Introduction
This essay explores the nursing interventions provided to Sam, a 60-year-old informal patient admitted to an acute mental health setting with a diagnosis of personality disorder and associated abnormal behaviour, including selective mutism without physical impairment of speech muscles. As a nursing associate, I encountered significant communication challenges stemming from Sam’s illness, environment, and unique situational factors. To critically reflect on this experience, I will utilise Gibbs’ Reflective Cycle, a structured model widely used in nursing to facilitate learning from practice (Gibbs, 1988, as cited in Howatson-Jones, 2016). The essay aims to outline the context of Sam’s case, describe the communication challenges, evaluate the nursing interventions employed, and explore the implications for future practice. Through this reflection, I seek to demonstrate a sound understanding of mental health nursing principles, supported by recent academic evidence.
Context of Sam’s Case and Communication Challenges
Sam’s admission to the acute mental health unit followed a diagnosis of personality disorder, a condition often characterised by inflexible and maladaptive patterns of behaviour that can significantly impact interpersonal interactions (National Institute for Health and Care Excellence [NICE], 2015). His selective mutism—whereby he chose not to speak in specific situations or to certain individuals despite having intact speech capabilities—presented a unique barrier to effective communication. Selective mutism, while more commonly associated with anxiety disorders, can also manifest in personality disorders as a form of emotional withdrawal or control (Krysanski, 2018). Additionally, the unfamiliar and often overstimulating environment of the acute ward, combined with Sam’s reluctance to engage, further complicated efforts to build rapport and assess his needs. As a nursing associate, my role was to facilitate communication, ensure Sam’s safety, and support his therapeutic journey, necessitating tailored interventions to address these barriers.
Application of Gibbs’ Reflective Cycle
Description: What Happened?
During my initial interactions with Sam, I noticed his consistent refusal to speak, often resorting to nods or minimal written notes to express basic needs. This behaviour was particularly evident during multidisciplinary team meetings or when unfamiliar staff approached him. Despite this, he appeared more responsive to familiar faces, suggesting that trust and rapport could influence his willingness to engage. My primary intervention involved spending dedicated time with Sam in a quiet, low-stimulus environment to reduce environmental stressors, alongside using non-verbal communication tools such as visual aids and written prompts to encourage expression.
Feelings: What Was I Thinking and Feeling?
Initially, I felt frustrated and uncertain about how to connect with Sam, as his selective mutism limited conventional dialogue. There was a concern that my inability to elicit verbal responses might hinder accurate assessments of his mental state. However, as I persisted with consistent and patient engagement, I began to feel more confident in interpreting his non-verbal cues. Reflecting on this, I recognised the importance of managing my own emotional responses to avoid projecting frustration, which could further alienate Sam (Stickley and Hui, 2017).
Evaluation: What Was Good and Bad About the Experience?
The positive aspect of this experience was the gradual improvement in Sam’s engagement through consistent, empathetic approaches. For instance, using written communication allowed Sam to express urgent needs without the pressure of verbal interaction. However, the approach was not without limitations; it was time-intensive and did not fully address deeper emotional or therapeutic needs due to the lack of verbal dialogue. Additionally, the acute ward’s busy environment often disrupted these one-to-one interactions, underscoring a systemic barrier to personalised care (Bowers, 2014).
Analysis: What Sense Can Be Made of the Situation?
Analysing this experience, it is evident that Sam’s selective mutism was both a symptom of his underlying condition and a response to situational stressors. Research suggests that personality disorders often involve difficulties in emotional regulation, which can manifest as withdrawal behaviours like mutism (Linehan, 2015). Furthermore, the acute mental health environment, with its inherent unpredictability, likely exacerbated Sam’s reluctance to communicate. My intervention of fostering a calm, predictable interaction space aligns with trauma-informed care principles, which prioritise safety and trust-building (Sweeney et al., 2016). However, the limited scope of non-verbal tools highlights the need for broader strategies, such as involving speech and language therapists or using digital communication aids, as supported by recent studies (Smith and Duggan, 2019).
