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Reflective Essay

Counselling: from theory to practice (psy2018), university of northampton.

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18407463 Counselling AS Reflective essay

In the counselling lectures, we focused on the underlying principles of the main theoretical models of counselling and how those theoretical principals are applied in different aspects of counselling through the use of counselling skills. In this essay, I will provide a reflective account of my learning of the counselling process based on the class materials covered and some of my own independent research.

Contracting, Greetings and Departures

Before counselling sessions can commence, it is a professional and legal requirement to have a contract with your client. This must be a mutually agreed contract with clear boundaries set, this covers things such as punctuality, finance, safety of both parties and the relationship in and out of counselling. As well as these things, some things I learned are critical to include in the contract are the counsellor’s qualifications, an overview of the services that you will be providing and what the counselling involves. With further reading, (Sills, 1997), I now understand the importance of this as it can act as a reassurance to clients who are new to therapy and that the services being provided will be performed in a safe and professional manner. It will also reassure them that their goals of counselling can be met by the particular counsellor depending on their theoretical orientation. This sets the tone for the relationship. The counsellor can be there to simply assist the client in rehabilitation with no coercion or power inequality, an approach often used in person-centered counselling, or the counsellor acts as the authority figure due to their knowledge and expertise in their area, primarily used in cognitive behavioural therapy. In the contract, it is essential to make clear the duration of the process. This includes the duration of each session and how many sessions until the termination of the contract. One thing I learnt is that you as the counsellor also have the power to terminate the contract where you see fit. This can be due to a variety of things such as the client not adhering to what was set out in the contract, personal conflicting views which get in the way of progress being made or if you feel no progress is being made.

Another aspect of counselling I had overlooked was introductions. I had overlooked greetings as it seemed so trivial as it’s something we do on a daily basis, so I had never put much thought into it. However, from class group discussions I was reminded that when dealing with vulnerable people, caution should be taken. For example, if a greeting is not welcoming and friendly, someone with anxiety may assume it is because you as the counsellor do not like them which could negatively impact the rest of your relationship with them and progress to be made going forwards. Another example is that being too friendly, such as giving hugs, may be damaging for victims of violence who may have past trauma to physical touch or it may lead clients to have the wrong idea of your professional relationship with them and even lead to a possible over- dependency on you.

18407463 Counselling AS

Counselling Process

One counselling skill I have developed from the lectures and group tasks is the ability to listen to understand than to listen and simply explain a psychological theory in response. Although many clients will come to you as the counsellor with similar, if not the same, psychological distress, it is important to really listen to what each client has to say about their experience to understand them individually. This includes listening to how they were before, what they feel may have caused the onset of their distress and what makes it worse/relives it. This is the beginning of building a strong rapport with the client, as well as really understanding for yourself as the counsellor which therapy will benefit them to reach maximum results. Understanding their problems will also help you in being able to explain what the therapy entails and how you will be using it to help them in their unique situation. Practicing this skill in class really made me aware of my habit to just simply explaining my textbook knowledge of each therapy and how it can help in broad general terms. This challenged me to change the way approached explaining what the specific theoretical principals I would be using are and how exactly I aim to tailor them to help the client. This is important as it instills confidence in the client and makes the process more personal for them so they feel they are really getting the best care possible. This type of self-reflection is extremely important, especially in counselling, as it allowed me to be aware of my own interpersonal skills. Having the relevant knowledge is key however, it’s the way that you deliver the information which has an impact on the client. Giving them endless amount of information without relating it to their specific situation or speaking to them in a way they will be able to understand and apply the theoretical knowledge to their lives is no help to the client.

Another aspect of self-awareness that was highlighted to me in class discussion was emotional-intelligence. It is important to take time as a counsellor to understand and comprehend your own emotions and reactions to things going on in your personal life, in order to not allow them to enter a clients session. When we are faced with a client who presents a similar situation to your own or one you have previously experienced, it is easy to allow past emotion to influence or sway your answer. At first, to me, it seemed beneficial to relate to the client so they can feel like what they are going through they are not alone and that others have been through it also and come out on the other side. However, keeping up with self-reflection will allow you to experience your emotions but keep them separate from your counselling life. It reduces the probability of you associating your clients problems with your own and projecting your personal feelings onto the client. Rose (2011) states that complete self-awareness is not exclusively for the client, but also for the continual professional development of the counsellor.

When practicing this skill in group scenarios after a client had asked us, the counsellors, for our advice/opinion on a situation they were currently going through that was similar to our own personal experience, I found this is a skill I need to further develop. On

18407463 Counselling AS burnout of the job and job turnover (Scanlan and Still 2013; Hardiman and Simmonds 2013).

In conclusion, I feel that I have done well at using the resources provided to me to further my knowledge of the counselling process. I enjoyed the face-to-face lectures as it gave me a chance to not only practice the skills we had learnt, but to also expand and change my way of thinking by being challenged by other students in group discussion and videos we watched in lectures. I think the most valuable skill I have learned is to explain the counselling process thoroughly to the client in a way they will understand and apply my chosen theoretical approach directly to their specific situation. To consolidate this learning, I will continue practicing communication and application skills in counselling scenarios as well as doing further research into different ways counsellors have tackled difficult situations in their experience.

