Wendy Hawkesworth – A Curriculum for Nurse Training (Supplementary Papers)
Module 1: Awareness of judgements
Introduce In- practice reflective template to inform clinical decision making at the time. To be
used during education and within clinical practice as part of ongoing supervision post
education.
In practice reflective template
Comments
Awareness
Reasoning
Communication
Knowledge
1.1 Admission Scenario
John* is a 35-year-old man living with schizophrenia. His last admission to the inpatient unit
was four months ago. He was admitted via his case manager who tells you the following
admission details:
He was alerted to John’s unit by the neighbours who said that John had been knocking on
their door accusing them of listening in to his conversations and poisoning his cat. The case
manager had gone around to John’s house that day to see what was happening but John
refused to let him in. He informed John that he would like him to see the psychiatrist for an
assessment. John refused to talk to him shouting abuse and accusations about him being in
allegiance with the neighbours. He called the police who are escorting John to the unit under
the mental health act. John is not resisting this show of force.
It is not an uncommon occurrence that people are admitted to the unit under highly charged
conditions. What picture do you have of John from this information?
(Assumptions are a normal part of how we understand the world around us. Information is
judged according to the values we hold this is influenced by our past personal and
professional knowledge. Being mindful of our judgments is a way we can consider others
point of view).
What assumptions do you make about John? What are these assumptions based on?
Think about your past personnel and professional knowledge how are these influencing your
thoughts?
What other information do you need? Complete reflective template.
Clarifying assumptions:
It may help to think of the reason why John maybe thinking this?
Have another look at the scenario.
What do you think John’s values may be?
What questions would you be putting to the case manager around what is happening for
John?
Think about the medical perspective - What is known about stress vulnerability and
psychosis?
John’s perspective
I am scared. The voices are so strong. They are calling me a filthy person… that I shouldn’t
talk to anyone. My voices are getting worse. I can’t concentrate any more they have been
waking me up at night I haven’t slept for two weeks I know the neighbours have been
watching me they have been knocking on my door asking if I am ok but I don’t want to talk to
them they were the ones that called the police last time I was admitted. My case manager
came snooping around banging on the door wanting to take me away. I am not letting him in.
I have no one to talk to I haven’t been to my club house stepping stones for a week. I haven’t
seen my cat for three days they must have poisoned her.
Does this change your picture?
1.2 Therapeutic communication
It may be the case that at this time the person with schizophrenia may not be in a position to
articulate his feelings in such a concise way as this. What is your experience of this?
The concern is the other perspective is either ignored or pathologised where it isn’t
understood. Being mindful of this allows a seeking of further information /clarification or
acceptance of being unclear at this time.
Recommendations:
 Communicate in a way that attempts to meet where the person is at
 Slow down
 Avoid pre-judgments
 Attempt to understand
 Gather information from other sources .There may be other folks that can add light
on the picture
 Mindful of only working from one perspective.
Is there anything else that you have found which helps with this?
Language
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Is there anything that strikes you about the language in the scenario?
What does “show of force” mean? (Challenge the idea that this is akin to control)
Is this what mental health nursing is about?
What other language do we use that relates to control? (e.g. “take down” , “lock
down” )
What is the alternative language that can be used?
Module 2: Admission to the ward
The result of human reasoning is context dependent. The structure of memory not only the
long term storage organization (what do I know) but also current context (what is in focus at
the moment).We believe that this is an important feature of human thought not an
inconvenient limitation (Hubert Dreyfus, social researcher)
John is admitted to the ward .The nurse who does the admission is David. David is a 42 year
old nurse that has worked in the inpatient unit for two years. David has two teenage children
from his second marriage. He used to work as a manager in a correction facility but left to
work in mainstream acute psychiatry because he wanted to work closer to home.
David has nursed John before and has seen John when he is well. John remembers David
and is pleased to see him. David is nearly at the end of his shift. He offers John a cup of tea,
shows him to his room and says ok let’s get down to it.
“It’s good to see you John I am sorry that you have been admitted again. It sounds like you
have been having some trouble with the neighbours? Everywhere is the same as before. Do
you remember where the bathroom is? OK Now I need to do a quick risk assessment for our
record and ask you a few questions and then I’ll leave you to it.”
David conducts the risk assessment.
Do you hear voices? Are you feeling suicidal?
At this point John stands up and starts yelling.
“Now calm down mate”
“I do not want to be here I am not unwell I need to leave”
“Look you’ll be ok. The doctor will see you soon I just need to fill in these forms and then I’ll
have finished.”
John is getting increasingly angry.
What is happening within this communication?
Discuss the relationship of communication and risk.
What is the risk for John?
Consider this in light of Support the persons wellness through a process of care based on
sharing and support .
2.2 A shared approach
Discuss Three Keys to a Shared Approach (2008)
1. Active participation, with key folks including service providers and carers
2. Different provide perspectives, within an MDT
3. Person centred perspective building on strengths, resilience and aspirations as well
as needs and challenges
How can David connect with where John is coming from?
