Occupational Health - Therapeutic Approaches in Psychology - Assignment Example

Occupational Health Assignment Introduction Critical incident reporting is an important aspect of nursing care. It helps assess the skills of the nurse in caring for patients during critical incidents and it also helps analyse the needs of patients during these instances. This paper shall present a critical incident in current nursing/health care practice, reflecting on the professional, moral, and legal issues arising from it. This paper shall also critically assess the role played by the participants and the stakeholders in this incident. The names used in this incident report are all fictitious names. They are meant to protect the identity and ensure the anonymity of the patient and the staff involved. This practice is being employed in accordance with clause 5 of the Code of Professional Conduct (2004) and the Department of Health’s Caldicott Committee Report (1997). Incident I was asked to see an employee of the UK-wide Bakery service who had been off sick for a laceration on both her arms. The patient, Cynthia, was 32 years old, single, and living alone in a one bedroom apartment within the vicinity of the city’s commercial district. She had been working the night shift with the Bakery service for 5 years running and about 2 days prior to my visit, she reported to the HR that she was taking time off work for injuries she suffered when she fell through a glass door. She had lacerations on both her arms due to her accident. She was later taken to the hospital where she was stitched up and sent home. However, during my visit, she confided in me that she did not actually obtain the injuries from falling through a glass door. Instead, they were self-inflicted injuries and she did not inform the hospital that her injuries were self-inflicted. She said that she attempted to take her life because she had a dispute with a co-worker with whom she was having a relationship. She also felt alone and depressed about her life and the direction that her life was taking. When I saw her, she was weepy, sad, and very glum. Her wounds were healing well, but I could see that she lost the general interest in life. She looked haggard and looked like she had not slept and eaten for days. I was concerned about her situation because she still had feelings of suicide. I managed to persuade her to confide in her HR. Between me and the HR, we were able to convince her to attend Cognitive Behavioural Therapy and to see a counsellor. At work, the HR and the manager decided to move her to the day shift in order to give her more interaction with other employees. After a few days, Cynthia was able to return to work and through the skilled management of all parties concerned, Cynthia’s feelings of suicide were eliminated. The Problem My critical incident now revolves on whether or not it was prudent for me to go against patient confidentiality and subsequently inform her manager of HR of the fact that she had attempted to take her life. Human Resources The Human Resources Department was ill-informed about the true cause of Cynthia’s injuries. They were also ill-informed about her true emotional state and the fact that she was a suicide risk. Since they were not properly informed about her emotional state, they did not give her emotional support. They also let her go home to recover when she should have been put on counselling and therapy. Nursing Staff The nurse was blind-sighted by her visit to the patient. She thought that she was visiting and checking up on an injured patient, instead she was confronted with an emotionally distraught and suicidal patient. She did not have all the accurate facts during her visit and she was exposed to a situation that was dangerous for her and for the patient. Discussion A critical incident report is a means of reflecting on troubling interactions in the healthcare practice. A critical incident is defined as “any event or circumstance that caused or could have caused (referred to as near miss) unplanned harm, suffering, loss or damage” (Webb, et.al., 2005, p. 4). It is an incident that lingers in the mind of the health care professional often prompting the latter to discuss it with other people. These incidents may or may not always be negative experiences; they may also be positive incidents that would compel the health care professional to share his feelings with other health care professionals. Critical incident reports were first seen during the Second World War when authorities in the military and the industry recognised the importance of setting up a voluntary reporting system. The Aviation Safety Reporting System was established in the United States in order to collect, analyse, and respond to aviation incident reports and thereby, reduce the likelihood of accidents. Soon after, other nations, including the UK, were setting-up their own incident reporting practices. In the healthcare industry, there are so many possible incidents that may trigger concern from healthcare professionals. Critical incident reports help provide accounts of incidents in the healthcare practice that can affect the proper care of the patient. Critical incident reports serve a variety of purposes. They help draw attention to the scale of a problem in the healthcare practice; they help improve patient safety and reduce the risk of harm through error; they help encourage healthcare professionals to report without fear of reprisal; they encourage collaboration between the different healthcare professionals in terms of patient care; and they help provide information about adverse events, making it possible to identify factors that lead to such incidents (Webb, et.al., 2005, pp. 5-7). Critical incident reports can be characterized by the fact that they focus on near misses, they provide incentives for voluntary reporting, they ensure confidentiality, and they emphasize systems approaches to error analysis (Webb, et.al., 2005, p. 7). They provide reports of incidents which could have turned into disastrous and dangerous