A critical incident is a situation that occurs as a result of a person’s actions, causing an emotional reaction. Through reflection, it allows individuals to analyze the incident and make necessary changes both personally and professionally (Burns and Rosenburg 2001). The purpose of this essay is to examine an incident that occurred during my clinical placement. Using my chosen reflection model, I will reflect on the incident by analyzing its positive and negative aspects, evaluating my performance, and creating an action plan for future practice.
This essay will provide an opportunity for in-depth reflection and critical discussion of my actions and performance. I have chosen to follow the Gibbs model of reflection (Gibbs, 1988) as it allows for the expression of thoughts and feelings. This model is less structured than others, which enables me to offer a deeper explanation and critical analysis on a less structured level (Wilding, 2008). In accordance with the Nursing and Midwifery Council (NMC) code of conduct (2008), the location of the clinical placement and names of those involved will be omitted from this essay to maintain confidentiality.
To follow the Gibbs model of reflection, this section will focus on examining the incident description and the feelings of those involved. The incident I wish to discuss occurred during my first week of clinical placement in an older adult psychiatric ward. The individuals involved were myself, my mentor, and a female patient.
Upon quickly settling into the ward, my mentor pointed out that I had developed strong relationships with both staff and patients.
My mentor suggested that I conduct unsupervised 1:1 care plan reviews for a specific reason. This opportunity was significant to me because it was my first chance to engage with clients without supervision and take sole responsibility for a patient. Developing skills in this area is crucial since it is a common feature of nursing that helps with recovery. Situations like these have also been claimed to offer some sort of therapy in themselves (Priebe and McCabe 2008).
During my first care plan review, I had the opportunity to work with an elderly female patient who had been informally admitted to the ward due to low mood and anxiety. With her consent, I accompanied her to a quiet location where we could discuss her care plan without any interruptions and ensure confidentiality. The review lasted for 45 minutes, during which we worked together as partners to evaluate and revise the current care plan. I made sure to use this time as an opportunity to strengthen our therapeutic relationship while documenting all relevant details of our conversation.
At the beginning of the review, my initial confidence began to diminish. Although I remained warm and open, I felt that the conversation was stilted as I relied upon written questions. The patient appeared relaxed and was very forthcoming with her views and further information. As a result, I began to relax and trust my abilities. However, although my interpersonal skills improved, I found it difficult to record information while maintaining the conversation.
After completing the review, the patient stated that she found me very approachable and felt at ease knowing that there was someone she could approach with any issues. Although I was nervous at the beginning of the review, I relied on my interpersonal skills to make the patient feel relaxed. During the review, I felt pressured when recording information and had to complete some of the paperwork afterward to ensure accuracy and legibility. (Section 2)
Within this section, I wish to explore two key issues that I feel play an important role in this particular critical incident. This section incorporates the evaluation and analysis element of the Gibbs model of reflection (Gibbs, 1988). A therapeutic relationship has been described as an ongoing partnership between the practitioner and the patient involving appropriate communication that develops trust and a feeling of honesty (Krauss, 2000). Priebe and Gruythers (1993) stated that building a therapeutic relationship can improve the outcome of interventions and assist with patient recovery.
Building a therapeutic relationship is the main topic I wish to address in this essay. In past situations, I have always taken a partnership approach to nursing interventions. This may be due to my personality and training, as the importance of partnerships has been repeatedly highlighted in the Ten Essential Shared Capabilities (ESC) framework (Department of Health, 2004) and the Millan principles which are the foundation of the Mental Health (Care and Treatment) (Scotland) Act 2003.
Research conducted by Berg and Hallberg in 2000 found that there are two styles of mental health nursing: the collaborator,” who establishes a therapeutic relationship based on partnership, and the “expert,” who takes an authoritative approach and leads interventions. During this incident, it became evident to me that I wanted to establish a partnership with the client, which greatly influenced the progression and style of the care plan review.
Rodgers (1951) emphasized the importance of unconditional positive regard in developing a therapeutic relationship. During my review, I made sure to remain polite to maintain a friendly atmosphere and ensured the patients’ dignity at all times. This was achieved by obtaining consent before progressing, choosing a private location, and maintaining unconditional positive regard towards the patient. A study conducted by Dziopa and Ahern (2009) found that treating patients with dignity was one of the most crucial factors in developing a therapeutic relationship.
