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Introduction: corrected
During my placement at an eating disorder unit, I encountered a significant episode of care involving the insertion of a nasogastric (NG) tube for a patient named Ada. To uphold ethical guidelines outlined in the NMC Code of Conduct (NMC, 2018), a pseudonym, “Ada,” will be used to refer to the patient. As a mental health nursing student, I participated in Ada’s care under supervision. Ada’s refusal to eat led to significant weight loss, prompting interventions including the NG tube insertion. Throughout this assignment, I will critically reflect on this episode, focusing on the therapeutic relationship between nursing staff and Ada. Ada’s case was chosen due to its complexity and profound impact on her well-being. The risk in this episode stemmed from Ada’s refusal to eat, resulting in weight loss and deterioration of her physical and mental health, compounded by her self-harming behaviors. The insertion of the NG tube highlighted ongoing risks of self-harm and strained therapeutic relationships with the nursing staff on the ward. In this assignment, I will examine the evidence-based holistic nursing assessment of Ada’s situation, critically reflect on my experiences, appraise relevant evidence and theories, evaluate nursing interventions, and conclude with recommendations for similar episodes of care in the future. Additionally, I will delve into the therapeutic relationship between nursing staff and patients, emphasizing its pivotal role in patient recovery. Examples from my experience will be provided to illustrate the importance and impact of this relationship on patient outcomes.
Evidence-based holistic nursing assessment:1: During the progression of this care episode, Ada expressed to us that she thought food was 
Ada’s thoughts, feelings, and behaviors during the episode of care portrayed profound struggles with eating and self-harm. Despite her declining physical health, Ada adamantly resisted eating, reflecting underlying psychological distress and disordered eating patterns. 
Use this paragraph to adjust the written paragraph above to describe Ada’s thought, feelings and behaviour. Use words like Ada’s expressed this and this?!
Ada’s will constantly tell us that she thought food was the devil. Ada was underweight.
Ada adamantly resisted eating as she would throw up straightaway after eating and results to head banging. This part of behaviour (which theory?) suggest that there’s a psychological distress occurring and maybe disorders patterns of eating.
Additionally, Ada’s self-harming behaviors, such as head banging, underscored her profound emotional turmoil and coping mechanisms. 
Use simple language for clear understanding in this section?!
A holistic assessment of Ada’s bio-psycho-social context unveiled a complex interplay of factors contributing to her current presentation. 
Use simple language and explain what this means?
Ada’s history of trauma significantly influenced her relationship with food and her sense of self-worth
Use the below to make adjustments to the above! Delve into it?
Ada’s history of trauma significantly influenced her relationship with food because she envrious that and why Ada expressed  the reduce a sense of self  worth as she  often expressed her feelings saying I’m not worthy, I’m useless etc.
Early experiences of distress left enduring scars, exacerbating her disordered eating behaviors and self-harm tendencies within the supportive yet triggering environment of the eating disorder unit.
Use the below to make adjustments and use simple language to delve deeper?!
From actively listening to the words that Ada says, and how she expressed her emotions to us left us with the understanding that her real experience has left her with enduring scares.
Ada’s family played a crucial challenging role in her care. While they provided emotional support, and faced challenges in understanding and addressing Ada’s complex needs, Ada’s struggles strained their relationship, leading to frustration and helplessness. Despite their best efforts to support Ada, they grappled with the depth of Ada’s psychological and emotional distress, highlighting the need for a comprehensive approach to her care. 
Use the below to make adjustments and use simple language to delve deeper?!
Ada’s family played a crucial role yet what she described as a challenging role in her life. Talk about her family background, the issues she had with her family, family not understanding and accepting her due to her being bisexual. Which emotional support did the family provide Ada? Also start by saying Ada’s family attempt to provide what they perceived as emotional support for Ada, they face challenges in understanding and addressing Ada’s complex needs, Ada’s struggle strained they relationship which led to frustration on behalf of Ada and what she expressed of feelings of helplessness?!
Show how Ada verbalised her experience to us.? From Ada’s perspective, what she verbalised towards , how she was experiencing her care.
The assessment of risk in Ada’s case revealed multifaceted challenges to her physical and emotional well-being. Her ongoing self-harm behaviors, including skin peeling and head banging, posed immediate risks to her physical safety and well-being. Furthermore, Ada’s compromised physical health due to severe malnutrition and refusal to eat necessitated urgent intervention to prevent further deterioration. The nursing care Ada required a holistic approach, addressing her bio-psycho-social needs, focusing on promoting physical healing, addressing psychological distress, and rebuilding therapeutic relationships.
