Critical Incidence and Reflection

The following reflective essay is based on the critical analysis of an incident through the use of Driscoll’s Model of Reflection (2000) by BalliereTindall. The essay will initiate with a brief overview of the importance of critical incident and reflective study in nursing followed by description of the incident feelings experienced during that incident followed by evaluation. The evaluation will focus of three different themes which will be critically analysed during the later part of the essay.

According to Moon (2013), critical incident in nursing are snapshots of some events that have occurred to a patients and/or their family members and nurse. Such incidents can have positive or negative outcome on patient’s life. Moon (2013) is of the opinion that reflection and analysis of the critical incident in nursing is widely acknowledged as an important learning tool for the nursing professionals. Under reflective practice, nurses reflect on an incident and then they describe what they have learnt from that incident through describing the actions have worked and which didnot. This kind of practice helps the nurses to explore their actions and feelings and relate it with the evidence-based literature. The overall approach assists in bridging the gap between the theory and practice. Redmond (2017) stated that reflective practice in nursing provides the nurse an opportunity to change their way of critical thinking or practice and thereby helping to improve the overall process of care. According to Burrell (2014) the main benefits of reflective practice is promotion of deep learning, proper identification or professional and personal strength, areas of improvement and educational needs. It also acts as a source of self-motivation and clinical confidence. However, there are certain criticisms which are associated with practicing nursing reflection and this includes unwanted consumption of time, inadequate skills of the nursing professionals in understanding the reflective practice tools and discomfort among the nursing professionals in challenging or evaluating their own practice (Adam, Osborne and Welch, 2017).

In this essay, I have selected Driscoll’s Model of Reflection (2000) by BalliereTindall. Driscoll’s Model of Reflection has three parts “What”, “So what” and “Now what”. Each part if subdivided into numerous sub-heads (Bassot, 2015). The first part (What) of the reflective framework deals with the detailed description of the situation. It is known as returning to the situation. This part initiates with the purpose of returning to this particular situation, in this essay it will be my experience with a 32-year old multipara women who was admitted to hospital on her 32-week of gestation due to abdominal pain and bleeding in vagina. This part will also discuss the key aspect of the situation and actions of other healthcare professionals who are involved in that situation (Bulman, 2013). The second part (so what) helps in proper understanding of the content. This understanding of the content deals with detailed description of the feelings and experiences of the nursing professionals along with the underlying causes of the feeling. Detailed description of feelings is illustrated in a time specific manner, troubles that are faced and comparative experienced (Bulman, 2013). The third part of the reflective framework (now what) highlights the modification of the future outcomes. This part helps to define the main implications of practice and action plan for futurewhile coming across similar situations (Bassot, 2015). Thus it can be said the reflective framework helps in succinct illustrations of the entire situation along with a detailed description of the learning outcomes (Bulman, 2013).  

Driscoll’s Model of Reflection

The main purpose of returning to the situation is to recall back my experience in the hospital ward while handling a 32-year old multipara patient (Patient Z) of 32 week gestation.

Patient Z was admitted in the maternity unit of the hospital with abdominal pain and bleeding from vagina. Upon inspection by a gynaecologist, she was treated with Duvadilan 2 amp in IVF NS 500ml. On next day, when she started feeling netter Duvadilan drip was discontinued and changed to Duvadilan tablet 1 TID. This was the case history when I came as a change of shift nurse in the midnight.

Within my shift, at around 7 am in the morning, the maternity ward nurse informed me that Z is again complaining of abdominal pain. I instantly assessed Z and found that she is experiencing mild uterine contraction however her FHS (fetal heart sound) was regular. I immediately informed the condition of Z to the concerned gynaecologist. However, I did not performed vaginal examinations there was specific instructions from the doctor.

When, the duty nurse who was assigned to monitor the patient informed me that the abdominal pain of Z has increased and the immediately after that when the by-standard informed me the patient was feeling pushing and she is going to deliver I immediately understood the emergency and rushed to the ward. I was extremely concerned with the condition of the patient and was worried. When I reached the emergency ward, I was surprised with the unpredicted progress in the pregnancy of Z. I immediately asked the duty nurse to shift Z in the labour room with her bed for processing the delivery.

The duty nurse and the by-standard of the ward were active in communicating the patient’s current situation and were always present at the side of the patient. According to Ek and Svedlund (2015) it is the duty of the nursing professionals to constantly monitor the patient’s condition and notify the physicians on time at the time of emergency. This helps to avoid unwanted emergency or complications. Phiriet al. (2014) also noted that it is also a duty healthcare professional to provide mental support to the patient via staying by her side

The overall outcome of the situation was not fatal as Z successfully delivered a healthy baby boy in the ward bed only and both she and her baby were fine. However, the condition which went normal might turnout to be risky endangering the life of both the mother and the child. According to Koblinsky, Campbell and Harlow (2018) evidence suggests that complications are common in women who are more than 30 years old and multipara at the time of childbirth. Moreover, this news of childbirth outside the labour room got leaked in media which negatively affected the goodwill of the hospital and the healthcare professionals.

