A Valuable Tool for Learning - Essay Example

The Utility of John’s Model in Reflective Analysis: A Valuable Tool for Learning Introduction Before proceeding with the analysis of the critical incident using John’s model, I would first like to provide a comprehensive background of the critical incident technique. Since the documentation of Flanagan’s (1954) acclaimed The Critical Incident Technique, the use of the critical incident (CIT) has made significant headway through numerous pragmatic contexts. Its original conception was intended to craft procedures to be utilised in the recruitment and placement of aircrew personnel in the US Air Force. Since then, CIT has been used in a variety of practical applications across other contexts (Kemppainen, 2000). It is worth noting that in recent years, CIT has been utilised in newer settings, including the determination of poor and effective service episodes in the retail and healthcare industries. A comprehensive review of these contemporary uses of CIT specifically in the healthcare sector is provided by Kemppainen (2000). Critical incident analysis permits the emergence –instead of the imposition – of an evaluative framework and concentrates on the occurrences and dimensions of the patient experience that are most prominent, striking, and with greater likelihood to be recounted to others (Ruben, 1993). This paper thus presents a critical incident, and uses reflective analysis to draw insights from the incident, with the ultimate goal of improving patient service. A secondary goal is to derive personal lessons which I may use for my own professional development. The following portion expounds on the value of reflective learning and analysis, as a means of gaining insight from a critical incident. The Value of Reflective Learning and Analysis Boyd and Fales (in Getliffe, 1996, p. 362) gives the following definition of reflection: … the process of internally examining and exploring an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of self and which results in a changed conceptual perspective. As a process, reflection is integrated in numerous conceptual frameworks (Hutchinson & Allen, 1997; Kember et al., 1999; Riley-Doucet & Wilson, 1997). I have chosen Johns’ (1994) framework for structured reflection for this analysing the critical incident. Johns model for structured reflection can be utilized as a guide for for reflecting on a critical incident or general reflection on an experience. This would be useful for more complicated decision making and analysis at levels 3 and 4. Johns (1994) advocates the need for the learner to work with a supervisor throughout their learning experience. He refers to this as guided reflection, and recommends that students use a structured diary. Johns considered that through sharing reflections on learning experiences greater understanding of those experiences could be achieved than by reflection as a lone exercise. Johns also uses Carper’s (1978) four patterns of knowing, aesthetics, personal, ethics and empirics adding a fifth pattern ‘reflexivity’. Platzer et al (2000) determine this as a strength of the model as it is one of the few models of reflection that pertain to the development of an epistemological base to reflections. Rolfe (2003) poses a critique the reflexive pattern of knowing, though, as it only responds to a situation, which has been addressed. The question, then, of ‘How would I do it next time?’ is appropriate for that instance. If the situation went on though, the practitioner would want to know ‘How can I take this forward?’ Rolfe (2003) does not consider that Johns has made provision for this question. If you use this model for a situation that is ongoing you could adapt the reflexive section using cues from another model or develop your own set of cues. John’s (1994) model of structured reflection is presented as follows: Looking In Find a space to focus on self Pay attention to your thoughts and emotions Write down those thoughts and emotions that seem significant in realising desirable work. Looking Out Write a description of the situation surrounding your thoughts and feelings. What issues seem significant? Aesthetics What was I trying to achieve? Why did I respond as I did? What were the consequences of that for the patient/others/myself? How were others feeling? How did I know this? Personal Why did I feel the way I did within this situation? Ethics Did I act for the best? (ethical mapping) What factors (either embodied within me or embedded within the environment) were influencing me? Empirics What knowledge did or could have informed me? Reflexivity Does this situation connect with previous experiences? How could I handle this situation better? What would be the consequences of alternative actions for the patient/others/myself? How do I now feel about this experience? Can I support myself and others better as a consequence? How available am I to work with patients/families and staff to help them meet their needs? The reason for choosing it lies in the fact that it is a relatively simple framework and can be easily explained and utilised. This model purports that the first phase of reflection is awareness. This may be triggered by either disturbing or positive thoughts or feelings about a situation or event – which in this case is the critical incident. During the second phase of reflection, the person undertakes a critical analysis of what transpired. He draws upon his significant knowledge and experiences, and on the application of novel knowledge. Such realizations, in the form of new knowledge, are the expected output of the analysis. This entails critical thinking and self-assessment – this comes with increasing awareness about the self (Johns, 1994). The last stage is the development of