It is important for practitioners to regard patients unconditionally and avoid judging or evaluating them based on personal views. Adopting this attitude allows nurses to avoid imposing any restrictions on patients, allowing them to express themselves and accept their own decisions (Todd & Bohart 1994). During the review, I noticed that some of the reasons behind the patient’s low mood were similar to those faced by the average member of the public.
However, these were my personal feelings. I understood that patients with low mood tend to catastrophize events and situations (Armstrong, 1998), causing them real distress. In researching the factors that constitute a therapeutic relationship, Scanlon (2006) found that some participants believed that patients’ opinions can be formed immediately during the first meeting and it is impossible to completely remove oneself from these opinions.
However, I found that despite having personal feelings, I was able to detach from them and maintain a non-judgmental attitude. This has been highlighted as a key feature in building a therapeutic relationship (Safran and Muran 2003). Dziopa and Ahern (2009) discovered that nurses who adopt an equal partner approach believe that communication is an essential factor in developing a therapeutic relationship. In the early stages of the interview, my anxieties affected my questioning skills as I relied on a set of pre-written questions.
This incident impacted my professionalism, and I feel it allowed the atmosphere to develop into one focused on completing tasks rather than assisting with recovery. In the same study, nurses interviewed valued communication but saw little benefit in self-monitoring their performance (Dziopa and Ahern 2009). However, upon reflection of this incident, I disagree with that statement. Recognizing my faults helped me understand that I needed to change my questioning style or risk jeopardizing the relationship and care plan review.
After realizing that my questioning skills appeared rehearsed and unnatural, I quickly adopted a more relaxed approach. I used my interpersonal skills along with my knowledge of questioning to progress the interview on a more natural level. Realizing that there was a need for me to relax, I took a moment to pause and gather my thoughts. This allowed me to gain control of my breathing which had become quick and shallow.
After doing this, I remained conscious of my breathing pattern. Keeping my breaths long and deep, when possible breathing in through my nose and out through my mouth helped me remain relaxed (Wilkinson et al 2002).
Although I had improved my communication skills through my altered style, there were still times when I felt ill-equipped to respond to certain details disclosed. During the review, when a patient raised concerns and looked to me for answers, I sometimes felt unable to offer a reasonable response and sidestepped the question due to my current level of training. A study by Scanlon (2006) highlighted that providing information is a key element in building a therapeutic relationship.
According to the psychiatric nurses involved in this study, it is crucial to clearly explain your objectives and encourage clients to ask questions and seek clarification if they are uncertain about any issues. Additionally, nurses should always strive to provide accurate answers and not avoid any raised concerns. During the review, I noticed that I was not confident in responding to certain questions which I attribute to my lack of experience in these situations.
Priebe and McCabe (2008) stated that one reason for avoiding certain questions is a lack of specific training or experience in the area. Throughout the review, I maintained feelings of empathy and sympathy towards the patient. It’s crucial to have sympathy for the patient as it fosters a caring attitude. However, it’s also important that nurses don’t overlook the causes of these emotions, which is why empathy is essential. By using empathy, nurses can understand issues from patients’ points of view.
This allows the nurse to have a clearer plan of what needs to be addressed (Barker & Buchanan-Barker, 2005). By utilizing all these aspects, I was able to build upon the therapeutic relationship and develop a sense of trust between the patient and myself. The use of empathetic understanding helped encourage a sense of safety, allowing the patient to feel secure (Scanlon, 2006) and confident that they could come to me in the future with other issues or just as someone to talk with. Building a therapeutic relationship was important in fostering feelings of safety and openness so that patients felt at ease discussing their issues.
However, I feel that there is a need to discuss the importance of documenting the information and details disclosed. This is why I have chosen record-keeping as the second key topic to discuss as part of the critical incident. I will follow Gibbs’ model of reflection (Gibbs 1988) by evaluating and analyzing this key topic. Accurate and up-to-date record-keeping forms the basis of good nursing care, and maintaining these records is highly encouraged (Moores 1996). The care provided to patients relies heavily on the quality and relevance of information available to practitioners.