Anderson, S. K., & Handelsman, M. M. (2011). Ethics for psychotherapists and counselors: A proactive approach . John Wiley & Sons.

Geldard, K., & Geldard, D. (2002). Counselling skills in everyday life . Macmillan International Higher Education.

Hardiman, P., & Simmonds, J. G. (2013). Spiritual well-being, burnout and trauma in counsellors and psychotherapists. Mental Health, Religion & Culture , 16 (10), 1044-1055.

Rose, C. (2011). Self Awareness and Personal Development: Resources for Psychotherapists and Counsellors . Macmillan International Higher Education.

Scanlan, J. N., & Still, M. (2013). Job satisfaction, burnout and turnover intention in occupational therapists working in mental health. Australian occupational therapy journal , 60 (5), 310-318.

Sills, C. (Ed.). (1997). Contracts in counselling (Vol. 6). Sage.

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Module : Counselling: From Theory To Practice (PSY2018)

University : university of northampton.

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Reflective Practice and Personal Development in Counselling and Psychotherapy (2nd ed) Bager-Charleson et al..

2020, Bager-Charleson, S (ed) with du Plock, S., van Rijn, B. and Wright, J (2020) Reflective Practice and Personal Development in Counselling and Psychotherapy. 2nd ed. London: Sage

Reflective practice is a vital part of counselling and psychotherapy training and practice. This is the second edition of a 'go-to' introduction to what it involves, why it is important, and how to use different models for reflection and reflective practice to enhance work with clients. It aims to support personal development and professional development throughout your counselling training and into practice.

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Reflective Practice in Psychotherapy and Counselling Author: Jacqui Stedmon, Rudi Dallos ISBN-13: 9780335233618 Pub Date: SEPTEMBER 2010 Price ... Teaching Travel and Tourism 14+ Author: Cliff Huggett, Deborah Pownall ISBN-13: 9780335238262 (Soft cover) ISBN-13 ...

This resource has been prepared to support the development of reflective thinking and practice. It provides a variety of information intended to aid the learning of new knowledge and behaviours and/or enhance existing ones. The information, however, is quite flexible and is designed to assist with the construction of practices appropriate to the needs of individuals rather than being prescriptive.

Reflective practice is process of inquiry where educators reflect on their setting and think about what they may change. It is about considering how everyday ‘happenings’ shape thinking and influence decision making. Said to enhance teaching and learning, reflective practice is not a one off process rather a cycle of ongoing learning that occurs when educators take the time to stop and think, even momentarily.

Physiotherapy, 2000

"Maybe reflective practices offer us a way of trying to make sense of the uncertainty in our workplaces and the courage to work competently and ethically at the edge of order and chaos…" (Ghaye, 2000, p.7) Reflective practice has burgeoned over the last few decades throughout various fields of professional practice and education. In some professions it has become one of the defining features of competence, even if on occasion it has been adopted-mistakenly and unreflectively-to rationalise existing practice. The allure of the 'reflection bandwagon' lies in the fact that it 'rings true' (Loughran, 2000). Within different disciplines and intellectual traditions, however, what is understood by 'reflective practice' varies considerably (Fook et al, 2006). Multiple and contradictory understandings of reflective practice can even be found within the same discipline. Despite this, some consensus has been achieved amid the profusion of definitions. In general, reflective practice is understood as the process of learning through and from experience towards gaining new insights of self and/or practice (Boud et al 1985; Boyd and Fales, 1983; Mezirow, 1981, Jarvis, 1992). This often involves examining assumptions of everyday practice. It also tends to involve the individual practitioner in being self-aware and critically evaluating their own responses to practice situations. The point is to recapture practice experiences and mull them over critically in order to gain new understandings and so improve future practice. This is understood as part of the process of lifelong learning. Beyond these broad areas of agreement, however, contention and difficulty reign. There is debate about the extent to which practitioners should focus on themselves as individuals rather than the larger social context. There are questions about how, when, where and why reflection should take place. For busy professionals short on time, reflective practice is all too easily applied in bland, mechanical, unthinking ways,