Write down a conversation that you think David may have with John that may show a shared
understanding. (getting close to the subjective ) Understanding the person’s perspective
from a narrative (rather than reductionist) point of view.
Empathising with John’s position is a way of finding a shared understanding. This doesn’t
mean you have to agree or go along with John but it puts you in a better space to work with
where John is coming from.
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What would you feel like if you had been brought in by the police?
If you thought you did not have a mental illness and yet you were being told that you
did?
Have you ever been accused of something that you do not believe?
2.3 Balancing science and values
A balanced approach:
What options does David have around the process of admission?
Emphasis on the process rather than the task
If someone is unwell, particularly in a crisis situation, they may not be able or want to be
actively involved in how their problems are being assessed. Rather, assessment should be
ongoing so that an individual can bring in their own understanding of their problems when
they are well enough to do so.
Cameron walks past.
Cameron is one of the consumer companions.
You ask Cameron if he can be with John a while.
John feels more at ease with Cameron.
Provide a choice of clinician wherever possible:
Most people select as confidents people who share their own values, beliefs and
experiences. (Fehr 1996)
2.1 Recording information
Documentation
David writes down: difficulty with engagement, angry, resistive, concerned that he will leave
the unit cannot agree on his safety to be nursed on a constant observation high risk of
AWOL.
Complete a reflective template.
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What is missing in this documentation?
What would the documentation look like if it was to reflect a shared approach?
What is John struggling with? What are his difficulties? What are his needs and what
are his strengths, resources and aspirations?
Handover
What information would be included in the handover as a result of this thinking?
Module 3: Dining room - Analysis of knowledge influencing practice
Dining room (Scenario 1)
It is a Tuesday morning and you are the clinical Nurse in charge of a busy shift at the
hospital. You have five nurses working on the shift, one of which is agency and the others
regular staff. There are ward rounds, ECT, escorts to x-ray and discharges to be arranged.
The ward is full to capacity and there are a couple of folks waiting in ED to be admitted.
It is 8am in the morning time for breakfast and medications. It is practice for staff to be in the
dining room. Today there are four staff in the dining room talking about their day ahead and
observing consumers interactions.
3.1 Questioning practice
 What is the reason for observing meal times?
Whilst walking through the dining room you over hear Sue who is one of the nurses telling
another nurse that John has been observed to be responding to voices and has been
jumping up and down from his seat and going to other consumers and shouting. She is
concerned about him disrupting the others. She asks the nurse to keep a watch on him
whilst she goes to get some extra medication.
You talk to Sue about her decision.
She says her reason for deciding to give John medication is that he is decompensating in his
mental state that she is concerned that he will disturb the others that he is escalating and
needs to take medication to calm down.
3.2 Ethical reasoning
What are the ethical reasons behind the decision?
 Beneficence
 Maleficence
 Autonomy
 Justice
Is there any other knowledge that could be included?
Complete a reflective template to consider your response.
 Knowledge about the situation
 Knowledge about John’s perspective.
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What might be the organisational, professional and personal values that drive Sue to
make this decision?
If Sue was more informed of the reason for John’s behaviour would her decision have been
different?
What knowledge of psychosis is driving Sue’s thoughts at this time?
 How is John’s behaviour viewed?
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How do we come to know about this behaviour? (interpretation and observation)
What is it within this medical knowledge frame that the nurse is basing her decision
on?
Comes to the above conclusions through medical professional knowledge, an interpretation
of the person’s behaviour as an internal problem fixed by medication.
Is the nurse balanced in her decision making? Balance between a problem base versus an
understanding perspective.
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How does this fit with a recovery approach?
What is the evidence around medication with the person who is psychotic?
What happens next?
In between the nurse getting the medication, John walks over to a table away from the
window and sits down on his own. One of the nurses brings his breakfast over. He continues
to talk to himself however he is focusing on eating his breakfast rather than shouting at
others.
Is this significant? (Dynamic reasoning)
3.3 Case-based reasoning
Discuss case based reasoning as a compliment to principle based reasoning.
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Do you think this change in behaviour should be considered?
Why would it not be considered?
What was the consequence of this?
Ignoring the consumer values can lead to conflict.
Refusing medication
The nurse approaches John with the medication.
She says, “Here John, take this. It will make you more settled”
“I don’t want that. I am fine. Take it away,” John replies.
The nurse reiterates to him, “No John, you are unsettled and you need to take this. It will
help you to settle. Please take your medication, John it will help you”
“No. I don’t want to take it. I am fine.”
John’s response is to shout at the nurse, that he is not going to take that, that he needs to
speak to someone in higher authority. He is sick and tired of being pulled and pushed from
pillar to post in this place whilst all the nurses do is to control and talk about him. “You take it
if you need it, I am not having it.”
Concerned that he is becoming more agitated and disturbing to the other consumers, the
nurse says that he needs to take this to calm down and if he doesn’t take this medication,
she will have to call security and give him an injection.
 What has happened?
 What could have been the demands on the nurse at the time?
 What are the barriers to finding shared understanding?
How could this have been different?