feelings of wanting to protect him from such annihilative distress, although I recognised that I was over-identifying with him due to my own grief. I considered that he mogul have been broken by the emotional state he was in and his inability to control his grief he could not speak, maintain eye contact or even physically sta nd.What sense could I make of the situation (Gibbs 1988)? We adjourned for a few minutes so that my mentor and I could assess the situation. I thought it might be appropriate to utilise Herons Six Category Intervention Analysis (1975) evacuant intervention as a therapeutic strategy to enable the patient to release emotional tightness such as grief, anger, despair and anxiety by helping to (Chambers 1990). I hoped it would facilitate the opportunity for Neil to open up and express his full feelings in a safe and supportive environment. I initially think to sit quietly with him and briefly put a reassuring hand on either his hand, arm or shoulder. My mentor supported this action.I was aware that I ran a risk of misinterpretation by choosing therapeutic touch. Therapeutic touch may be criticised because it is open to misinterpretation by the patient and misapply of power by staff. The patient may view holding anothers hand as a sexual advance, violation or abuse, so nurses should a lways consider patient consent, appropriateness, context and boundaries. article 2.4 of the treat and Midwifery Council (2002) Code Of original Conduct says that at all times healthcare professionals must maintain appropriate boundaries with patients and all aspects of care must be relevant to their inescapably.Therapeutic touch appeared congenial given his situation and seemed appropriate to the context it would be performed in, given that my mentor would supervise me. As per Gibbs (1988) Reflective Cycle I considered what else I could have done especially if the situation arose again and mentor not been there. I would may have chosen to utilise Hansons (2000) approach of being with whereby I use therapeutic use of self through the sharing of ones own presence, and not entangled any form of touch, avoiding any misinterpretation or breach of boundaries.I was anxious because I felt concerned that my nursing skills would be inadequate to address his needs due to his acutely dis tressed state. In reflection my mentor helped me acknowledge that this was about my own anxiety rather than being accurately reflective of my nursing ability. I approached Neil and explained that if it was acceptable with him I would akin to sit quietly with him so that he was not alone in his distress. It is likely that the nursing process is therapeutic when nurse and patient can come to know and to respect each other, as persons who are alike and yet different, as persons who share in the solution of problems (Peplau 1988). I gently placed my hand onto his. Neil reacted by given the impression that he physically disintegrated, he become extremely distressed and crying loudly, squeezing my hand tightly.This last outd for several minutes. Neil became calmer and started to talk about his situation. This was a good outcome. I was able to utilise Herons (1975) cathartic strategy with positive way out via empathising with Neils situation and using myself as a therapeutic tool throu gh the use of touch, therefore enabling Neil to express his emotions and activate a nurse-patient relationship. Studies have shown that nurses can express compassion and empathy through touch, using themselves as a therapeutic tool (Routasalo 1999, Scholes 1996) and this has a cathartic value, enabling the patient to express their feelings more easily (Leslie Baillie 1996).The therapeutic value of non-verbal communication and its harmfulness is overlooked (Salvage 1990). Attitudes are evident in the way we interact with others and can create atmospheres that make patient care uncomfortable (Hinchcliff, Norman, Schoeber 1998) On one occasion, one nurse privately referred to Neil as a wimp because he was having difficulty coping with the death of his wife. I wondered whether her body language had transmitted her bad attitude towards Neil, alter to his distress and difficulties in communicating with staff. again using Gibbs (1988) Reflective Cycle, I shall provide another example to highlight my learning in practice. What happened (Gibbs 1988)? Cycle On one occasion my mentor and I received a phone call from A E asking us to review an 18-year-old girl called Emma who had taken an overdose. They said she was medically fit to be assessed. When we arrived they claimed that she was pretending to still feel unwell and described her as milking it. We found her to be vomiting and spy she had been left in a bed in the corridor of A E for 8 hours. McAllister (2001) found that patients who had self-harmed were ignored, had exceptionally long waits and suffered judgemental