Demonstrate an understanding of what bio-psycho-social assessment and what it means and what theory was used and the holistic approach considering Ada as a whole person, addressing her  bio-psycho-social assessment? Discuss relevant theories and concepts related to holistic nursing care, considering Ada as a whole person and taking account her unique circumstances, also address all aspects of her well-being are addressed?!
Ada’s cultural background and experiences of discrimination and rejection due to her sexual orientation further compounded her emotional distress and sense of isolation. Growing up in a society where homosexuality is stigmatized and even criminalized before moving to the UK, Ada faced immense pressure to conform to societal norms and conceal her true identity. The rejection and lack of acceptance from her family due to her sexual orientation exacerbated her feelings of worthlessness and alienation, contributing to her struggles with disordered eating and self-harm.
Furthermore, Ada’s experiences of bullying and discrimination during her high school intensified her feelings of inadequacy and fueled her self-destructive behaviors. The intersectionality of Ada’s identity as a lesbian from a culturally conservative background highlighted the complex interplay between societal expectations, internalized shame, and mental health struggles.
Critical reflection on self:
During Ada’s episode of care, my experience was indeed marked by complexity, empathy, and a profound exploration of my role as a caregiver to a patient struggling with eating disorders and self-harm behaviors. Ada’s initial reticence gradually shifted as instances of self-harm became more pronounced, presenting a significant challenge for both Ada and the healthcare team. Witnessing Ada’s distressing behaviors, particularly during episodes of head banging, evoked a strong emotional response within me. The sense of helplessness was palpable as Ada remained unresponsive and resistant to engagement with the staff. This experience left a profound impact on me, reinforcing my determination to find effective ways to support her through her struggles. The episode where Ada engaged in head banging and required restraint by two HCA staff members was particularly challenging. Despite our collective efforts to intervene and prevent harm, Ada remained unresponsive, underscoring the severity of her condition and the urgent need for comprehensive support and intervention. This experience deepened my resolve to connect with Ada on a personal level and explore innovative approaches to facilitate her recovery.
An opportunity to connect with Ada presented itself when I had a one-on-one conversation with her after she had settled down. Engaging her in games and casual conversations allowed us to establish a rapport, and I noticed a noticeable shift in her demeanor as she began to open up. This interaction sparked my curiosity about Ada’s background and experiences, prompting me to delve into her records to gain a deeper understanding of her challenges and needs. As I delved into Ada’s records, a profound sense of empathy swept over me as I began to grasp the depth of the challenges she had endured. Her history shed light on the underlying factors contributing to her current presentation, further motivating me to provide personalized and compassionate care tailored to her unique needs. It became evident that Ada’s journey toward recovery would necessitate a holistic approach addressing her physical, emotional, and psychological well-being. In retrospect, this experience served as a poignant reminder of the importance of empathy, connection, and personalized care in mental health nursing. By critically reflecting on my practice and learning from this experience, I am better equipped to navigate similar situations in the future and advocate for the holistic well-being of my patients, like Ada. As Ada’s condition progressed, I found myself increasingly drawn to her case, particularly intrigued by her selective interactions, which were mostly directed towards me. Our shared age and proximity fostered a connection that allowed Ada to gradually open up to me. Our conversations, seemingly mundane on the surface, held significant meaning for Ada, providing her with a sense of comfort and support during her time in the unit. Over time, I became more involved in Ada’s care, accompanying her to nursing clinics during her NG feeds and providing emotional support before and after each feed. The turning point came when Ada accepted her NG feed without struggles and began to show signs of relaxation and progress. Witnessing this transformation in Ada’s attitude, where I played a role in influencing her mindset and catalyzing positive change, filled me with a profound sense of pride and satisfaction. In addition to our conversations, I also engaged Ada in games, particularly Ludo, and encouraged her to participate in activities such as making necklaces and bracelets with other peers. These activities served as a source of distraction and enjoyment for Ada, cheering her up and providing moments of respite from the challenges she faced. Our shared experiences in these activities further strengthened our bond and contributed to Ada’s overall well-being during her time in the unit.
Critical appraisal of evidence:
In the context of the episode of care involving Ada, who exhibited resistance to eating and engaged in self-harming behaviors such as head banging and skin peeling, the application of therapeutic relationship theory is essential in understanding the dynamics between the healthcare staff and the patient. The therapeutic relationship theory emphasizes the establishment of a strong, empathetic, and effective connection between healthcare providers and patients, contributing to improved patient outcomes and overall well-being (Hartley, 2020). Analysing the clinical guidelines and evidence pertaining to the care of individuals with eating disorders and self-harm behaviors reveals the necessity for a multifaceted approach. According to clinical guidelines, individuals like Ada should receive comprehensive care addressing both physical and psychological needs, including nutritional support, psychological assessment, and therapeutic interventions (NICE, 2022). However, it is crucial that these interventions are carried out within the context of a therapeutic relationship, prioritizing communication, empathy, and trust-building (Sharma, 2023).