a novel approach in accordance with one’s critical analysis and the implementation of novel knowledge onto the context or situation for which one has undergone the reflection. The new approach that one intends to adopt may be characterized by cognitive, attitudinal and behavioural modifications. A logical expectation would be adaptive when one considers that the person increases in his effectiveness both as a person and as a team member. Apparently, learning has transpired. In effect, this perspective of reflective learning suits a handful of theoretical models. These include that of Schon (1987) which advocates the reflective practitioner and “knowing-in-action” framework. An Account of the Critical Incident To maintain confidentiality, the identities of the parties involved were withheld, including those of the hospital and that of the patient. The medical staff that treated this lady has been referred to as the Nurse or Nurse Practitioner and Clinical Fellow. I, on the other hand, am working as an ECP, with the incident transpiring in a hospital placement. The critical incident involved a 35-year old lady who walked into the Accident and Emergency Department and presented with a very swollen and painful right ankle. This had happened three days ago while the patient was playing netball (refer to Appendix 1). This patient was able to walk on it at the time although walking with a limp. On this particular day, the patient woke up at 0700hrs and put her foot to the floor, experiences a lot of pain, and collapses on the bed with a temporary loss of consciousness. The Nurse Care Practitioner failed to take a history that would lead to a diagnoses or differential diagnoses. There were portions of the history that were omitted – and quite alarmingly, since these were critical to the situation. What he failed to ask was the presenting complaint. He made a judgment that it was just another ankle injury and asked for the patient’s medical history. He then examined the ankle and told the patient it was not broken, that he ought to go home and rest it, and take some painkillers. The patient replied with a very surprised look and said “I know it’s not broken, I have come about the reason for my loss of consciousness.” A very embarrassed Nurse Practitioner entered into a confrontational dialogue with the patient and proceeded to blame everybody else including the receptionist. The Awareness and Analysis Phases While Johns’ (1994) reflective analysis model seems to present the awareness and analysis phases as distinct, they are strongly linked, as one comes immediately after the other. Given this, I shall present my reactions to the critical incident, followed by a reflective analysis of these reactions. Analysis of the Critical Incident Using Johns’ Model Lack of Critical Soft Skills When this incident happened, my first reaction was that the nurse practitioner lacked some competency to which the occurrence of the critical incident may be attributed. I agree that a competency sums up to more than a set of skills; it is a mix of aptitudes, attitudes and personal traits possessed by effective managers (Weightman, 1995). A competency is a relatively deep and lasting part of an individual’s personality and can predict behavior in a broad array of situations and job tasks. That it has a causal relationship indicates that a competency causes or predicts behavior and performance. Moreover, being criterion-referenced indicates that the competency is a predictor of doing a task effectively or poorly, as evaluated by a particular reference or standard. Why are competencies important in this particular incident? Clearly, the critical incident demonstrates that there is a lack of communication skills on the part of the nurse care practitioner, who immediately assumed that the presenting complaint was an ankle injury instead of dutifully asking the patient himself. Given this, the situation turned out to be an embarrassment for the nurse, and somewhat a frustration for the patient. Given that this and similar critical incidents happen that may be attributed to the lack of soft skills, nurse managers may perhaps allot some time to assess their nurse staff and draft a competency profile of a successful nurse. This profile will specify all of the competencies that a nurse ought to have considering her level and her role. Such a profiling exercise would prove beneficial because the nurse practitioner may immediately be informed of both her strengths and weaknesses as a professional. Prescribing these competency requirements would also help in selecting competent nurses in the future, effectively plan their careers, and constantly ensure external competitiveness and internal equity of their pay packages (Development Dimensions International, 2005). The National Institute for Clinical Excellence (NICE) defines clinical effectiveness as the “provision of high quality treatments or services in a way that allows the recipients to achieve the maximum health gain. This encompasses the provision of interventions/services that are acknowledged as effective (evidence-based practice), and according those services within a system that permits the recipient the most optimal benefit. This will cover environmental, time courtesy, safety (risk management) (The Chartered Society of Physiotherapy, 2005). Moreover, clinical effectiveness must also include offering care based on high-quality evidence-based clinical principles. In addition, this encompasses an assessment of practice or service through the utilisation of clinical audit or outcome metrics, for quality enhancement. Based on these standards, I and other practitioners ought to do “the right thing (evidence-based practice), in the right way (skills and competence), at the right time (providing