Critical Incident – Preconceived Ideas

No names are used in this writing to maintain patient confidentiality and conform to the data protection act 1998Critical incidents originated in the United States, Colonel John C Flannagan was a psychologist who worked closely with the Air Force and their procedures for reporting evidence concerning effective or ineffective behaviour within different situations (Ghaye 2006:64-65). Tripp (1993: 24-25) claims that “critical incidents appear to be ‘typical’ rather than critical at first sight, but are rendered critical through analysis”.
Critical incidents can be either positive or negative; They “are usually experiences that make you consider the events that have happened to try to give them some sort of meaning” (Hannigan, 2001). Using a critical incident as a way of reflecting helps individuals identify practice that has been helpful or unhelpful in a situation. The value of a critical incident can differ from person to person; it is usually a personal experience with meaning to an individual, however critical incidents can be useful for a range of people for example, students, lecturers, service users and the general public.
They give an insight into the feelings of the person writing and are often relatable to others. In appendix 1 I have described my critical incident. Following this I will explain the importance of a critical incident and the effect on practice, in particular how it has influenced my practice as a student nurse. This experience has greatly influenced my training in a number of ways. As a student nurse I believe it is hard to avoid having a preconceived judgement of a patient.

After receiving a brief description of the patient’s diagnosis from my mentor, I believed this patient would possibly be frail and sedentary, laid in bed with a poor quality of life. However what I was greeted with was the total opposite. This is affected by the patient’s own judgement of her illness, often receiving a prognosis such as this prompts a dramatic change in the patient’s lifestyle. It can be argued that this is the hardest part in ‘accepting’ a diagnosis is the need to change. ‘In accessing readiness to change, we need to look at the individual’s state’ (Broome 1998:31).
If a particular patient is not ready to adapt their lifestyle it can become difficult for them to come to terms with their diagnosis. Patients unable to come to terms with their diagnosis or patients finding their illness difficult after a period of time are likely to suffer from depression or anxiety (Reid, et al 2011). However upon visiting this patient it was clear to me that this patient was able to accept her diagnosis and had readily accepted the challenge to adapt her lifestyle. To me this seemed like a phenomenal act for her to achieve in such a short space of time following the diagnosis.
Communication is a key aspect of any type of care, in particular terminal care as the patient in question is likely to feel scared and anxious about their prognosis. There are a number of different reasons for this;“Including diagnosis and treatment of their disease, long-term physiological alterations, fears of relapse and death, dependence on caregivers, survivor guilt and negative effects on families”. (Groenwald et al 1992: 580)Communication should be an equal conversation that allows both the nurse and patient to include what they need to say.
For a nurse it is important to listen to a patient as developing a therapeutic relationship will often make the patient feel more open to discussion about their feelings and concerns. The therapeutic relationship facilitates the ability for a patient to achieve their desired state of maximum health (Brooker, and Waugh, 2007:236; Kozier, et al 2012:95-97) Patients should be able to “freely express their beliefs, values and concerns in a non-judgemental and supportive way” (Barker 2010:31).
A therapeutic relationship is essential in developing trust between a patient and nurse and is fundamental for care with service users such as my patient. A therapeutic relationship can be described as “one that allows for the meeting of nursing needs to the mutual satisfaction of a nurse and patient” (McQueen 2000:9). This should reduce anxiety and may allow the patient to feel more comfortable in addressing any concerns surrounding the prognosis. This incident has made me think about the barriers to communication and the effects they can have on other staff members, patients and their families. Understanding the potential problems allows us to better understand how something might be able to work more efficiently” (Ellis 2011:88). There are a number of barriers to communication for example; physical barriers such as a door being closed, perceptual barriers for example going into a conversation thinking that the person isn’t going to understand or be interested in what you are going to say. Emotions can also be barriers to communication as well as cultural, gender, interpersonal and intellectual (Kozier et al 2012:46).
I believe my patient may have had emotional barriers to communication with the nurse and myself. She had already accepted her diagnosis and her decision not to converse with us about her condition may indicate that it was difficult for her to discuss it with others, despite being comfortable with it herself. The fact that the patient was comfortable with her illness made me think about the definition of health. My patient had said she felt healthy and therefore to her, despite having an illness, she didn’t consider herself as ‘unhealthy’.