Aims: This review aims to explore the existing qualitative research on qualified therapists' use of reflective practice, identify gaps in the research and explore any implications for practice and research. Design: A systematic review was carried out in July 2017, which involved undertaking a comprehensive and systematic search of the literature; critically appraising the studies; and synthesising the data using a narrative approach. The narrative synthesis consisted of three stages: (1) developing a preliminary synthesis; (2) exploring relationships in the data; and (3) assessing the robustness of the synthesis. Findings: Eight studies met the full inclusion criteria. The synthesis identified seven interrelated themes, which are encapsulated by two overarching themes: the value of reflective practice and conceptualising reflective practice. Therapists reported many benefits to reflection, including: increasing selfawareness, enhancing connection with clients, enhancing clinical practice and facilitating self-care. Reflection was experienced as distressing but this was viewed as necessary to derive value from the experience. Despite difficulties with understanding and integrating reflective practice, reflection was experienced as part of therapists' personal and professional identity. Conclusions: The review highlighted a lack of qualitative research on qualified therapists' experiences of reflection as well as significant heterogeneity across the literature. The methods used to examine reflection tended to report more general perspectives on reflection, as opposed to reflections specifically linked to therapists' clinical practice. Future research capturing therapists' specific experiences of using reflection in their clinical work would help to build a better understanding of how it is being used to inform practice.

Development of professional practice through reflection, including an originally created model of reflection.

In this paper, I explore reflective practice literature and the elements of critical reflection, and I reflect on my experiences of learning and using a critical reflection approach to better understand a significant incident. This reflective paper is written from my personal perspective as a social worker using Fook and Gardner's model of critical reflection to provide a framework to reflect, explore and learn from my own experiences. The Fook and Gardner approach to critical reflection encourages deconstruction and analysis of a personal or professional experience to understand the different assumptions, relationships and influences embedded within it and how it affects our practice. As new understandings emerge, the individual is able to reconstruct this incident and develop new techniques to deal with a similar incident in the future.

The Veterinary Nurse, 2018

There may be differences between this version and the published version. You are advised to consult the publisher's version if you wish to cite from it.

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Reflective Practice – Examples

Important Points to Remember reflections

• Gibbs’ reflection cycle
• Edward de Bono’s six thinking hats
• John’s model of structured reflection
• Boud, Keogh and Walker’s model
• Brenner’s Critical Incident Analysis

Doesn’t matter which one, you can try each and then use the one that suits your personal style better.

• Read GMC guidance on reflection but most important take home message is to keep the details and descriptions of events short, outlining the case anonymously.
• Most of the writing should be about what was learnt including what you will do differently e.g. If using the Gibbs’ reflective cycle this will be the analysis and evaluation section.
• If you’re stuck about what to say about future management, imagine the scenario in a different setting e.g. if you encountered the case out of hours, if had said something differently, if you had tried a different line of treatment etc.
• Theory e.g. you learned how to manage a certain problem, you’ve since read certain guidelines.
• Something you learned about yourself e.g. how to manage your feelings/emotions. It can be something you learned about medical ethics etc.
• A reflection on your ‘soft’ skills e.g. your leadership skills, team working etc.

Here are few examples of reflections

Example # 1:.

Title: Attended a full day GP Update Course (Date – venue)

As a GP it is important to continue to renew our knowledge even in areas that we become experts in such as hypertension, asthma and diabetes. Common things are common but medical research is always evolving hence the importance to continue to update our current knowledge base. It was a useful course and new useful guidance is always gained when attending this course.

Reflection:

Amongst many nuggets of knowledge I learned the following:

NSAIDS & Antidepressants- co-prescribing these increases the risk of intracranial haemorrhage (ICH) particularly in the first thirty days. ( BMJ2015;351:h3517) I have always advised patients on short courses of NSAIDS and AD to beware of GI bleeding but had not considered ICH.

The study also suggests that this risk is across the range of antidepressants such as TCAs, SNRIs as well as SSRIs. I will continue to use these with caution. Of course, nothing is straightforward in General Practice. We do not know of the risk beyond 30 days. This risk is also higher in men but surprisingly no increased risk is seen in older people or those with co-morbidities.

Given that we prescribe approximately forty million prescriptions for antidepressants across the UK, we are unaware of patients using NSAIDS over the counter, we have to use caution and advise our patients against such risks.

This has a direct impact on multimorbidity and polypharmacy in primary care. I have made it clear to patients taking antidepressants about the risks of using NSAIDs. More so, there are a number of patients with depression with chronic pain, these groups are clearly vulnerable to the risks mentioned. There is a suggestion with NICE guidelines that if an SSRI & NSAID is co-prescribed, gastro protection should be advised.

I have discussed this with our practice pharmacist, as she does the majority of our medication reviews, and made her aware of the risks. On a personal note, I will be adding gastro protection where possible and advising patients to avoid OTC NSAIDS. We also discussed the use of NSAIDS which in actual fact cause more deaths than RTA. This has certainly put things into context for me!

Example # 2:

Title: Menopause Masterclass

A refresher about menopause and risks/benefit in the current climate.

Women are far more self-aware of the menopause and approach the doctor to discuss treatment for the menopause than perhaps decades ago. As women are also living longer, as is the general population, so comes with it increasing the risk of cardiovascular diseases and other co-morbidities.