treatment/services when the patients need them), in the right place (location of treatment/services), and with the right result (clinical effectiveness/maximising health gain). I should be able to give the patient the full package of the patient experience, and contextualise this based on the ‘best available evidence’ (The Chartered Society of Physiotherapy, 2005). It is imperative that nurses’ people skills be given adequate attention. An effective nurse is someone who is a master at managing through ambiguity; inspires confidence and belief in the future; have a passion for results; are marked by unwavering integrity; set others up for success; have strong rather than big egos; and have the courage to make big decisions. Soft skills are as equally if not more important than technical skills, in the development of potential. These competencies must also be integrated into my success competency profile and adequately addressed through formal classroom or on-the-job training. Can the Critical Incident be an Indicator of ‘Organizational Illness’? Looking at it from a more profound perspective, this critical incident may be taken as a mere indicator of a long-standing organizational illness. To achieve and maintain organisational health, commendable management practices must be exercised, and the principal role of employees in carrying this out cannot be overemphasised. The importance of these management practices may be concretely seen in the outcomes that they bring forth including integrated job design, employee engagement, and a proactive approach to employee welfare. At the center of all these is the firm belief that people are the main assets of the corporation (Doherty & Tyson, 2000 in McHugh, 2001). Moreover, Cox and Thompson (2000 in McHugh, 2001) express that the organisation may influence employee behavior through several venues – that is, through the design and management of its work systems and procedures, work factors that cause stress, and the overall impact of the organisation on employee behavior. This indicates that this critical incidents and similar occurrences may be reflective of the work conditions within the hospital; it is critical for hospital management to investigate or at least have a pulse of how nurses feel about their jobs and the work factors that they experience within the hospital (McHugh, 2001). The nursing practice environment is a reflection of the hospital managers' approaches to organizing nursing care (Lake, 2002). A professional model of nursing care (characterized by a greater involvement of registered nurses with patients, greater decision-making authority and flexibility) is considered preferable to a bureaucratic model (characterized by hierarchical authority structure) (Flood and Scott, 1987). An environment that reflects a professional model of nursing care is hypothesized to improve nurse-patient interactions and the perceived quality of patient care which, in turn, results in improved patient health outcomes and greater satisfaction with care (Flood, 1994). This model indicates that improvements in nurses' work environment have the potential to enhance the quality of patient care and decrease grave negative outcomes (e.g. nosocomial infections, medication errors, complaints by patients and families). The hospital should then be sensitive to these occurrences and take them not only at face value – but as superficial indicators of deeply held organizational issues. Improving the Nurse Practitioner’ s Potential Taking off from Benner’s learning stages, another possibility for such an incident happening is that the nurse care practitioner is still a novice and have yet to experience more to get used to the protocol of taking diagnoses and making the presenting complaint explicit at all times. Benner’s Learning Stages Patricia Benner (1982) has expertly adopted a skills and acquisition development model which has been initially discussed by Dreyfus & Dreyfus (1980). While the original model has proposed this for other professions, Benner (1982) has been successful at customizing it for the nursing profession. According to her model, a nurse goes through the five stages of novice, advance beginner, competent, proficient, and expert. In the novice stage, procedures and operations patients underwent are studied lengthily; moreover, they eagerly learn by asking more senior staff with queries, more frequently dealing with technical matters. The discussion of Benner’s (1982) learning model among nurses may be helpful in finding the underlying reasons why such an incident happened. The advanced beginner takes note, based on actual experience, ‘the recurrent meaningful situational components (Benner, 1982, p. 403). Transformation occurs when the nurse starts to acknowledge facets of situations that require from her a specific response (Benner, 1982). This recognition does not emanate from a book or from similar learning material, but from exposure to or familiarity to the situation. Under this stage, the nurse already has the capacity to change ones view or approach as appropriate response to changes which would seem ‘unintelligible nuances in the situation (Benner, 1984). Finally, the expert level is beyond proficiency; for instance, there ceases to be a struggle to employ novel approaches as necessary. The incumbent is able to reframe most easily, and transpires at the preconscious level. This suggests that she is free to address other tasks (Benner, 1984). Nursing undergraduates’ knowledge development and style of reasoning style forms their rule-based reasoning (O'Neill & Dluhy, 2005). This implies that they are still highly dependent on rules as a gauge of their performance, which are based on scientific principles and nursing processes, and are aptly guided by