As nurses are at the forefront of care, they are regarded as key instruments for obtaining and recording patient information. This information is then used by other practitioners to plan, assess, and evaluate care given (Moloney 1999). When entering into this situation, I understood the importance of documentation as this information would inform other practitioners about what has occurred (Taylor 2003). As a nurse is accountable for their actions, it is essential that the documentation is accurate and relevant. It should state the reasons why an intervention was carried out and its outcome (NMC 2008).
A nurse is accountable to the patient, the profession, the employer, and themselves. Therefore, it is vitally important to be able to justify any decisions made (NMC 2008). These decisions should be evidence-based and promote safe nursing care. In some legal cases, it has been argued that if a procedure or intervention has not been recorded, then it is considered not to have taken place (NMC 1998). This highlights the need for accurate records. Although I had an understanding of the theory and reasoning behind accurate record-keeping, I lacked experience in doing so which affected my performance in a number of ways.
During the review, I attempted to document the nursing process as accurately as possible. However, I felt that the formality of record-keeping detracted from describing how patients’ issues were addressed. This view was also expressed by some nurses involved in research by Martin et al (1999). These nurses stated that nursing records sometimes do not accurately describe the quality of care provided. When writing the evaluation for the review, I realized that I got too involved with documenting specific details and omitted potentially useful information about how patients responded.
Taylor (2003) stated that areas commonly omitted from records are those surrounding the maintenance of dignity, meeting emotional, spiritual, and cultural needs. While I agree with this statement to some extent as I did omit some of this information, I also understand the importance of keeping records specific, factual, accurate and consistent (NMC 2004), which is how my evaluation and care plan review was presented. As the care plan review was completed in partnership, it was important that updates to the care plan were made as we progressed.
This approach had its advantages as it allowed for updates and reviews to be completed based on the patient’s own views, making them feel involved in their care (Department of Health, 2004). Providing care in this manner aligns with ethical principles such as autonomy, choice, equity, and fairness (Beauchamp & Childress, 2001). However, a disadvantage was that I felt pressured to complete the records accurately while conducting the review. This pressure affected both the information I documented and its presentation.
During the interview process, I made a mental note of the issues that were being expressed. At the end of each section, we completed paperwork documenting the outcome. However, upon reviewing the information after the interview, I realized that I had omitted some of the disclosed information. This may have been due to time constraints. Taylor (2003) stated that omissions can occur when there is a lack of time and nurses may make a mental note of information that they later deem to be unimportant.
Upon reflection, if I had incorporated every detail that was disclosed, the care plan review would have become very lengthy. Additionally, some of the material may have been irrelevant and outside of the NMC (2004) guidelines. Completing the care plan records in this way also affected the presentation of the document. My handwriting was rushed at times and my spelling questionable. However, in this situation, any spelling errors made would not have had a detrimental effect on the patient’s care.
In some cases, spelling errors and illegible handwriting can have a serious impact on actions undertaken by other practitioners. For example, incorrect spelling of a patient’s name may result in the inability to obtain test results or errors in the spelling of medications may result in medications not being administered or the wrong medication being offered (Diamond 2005). Although the errors made during this review were few and of little importance, I felt that the document looked unprofessional and clearly displayed my inexperience. This disheartened me a little.
In keeping with the basis of the Ten ESC’s and the Recovery Approach, it was necessary for me to include the patient in documenting the review. This ensured that the review details expressed the true feelings and views of the patient in question, promoting ethical value of autonomy. Working as partners ensured that we agreed on a care plan with achievable aims, ensuring I was doing what was best for my patient while promoting their wishes and choices (Beauchamp & Childress 2001).
This approach assists in the recovery of patients as it gives them some control over their care and allows them to develop feelings of confidence and optimism (Department of Health, 2004). Although I saw the benefits of conducting the review in this way, I felt that sometimes my attention was drawn to writing notes and paperwork. Dziopa and Ahern (2009) found that nurses considered giving full attention to the patient a high priority when building a therapeutic relationship.
Although the lack of attention was minimal, I felt that it detracted from the relationship and flow of the review. At times, I would lose eye contact which affected my interaction with the patient (Section 3).
Having evaluated and analyzed the main key issues, I now wish to examine what else could have been done to improve patient interaction. This section aligns with the conclusion section of Gibbs’ (1988) model of reflection. Overall, I feel that there is room for improvement in future reviews.