Introduction to Incident

When I was informed by the duty nurse that the abdominal pain of Patient Z has increased and immediately after that when the by-standard informed that Z was experiencing labour pain and is going to deliver, I immediately felt concerned and tensed about the patient. Out of concern and staying alert about my duty, I immediately rushed to the emergency condition. When I saw the condition by myself, first I was surprised because I was not expecting such sudden complications and then immediately became concerned about the patient in order to avoid the further complications.

After delivery of the child, in the emergency ward only, I was relaxed when I found both the condition of the baby and the mother was fine and healthy. However, I got sad when I was informed by the hospital manager that there was a article in daily news that a patient delivered outside the labour room on her way to shift. I felt devastated thinking that such unwanted scandals might have been avoided if I had performed the vaginal examination earlier. At the same time the news in the media made me frustrated as it highlighted the gaps in practice by the nursing professionals. However, the nurses were concerned about the patient and they smoothly performed their duty. At present my feelings are neutral and but I still regret of not conducting the vaginal test. I still considered this as a gap in my practice or rather lack of pro-active initiatives while treating the patients. Though the situation went well without any complication to the patient but something or the other might have happened endangering the life of both the mother and her child.

The good emerged from the situations is my understanding that even if there are no written instructions from the doctor, if I feel any particular action is important for the patient care plan, I will execute the same with active self-initiative. However, before executing the actions I will notify the doctor about the plan. According to McConnell, Slevin and McIlfatrick (2013), it is the duty of the nursing professionals to work as per the best interest of the patient depending upon the current situation in order to avoid any impending harm.

About the difference in the feelings, I would like to say that both me and the other nursing professional felt similarly as we all were frustrated about the rumours spread  by the media however, I was feeling guilty for not having conducted the vaginal examination beforehand.

Feelings

The things which went well in this scenario areeffective communications among the nursing professionals. This effective communication among the nursing professionals helped in exchange of the valuable information about the patient’s progress of deterioration on time and this helped to the healthcare professionals to work accordingly. Moreover, proper follow-up about the patient’s history was communication during the change of shift which further facilitated effective communication.

However, there are things which does not went right first is negligence in conduction of the vaginal test when Patient Z was experiencing abdominal pain all over again even while kept on medication (Duvadilan tablet). This can be graded under the lack of proper decision making skills or critical thinking skills at the time of emergency of depending on the patient’s situation.

Child was under-weight at the time of birth (1.5 kilograms while normal weight of child at the time of birth is 2.5 to 4.5 kilograms). According to Sperling (2014), low birth weight is a common consequence during the preterm delivery and requires immediate intervention by paediatric endocrinology nursing specialist (PEN) in order to avoid complications associated with endocrine and metabolic disturbances. However, the child was sent to NICU (neonatal intensive care unit) further check up, initially no arrangements were made for PENs when Patient Z was prepared for her shift in the labour room.  

According to Lancaster et al. (2015), the overall concept of healthcare is based on the effective exchange of information among the physician, nursing professional and unlicensed assistive personnel. In relation to analyse the importance of effective communication among the healthcare professionals, Lancaster et al. (2015) conducted a phenomenological study in a metropolitan hospital. The authors mainly used semi-structured face-to-face interview in order to collect the data. The analysis of the themes highlighted that physician, nursing professionals and the unlicensed assistive personnel (UAPs) have their own shares of responsibility in-order to cumulatively deliver quality care to the patients and for this one of the important trait are timely exchange of information about patient’s current condition and data about the disease prognosis. However, Lancaster et al. (2015) highlighted in majority of the metropolitan hospital, there is lack of effective communications among the healthcare professionals as the doctors see themselves as a superior entity in making decision about the patient’s care.

In such cases, the nursing professionals feel neglected and hence there occurs gap in information exchange through effective communication. Lancaster et al. (2015) also highlighted that though physicians and the nursing professionals tend to work and consult each other, the UAPs are rarely included. However, in the case study, the by-standard and the nursing professionals took active initiative in exchanging of the patient’s information on time. In order to study the importance of effective communication among the healthcare professionals, Curtiset al. (2013) conducted a randomised control trial. The participants (391 internal medicine professionals and 81 nursing professionals) were randomised to an 8-session, simulation-based communication skills intervention. The primary outcome of the study highlighted the importance of quality communication in effective exchange of the patient’s information for handling emergency situation as it helps in taking prompt decision. The secondary outcome highlighted improvement in the overall quality of care for the patients (Curtis et al., 2013). This scenario is again significant in relation to the case study. This is because; the nurses were briefed about the patient’s case history the effective exchange of information was done during the time of emergency with no delay. For proper training of the effective communication and for adequate application of effective communication, proper use of SBAR is important. De Meesteret al. (2013) highlighted in their study that use of the SBAR form (situation, background, assessment, recommendation) helps to increase the perception of effective communication and collaboration among the nursing professionals.

