A critical incident is a situation that occurs as a result of a person’s actions that causes an emotional reaction and through reflection can allow a person to analyse the incident and make change, personally and professionally, where necessary (Burns and Rosenburg 2001). The aim of this essay is to examine an incident that occurred whilst I was on clinical placement. Using my chosen reflection model I will reflect back on the incident, analysing the positive and negative aspects, evaluating my performance and producing an action plan for future practice.
This essay will allow for in depth reflection and give the opportunity to critically discuss my actions and performance. I have chosen to follow the Gibbs model of refection (Gibbs 1988) (Appendix 1) as this allows for the expression of thoughts and feelings. This model is also less structured than others which and will allow me to offer deeper explanation and critical analysis on a less structured level (Wilding 2008). To maintain confidentiality, the location of the clinical placement and the names of those involved will be omitted from the essay in accordance with the Nursing and Midwifery Council (NMC) code of conduct (2008).
In order to follow the Gibbs model of reflection, the remainder of this section will now concentrate of examining the description of the incident and the feelings of those involved. The incident that I wish to discuss arose during my first week of clinical placement in an older adult psychiatric ward and those involved were my mentor, a female patient and I. After settling in quickly to the ward it was highlighted to me by my mentor that I had very good relationships with both staff and patients.
It was for this reason that my mentor suggested that I conduct unsupervised 1:1 care plan reviews. This situation has a great significance to me as this was the first opportunity I have had to engage with clients unsupervised and take sole responsibility for a patient. Developing skills in this area is vitally important as this is a feature of nursing which is common place to assist with recovery and situations like these have also been claimed to offer some sort of therapy in itself (Priebe and McCabe 2008).
My first care plan review involved an elderly female patient who had been informally admitted to the ward presenting with low mood and anxiety. After gaining consent from the patient I accompanied her to a quiet location where we would not be disturbed and would promote dignity and confidentiality. The review lasted just over the allocated 45 minutes and during this time, as a partnership, we discussed and reviewed the current care plan. During this period I endeavoured to build upon our current therapeutic relationship and document the details of our conversation.
At the beginning of the review my initial confidence had began to diminish. Although I remained very warm and open I felt that conversation was stilted as I relied upon the written questions. The patient appeared relaxed and was very forthcoming with her views and further information. As a result of this I began to relax and trust my abilities, although my interpersonal skills improved I was finding it difficult to record information whilst maintaining the conversation.
After completing the review, the patient stated that she found me very approachable and felt at ease knowing that there was a person that she could approach with any issues. Directly after the incident I felt that although I was nervous at the beginning of the review, I was able to rely on my interpersonal skills to make the patient feel relaxed. During the review I felt pressurised when recording information and had to complete some of the paper work after the review to ensure that the information was accurate and legible. (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 to 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 which 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 assists with patient recovery.
It is for this reason, building a therapeutic relationship the main key topic that I wish to address during this essay. In past situations I have always taken a partnership approach to nursing interventions. This may be a result of my personality and my training as the importance of partnerships has been repeatedly highlighted in the ten essential shared capabilities (ESC’s) framework (Department of Health 2004) and the Millan principles which are the foundation of the Mental Health (Care and Treatment) (Scotland) Act 2003.
Research by Berg and Hallberg (2000) found that there are two styles to mental health nursing, the “collaborator” who bases the therapeutic relationship on a partnership and the “expert, who takes an authoritive approach and leads interventions. During this incident it was clear to me that the type of relationship that I wanted with the client was one of a partnership and this greatly influenced the progression and style of the care plan review.
Rodgers (1951) highlighted unconditional positive regard as a key element when developing a therapeutic relationship. During the review I made a point of remaining polite in order to maintain a friendly atmosphere. I ensured the patients’ dignity at all times, firstly by obtaining consent before progression, choosing a private location and maintaining unconditional positive regard towards the patient. A study by Dziopa and Ahern (2009) found that treating patients with dignity was one of the most important factors when developing a therapeutic relationship.
As the regard for the patient should be unconditional it is important that the practitioner never judges or evaluates the individual based on their own personal views. By adopting this attitude the nurse will not impose any restrictions upon patients and allow them to express themselves and accept the decision they have made as their own (Todd & Bohart 1994). During the review there were times that I felt that some of the reasons behind the patients low mood were no different from the troubles the average member of the public faces.
These however were my personal feelings and I understood that as a result of the patients low mood they have a tendency to catastrophise events and situations (Armstrong 1998) and the distress this is causing them was very real. During research on what factors constitute a therapeutic relationship, Scanlon (2006) found that some of those participating found that opinions of patients can be formed immediately on the first meeting and that being able to totally remove themselves from these opinions is not possible.