Applying this evidence to Ada’s episode of care, it is evident that the insertion of a nasogastric (NG) tube was a necessary intervention to address her severe malnutrition and prevent further physical deterioration, aligning with clinical guidelines for medical management (NICE, 2022). However, the effectiveness of this intervention is contingent upon the quality of the therapeutic relationship between the healthcare staff and Ada. In Ada’s case, the nursing staff’s ability to establish a supportive and empathetic connection with her was crucial for fostering trust and engagement in care. By demonstrating empathy, active listening, and non-judgmental acceptance, the nursing staff created a safe space for Ada to express her feelings and concerns, facilitating a collaborative partnership in her recovery journey (Bolsinger, 2019).
According to Rogers (1951), the therapeutic relationship theory provides a foundation for holistic and patient-centered care. This theory posits that a positive relationship characterized by empathy, trust, and open communication enhances patient engagement and adherence to interventions (Ardito, 2011). In Ada’s case, her gradual acceptance of NG feeds and willingness to engage in activities and conversations with the nursing staff suggest the positive impact of the therapeutic relationship on her recovery. Assessing the quality of the evidence, it is essential to acknowledge that clinical guidelines are typically grounded in a combination of empirical research, expert consensus, and best practice principles. However, the effectiveness of these guidelines can be variable based on the context and the unique characteristics of each patient (Mitchell, 2021). Additionally, the evidence regarding the therapeutic relationship’s impact on patient outcomes is well-established and widely accepted within the healthcare community (Yao, 2023). It is reinforced by studies showing that a positive therapeutic relationship contributes to better patient satisfaction, adherence to treatment plans, and emotional well-being (Steindl, 2023).
Considering the research identified, there is a strong case to argue that the principles of the therapeutic relationship theory would be effective for Ada’s episode of care. The personalized connection that developed between Ada and the nursing staff suggests that the theory’s emphasis on building trust and rapport can indeed lead to improved patient outcomes. However, it is essential to be mindful of potential limitations, such as over-dependency on specific staff members, which could hinder Ada’s ability to interact with a broader range of healthcare professionals (Morse, 2012). In Ada’s case, the therapeutic relationship theory provides valuable insights into the dynamics between Ada and the nursing staff, emphasizing the importance of empathy, trust, and open communication in promoting positive patient outcomes. By applying evidence-based practices informed by therapeutic relationship theory, healthcare providers can optimize the quality of care provided to individuals like Ada, ultimately contributing to their recovery and well-being.
Evidence-based nursing interventions:
Evidence-based nursing interventions are crucial for effectively managing complex cases such as Ada’s, particularly when addressing self-harm behaviors like head banging and skin scratching. Hawton et al. (2015) highlight the prevalence of self-harm behaviors among individuals with eating disorders and emphasize the importance of tailored interventions to address these behaviors. In Ada’s case, her engagement in head banging and skin scratching poses significant risks to her physical health, as evidenced by her hospital visits due to resulting wounds. This underscores the need for proactive risk assessment and management strategies to prevent further harm.
Moreover, Mitchell et al. (2018) emphasize the role of therapeutic relationships in reducing self-harm behaviors and promoting recovery among individuals with eating disorders. Nursing interventions that focus on building trust, empathy, and communication are essential for fostering a supportive environment where patients like Ada feel safe to express their emotions and concerns. For example, engaging Ada in meaningful activities, such as art therapy or relaxation techniques, could provide alternative coping mechanisms to reduce the urge to engage in self-harm behaviors.
Furthermore, guidelines from the National Institute for Health and Care Excellence (NICE, 2020) emphasize the importance of multidisciplinary collaboration in the management of eating disorders and associated self-harm behaviors. This involves coordination between nursing staff, mental health professionals, dieticians, and social workers to develop comprehensive care plans tailored to the individual’s needs. In Ada’s case, involving mental health professionals in conducting psychotherapeutic interventions, such as dialectical behavior therapy (DBT), could help address underlying emotional dysregulation contributing to her self-harm behaviors. Additionally, ongoing education and training for nursing staff are essential for enhancing their knowledge and skills in managing self-harm behaviors effectively. Workshops or seminars on trauma-informed care, crisis intervention, and de-escalation techniques can equip nurses with the necessary tools to respond to challenging situations like Ada’s with confidence and competence (Kutash et al., 2016). Moreover, regular case discussions and debriefings provide opportunities for reflection and learning from past experiences, enabling staff to refine their approach and improve patient care over time. In evaluating the appropriateness, effectiveness, and quality of nursing care provided to Ada, it is essential to consider whether the interventions implemented were tailored to her individual needs, preferences, and cultural background. Assessing whether the risks associated with Ada’s self-harm behaviors were effectively identified and managed according to established protocols and guidelines is crucial. Additionally, evaluating the effectiveness of nursing care entails measuring whether the interventions employed yielded the desired outcomes, such as observable improvements in Ada’s behavior, emotional state, and overall well-being. Lastly, analyzing the quality of care given involves considering factors such as patient satisfaction, safety, and adherence to best practices, ensuring that nursing interventions were aligned with evidence-based guidelines and administered with compassion and respect.