It was useful to look at the quality standards that are now in place for HRT. There were several useful websites for information for both health professionals and patients: British Menopause Society- BMS Menopause  matters.org M anagemymenopause.co. uk Also, for younger women with premature ovarian failure the  daisynetwork.org.uk < br />

There was useful information on the use of testosterone. I had a peri-menopausal lady who requested testosterone gel to improve her libido. I had no experience in this area so wrote to the HRT clinic, she is now a very happy patient on testosterone gel. As long as the testosterone levels are measured every 3months to ensure that low maintenance doses are continued it is acceptable.

Given that I see a lot of women who often come with an agenda and an expected outcome this seminar was very useful in addressing these issues. HRT can have a lot of expectation for women. Some women are very reluctant to stop taking HRT, it is challenging such as stopping HRT after 5years or more when the risk becomes more concerning that I find challenging. The risk increases in term of CVD, obesity and breast cancer.

I have used the BNF statistics to place this risk into context for women who have been on HRT for many years. On one occasion in a 72year old lady, I stopped HRT much to her consternation. I did refer her to the HRT community clinic where it was restarted. Unfortunately, the risk and responsibility fall on the prescriber and I decline to continue to prescribe in this scenario. This seminar reinforces my practice in such unique case scenarios.

This was a good seminar, given the subject, it validated my current practice and helped me develop a more patient-centred paradigm within our current approach.

Example # 3:

Title: Dermatology update day

(Venue) – Evening lectures covering typical skin scenarios commonly seen and dealt with in the primary care setting.

The topics discussed on the day were eczema and skin conditions in young children, vulval rashes and psoriasis in the community. I see a lot of vulval rashes and being contraception lead at my surgery. Also, I have a lot of consultation with women so find that this area needs to be kept up to date.

It was reassuring to know that my management of childhood eczema was in keeping with dermatologist consultant approaches. The key points to take home were that GPs tend to undertreat eczema rather than over treat. It is reasonable to continue a moderate potent steroid cream as long as it is for a short period and stepped down at the earliest possible.

Outcome: I will continue to practice as I have been but will take on board certain practices such as treating superimposed infection in eczema for 2weeks and also despite what the instructions are on steroid creams we can apply to broken and infected skin!

Example # 4:

Subject title: Autism Spectrum Disorder (ASD)

What were you reading?:

I read the article ‘Autism in Adults’ published in InnovAiT in June 2017.

Why were you reading this?:

I identified that this is a learning need of mine from a previous reflection on a case I was involved in.

What did you learn?:

I learnt a lot from this very thorough article. I learnt about the terminology currently in use. I did not know that ASD is now an umbrella term that includes Autism and Asperger’s Syndrome. I learnt about the clinical features of Autism, including challenging behaviour, communication difficulties, processing difficulties and rigid/repetitive behaviours. I learnt how to assess patients with suspected ASD. I also learnt how to manage patients with ASD in primary care. The article suggested reasonable adjustments that can be made at a surgery to make healthcare more accessible to people with ASD and it also gave a number of tips regarding communication during consultations. Reading this article, I was able to reflect further upon a patient I reviewed with ASD who had presented with suicidal ideation. I had found this assessment difficult. I found it difficult to build a rapport with this patient and had a lot of difficulty assessing her level of risk. I identified during the assessment that she was struggling to answer open questions and one of the tips in this article is to ask direct closed questions. It also suggests waiting for a response rather than repeating the question or asking in a different way. This is something that I did whilst trying to assess this patient and may be some of the reason why I failed to do an appropriate, effective assessment on her.

What will you do differently in future?:

In future, I would try to follow some of the communication advice written in this article. That said, another important point raised by the article is that ASD, as the title suggests, is a spectrum. This means that no two patients are the same and while some may respond better to the communication advice provided, others may not. I will therefore keep an open mind and endeavour to adjust my communication technique as I feel appropriate.

What further learning needs did you identify?:

I had already identified that I needed to learn more about ASD. Whilst I now need further practice at managing patients with ASD, this reflection goes some way towards closing this learning cycle.

Example # 5:

Subject title: Urge incontinence

What happened?:

A 41 year old woman presented with a few months history of increasing urge incontinence. She had had one normal vaginal delivery 10 years ago. She reported that she had been consistent with doing regular pelvic floor exercises since the birth of her child. She also reported that she had already tried to cut down on her caffeine intake in an attempt to manage her symptoms. She felt that her symptoms were beginning to have a negative impact on her life and she was beginning to feel reluctant about going out in case of any accidents.

What, if anything, happened subsequently?:

I consulted the NICE CKS guidelines and referred her to the continence team for bladder retraining. I advised her to complete a bladder diary in the meantime.