events for both the patient and the healthcare professional. Their confidential nature encourages both the patient and the healthcare professional to open up about the incident and the things they could do to avoid a repeat of such incident. Critical incident reports are favoured by patients and by healthcare professionals because they are confidential; there is a culture of discussion and learning from the incident; there is immunity from blame; there is effective training in the use of incident reporting tools; there is easy access to incident reporting tools; there is outsourcing of report collation; there is rapid feedback to all involved parties; and there is sustained leadership support (Webb, 2005, p. 8). Human errors in the healthcare setting can trigger the generation of critical incidents. Some incidents reported may not have serious repercussions; however, some incidents do greatly affect the patient and the health care giver. It is important for the health care giver to understand that such reports may not accurately reveal the real details of critical incidents. These reports, however, do “provide a relatively simple way of drawing attention to things that have gone wrong...and they allow individuals...to analyse their own behaviour and attitudes, and they provide a stimulus for action to try and prevent further incidents” (Wright, 1999). And ultimately, the patient quality of services can be improved through critical incident reporting. In this incident, I broke the nurse/patient confidentiality by revealing Cynthia’s attempted suicide and her suicidal tendency to other people. It was necessary for me to violate her confidence because her life was in danger. I am so much more aware of protecting the patient’s confidentiality. At some point, I was struggling with myself because I feared that if I reveal to other people what she told me in confidence; she may not want talk to me anymore. And I knew that I put her in greater risk by confiding in other people. Reflective practice involves the individual and his or her experiences, leading to a new conceptual perspective or understanding (Boud, et.al., 1985, as quoted by Racey, 2005). This process also involves learning and is an outlet of expressing a response to the experience. The reflection process can be done in an individual or a group setting, and it may undertake different written forms from reflective diaries to journals. Diaries have become the most popular means of recording experiences and journals have become one of the most common academic mediums used by students in order to reflect on their activities while caring for the patient. Reflective practice can be adopted in a group setting by students and other practitioners. This usually helps the medical health team reflect on their activities on a particular patient in order to improve coordination of health care for the patient (Racey, 2005). Reflective practice has been supported as a means to encourage supervision, professional development and continuing education. It has been supported also as a means to safely appraise practice, to develop professional skill, to question established practices, and to seek new approaches. The process of reflection can be used as a starting point and a framework for widely educational settings. It encourages new ideas and guides the practitioner to assess his feelings, the experience, and evaluate an action plan for the critical incident (Racey, 2005). The reflective process helps to direct nursing practice into a professional realm of learning and of honing one’s craft. The critical reflection involved in this study refers to our capacity to uncover assumptions about ourselves, other people and the workplace (Somerville & Keeling, 2004). We all have standards and maps we adhere to in our daily activities, and these standards help us understand our environment and our personal experiences. Two different people may have different interpretations of the same event. And “critical reflection involves uncovering some of the assumptions, beliefs, and values that underlie the construction of our maps” (Somerville & Keeling, 2004). It was necessary to convince Cynthia to reveal to the HR the real cause of her injuries because not doing so would cause her further harm and, worse, possibly cause her death. However, it is important to note how vital the confidentiality agreement is between the nurse and her patient. A confidentiality agreement covers all aspects of nursing care – from admission to discharge and beyond. Confidentiality is a basic right of every patient. It is a right ensured along with a patient’s right to privacy (Thompson, 2000, p. 143). Experts and other practitioners emphasize that our link and connection with the patient depends largely on preserving and honouring this confidentiality agreement. However, at present, with all the advances in information technology and patient care, this agreement is becoming more difficult to maintain. Nevertheless, the obligation and responsibility to honour this agreement is there, and it has to be maintained. The concept of confidentiality is protected by the law – NHS codes and contracts of employment. It is also guaranteed by common law and statute law. And it is ultimately a part of the professional practice that “protects human rights, as spelled out in the European Convention of Human Rights” (Dowd, 2009). People have the right to assume that the information they will reveal to the healthcare professional will only be used for the reason it was given and that it will not be disclosed to another person without the patient’s permission. Patients also have the right to restrict access to their personal information and to expect that their information shall not be discussed outside the clinical setting and in public. Breaking the confidentiality agreement in cases of suicidal patients is a risky decision because patients may lose trust in their nurses and in other health care professionals after breach of this agreement. In fact, many patients are often reluctant to access