The World Health Organisation (WHO) describes the definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO 1948; Kozier et al 2012:6) although this is the most commonly used definition for health, seeing this patient led me to review its significance. The patient I saw clearly didn’t view this definition to be the same as her meaning of health. Health differs for every individual, my patient felt well and therefore in her opinion she was healthy.
It is understandable that she didn’t want to be continually reminded of her cancer, it was enough that her independence had been reduced due to the fact the nurses were coming into her home in the first place. My mentor and I decided to respect the patients wishes and allow her to come to us when she felt she would like to talk rather than forcing her to speak to us, we arranged to keep nurse interaction with this patient to a minimum so she could retain some ‘normality’ in her life. “Patients are made aware that they have the right to choose, accept or decline treatment and these decisions are respected and supported. (NICE Guidelines 2012) It was at this point I began to understand the value of concordance. McKinnon (2011:69) states “a partnership of equals on which care plan is negotiated”, concordance enables patients to not only make decisions about their care, but to work in parallel with the health care professionals towards a mutually agreed outcome. It could have been easy for my mentor to disregard the patient’s wishes and focus solely on her wound care and expect her to simply comply as the nurses are considered to be the experts, however her feelings were recognised and her autonomy wishes were responded to.
My mentor displayed an excellent example of holistic care according to Linsley (2011:273), who states that nurses have to be aware of the social, environmental and psychological aspects of health and not just physical signs and symptoms of an illness. Before meeting this patient, I didn’t realise how daunting the experience of health care professionals can be, I had always wrongly presumed people would be happy to receive care to make them feel better, however in this instance it has proved to me that not everyone has this view.
It has enabled me to think about my role as a student nurse and it has made me reflect on so many different aspects of good nursing care, from communication and concordance to holistic care. Before my interaction with this patient, I didn’t understand just how important it was for patients to have their say. I couldn’t help but wonder if I had been the registered nurse in that situation, would I have been task orientated and wanted to get the job done rather than taking into consideration the patients wishes? As a first year student I am aware of my limitations and understand that I have a lot to learn.
I thought about how I would feel if I was in the patient’s situation and of course I’d want to be involved in the decisions made concerning my care. The experience with this patient has enabled me to develop as a student nurse, and will inform my practice throughout the whole of my career. Seeing first hand such a good example of concordance and holistic care from my mentor has given me a great platform to base my learning experiences on. References Barker, J (2010) Evidence-Based Practice for Nurses. London: Sage Publications Ltd. Berman, A. Erb, G. Harvey, S. Kozier, B.
Morgan-Samuel, H. and Snyder, S (2012) Fundamentals of Nursing: Concepts, process and practice. Harlow: Pearson. Broome, A. (1998) Managing Change. Hampshire: Macmillan Press Ltd. Ellis, P. (2010) Evidence-based practice In Nursing. Exeter: Learning Matters Ltd. Ghaye, T. and Lillyman, S. (2006). Learning journals and Critical Incidents. 2nd ed. Hampshire: Palgrave Macmillan. Groenwald, S. Goodman, M. Hansen Frogge, M. and Henke Yarbro, C (eds. ) (1992) Comprehensive Cancer Nursing Review. Sudbury: Jones and Bartlet publishers Inc. Linsley, P. Kane, R. and Owen, S. eds) Nursing for Public Health: Promotion, Principles, and Practice, Oxford: University Press. McKinnon, J. (2011) ‘The nurse-patient relationship’ in Linsley, P. Kane, R. and Owen, S. (eds) Nursing for Public Health: Promotion, Principles, and Practice, Oxford: University Press, pp. 64-74. McQueen A. (2000). Nurse-patient relationship and partnership in hospital care. Journal of Clinical Nursing. 