I learnt that I am not confident at managing patients presenting with urinary incontinence. I learnt from the guidelines that it is advisable to refer patients for bladder retraining prior to initiating medication. I would not feel confident at initiating medication at this stage. I learnt that these symptoms can have a big impact on lots of aspects of someone’s life. This patient is beginning to feel reluctant about going out due to the risk of her being incontinent while she is in public. She was quite tearful as she described how it made her feel even in her own home when she is incontinent in front of family members. She has a young child that she wants to go out with so her symptoms are now beginning to affect their family life. She wishes to lose weight (which would probably benefit her urge incontinence) but is struggling even more with body image and low esteem as a result of these symptoms.

In future, I will refer patients for bladder retraining as I did in this case. I will try to be as sensitive as I can when taking a history as I understand that this can be an embarrassing experience for patients.

I need to learn more about the management of urge incontinence.

How and when will you address these?:

I will undertake some reading on this subject and record what I learn from this in my eportfolio.

Example # 6:

Subject title: Assessing Risk Out of Hours

During an evening shift, along with a member of the Home Treatment Team, I assessed a 22 year old woman who had been referred urgently by her GP due to increasing thoughts of self harm and suicide. She had been referred to the Community Mental Health Services some weeks previously but not yet been assessed. Although she had experienced a number of significant precipitating life events and also disclosed during assessment that she had been sexually abused as a child, there were no specific triggers for the recent deterioration in her mood. She described how over the past 12 months she had been unable to hold down a job or maintain personal relationships. She had fallen out with a number of close friends and been in more than one abusive relationship. She lived with her family and had a very good relationship with her mother. Her mother had accompanied her to the assessment. She also described how she had been arguing with her family and taking out her frustration on them. She felt very guilty about this. Over the past few weeks she had been struggling with insomnia. She had a history of having taken an overdose approximately 6 months prior to this with the intent to end her life and admitted to contemplating doing the same thing again. She had been prescribed medication by her GP for her mood and planned to take an overdose of this.

Following a detailed assessment, myself and the CPN from the Home Treatment Team discussed management options. The options were admission to hospital or discharge home with either follow up from her GP or follow up from the Home Treatment Team. My colleague and I agreed that, although she was relatively high risk for self harm and even possibly suicide, she had a lot of support at home, especially from her mother. We agreed that the best option would be for her to be discharged with follow up from the Home Treatment Team until she felt improved enough to control her thoughts. We discussed the plan with the patient and her mother and asked her to sign a ‘Safety Contract’ that included a plan of action in case she felt like she wanted to act on her thoughts. Both her and her mother were happy with this management plan. We also agreed to give her some night sedation as she was having such difficulty falling asleep. Her mother was to keep these tablets in a safe place.

This was an excellent opportunity for me to practice assessing risk of self harm/suicide. I have assessed this risk on my own many times in the Emergency Department and in General Practice and generally err on the side of caution, as evidenced by a previous reflection on this subject. If I had assessed this patient on my own I would have probably admitted her. This time I was working with an experienced colleague and I valued the opportunity to discuss the risk and subsequent management plan with them. Sharing this decision helped alleviate some of the anxiety I sometimes feel when weighing up the risks myself. I feel anxious as I am concerned about the patient’s safety; I would worry about deciding to discharge a patient home who later seriously self harmed or committed suicide. I felt very moved by this patient’s history and she worried me. Having the opportunity to discuss this case gave me more confidence to decide with my colleague that the patient did not need admission. I also had opportunity to practice completing the WARRN documentation and found this to be a very useful tool to aid our decision making. The WARRN is much like a checklist and can be repetitive but it provided me with a template for considering the level of risk for this patient. There was a lot of detail in this case and the documentation helped to highlight the salient points. I have used checklists in medicine many times and find them very useful. In my experience, not all cases will fit neatly onto a checklist but they are designed so that important points are not missed and all relevant information is recorded. I learnt more about how to investigate symptoms of auditory hallucinations. The patient reported that she was hearing voices telling her to kill herself. Previously, I would have just documented this in the notes. However, my colleague questioned this further and was able to ascertain that rather than auditory hallucinations, the patient was experiencing ruminating thoughts about suicide and becoming increasingly preoccupied by this. I would not have previously been able to make this distinction. Working with a member of the Home Treatment Team gave me the opportunity to discuss with him how this team may be able to help this patient (and others). Previously, I did not know that the Home Treatment Team were able to prescribe medication and I had incorrectly thought that they were less available than they are.

In future, I would feel more confident about assessing risk of self harm/suicide and deciding on appropriate management plans. In General Practice we do not complete WARRN documentation and doing so would take too much time. However, I would try to think about the risk in the way it is set out in a WARRN to aid my decision making. If I had any doubts or concerns that a patient was at high risk of self harm/suicide, I would again err on the side of caution and, as a GP, would refer patients to secondary care on an urgent basis for further assessment. Regarding checklists/proformas, I would look to use such tools in my future practice as I feel they play a role in ascertaining the salient points of a case and ensuring all relevant information is recorded. Whilst they do not fit every case, they can also assist in decision making.