medical or mental help for their suicide ideation because of the issue of confidentiality, trust and confidence that they may or may not be able to access in the medical centres. Once they feel that they can trust the health care giver, they may now be in a better frame of mind to open up about their thoughts (Hawton, 2006, p. 133). However, as was previously mentioned, it is important for the nurse to explain to the patient the limits of the confidentiality agreement. The nurse has to explain to the patient that the information that she (the patient) will reveal to her in confidence is information that she (the nurse) may be prompted to reveal to other people in the interest of the patient’s care and recovery. This will help properly and accurately warn the patient that the nurse may reveal the information to other health professionals. The fact that the patient may still choose to reveal vital information to the nurse is a sign that the patient may be willing to accept help from other people. In this case, the fact that Cynthia revealed to the nurse the true cause of her injuries may actually be construed as a cry for help. And the fact that the nurse was able to convince Cynthia to inform the HR about her true condition is a point in Cynthia’s favour. It shows Cynthia’s desire to be helped and her willingness to accept professional help for her mental health. The nurse went through the proper process of convincing the patient to reveal her true mental state to the HR. By doing so, the confidentiality agreement was not breached in the true sense of the word because the nurse was able to convince the patient to reveal to the HR her medical status. His consent can now be taken to mean that she is waiving her right to confidentiality (Cave, 1999, p. 122). Hence, the nurse can now be free to inform the health care authorities of the patient’s condition. In instances where the patient is suicidal, it is important for the nurse to refrain from assuring complete confidentiality to the patient. It is not completely possible for a nurse to keep to herself confidential information about a patient’s suicidal thoughts. The nurse has a duty to care for patients and to ensure that their life is not put in danger by their hands or by anyone else’s. The nurse has the responsibility of informing the proper medical authorities of the patient’s plans. Experts and other practitioners insist that “it is probably best never to promise complete confidentiality to the patient, as there are always potentially difficult disclosures that the nurse may have to share with other professionals” (Hardy, et.al., 2002, p. 249). Other possible solutions/actions that the nurse could have taken in order to promote and ensure safe practice in the care of this particular patient is to put the patient on suicide watch. Although, Cynthia’s suicide was ultimately prevented, there are other possible measures that the nurse could have taken in order to ensure that Cynthia would no longer be suicidal. She should have placed Cynthia on suicide watch. This is part of the process of keeping a patient safe. And if keeping the patient safe calls for physically preventing her from harming herself, this type of care should be made available to the patient (Harrison, et.al., 2004., pp. 164-165). Since Cynthia chose to confide in the nurse, the burden of caring and ensuring that Cynthia would not succeed in her attempts, is now passed on to the nurse. In order to ensure that Cynthia is properly cared for during this difficult and emotional time, professional and medical help must be made available to her. The nurse has then to inform other people, especially other health professionals to help watch and care for the patient. She cannot realistically be with the patient 24 hours a day, and so a rotation or shifting in schedule with other nurses can be worked out. There is a greater risk that the patient would succeed in his planned suicide if only one nurse is watching him. “A client who is continually observed by the same person may also experience increased anxiety, which negates the benefits of therapy” (Wysoker, 1997, as quoted by O’Brien, p. 142). This method will also allow better distribution of staff and prevent administrators from violating institutional regulations In employing the above remedy, the confidentiality agreement with the patient cannot remain inviolate. A nurse has to reveal to other members of the health care team details about the patient’s condition. The health care team cannot blindly care for the patient without knowing pertinent details about the patient’s physical and mental health status. It is therefore impossible for the nurse to ensure that the patient would no longer harm herself at the same time not breach the confidentiality agreement. However, such breach may not be necessary if the nurse is able to convince the patient that it is in her best interests to reveal to other people her medical condition. “Issues around confidentiality should not be used as a reason for not listening to carers, nor for not discussing fully with service users the need for carers to receive information so that they can continue to support them” (Department of Health, 2002, as quoted by National Institute for Mental Health in England, n.d). The reflective practice in health care has a large role to play in these instances because members of the health care team can consult with each other and discuss possible scenarios that they are likely to encounter in their practice. It can also be used by the nurse to personally reflect on her activities while caring for the patient; whether or not she was effective in deterring the patient from her suicide plans; and whether or not the medical health care team was also effective in caring for the patient (Winter, 1999, p. 175). As regards issues in confidentiality, the team can discuss how they can best care for a suicidal patient when such patient does not want the confidentiality agreement to be breached. In some instances, role-playing and assessing possible outcomes of their