Although the process was satisfactory and I was able to start building upon the therapeutic relationship, there were still many areas that could have been improved. In the evaluation section, I highlighted that my personal feelings were apparent to me. Initially, I had issues with my confidence which heightened my anxieties. Ecroth-Bucher (2001) stated that self-awareness is an important part of mental health nursing, which I feel was an element missing from my interaction. Although I was very aware of how I should be treating the patient, I neglected to examine my own vulnerabilities before entering into the situation.
Before inviting the patient to the review, it would have been beneficial for me to examine my feelings and abilities. This would have allowed me to think about my accountability and address any anxieties I may have had. Additionally, it would have given me the opportunity to organize my paperwork and arrangement of the interview.
If I had conducted myself this way, I could have explored my own motivations for the interview, examined my beliefs, and reflected on previous experiences (Dziopa and Ahern 2009).
This would have allowed me to address any personal issues or views that may have become apparent during the review. Doing so would have assisted me in detaching from my personal views and thoughts. Additionally, I highlighted issues related to my communication skills, specifically regarding my questioning abilities and answering some patient questions. In retrospect, I feel that if I had examined myself a little further, I would have realized that although I may have been anxious, I possessed the necessary interpersonal skills to conduct the review in a pleasant and dignified manner.
Communication is a skill that develops over time. However, it is important to remember that a nurse’s personality can greatly improve a situation even if there are deficiencies in communication (Priebe & McCabe, 2008). Therefore, when I was struggling with my confidence and questioning myself, it would have been helpful to use my personality and interpersonal skills earlier. As for my record-keeping abilities, I believe there was little else that could have been done differently at the time.
I would still conduct the review in this way, as it respects working as a partnership. However, it may have been more appropriate to not take short notes and rely on my listening skills to pick up and remember information. This would have allowed me to maintain eye contact and give my full attention to the patient (Dziopa and Ahern 2009), then summarize and complete paperwork together. Certainly, my handwriting could have been improved, and I could have put more concentration into presenting information accurately.
However, the presentation of records can vary greatly depending on factors such as the importance of the task and the time constraints that the nurse is under at that time (Diamond, 2005). After highlighting my perceived deficiencies during this critical incident, it is important to develop an action plan to assist me when a similar situation arises again (Gibbs, 1988). My initial action after this incident was to include this experience in my reflection diary which I kept while on placement.
This experience greatly assisted me in reflecting back on the incident and evaluating my performance. It has also allowed me to maintain my personal and professional portfolio, which is a requirement of the NMC Code of Conduct (2008).
Furthermore, this incident highlighted the importance of clinical supervision. As a student nurse, I work in a continually changing environment and face new challenges regularly. Clinical supervision provided me with an opportunity to explore my issues and performance, encouraging an environment of self-awareness (Rice et al., 2007).
For this reason, I will always seek support in potentially stressful situations and to assist with my professional development. As a result of this experience, it became apparent that I must spend more time getting to know myself better and become self-aware. This will allow me to evaluate my own skills and views on an ongoing basis, which will improve my abilities and confidence when conducting future interviews. Adopting this approach will enhance my reflection skills and, in the future, allow me to act on a more natural and instinctive level rather than something that has been learned and deeply thought about (Scanlon 2006).
In the future, I will ensure that I address any personal views and issues before conducting any kind of interaction. This will ensure that I separate my personal problems and issues from those of the patient (Dziopa and Ahern, 2009). This once again highlights the importance of reflecting on our professional practice and personal life since we continually experience different situations and make decisions that influence our learning (Hannigan, 2001).
Through practice, I will continue to improve my record-keeping skills. It is only in this way that I will be able to develop my professional style and become confident when assessing what information is important. In the future, I will ensure that I give patients my full attention by utilizing my listening skills and leaving documentation until the appropriate time. Conducting myself in this way may also give me more time to concentrate on writing and spelling to make the document legible and professional in appearance. In conclusion, I feel that this incident has contributed greatly to my personal and professional development.
It is clear to me that not all patients will react and present in the same way. Therefore, I will have to continually develop my skills to effectively communicate with them. This will require ongoing training, supervision, reflection, and evaluation. It is not only important that I am aware of the patient’s needs and issues but also vitally important that I am self-aware and examine the ethical issues surrounding care.
Practicing in this way has improved my professional performance but has also helped me develop on a personal level. Now, I truly understand the importance of reflection.