I need to continue to practice assessing risk of self harm/suicide with colleagues and alone. Whilst on this placement, I need to practice using WARRN documentation to become more familiar with the layout.

I will continue to practice assessing risk and reflecting upon my experiences.

Example # 7:

Subject title: Psoriasis vs Lichen Planus

I read information about these two skin conditions from three different resources; Primary Care Dermatology Service, British Association of Dermatologists and DermnetNZ. I also read about differential diagnoses for an itchy rash on the PCDS website.

I had previously identified this as a learning need when I struggled to diagnose and manage a patient with an extensive itchy rash. I noted that two GPs had subsequently treated the patient for a different condition and realised that I needed to do some reading on these topics.

I learnt about Lichen Planus including it’s presentation and management. It can be intensely itchy and is managed with emollients and potent steroids. It usually lasts for two years and as the papules/plaques settle they are replaced by hyperpigmentation. I also learnt about Psoriasis including it’s presentation and management. It presents as symmetrical scaly plaques and is managed with potent steroids, topical vitamin D preparations and coal tar amongst other treatment options. In addition, I learnt about differential diagnoses for an itchy rash, including how to investigate someone with generalised pruritis without rash. I also read about the Dermatology Life Quality Index (DLQI) as a measure for how much a dermatological condition is affecting someone’s life. This would be useful information to consider for referring patients to secondary care. These are three resources that I regularly use when managing skin conditions. It was interesting to compare the three. Two of these resources are UK based and one is specifically for GPs in the UK. The management advice of each was pretty much identical which was reassuring. I found PCDS had more photographs on their website which is particularly useful when learning dermatology. BAD had lots of useful patient information leaflets which are available for printing. Reflecting upon the original case, as I read this information I think that lichen planus and psoriasis could quite easily been mistaken for each other. They both present as itchy plaques, have similar triggers and can present with the Koebner phenomenon. Management for each condition is different, however, and given that this woman did not respond to potent topical steroids that could indicate that lichen planus is not the correct diagnosis. Her diagnosis of lichen planus had been made 10 years ago so it is quite possible that this rash is not the same thing. Additionally, back in 2009, she had been treated with diprosalic ointment which is often used in psoriasis to remove scale. After my reading and after reflecting, I think that psoriasis is the more likely diagnosis here and I will be interested to find out what the dermatologist thinks when she is seen in clinic.

In future, I will have a better idea of differential diagnoses for patients presentingwith itchy papular skin lesions. I will be better able to differentiate between psoriasis and lichen planus and better able to manage them effectively. I also know which resources I prefer to use with regards to dermatology and would be able to direct patients to information that might be helpful to them, in particular the patient information leaflets on the BAD website.

This completes my learning cycle.

Example # 8:

Subject title: Management of agitated patients and rapid tranquilisation

During my OOH psychiatry SHO shift, I was asked by a nurse on an adult psychiatric ward to prescribe anxiolytic and antipsychotic medications in order to reduce a patient’s agitation. This health board revert to a rapid tranquilisation policy for these matters.

This patient was extremely agitated and had already cause some (minor) harm to themselves. There was also a risk of harm to staff and patients on the ward due to the severity, nature and unpredictability of the patient’s aggression. To manage this patient, police needed to be called to help de-escalate the situation before any medications could be administered. The patient was transferred to Psychiatric ICU for further management and assessment.

This was quite a big learning curve during my first on-call: Firstly, was learning how to manage a patient expressing this degree of aggression and agitation as there was limited we could do safely and legally at this point, which is why the police were called to utilise their different skills for managing these patients. Secondly, utilising the rapid tranquilisation guideline – the nurses were most comfortable/familiar with using Haloperidol and Lorazepam as a combination, however, further reading indicates that Haloperidol and Promethazine are a useful combination because there is some evidence that promethazine can help counter-act potential extra-pyramidal side effects associated with Haloperidol. The negative factor is both have the ability to cause prolonged QTc. Finally, was managing my own feelings because admittedly this was not a situation I had previously had to manage and despite one of the nurses having worked on the ward for 22years, all of the staff were looking at me for answers. Unlike medical or trauma related emergencies, I didn’t have an algorithm like <C>ABCDE to resort to in order to reduce my bandwidth and so having headspace to think in this unfamiliar situation was more difficult but definitely helped by delegating tasks or trying to utilise the team by focusing on priorities e.g. “how do we make this situation safer?” to which the nurses suggested calling the police. Luckily this patient was on the ward on a section, had the patient been ‘informal’ then this could have added additional ethical and legal complexities but may have resorted in putting the patient on a section 5(2) if appropriate or giving the medication as a one off dose in the patient’s best interests.