comments.What were my thoughts and feelings (Gibbs 1988)? I felt very livid towards A E staff as I felt that she was being unfairly treated because she had caused harm to herself, she had been labelled as a troublemaker by staff and I do not believe she had received good quality care. Emma explained that in the last month her father had died, she had miscarried her baby, discovered that her partner was having an affair, and she had been made redundant leaving her with debts that she couldnt pay. As I looked at her, I saw a vulnerable young woman at the end of her tether. I felt saddened and disappointed by the judgemental attitudes of the A E staff who had not even taken the time to talk to Emma or ask her why she had taken an overdose, instead they describe her as an immature and management seeking kid.As per Gibbs (1988) Reflective Cycle, I felt this was a very bad experience of forgetful care, bad attitudes and unacceptable moral judgement being made by A E staff. Cohen (1996) and Nettleton (1995) identify that social status age, gender, race and class contribute to stereotyping and judgemental attitudes. I noticed that muckle who self-harmed were judged differently dependent upon their age and the younger they were the worse the attitude of A and E staff. Interestingly ageism towards juvenility is an area that I could find no research on. I believe ageism towards yo unger people is overlooked and is really only identified in the elderly.During the assessment I was aware of how my physical presence can impact on the care given. However, I have learnt about the importance of considering how one can communicate to the patient via body language. By attending to patients in a non-verbal or physical way it is another method of saying, Im interested, Im listening and I care. To do this during Emmas assessment I utilise Egans (1982) acronym S.O.L.A.R. This meant that I sat facing Emma Squarely, with an Open posture, Leaning towards her, whilst do Eye contact and Relaxing myself, to give her the feeling of my willingness to help. This leaf node centred care recognises her equality in the nurse-patient relationship.What sense did I make of the situation (Gibbs 1988)? I was very unhappy about the attitude of A E staff but recognised that they had a lack of sense and knowledge. In one study looking at self-harm admissions it was discovered that patie nts who deliberately self-harm are often deemed as unpopular patients, being labelled and judged as time wasters by A E staff. Apparently 55% of general nurses perceived these patients as tutelage seekers and disliked working with them, 64% found it frustrating, 20% found it depressing and almost a triplet found it uncomfortable (Sidley, Renton 1996).What else could I have done (Gibbs 1988) After reflecting upon the experience with my mentor, I was able to realise that part of my role is to act as a representative for mental health. If this happened again what would I do (Gibbs 1988)? If staff were to make judgemental comments again it is part of my role to educate and inform them so they can have a positive understanding of the needs of the mental health patient and learn to address any judgemental comments made. This is a view supported by washbasinstone (1997), who says that if we are made aware of our actions when we are judging and labelling people it is our responsibility to correct this.Medical staff need to be aware of mental health promotion, and need further training and education in respects of helping to care for and understand of this vulnerable patient group (Hawton 2000). This is a view supported by the Department of Health (DOH 1999a) who have recommended closer physical contact between mental health and A E services in an effort to address the poor understanding and negative attitudes of A E staff. I have also learnt that I must look at both sides of each situation and should show more understanding towards the A E staffs feelings, as they are often confronted with shocking and distressing acts of self infliction which can make them feel despair, helpless and unskilled to deal with these sort of patient.I believe nurses negative attitudes develop because we all transcendentally apply own our values and views to everyday situations, people, experiences and interactions. It may be the staff members own coping mechanism to keep their dis tance from the patient or to label them as solicitude seeking in order to make sense of the situation for themselves. This is a view supported by Johnstone (1997).In reflection, following the assessment and planning of care for Emma my mentor and I reflected upon the care I provided for her. I recognised that I felt nervous because it was my first experience of conducting an assessment. Having my mentor there to observe me made me feel secure because I trusted my mentor and could rely on her expertise to ensure that I provided