Conclusion: What Else Could I Have Done?
Reflecting on this experience, I could have explored additional resources earlier, such as consulting with a speech therapist to develop more structured communication strategies tailored to Sam’s needs. Moreover, involving Sam’s family or trusted individuals might have provided insights into triggers for his mutism and facilitated a more person-centred approach, as advocated by NICE guidelines (2015). Indeed, while my initial interventions showed some success, a more multidisciplinary and collaborative effort could have enhanced outcomes, particularly in addressing the emotional underpinnings of his behaviour.
Action Plan: If It Arose Again, What Would I Do?
If faced with a similar situation, I would adopt a more proactive stance by seeking immediate input from multidisciplinary team members, including mental health specialists and therapists, to devise a comprehensive communication plan. I would also undertake further training in non-verbal communication techniques and trauma-informed care to better support patients with complex needs. Additionally, advocating for environmental adjustments, such as designated quiet spaces within the ward, would help mitigate situational stressors. This action plan reflects a commitment to continuous professional development, a core principle of nursing practice (Nursing and Midwifery Council [NMC], 2018).
Implications for Nursing Practice
This reflection using Gibbs’ model has illuminated several critical aspects of mental health nursing. Firstly, it underscores the necessity of adaptability when addressing communication barriers, particularly with patients exhibiting selective mutism or withdrawal behaviours. Tailored interventions, grounded in empathy and consistency, can yield progress, albeit gradually.Secondly, the experience highlights systemic challenges within acute settings, such as environmental noise and time constraints, which can impede effective care delivery. Addressing these requires not only individual effort but also institutional support for staff training and resource allocation (Bowers, 2014). Finally, the importance of multidisciplinary collaboration cannot be overstated; integrating diverse expertise ensures a holistic approach to patient care, aligning with current best practices (NICE, 2015).
Conclusion
In conclusion, reflecting on my nursing interventions for Sam, a 60-year-old patient with personality disorder and selective mutism, using Gibbs’ Reflective Cycle has provided valuable insights into effective communication strategies in acute mental health settings. While initial efforts to build rapport through non-verbal tools and a calm environment showed promise, limitations in scope and systemic barriers highlighted areas for improvement. The experience has reinforced the importance of patience, adaptability, and collaboration in nursing practice. Moving forward, my action plan prioritises multidisciplinary engagement and professional development to enhance care delivery. Ultimately, this reflection underscores the broader implication that personalised, trauma-informed approaches are essential for supporting vulnerable patients, contributing to safer and more effective mental health care environments.
References
- Bowers, L. (2014) Safewards: A new model of conflict and containment on psychiatric wards. Journal of Psychiatric and Mental Health Nursing, 21(6), pp. 499-508.
- Howatson-Jones, L. (2016) Reflective Practice in Nursing. 3rd ed. London: Learning Matters.
- Krysanski, V. L. (2018) Selective mutism: A review of etiology, comorbidities, and treatment. Psychiatric Times, 35(3), pp. 18-20.
- Linehan, M. M. (2015) DBT Skills Training Manual. 2nd ed. New York: Guilford Press.
- National Institute for Health and Care Excellence (NICE). (2015) Personality Disorders: Borderline and Antisocial. NICE Guideline [QS88]. London: NICE.
- Nursing and Midwifery Council (NMC). (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: NMC.
- Smith, A. P. and Duggan, M. (2019) Communication aids in mental health nursing: Tools for non-verbal patients. British Journal of Mental Health Nursing, 8(2), pp. 75-82.
- Stickley, T. and Hui, A. (2017) The impact of nurse emotional intelligence on patient care. Mental Health Practice, 20(5), pp. 28-33.
- Sweeney, A., Clement, S., Filson, B. and Kennedy, A. (2016) Trauma-informed mental healthcare in the UK: What is it and how can we further its development? Mental Health Review Journal, 21(3), pp. 174-192.