the American Nurses Association standards of nursing practice. These prescriptive standards present the manner in which nurses are expected to carry out patient care (American Nurses Association, 1998). When new graduate students enter the nursing practice for the first time, they do not have the benefit of experience; in essence, the meaning and relevance of these rules and their expected behavior remains ambivalent. Having recognized this, how is it possible to develop the potential of such novice nurses? Developing the Potential of the Novice Nurse The novice acquires clinical judgment and skill over time. Knowledge is refined through actual clinical experience; this moves her from a rule-based, context-free stage to a more analytical, logical and intentional pattern of thinking (Benner, Tanner, & Chelsea, 1996). To effectively provide a conducive learning environment, new nurses need venues for examining and developing their problem solving and reasoning skills towards making clinical judgments (Miller, 1992). Such venues transpire through numerous learning experiences. The literature clearly suggests that the novice nurse, to acquire proficiency – develop self-mastery – and eventually lead and coach others, must expose herself to venues and learning opportunities that will allow her to exercise problem solving and reasoning skills. Participating in varied learning experiences offers the chance to apply classroom theory in the clinical setting. These experiences can help them in developing the learner from the novice phase to advanced beginner. The advanced beginner has been exposed to choice real-life situations and therefore has more contextual rules. Advanced beginners, however, are in greater need for supervision and guidance. They are only starting to learn repetitive meaningful patterns in clinical practice. Clinical experiences enable the formation of meaningful related information on the basis of what the nurse has learned in the classroom. There is an expectation that with more experience, this novice can move from the level of advanced beginner to the level of competence by program completion (Carnaveli & Thomas, 1993). Clinical judgment is defined as nursing decisions about which areas to assess, analysing health data, prioritizing which task to do, and who should carry it out (Carnaveli & Thomas, 1993). For clinical judgment to be assessed as sound, it should be arrived at using critical thinking and logical reasoning, that will enable the deduction of valid conclusions, and the decisions that may be borne from these. To make the most of my clinical exposure, I hope to establish a strong mentoring relationship with a senior nurse and/or a doctor who will be able to coach me on increasing competence in my clinical practice. Coaching and mentoring is a very effective way of developing my potential because it does not only develop me in terms of technical expertise, but it will also allow me to actually experience how these experts undergo the coaching and mentoring exercise. I feel that such a mentoring relationship would expedite my learning from clinical experience. Critical Thinking as a Skill of the Nurse Practitioner Critical thinking is a cognitive process of dexterously undertaking analysis, synthesis, and evaluation of data gathered from observation, experience, reflection, or communication as a guide to belief or action (Paul, 1993). Several researchers have presented critical thinking as a reflective, reasoned thinking process (Ennis, 1985; Halpern, 1989). It is utilised to allow clinical judgments to act based on the information analysed or processed (Ennis, 1985; Halpern, 1989).Clinical reasoning is a cognitive process of progressing from what one already knows to more knowledge (Anderson, 1990). Reasoning is used to make a clinical judgment. Reasoning entails a capacity to remember facts, organize them in a meaningful whole, and then apply the information in a clinical patient care situation. Individuals can make use of reasoning to help in formulating principles or guidelines as a basis for their practice judgment decisions. This demonstrates that nurses ought to have critical thinking skills to enable them to make sound judgment in a wide array of clinical situations. Moreover, care should be taken so that no conclusions are made unless all protocol have been carried out; this helps in avoiding the errors that occurred during the critical incident. Improving Decision Making Skills We nurses determine and resolve client issues in the nursing domain as well as being aware of, identifying and implementing treatment (under medical supervision) of client problems in the biomedical domain. Carnevali (1984) emphasizes the idea that by convention and training, nurses have been biased to direct problem solving chiefly and apparently towards the biomedical domain. This may have been the practice, but with the transition to holistic care and the dynamic mindset in health care, nurses make apt and gainful choices about when to direct their decision making and judgment to daily living as associated to health. These daily living requisites are vital to the nursing practice domain. Much work has been undertaken in an attempt to explain and teach Clinical Decision Making in nursing and other practice disciplines. Many attempts have been made to use paper simulation and more recently computer simulation to teach the process. Mattingly (1991) depicted clinical reasoning as mainly inferred and highly inventive. A fact often neglected is that the client in reality, hires health professionals, either directly or indirectly for their expertise in both diagnosis and treatment. Distinctive discipline specific perspective and expertise is therefore critical. Nursing has tried to abridge and explain