Our on-calls are off-site i.e. they are based in a different community hospital and we travel to patients or give telephone advice: During my first on-call I had to familiarise myself with everything inc. passwords to unlock doors, finding staff members, finding on-call rooms etc. If I ever have to do on-call shifts like this again, I will ensure I shadow a more experienced colleague/at least see the on-call location before I attend my own on-call to reduce the uncertainty and unfamiliarity. This might help me feel more at ease and give me more headspace e.g. wasting time trying to find paperwork or being locked out of a ward. With regard to this specific case, it demonstrated a reversal in my relationship with the nurses i.e. throughout the on-call I was relying on the very experienced nurses to help with explaining how various systems worked, where paperwork was and sometimes providing clinical information that added to my assessments of patients. However, in this emergency situation, it was completely expected for me to take charge and tell people what to do. I found this quite interesting, not dissimilar to what can happen on a medical ward but I believe medical training is set toward managing medical emergencies a lot better than emergencies in mental health and so the answers weren’t so readily available to me. I don’t this affected the clinical situation too much but certainly interesting to reflect on. It also strengthened my relationship with the nurses, perhaps because it balanced out me asking them for help prior to this event! This patient was naïve to antipsychotics and had a normal ECG documented from a previous A&E attendance 3 months prior. It was not appropriate to attempt an ECG for this patient at this point. In terms of choice of anxiolytic, despite evidence showing the use of Promethazine being a useful combination with Haloperidol, I don’t know that I would have used it in this patient due to concomitant risk of prolonged QTc.

1. I need to learn more about antipsychotics as I am not as familiar prescribing them 2. I need to discuss with my consultant methodology for more focussed prescribing of antipsychotics 3. I need to learn more about MHA and police powers, in particular for managing patients like this

1. Self directed learning on antipsychotics 2. Discuss with adult psychiatrist in clinic about antipsychotic prescribing esp. PRN doses and combinations 3. Conduct e-learning on MHA and police sections

Example # 9:

Subject title: DNACPR discussion with patient relative

A patient with advanced dementia and multiple co-morbidities was admitted onto the ward and did not have DNACPR form. The patient did not have any close relatives aside from an elderly brother. His brother was invited in for a discussion about discharge and the subject of DNACPR was raised.

DNACPR form was discussed and signed

Understanding surrounding DNACPR forms seems variable: In particular I have noticed that having the conversation with a family member who is younger e.g. children of the patient is a lot easier to explain than when discussing it with a spouse or similarly aged relative. I don’t know whether this is because the older generation have less understanding and read less about the forms or whether the decision is more difficult because of their own age and potential frailty. The patient’s brother was very alarmed at the idea that he was discussing this for his younger brother and he kept reiterating his difficulty coming to terms with this. The guidance for DNACPR forms is that they should be discussed with relatives, however, relatives can often understand this to mean that it is THEIR responsibility and decision alone and so can feel reluctant to agree to signing it. Another aspect that I think is important for patients to understand is that the DNACPR form doesn’t represent stopping all treatment, just not starting CPR in the event of arrest. I explained this to the patient’s brother and he was content with this. It was more difficult to explain the likely outcome of CPR in this patient and patients in general.

What will you do differently in future? :

It was useful to incorporate the discussion of the DNACPR as part of the discharge planning process. I have previously found these conversations more difficult when there is not a ‘way in’ i.e. the patient is not acutely unwell etc. Although I appreciate the guidance is to have a discussion whilst a patient is well as it promotes a healthier understanding, rather than understanding it to be a part of planning a patient’s death but sometimes it is helpful to discuss this when these sort of planning processes are at the front of the relatives mind. It was clear that the patient’s brother had never heard of DNACPR forms, but when we arranged the meeting, we encouraged him to bring a relative who might help him process the information. He brought his granddaughter, who was a trained GP. Although this was quite daunting for me initially, as I was conscious that another clinician might have their own feelings about how to have this conversation, it was very reassuring for the patient’s brother and so I felt her presence was helpful. She allowed me to explain and then provided reassurance for her grandfather. His main concern was that he didn’t feel, as the patient’s brother, that he was close enough to “sign him off”, I felt it was important to explain the clinician and relatives’ responsibilities in signing DNACPR forms, so that he didn’t have any sense of overburdening of responsibility or feel any guilt. Relatives and patients have different barriers to discussions and decisions surrounding DNACPR and end of life planning. In this case, I believe I understood these barriers and pre-empted them well e.g. by asking the brother to bring a relative to the meeting. It also acts as a “warning shot” i.e. that more complex or serious discussion is planned, which I think probably helped frame his mindset prior to attending. For this case, having a relative who understood the process was reassuring in this case but I felt that overall the conversation we had about the form was set at the right level and pace, so had the relative not been medical, they hopefully would have been reassured. If the relatives had not agreed with the process, I would have addressed their specific concerns and barriers, corrected any areas of confusion and explored their expectations. Failing these conversations I think I would have deferred to the consultant and directed the relatives to NHS website resources to further think about the topic and ask them to return to discuss further.