However I found that although I had these personal feelings I was able to detach from them and I maintained a non judgemental attitude which has been highlighted as key feature of building a therapeutic relationship (Safran and Muran 2003). Dziopa and Ahern (2009) found that nurses who adopt an equal partner approach thought that communication was an important factor when developing a therapeutic relationship. During the early stages of the interview I found that my anxieties affected my questioning skills as I relied upon a set of pre written questions.
This impacted on my professionalism and I feel allowed the atmosphere to develop into one of a task that must be completed rather than one of assisting recovery. In the same study it was found that although the nurses interviewed valued the benefit of communication, they saw little benefit of self monitoring their performance (Dziopa and Ahern 2009). On reflection of the incident, I disagree with this statement as I found that when I recognised my faults I understood that I must make changes to my questioning style or risk jeopardising the relationship and the care plan review.
After realising that my questioning skills appeared rehearsed and unnatural I quickly adopted a more relaxed approach, using my interpersonal skills along with my knowledge of questioning to progress the interview on a more natural level. Realising that there was a need for me to relax, I took a moment to pause and gather my thoughts which 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 and when possible breathing in through my nose and out through my mouth which helped me remain relaxed (Wilkinson et al 2002).
Although my communication skills had improved through my altered style there were still points where I sometimes felt that I was ill equipped to respond to some of the details disclosed. At points during the review when the patient raised concerns and looked to me for answers I felt that at my current level of training I was unable to offer a reasonable response and side stepped the question. During a study by Scanlon (2006), providing information was highlighted as a key element when building a therapeutic relationship.
Psychiatric nurses involved in this study stated that it was important that you are clear about explaining what you are trying to achieve and encourage the client to ask questions and obtain clarification if unsure of any issues. It was also stated that nurses should always try and answer questions as accurately as possible and do not side step any issues raised. At points during the review I was clearly not confident when responding to certain questions which I link with my current lack of experience in these situations.
Priebe and McCabe (2008) stated that one such reason for avoiding certain questions is that the individual may have not have specific training or experience in this area. During the whole review I tried to maintain feelings of empathy as well as being sympathetic towards the patient. It is important to have an element of sympathy for the patient as this fosters a caring attitude but it is also key that the nurse does not overlook the causes of these emotions which is why empathy is important. By using empathy the nurse is able to understand issues from the patients’ point of view.
This allows the nurse to have a clearer plan of what needs to be addressed (Barker & Buchanan – Barker 2005). Using all these aspects I was able to build upon the therapeutic relationship and develop a sense of trust between the patient and myself. Using empathetic understanding assisted to 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 to foster a feeling of safety and openness so that the patient felt at ease to discuss their issues.
However I feel that there is a need to also 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 the guide of Gibbs model of reflection (Gibbs 1988) by evaluating and analysing this key topic. Accurate and up to date record keeping forms the basis of good nursing care and the maintenance of these records is highly encouraged (Moores 1996). The care provided to patients is highly reliant 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 taken and 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 be used to inform other practitioners on what has occurred (Taylor 2003). As a nurse is accountable of their actions it is essential that the documentation is accurate and relevant, stating the reasons why an intervention was carried out and the outcome (NMC 2008).
A nurse is accountable to the patient, the profession, the employer and their self so it is vitally important that you are able to justify any decisions made (NMC 2008) and that these decisions are evidence based and promote safe nursing care. It has been argued in some legal cases that if a procedure or intervention has not been recorded, then it is considered not to have taken place (NMC 1998) which highlights the need for accurate records. Although I had the theory and reasoning behind accurate record keeping I found that I lacked experience in doing this which affected my performance in a number of ways.
During the review I attempted to document the process as accurately as possible. However I felt that the formality of the record keeping detracted from the description of the actual nursing process and how the 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 the care provided. When writing the evaluation for the review I felt that I got too involved with documenting the specific details and omitted some potentially useful information about how the patient responded.
Taylor (2003) stated that area’s that are commonly omitted from records surround the issues of maintaining dignity, meeting emotional, spiritual and cultural needs. Although to an extent I agree with this statement as I clearly did omit some of this information, I also understand that it is important to keep 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 being completed as a partnership it was important that the update to the care plan was completed as we progressed.
This had its advantage in that the update and review was completed using the patients own views and they were made to feel that they were involved in their care (Department of Health 2004). Providing care in this way captures the ethical principles of autonomy, choice, equity and fairness (Beauchamp & Childress 2001). The disadvantage was that I felt that I was under pressure to complete the records accurately whilst conducting the review, this effected the information I documented and its presentation.
During the interview process I made a mental note of issues that were being expressed and at the summary of each section we completed the paper work documenting the outcome. However on re reading the information after the review I felt that I had omitted some of the information disclosed which may be attributed to the time constraints I was under. Taylor (2003) stated that omissions can be made as a result of a lack of time and that nurses can sometimes make a mental note of information and then later deems that information to be not vitally important.