safe practice for Emma. However, I still felt anxious as I was faced with an inglorious situation. This made me realise how difficult and intimidating the assessment process may have felt to Emma. I had the security of feeling safe in the relationship with my mentor. Emma didnt know either of us. This highlighted the huge value of the nurse-patient relationship and how the importance of utilising Rogers (1961) theory of client-centred care involving uncondit ional positive regard, warmth, genuineness and empathy towards patients.My mentor said that I provided turn up based care and I appeared to have a good humanistic approach, sensitively providing client centred care. She joked that I was so keen to get it right that I was practically sat on Emmas knee in my efforts to non-verbally show to Emma that I was attentive and listening to her. I think that whilst this was a joke, I will endeavour to continue to be keen but will relax a bit more, hopefully as I gain more experience myself. I will also use the insight and understanding from these experiences to benefit my future practise and the care I provide for patients.Boyd Fales (1983) suggest, Reflective learning is the process of internally examining an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of self, and which results in a changed conceptual perspective. Self-reflection helps the practician find practice-based answers to problems tha t require more than the application of theory (Schon 1983). I have discovered this to be true, especially in mental health nursing where problem solving may be in the realm of religious, spiritual or cultural beliefs, emotional or intuitive feelings, ethics and moral ideals, which sometimes cannot be theorised.With one patient I couldnt understand his unwillingness to engage in therapy even though he turned up for a weekly appointment. Once I reflected on this with my mentor I realised that I was not considering his strict religious and cultural background, which complicated his care. I realised that I had been completely ignorant of his needs and had in-fact lacked self-awareness otherwise I would have recognised these issues sooner. According to Kemmis (1995) a benefit of self-reflection is that it helps practitioners become aware of their unawareness.I have learnt that there are barriers to reflection. On occasions after seeing a patient my mentor may interpret events in a reaso nably different way to myself. Newell (1992) and Jones (1995) criticize the idea of reflection arguing that it is a flawed process due to inaccurate recall memory and hindsight bias. Another criticism of refection is that it aims to theorise actions in hindsight therefore devaluing the skill of responding intuitively to a patient ( well-situatedardson 1995). I considered that my thought to hold Neils hand may have been intuitive but because we must use evidence based practice and appropriate frameworks of care, I theorised my care and utilised Herons (1975) framework.I believe self-reflection helps me to become self-aware. Self-awareness is achieved when the student acknowledges there own personal characteristics, including values, attitudes, prejudices, beliefs, assumptions, feelings, counter-transferences, personal motives and needs, competencies, skills and limitations. When they become aware of these things and the impact they have on the therapeutic communication and relationsh ip with the patient past they become self-aware ( puddle 1999). I have learnt through these experiences that reflection can be a awed experience as I have recognised my own imperfections and bias. I have felt angry with general nursing staffs attitudes towards mental health patients and have now been able to realise that this emotion is uncooperative and instead I should be more tolerant and understanding and help them to understand the patients needs. It is also difficult especially if one is experiencing strong emotions such as anger, frustration and grief (Rich 1995).At times I have over-identified with my patients and personalised their situation to similar situations of my own. This is known as counter-transference and has blinded my ability to address their care needs. Counter-transference is the healthcare professionals emotional reaction to the patient, it is constantly present in every interaction and it strongly influences the therapeutic relationship, but is often not reflected upon (Slipp 2000). Counter-transference can be defined as negative as it can create disruptive feelings in the clinician, causing misguided values and bias (Pearson 2001).I have learnt that it is all-important(a) for me to consider how my reactions to a patients problem can impact on the care I provide. Whilst I endeavour to always give 100% best and unbiased care to each patient, I have realised I respond more favourably to patients that I like or identify with. For