1) Further experience with DNACPR discussions in different environments 2) Understand palliative care support available in the community inc. for specific needs of certain illnesses e.g. dementia, MND, cancer, MS etc.

1) Reflect on cases in future placements 2) self directed study

Example # 10:

Subject title: Assessing a patient with Learning Disability

I was asked to assess a 21 year old patient out of hours who had a diagnosis of learning disability, living with his mother who also had a learning disability but less severe. His mother explained that the patient had been leaving the house regularly in order to ‘find friends’, resulting in him hanging around homeless persons and searching out known gang members. The patient had been drinking dregs of alcohol bottles/cans left on the street, smoking cigarette butts and taking unknown drugs offered to him by gangs (but his mother suspected they were making a tally of costs he owed). He also had been steered home by these gang members to ask his mother and family for money for them. The incident preceding this admission involved the police following a fight between 2 known gangs carrying machetes. The patient was found by police visibly upset and confused so was taken home. The patient had been developing psychosis over the preceding months causing him to behave aggressively and fleeing his home spontaneously due to fear of his hallucinations of ‘Freddie’.

The patient was admitted due to concerns surrounding his safety. Initially admitted to an adult ward, with a view for transfer over to the learning disabilities ward.

The 2 main learning points of this case were surrounding safeguarding issues and communication. This patient was extremely vulnerable, despite his age, his communication skills and understanding of the world could not have been more than that of a 4-5year old. The hallucinations he was experiencing seemed to re-enforce this because his fears and hallucinations were of ‘Freddy Kruger’, a monster like character, under his bed or in his wardrobe. Hallucinations are often congruous to the persons’ age, culture and experiences. These hallucinations were scaring him and his response was to run away from them, which his mother was having difficulties managing because of her own LD and his violent behaviours. This patient was extremely socially isolated – due to his age there were limited services available to him to help him socialise and make friends, therefore he sought out opportunities to meet people and then mistook the manipulative and exploitive behaviour of the gang members he met as acts of friendship. From the history these gang members were evidently exploiting his vulnerability and perhaps even his mother’s. There was limited support given to the mother, aside from the police, who she regularly called to report the patient as a missing person. I found this quite sad; the mother reported that they had been on the ‘list’ for a social worker for 18months and were still waiting for some support. She was anxious that her son wasn’t arrested for his involvement with gang members and possibly drugs. This consultation required a lot of time: The patient had an obvious processing delay, exacerbated by the sedative medication that he took to manage his psychosis. He had significant poverty of speech and so his mother had to relay a lot of his history, which in itself was not always clear or was missing elements because the mother hadn’t been there. I noticed that the patient had a tendency to agree to things and so I avoided questions with a ‘yes’/’no’ answer, but this was also quite difficult due to the patient’s poverty of speech and general shyness being asked questions by a doctor he had never met. With time, we managed to gain a clear enough picture to be able to understand what had been happening. The patient also had a sister who cared for both the patient and patient’s mother alongside her own young family and so, when it became a more suitable hour, I called her for collateral information and carer’s perspective which was useful.

This was a really difficult case, especially for a GP to manage without rapid support and input from community, social support and mental health services. There were so many safeguarding issues for both the patient and mother’s perspective. They are known to be vulnerable characters in the community and on further information gathering, have been targeted and exploited previously by gang members and also fraud perpetrators. Having said that, the patient had not had a social worker since he was a child and was on a waiting list yet to receive allocation, which illustrates a disconnect between child and adult services. The referral to social services had been made 18months prior, I think this case demonstrates the importance of updating referrals to try and expedite them when a situation deteriorates. This would also be a case I would discuss with the practice to try and share ideas on how to manage this case. A key part of the patient’s perceived problem was that he wanted friends: I think it is easy to overlook the social problems/group them as one big factor that we can’t address easily and then focus on the medical side. I have learned not to underestimate the value of social network groups. Perhaps this patient would have benefitted from being counseled about groups such as ‘mind’ which offer social structures for younger adults. Finally, for patient’s with LD, it is important to try and give more appointment time for them so they can have the opportunity to explain what has happened and more completely understand what counseling or advice is offered, in addition to being able to explore and come up with solutions together. I cannot imagine that a GP would have been able to assess this patient in a 10 minute consultation.

1) More understanding and experience managing patients with safeguarding issues 2) More experiencing communicating with patients who have special communication requirements inc. language barriers

1) Safeguarding e-learning on elfh and other sources 2) Reflect on safeguarding cases in psychiatry, paediatrics and GP placements 3) Attend safeguarding MDT meetings 4) Develop better consultation techniques for patients with LD

Special thanks to my wife and my GP trainees for sharing the examples of reflective practices

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