the clinical decision making process and many frameworks have been drafted. However, because of the nuances of the process, the task of teaching students clinical decision making persists as a challenge (Mattingly, 1991). With all these, we realize that while decision making is a critical competency of the nurse practitioner, there is marked difficulty in earning it. As suggested, the nurse practitioner has to undertake guided clinical exposure to earn these and similar other critical skills. I suppose that if the nurse in question had good decision making skills, the embarrassment caused by the incident would not have occurred. Or had he committed an error, she would have decided to address it calmly through a concrete, well thought of action plan rather than confronting everybody. She would have decided to make it an opportunity to learn, and get the most insight from the experience. First Order Problem-Solving Another way of analysing the critical incident is to see it as a case of first-order problem solving. Tucker, Edmondson & Spear (2002) have determined three factors that are ingrained in psychological and organizational features of the work environment that reinforce first-order over second-order problem solving. First, the nurses they have observed seem to have a heroic attitude about their ability to take care and protect their patients. In other words, first-order problem solving accorded psychological gratification to the nurse practitioner – who, through creativity and fortitude – may “solve” the problem on his own. Somehow, this is an indicator of reliance on oneself and competence. In addition, these behavioral principles seem to be rewarded by the work context that encouraged nurses to work as independently as possible. They are expected to concentrate solely on their task of caring for patients, and utilising quick solutions to work around discrepancies found within the system. In not being able to carry out first-order problem solving, nurses felt uncomfortable because this frequently meant waiting. This also connotes some sense of increased dependence on others to rectify the situation. However, such individual problem-solving efforts work against the notion that diagnosing and fixing underlying root causes is typically a collective endeavor in organizations (Deming, 1986). Second, nurses’ jobs are somehow structured to promote first-order problem solving. These workers – as is typical of front-line workers – seldom had the time in their work routine to address problems. They did not have easy and convenient methods for communicating about these setbacks, and they lacked access to other human resources who could assist them with difficulties. In these circumstances where time is an obvious constraint, nurses prioritized their tasks and less urgent system improvement efforts were low priority. The lack of resources and standard, quick procedures for communicating about problems with other functional groups made second-order problem solving efforts tedious and thus prohibitively costly to nurses (Senge, 1994). Conclusions There are various strategic options available for medical practitioners. These are enumerated as follows: 1) Tie up with various medical institutions; 2) Collaborate with other reflective medical practitioners; and 3) Alliances with leading players in medical learning tools. Tying up with medical school institutions would allow me to benchmark with their best practices, and assess the applicability of these to my own practice. A tie-up with various medical institutions offers tremendous benefits in terms of access to the institution’s reflective practice approaches, infrastructures and even its resources. However, these medical practitioners must not lose sight of their core competencies while pursuing these tie-ups. Otherwise, their public images might be put in jeopardy. This is also a means for exercising continous development in my own practice. Meanwhile, the collaboration with other medical practitioners who make use of reflective practices can be seen as an impractical move at first. However, upon close examination, this move could pave the way for nurses and other medical practitioners involved to improve even more their knowledge and experiences. The bottom line is both sides would be able significantly gain in such an alliance. The strengths of reflective practice combined with the capabilities of the Six-stage Level of Learning can transform nurses suddenly into an excellent medical practitioner to reckon with. One possible setback, however, is the differences in the cultures of the medical practitioners that might be involved. Another possible setback could be whether other medical practitioners have the need to form alliances. Collaborating with other medical school practitioners is a venue for synergy of ideas – sharing ideas about this and similar critical incidents would spur and trigger new ways of doing routinary or ordinary things. Finally, alliances with leading players in medical learning tools would also enhance my current practice. If it rose again what would I do? Taking everything into consideration, I would intervene earlier before the situation goes out of control. This was a non-emergency environment and even though the presenting complaint was not asked for I would instigate it at the earliest opportunity. I would come forward with an apology since this can sometimes diffuse a situation and gain the respect and trust of the patient. The behaviour from the nurse would be reported to his first line manager. This may have not been the first time this has happened and may put the Hospital Trust in a in a precarious position. Word Count: 3991 References Aiken, L.H., Smith, H.L., & Lake, E.T. 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