example I was extremely compassionate and biased towards both Emma and Neil and I feel that my personal life experiences influenced me because I could really empathise with them both. However, I realised that I am only human and that as long as I recognise the impact of counter-transference then I can use it positively as my self awareness of the fact that the process is occurring will enable me to address and challenge my own thoughts, feelings and responses.To conclude, I have been able to highlight my lear ning over the last two and a half years, both personally and professionally. This has enabled me to look at the areas that I am good at and the areas that I can improve on. I have been able to look at the quality of the care I have given patients and considered what I have achieved, how I felt, how I could have done things better, what was successful and unsuccessful, what issues influenced me and what understanding I had of the experience. I have also been able to recognise my role as a representative for mental health nursing and how I can promote it to other healthcare professionals. I have also identified the value of the role of my mentor in helping me to develop as a nurse. I will use the insight and understanding from these experiences to benefit my future practice and the care I provide for patients.ACTION PLANWord Count 1086What are my goals?My mentor and I discussed the areas that I want to improve on. We identified that my stronger points are common sense, logical approac h and practical ability in terms of things like risk assessing and problem solving. I am also competent in the building of a therapeutic relationship, utilising a humanistic care philosophy, person centre approach, empathy, genuineness, unconditional positive regard and honest. I also have a good knowledge in respect of mental health promotion, anxiety management, basic counselling skills, understanding of the fundamentals associated with nursing, assessment and communication models and the basic principles of psychotherapy. I feel I have come a long way in two and a half years and have accomplished a lot.However, there are areas that I recognise that I can improve on and I am happy that I can address these as I hope this will improve my learning, skills and competency as a nurse in the future, providing better patient care. The areas I need to gain more knowledge and experience of include understanding the religious, cultural and spiritual needs of the patient and how this impacts on their care and quality of life, recognising and working with counter transference and my tendency to feel the need to over protect patients as this does not help the patient to utilise choice, be responsible for themselves or empower themselves. I want to continue developing my own self awareness through self reflection. at long last I wish to develop my academic abilities and to train further so that I have more knowledge.Why have I chosen these issues?I have chosen to improve my knowledge and understanding of patients religious, cultural and spiritual needs and how this impacts on their care and quality of life, because by doing this I hope to be able to address their needs holistically. To successfully undertake a thorough assessment the healthcare practitioner needs to identify the holistic needs of the patient, failure to do so would neglect the patients physical, psycho-social and spiritual needs (Stuart and Sundeen 1997.) At present I feel I am unable to fully comprehend or provide best care as I feel I lack the skills and knowledge to do so.I also wish to further consider the impact of counter transference and my tendency to feel the need to over protect patients. I feel that if I gain more understanding and recognition of how counter-transference can change my reaction to a patient then I will be able to address it and have more control and choice over my nursing and my responses. In practice, I have experienced strong emotional reactions to some patients, perhaps because I could identify with some of their issues. However, this can result in my wanting to over protect them, which may disempower them, and this is unhelpful. Different characteristic in patients can influence the emotional reaction of the nurse (Holmquist 1998). I need to be able to recognise these characteristics in the patient and be self aware of the way I am responding.I want to continue developing my own self-awareness through self-reflection, as I will need to be able to suff ice autonomous and expert judgement as a qualified nurse. The ability to use self-reflection as a learning tool to becoming self-aware will help me achieve this. This is a view supported by (Wong 1995). Boud, Keogh Walker (1995) believe self reflection is an important human activity, essential for personal development as well as for the professional development of the nurse. By being able to mull