9 (5): 723-731. Reid, A. Ercolano, E. Schwartz, P. and McCorkle, R (2011) ‘The Management of Anxiety and Knowledge of Serum CA-125 After an Ovarian Cancer Diagnosis. ‘Clinical Journal of Oncology Nursing’ 15 (6), [online], Available from: http://web. ebscohost. com. proxy. library. lincoln. ac. uk/ehost/detail? sid=7e50352a-778c-4db4-be37-388bb618120d%40sessionmgr114&vid=1&hid=103&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=c8h&AN=2011371794 [Accessed: 26th February 2013]. Tripp, D. (1993) Critical Incidents in Teaching, Developing Professional Judgement. Routledge: London. NICE Guidelines (2012) Supporting patient choice [online] National Health Service online. Available from http://www. nice. org. k/guidance/qualitystandards/patientexperience/SupportingPatientChoice. jsp [accessed 3rd February 2013]. Nursing Times (2004) Reflective thinking: turning a critical incident into a topic for research [online] London, Nursing Times online. Available from: http://www. nursingtimes. net/reflective-thinking-turning-a-critical-incident-into-a-topic-for-research/200145. article [Accessed 3rd february 2013]. World Health Organisation (1948) World Health Organisation Definition of Health [online] New York, World Health Organisation Online. Available from: http://www. ho. int/about/definition/en/print. html [Accessed 1st March 2013]. Bibliography Barker, J (2010) Evidence-Based Practice for Nurses. London. Sage Publications Ltd. Barrat, D, Wilson B, and Woollands, A (2012) Care planning A guide for nurses. Second edition. Harlow. Pearson Education Ltd. Benner, P. (1984) From Novice to Expert, Excellence and Power in Clinical Nursing Practice. Menlo Park Addison Wesley. Berman, A. Erb, G. Harvey, S. Kozier, B. Morgan-Samuel, H. and Snyder, S (2012) Fundamentals of Nursing: Concepts, process and practice. Harlow: Pearson.
Brooker, C. and Waugh, A. (eds. ) (2007) Nursing Practice: Fundamentals of Holistic Care. Philadelphia: Elsevier. Broome, A. (1998) Managing Change. Hampshire: Macmillan Press Ltd. Ellis, P. (2010) Evidence-based practice In Nursing. Exeter: Learning Matters Ltd. Ghaye, T and Lillyman, S. (2006). Learning journals and Critical Incidents. 2nd ed. Hampshire: Palgrave Macmillan. Groenwald, S. Goodman, M. Hansen Frogge, M. and Henke Yarbro, C (eds. ) (1992) Comprehensive Cancer Nursing Review. Sudbury: Jones and Bartlet publishers Inc. McQueen A. (2000).
Nurse-patient relationship and partnership in hospital care. Journal of Clinical Nursing. 9 (5): 723-731. Tripp, D. (1993) Critical Incidents in Teaching, Developing Professional Judgement. Routledge London. (Appendix 1) During placement I have managed to gain experience with terminal cancer patients. When you go into a patient’s house, I feel you can’t help but have a preconceived idea of the type of patient you are about to meet. I was surprised when visiting one patient, as I was told before I entered the home that the patient had terminal epithelial ovarian cancer. This type of ovarian cancer arises from a malignant transformation of the ovarian surface epithelium, how this transformation occurs is unknown. ” (Groenwald et al, 1992: 466-467) When I met this patient I was unsure of what I would discover. I expected a woman that was going to appear physically ‘ill’ and I imagined her to be like all the other patients I had seen with terminal cancer. To my surprise we found her sitting in her conservatory reading the newspaper looking well, she was dressed appropriately and had her hair and makeup done.
The patient seemed genuinely happy and didn’t meet any of the previous preconceptions I had when I was originally told about her. We were there to change a fluid bag from the patient’s abdomen and support the patient if she had any concerns about her illness. This is the only thing the nurses do for this patient, her partner, with some help from the Macmillan emergency care team complete the rest of her care. This patient had a persistent disease that couldn’t be controlled. She had previously been treated with chemotherapy to try and eliminate the cancer however this had been unsuccessful.
The patient had then decided along with the healthcare professionals, to withdraw treatment and only accept pain relief and support. “The staging of ovarian cancer is based on surgical evaluation and forms the basis of subsequent therapy”. (Groenwald et al, 1992: 466-467) The district nurse has only just become involved in her care, currently she is 5 months into her diagnosis. When the nurse and I tried to speak to the patient about her illness and how she was feeling, she seemed reluctant to talk about it. The patient decided she felt well in herself and didn’t want to be reminded of her illness, she went on to explain that she had already

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