According to Thompson et al. (2013) the judgements and decisions of the nursing professional have potential to help the healthcare organisations to save unwanted complications during the emergency situation when the doctors are not present. It also helps to allocate resources which increase the overall benefit of the patients while preventing patient’s harms. Evidence suggests that judgements and the clinical decision making process by the physicians can be improved if the physicians take active initiative in involving the nursing professionals in the decision making process. Moreover, the nursing professionals must also take proactive approach to take decision on their own or assisting doctors at the time of emergency. In relation to the study conducted by Thompson et al. (2013), it can be said that the nursing professional (myself) was aware that vaginal examination might be important since the patient is showing the signs of abdominal pain even while under the medication.

However, since there were no direct instructions from the doctor and the patient is not-term, she (me) ignored the vaginal examination. Scamell and Stewart (2014) conducted a study in order to examine the impact of the midwifery practice in clinical governance of vaginal examination among the pregnant women. The analysis of the results highlighted that that vaginal examination is crucial in order to monitor and manage the progress of labour. This helps to decrease complications that might arise during delivery. The research study conducted by Scamell and Stewart (2014) further highlighted that vaginal examination does not have any fatal threats to the child or the mother it can be performed easily by the midwives who are registered and have proper expertise. The only think that must be taken into consideration while performing the vaginal examination during pregnancy is sanitization of hand. If I said to reflect on the scenario then I would suggest that if the nurse (myself) had taken a self-initiative in performing the vaginal examination on time then the chances of delivery of the child in the emergency room bed might have been avoided. Chan (2013) stated that critical decision-making skills of the nursing professionals and the midwives are important and the requirement becomes extremely important when the midwives are handling multipara women. This is because; Mgayaet al. (2013) suggest that multipara women are more vulnerable in getting affected with pregnancy related complications. Thus, the critical decision making skills of the nursing professionals holds prime importance. However, the approach of critical thinking might change from time to time and thus there is a need from the educators perspective to help nurse to work on their critical thinking skills.

According to the study conducted by Ozdemiret al. (2013), preterm delivery is associated with numerous complications like poor birth weight of the child and this condition is relevant in this case study too. In such condition the child is bound to suffer from multiple complications like retarded growth and respiratory problems. In such cases, the role of the PENs becomes extremely crucial. However, in the case study, it is not highlighted that whether the NICU is equipped with a trained PENs and moreover, at the time of the shifting of patient Z there was no medical emergency call for PENs as it was already expected that it would be a preterm delivery. However, Ozdemiret al. (2013) highlighted that PENs are indispensible at the time of preterm delivery and the condition becomes extremely important in case the mother has past or prevailing case history of thyroidal hormone dysfunction. According to the guidelines published by the World Health Organisation and UNICEF (2017), proper presence of the paediatric trained nurse is important in order to avoid the complications arising out from the premature delivery. The guidelines highlighted that the after the delivery, the first step should be rapid initial assessment. This was done as highlighted in the case study where the weight of the child was taken and it was found the both the child and the mother was healthy with not significant complications. The next step involves informing the patient’s family member. However, such conditions were not highlighted in the case study. There are no references whether the patient’s family member was notified or not. Then comes general obstetric care followed by other care therapies. The most capable person for the execution of such therapy is the nursing professionals who are exclusively trained in the paediatric domain. The presence of the paediatric trained nursing professionals help to avoid complications arising during preterm delivery.

Conclusion:

Thus from the above reflective essay, it can be concluded that reflection is an important practice in nursing. It helps to increase the critical reasoning skills. This essay employs Driscoll’s Model of Reflection (2000) by Balliere in narrating the case scenario. Driscoll’s Model of Reflection is an important nursing reflective model which helps in detailed illustrations of case scenario along with feelings and evaluation of the narrator. The analysis of the case study highlighted three main themes. These themes include and these include importance of effective exchange of information through communications among the nursing professionals, the importance of the critical thinking skills and presence of paediatric nursing specialists at the time of child birth. This realization will help to improve my future practice. In future I will make use of my effective communication skills in interacting with patients as well as with other nursing professionals in order to exchange important patient’s health related information. I will also use critical thinking skills in order execute importance medical proceedings at the time of emergency. At the end, at the time of time birth in the gynaecology department I will seek presence of paediatric nursing professionals. At the end, I will make use of reflective problem in order to execute a past scenario once again while highlighting my realization and my future action plans.

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