On reflection if I was to have incorporated every detail that was disclosed, the care plan review would have become very lengthy and some of the material would possibly have been irrelevant which would be out with the NMC (2004) guidelines. Completing the care plan records in this way also affected the presentation of the document as in my hand writing was rushed and at times I felt my spelling was questionable. In this situation the spelling errors made would not have had a detrimental effect on the care the patient received.
In some cases spelling errors and illegible handwriting can have a serious impact on actions undertaken by other practitioners; such as the incorrect spelling of a patients name resulting in the inability to get test results or errors made to the spelling of medications resulting in medications not being administered or the wrong medication being offered (Diamond 2005). The errors made during this review were few and of little importance, however I felt that the document looked unprofessional and clearly displayed my inexperience which 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 the documentation of the review. This ensured that the review details expressed the true feelings and views of the patient in question and once again promoted the ethical value of autonomy. Working as a partnership ensured that the care plan was agreed and the aims set were achievable which ensured that ethically I was doing what was best for the patient and promoting their wishes and choices (Beauchamp & Childress 2001).
This approach assists with the recovery of the patients as it gives then some control over their care and allows them to develop feeling 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 the paperwork. Dziopa and Ahern (2009) found that nurses thought that giving full attention to the patient was a high priority when building a therapeutic relationship.
Although this lack of attention was minimal I felt that in some way it detracted from the relationship and the flow of the review as at times I would lose eye contact. (Section 3) Having now evaluated and analysed the main key issues, I now wish to continue by examining what else could have been done to improve the interaction with the patient. This section is in keeping with the conclusion section of the Gibbs (1988) model of reflection. Although I felt that on a whole the review
process was satisfactory and I was able to start building upon the therapeutic relationship, there are still many areas that could have been improved. I have highlighted in the evaluation section that I felt that my personal feelings were apparent to me and 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.
It would have been beneficial to the process if I had examined my feelings and abilities before inviting the patient to the review which would also have allowed me to think about my accountability. If I had conducted myself this way it may have given me a chance to address my anxieties and organise my paperwork and arrangement of the interview. This would have also given me the opportunity to explore my own motivations for the interview, examine my beliefs and reflect on previous experiences (Dziopa and Ahern 2009).
This would have allowed me to address any personal issues or views that may become apparent during the review, which would have assisted me in detaching from my personal views and thoughts. I also highlighted issues related to my communication skills with regards to my questioning skills and the answering of some of the patient questions. In this situation I feel that if I had examined myself a little further I would have realised that although I may have been anxious, I had the necessary interpersonal skills to make the review as pleasant and dignified as possible.
Communication is a skill that is developed over time but it is also important to remember that a nurse’s personality can greatly improve a situation even if there are deficiencies in communication (Priebe & McCabe 2008). Thus when I was having issues with my confidence and questioning it would have been useful to utilize my personality and interpersonal skills sooner. With regards to my record keeping I feel that there is little else at that time that could have been done differently.
I would still conduct the review in this way, in respect of working as a partnership, however it may have been more appropriate not to have been taking 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) and then summarize and complete the paper work together. Certainly my hand writing could have been improved and more concentration put into the presentation and spelling of information.
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). Having highlighted my perceived deficiencies during this critical incident it is important to now 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 dairy which I kept whilst on placement.
This assisted me greatly when reflecting back on the incident and evaluating my performance and has allowed me to maintain my personal and professional portfolio which is a requirement of the NMC Code of conduct (2008). This incident has also highlighted the importance of clinical supervision as I feel that as a student nurse I work in a continually changing environment, experiencing new challenges on a regular basis. Clinical supervision allowed me to explore my issues and performance which encourages an environment of self awareness (Rice et al 2007).
For this reason I will always seek support with potentially stressful situations and to assist with my professional development. As a result of this experience, it was apparent that I must spend some more time getting to know myself more and become self aware. This will allow me to evaluate my own skills and views on an ongoing basis which improve my abilities and confidence when conducting future interviews. Adopting this approach will enhance my reflection skills and in future allow me to act on a more natural and instinctive level rather than something that has been learned and thought about deeply (Scanlon 2006).
In 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 reflection on our professional practice and our personal life, as we are continually experiencing different situations and making decisions which influence our learning (Hannigan 2001).
Through practice I will continue to improve my record keeping skills, and 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 future I will ensure that I give the patients my full attention by utilising my listening skills and leaving documentation until the appropriate time. Conducting myself in this way may also give me more time to concentrate on my 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 so I will have to continually develop my skills to effectively communicate with them. This will require on going training, supervision, reflection and evaluation. it is not only important that I am aware of the patient’s needs and issues, it is also vitally important that I am self aware and also examine the ethical issues surrounding care. As I am now practicing in this way it has improved my professional performance but also has helped me develop on a personal level and I now truly understand the importance of reflection.
Cite this Critical Incident Analysis
Critical Incident Analysis. (2016, Sep 03). Retrieved from https://graduateway.com/critical-incident-analysis/