In conclusion: the episode of care involving Ada underscores the complexity and challenges inherent in managing individuals with eating disorders and self-harm behaviors. Through a comprehensive holistic nursing assessment, it became evident that Ada’s struggles were influenced by a multitude of factors, including her bio-psycho-social context, traumatic experiences, and cultural background. Critical reflection on personal experiences highlighted the importance of empathy, connection, and personalized care in fostering positive patient outcomes. Based on the findings and critical appraisal of evidence, several recommendations can be made for similar episodes of care in the future. Firstly, it is imperative to prioritize the establishment of a therapeutic relationship between nursing staff and patients, as this forms the foundation for effective care delivery. Building trust, empathy, and open communication are essential components of this relationship. Secondly, evidence-based nursing interventions tailored to the individual’s needs, preferences, and cultural background should be implemented. This may include multidisciplinary collaboration, psychotherapeutic interventions, ongoing education and training for nursing staff, and regular case discussions to enhance knowledge and skills.
Furthermore, proactive risk assessment and management strategies should be in place to prevent further harm and promote patient safety. This may involve close monitoring of self-harm behaviors, crisis intervention protocols, and the implementation of trauma-informed care approaches. Lastly, continuous evaluation and reflection on the quality of care provided are essential to identify areas for improvement and ensure that nursing interventions are aligned with evidence-based guidelines and administered with compassion and respect. By adhering to these recommendations, healthcare providers can optimize the quality of care provided to individuals like Ada, ultimately contributing to their recovery and well-being.
References:
1. Hartley, J. (2020). The therapeutic relationship in nursing practice: A literature review. Journal of Advanced Nursing, 76(1), 16-26.
2. NICE. (2022). Clinical guidelines for eating disorders management. Retrieved from https://www.nice.org.uk/guidance/ng69.
3. Sharma, S. (2023). Building therapeutic relationships in mental health nursing: A reflection on practice. Journal of Psychiatric and Mental Health Nursing, 30(2), 156-165.
4. Bolsinger, J. (2019). Therapeutic communication and the nurse-patient relationship: A qualitative study. International Journal of Nursing Studies, 94, 65-73.
5. Rogers, C. (1951). Client-centered therapy: Its current practice, implications, and theory. Houghton Mifflin.
6. Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: Historical excursus, measurements, and prospects for research. Frontiers in Psychology, 2, 270.
7. Mitchell, M. L., & Jolley, J. M. (2021). Research design explained. Cengage Learning Australia.
8. Yao, X., Zhao, J., & Yang, H. (2023). Therapeutic relationship and patient satisfaction: A systematic review and meta-analysis. Journal of Clinical Nursing, 32(3), 345-354.
9. Steindl, S. R., & Cook, J. M. (2023). The therapeutic alliance in trauma treatment: Clinical implications and research directions. Journal of Trauma & Dissociation, 24(4), 467-483.
10. Morse, G. (2012). Dependency and its impact on therapeutic relationships: A literature review. International Journal of Nursing Studies, 49(12), 1562-1574.
Hawton, K., Saunders, K. E., & O’Connor, R. C. (2015). Self-harm and suicide in adolescents. The Lancet, 385(9979), 2430-2441.
Mitchell, A. E., Cook, A., & Wicks, L. (2018). Therapeutic nursing in mental health settings. Nursing Standard, 32(13), 53-61.
National Institute for Health and Care Excellence. (2020). Eating disorders: recognition and treatment. Retrieved from https://www.nice.org.uk/guidance/ng69
Kutash, K., Armusewicz, K., & Friedman, R. M. (2016). The importance of staff training in the implementation of positive behavioral interventions and supports. Journal of Positive Behavior Interventions, 18(2), 95-100.

2. Transportation and housing are drivers of health and equity. Describe the steps you would take as a nurse to evaluate transportation and housing for your identified community population and what actions you could perform to identify resources
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