actions can help minimize dangers to actual patients. There are ways around the regulations on confidentiality which will still allow the patient his right to privacy and allow the health care team the chance to adequately care for his needs. Knowledge about a patient’s general circumstances can still make possible adequate health care. “The provision of general information about mental illness, emotional and practical support for carers does not breach confidentiality” (National Institute for Mental Health in England, n.d). And in retrospect, informing the HR may not exactly be the most prudent move in this case because the HR is not a medical professional who can assist in her care. The HR can make work concessions in her favour; however, the medical care would still depend on the medical professional. In some instances, it is most beneficial to involve the patient’s own physician in the assessment. A mental health professional can also make his assessment about the patient’s mental health (Berkshire Healthcare NHS Foundation Trust, 2008, p. 8). If the physician would confirm Cynthia’s mental state, he may recommend hospital admission for the patient. Again, before the doctor can make such assessments and subsequent recommendations, it is necessary for the confidentiality agreement to be breached. Studies and expert opinion on the subject matter emphasize that a nurse’s confidentiality obligation is not absolute. The Nursing and Midwifery Council firmly recommends that “nurses ensure that patients are aware that information relating to them may be shared with other professional involved in their care, as it would be impractical to obtain consent every time there is a need to communicate about the patient” (Taylor, 2005, p. 15). The nurse, in this case, made the right decision by informing the HR of Cynthia’s mental state. And, it resulted to the patient’s eventual recovery from her depressive and suicidal thoughts. Confidentiality is imposed on health care professionals in order to protect the patient. In following such pretext, a suicidal patient has to be protected or saved from her suicidal thoughts and tendencies. The NHS Confidentiality Code of Practice (2003, as quoted by Parr, 2006, p. 13) emphasizes that confidentiality agreements may be breached on justifiable grounds which include “patient safety, risk of harm to themselves or others, i.e., will the patient’s healthcare be compromised if information is not shared?”. The nurse can breach the confidentiality agreement with the patient because the patient still has suicidal thoughts and Cynthia cannot, by herself, prevent Cynthia from committing suicide. She cannot stay with the patient all the time, and she does not have the necessary mental health experience to handle Cynthia’s case. Mental health professionals have to be brought in to help Cynthia and to help her overcome her suicidal thoughts and plans. It is important for the nurse and other medical health professionals to be aware of the thin line of ethics and legality that they are crossing when it comes to caring for a patient who is not mentally fit. But the nurse should bear in mind that the breach is being done in the best interests of the patient (Burton, 2006, et.al., p. 33). The nurse is obligated to observe the suicidal patient; however, such obligation must be carried out in the most unobtrusive and invasive way possible. The patient may become more anxious if he is monitored constantly and intrusively at all times. Such anxiety can translate to an aggravation of his mental health condition. He may now find covert means to commit suicide in order to escape his feelings of anxiety. This will not bode well for both the patient and the nurse. It is therefore important for the nurse to access and avail help from other medical and mental health professionals in order to be effective in caring for the patient. Again, there is a need to breach the confidence bestowed by the patient on the nurse. And, in the best interest of the patient, such breach is necessary (Standing Nursing and Midwifery Advisory Committee, 1999, p. 2). As the nurse is now privy to information about the state of Cynthia’s mental health, it is now up to the nurse to make the initial assessment. The nurse, in this case, properly performed the necessary assessment of the patient’s condition. She noted how the patient was looking haggard, like she had not eaten and slept for days, like she has been weeping a lot; the nurse also interviewed the patient and established her depressed mental state (Royal College of Psychiatrists, 2004, p. 15). Such manifestations bear strong marks of a depressive and suicidal personality. The fact that suicide ideation is still in her thoughts is a strong sign for another possible attempt. The next move should have been to consult a doctor or a mental health professional for proper assessment. After due consideration, the doctor may then recommend the next move for the patient. The breach of confidentiality, in this case should not be used as an excuse not to consult with other health professionals. This report has helped me personally and professionally in the sense that it has made me more conscious of the legal implications of my actions. It has also made me more mindful of the importance of the nurse and patient confidentiality agreement. This is an important aspect of a nurse’s relationship with a patient. It can sometimes mean the life or the death of the patient. Applying it strictly can bring about disastrous consequences for the patient, and not respecting and honouring it can also break the trust of the patient in the nurse and in the health care professional. It is important for me to know where the lines are drawn, what the exceptions are in every rule in order for me to be a good nurse. I count myself fortunate for being chosen by Cynthia to confide in, but it is heavy burden to bear. And only by upholding the principles of the nursing practice can I definitively assist in the recovery of the patient. 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