over my experiences will help me challenge my beliefs and behaviour as an individual and a nurse. Finally I wish to develop my academic abilities and to train further so that I have more nursing knowledge. bonk alone is not the key to learning (Boud et al 1985). I wish to gain further qualifications so that I may further my career and knowledge, as this will provide a sense of achievement and fulfilment for me.How am I going to achieve my goals?I intend to develop my portfolio and keep an open reflective diary (Richardson 1995) to show evidence of my learning and prepare for my PREPP. Por tfolios are seen as a order of battle of information and evidence used to summarize what has been learnt from prior experience and opportunities (Knapp 1975), and acknowledges professional and personal development, knowledge and competence, providing nurses with evidence of their eligibility for re-registration every three years (NMC 2002). I believe maintaining my portfolio helps with ones self-assessment and will help me to develop my strengths, plus identify and critically evaluate my weaker areas, this is a view supported by Garside (1990).However in contrast Miller Daloz (1989) suggest there is no evidence to suggest that self assessment contributes to resurrect self awareness. A barrier to ones ability to self-reflect may be time constraints and socio-economic factors such as high staff and management turnover, low staff morale and staff illness (Bailey 1995) I hope to overcome this by being a supportive team member to my colleagues and maintaining a positive mental attitud e. I am happy to work on my portfolio and diary in my own time as I think it is a valuable learning tool.I will use my preceptorship, learning in practice, observation in practice and clinical supervision to help achieve my goals. expression on action is considered to be an essential part of clinical supervision (Scanlon Weir 1997). I will continue to use Gibbs (1988) Reflective Model to help me develop my learning through reflection.I will need to feel confident that by sharing my portfolio, diary, reflection or seeking advice via preceptorship and supervision that this will not reflect negatively on me and effect my ability to feel able to trust my mentor. Students and staff sometimes feel unable to fully express themselves or belittled by the power relationship if supervision is not in a trusting relationship feeling it could be open to bias, personality clashes, counter-transference or could prejudice them in terms of career development (Richardson 1995 Jones 2001). However, good clinical supervision enables nurses to feel better supported, contributing to safer and more effective nursing (Teasdale 2001, Jones A 2001).I hope to continue with life long learning and would like to be able to study for a degree in nursing. I shall do this by apply for funding once I am employed and hope that whoever my employers are they will support me in my goal to become better qualified.ReferencesBailey J (1995) Reflective Practice, Implementing Theory, breast feeding Standard, Vol 9 (46) 29-31Baillie, L (1996) A Phenomenological Study Of The Nature Of Empathy, daybook Of Advanced care for, 24,6, 1300-1308Beck A T (1986) Hopelessness As A predictor OF Eventual self-annihilation, Annals Of The New York Academy Of Science, Vol 487, 90-96Beech P, Norman I (1995) Patients Perceptions Of The Quality Of psychiatrical nurse Care Findings From A Small Scale Descriptive Study, ledger Of Clinical Nursing, 4, 117-123Boud D, Keogh R, Walker D (1985) Reflection Turning Experie nce Into Learning, London, Kogan Page,Boyd E M, Fales A W (1983) Reflective Learning Key To Learning From Experience, Journal OF Humanistic Psychology Vol 23 (2) 99-117Chambers M, psychiatrical and Mental Health Nursing Learning In The Clinical Environment , Cited in Reynolds W, Cormack D (Eds) (1990) Psychiatric And Mental Health Nursing, London, Chapman and HallCohen G (1996) mount up And Health Status In A Patient Satisfaction Survey, Social Science And Medicine, Vol 42 (7) 1085-1093Cook S (1999) The Self In Self Awareness, Journal Of Advanced Nursing, Vol 29 (6) 1292-1299Cormack DFS (1976) Psychiatric Nursing discovered A Descriptive Study Of The Work Of The Charge Nurse In Acute Admission Wards Of Psychiatric Hospitals, London RCNDepartment Of Health (1999) The National Service Framework for Mental Health, London, HMSOEgan G (1994) The Skilled jock Model, Skills Methods For Effective Helping, Brooks/Cole Publishing, Pacific Groves, California.Garside G (1990) Personal Prof iling, Nursing, Vol 4 (8) 9-11Gibbs G (1988) Cited in, Palmer A, Burns S, Bulman C (1994) Eds, Reflective Practice In Nursing, London, Blackwell ScienceHanson B (2000) Being With, Doing With A Model Of The Nurse lymph gland Relationship In Mental Health Nursing, Journal Of Psychiatric And Mental Health Nursing, 2000, 7, 417-423Hargreaves I, (1975) The Nursing Process, Nursing Times, 71,35, 89-91Hawton K (2000) General Hospital Management Of Suicide Attempters, The International Handbook Of Suicide And Attempted Suicide, Chicester, John Wiley SonsHeron J (1975) Six Category Intervention Analysis, Guildford, Human Potential resource Group, University Of SurreyHinchcliff S, Norman S, Schoeber J (1998) Nursing Practice And Healthcare, 3rd Edition, London, ArnoldHolmquist R (1998) The Influence Of Patient Diagnosis And Self Image On Clinicians Feelings, The Journal Of Nervous And Mental Disease, Vol 186, (8) 455-461Horsfall J (1997) Psychiatric Nursing Epistemological Contradictions, A dvances In Nursing Science, 20 (1) 56-65Johnstone L (1997) Self Injury And The Psychiatric Response, Feminism And Psychology, Vol 7, 421-426Jones P R (1995) Hindsight Bias In Reflective Practice An Empirical Investigation, Journal Of Advanced Nursing, Vol 21, 783-788Kemmis S (1985) Action investigate And The Politics Of Reflection, In Edwards M (1996) Patient-Nurse Relationships Using reflective Practice, Nursing Standard, Vol 10 (25) 40-43Knapp J (1975) A Guide To Assessing Prior experience Through Portfolios, Education Testing Service, Cooperative Assessment Of Experiential Learning,Princeton, New JerseyMcallister M (2001) Dissociative identity Disorder And The Nurse Patient Relationship In The Acute Care Setting An Action Research Project, Australian And New Zealand Journal Of Mental Health Nursing, Vol 10, 20-32McLaughlin C (1999) An Exploration Of Psychiatric Nurses And Patients Opinions regarding In-Patient Care For self-destructive patients, Journal Of Advanced Nursing, Vol 29 (5) 1042-1051The Mental Health Act, (1983) Department Of Health, London, HMSOMidence K, Gregory S, Stanley R (1996) The Effects Of Patient Suicide On Nursing Staff, Journal Of Clinical Nursing, Vol 5, 115-120Miller M, Daloz L (1989) Assessment Of Prior Learning, Good Practices hold back Congruity Between Work And Education, Equity And Excellence, Vol 24 (3) 30-34Nelson-Jones R, (1982) The Theory And Practice Of Counselling Psychology, London, CassellNettleton S (1995) The Sociology Of Health And Illness, Blackwell, Cambridge.Newell R (1992) Anxiety, Accuracy And Reflection The Limits Of Professional Development, Journal Of Advanced Nursing, Vol 17, 1326-1333Nursing and Midwifery Council (2002) Code Of Professional Conduct, London, NMCPearson L (2001) The Clinician-Patient Experience Understanding Transference And Counter-transference, The Nurse Practitioner, The American Journal Of Primary Health Care, Vol 26 (6) 2001Peplau H (1988) Interpersonal Relations In Nursing, London, M acMillan PressPoole AD, Sanson-Fisher RW, Thompson V (1981) Observations On The BehaviourOf Patients In A State Mental Hospital And A General Hospital Psychiatric Unit A relative Study, Behaviour Research And Therapy, 19, 125-134Playle J (1995) Humanism And Positivism In Nursing Contradictions And Conflicts, Journal Of Advance Nursing, 22, 979-984Rich A (1995) Reflection And Critical Incident Analysis, Journal Of Advanced Nursing, Vol 22 (6) 1050-1057Richardson R (1995) Humpty Dumpty- Reflection And Reflective Nursing Practice, Journal Of Advanced Nursing, Vol 21, 1044-1050Robinson D (1996a) Measuring Psychiatric Nursing Interventions How Much Care Is Individualised, Nursing Times Research, 1, 1, 13-21Robinson D (1996b) Observing And Describing Nursing Interactions, Nursing Standard, 13, 8, 34-38Rogers C (1961) On Becoming A Person, London, police constableRoutasalo P (1999) Physical Touch In Nursing Studies A Literature Review, Journal Of Advanced Nursing, 30, 4, 843-850 bowelless J (1990) The Theory And Practice Of The New Nursing, Nursing Times Occasional Paper, 86, (4) 42-45Scholes J (1996) Therapeutic intent Of Self How The Critical care Nurse Uses Self To The Patients Therapeutic Benefit, Nursing In Critical Care, 1, 60-66Schon D (1983) The Reflective Practitioner, London, Temple-SmithScanlon C Weir W S (1997) Learning From Practice? Mental Health Nurses Perceptions And Experiences Of Clinical charge, Journal Of Advanced Nursing, 26, 295-303Sidley G, Renton J (1996) General Nurses Attitudes To Patients Who Self Harm, Nursing Standard, Vol 10, (30) 32-36Slipp S 2000) Counter-transference Issues In Psychiatric Treatment, The American Journal Of Psychiatry, Vol 157 (9) 1539Stuart G W, Sundeen S J (1997) Principles and Practices Of Psychiatric Nursing, 6th Edition, St Louis, MosbyTeasdale K (2001) Clinical Supervision And Support For Nurses, An Evaluation Study, Journal Of Advanced Nursing, Vol 33, 2, 216-225Wilkinson S (1992) Good Communication In Cance r Nursing, Nursing Standard, 7 (9) 35-39Wong F (1995) Assessing The Level Of Student Reflection From Reflective Journals, Journal Of Advanced Nursing, Vol 22, (1) 48-57Whitworth R A (1984) Is Your Patient Suicidal? Canadian Nurse, Vol 80, 40-42