Critical Incident Analysis - Case Study Example

Critical Incident Analysis Introduction The critical incident occurred during my placement. This paper describes and analyses a critical incident that took place on labor ward during my clinical placement as a student nurse/midwife. The critical incident involved the RN performing a vaginal examination on a patient during labor without consent and taking over roles from the midwife and the student nurse without suitable communication. The rationale for this critical incident is because of the effect the critical incident had on me. This incident is categorized as a critical incident because the patient seemed to be in deep distress and pain to a point she collapsed after giving birth. Identification and analysis of the main aspects of the incident will be done with reference to relevant literature. Section 1 A 25 year old patient was admitted in the hospital in spontaneous labor during my placement. An RN carried out the initial assessment on her at 08.30hrs and a vaginal examination was done. The vaginal examination showed that the patient had spontaneous split of membranes and cervical os dilation of 5cm. The patient was taken to the delivery room and a midwife and student nurse took over the care of the patient. After five hours, an additional vaginal examination was done to evaluate how the patient was progressing with the labor. The assessment indicated that cervical dilation was at 8cm-9cm and for ischial spines; presenting part was -3cm. A CTG was performed and it indicated that the baseline of the featal heart rate was 145bpm, variability of 5-15bpm, there was a single early deceleration and standard uterine contractions as well. The RN was notified of the labor progress and on getting in the room, she took a quick look at the CTG reading. The RN advised the midwife to put up a syntocinon infusion. After 30 minutes, the RN got into the room again and carried out vaginal assessments twice in 1 hour. The RN did not seek informed consent from the patient and also she did not do an abdominal palpation before vaginal examinations. When the RN was performing the second vaginal assessment, the patient was in so much pain and distressed as well. In spite of this, the RN went on performing the vaginal examination and asked the patient to push down in order for further dilation of the cervix to occur. At this time, the patient was in so much distress and pain such that the student nurse had to hold her in order for the infant to be delivered on the bed and shortly the patient collapsed. There was inappropriate and poor management of the incident. First, the RN got into the room and took over the patient’s care from the midwife and the student nurse without any communication to the patient or the healthcare providers who were in charge of the patient. Basically, the continuity of care was disrupted and was not appropriate and also the communication skills were poor. In addition, there was no show of respect to the patient as an individual. There was no communication and respect yet these are very important aspects during nursing care. The patient was in so much distress and pain, and despite the fact that there is need for advocacy; my feelings were that it would be hard for me during my placement to affirm my insight by challenging the decision of a registered nurse. The nurse was supposed to obtain consent from the patient before performing vaginal examination (Gogos et al, 2011). By performing the vaginal examination the patient’s risk of infection was elevated yet the RN never obtained consent from the patient. As well, an abdominal palpation was supposed to precede the vaginal examinations that the burse conducted (Siwe, Wijma & Swahnberg, 2011). The nurse was supposed to have recorded and any noted abnormality, provided measures of support and infection control and also promoted comfort to the patient. The patient should have been encouraged to change position in order to promote comfort and facilitate fetal rotation and descent. The RN and other healthcare providers should have ensured that the patient was given continuous support to reduce the distress that came with the childbirth process. Studies show that constant support during child birth has several positive effects on key birth outcomes. There should have been efficient communication since communication during labor and birth is linked to higher rate of postnatal mental health problems such as postnatal depression and post traumatic stress disorder. Healthcare providers are supposed to support women in labor in using coping strategies such as breathing, relaxation and positions because these coping strategies help women in reducing pain and improving emotional experiences during labor. Midwives are supposed to be always updated with non-pharmacological techniques of pain relief such as water, massage as well as coping strategies. Section 2 The key features of the critical incident include; informed consent and using vaginal examinations in labor (Gogos et al, 2011). According to Shepherd & Cheyne (2013) vaginal examination is performed to provide a clear picture of how labor is progressing and an abdominal examination is supposed to be done in order to correlate findings. Through vaginal examination a midwife or a nurse is able to approximate the level of the presenting part, dilation and effacement of the cervical os, verify the presenting part, as well as establish how fetus are position and if the membranes are whole (Bjertness et al, 2012). Vaginal examinations during labor have its harmful effects. As Dixon & Foureur (2010) explain vaginal examination is an invasive procedure that has a probability of introducing an infection within the body. Additionally, even though rare vaginal examination presents a risk of latex allergy (Dixon & Foureur, 2010). In concurrence with this, evidence indicates that vaginal examinations can significantly affect women psychologically which has been a key contributor to post-traumatic stress syndrome (Singata et al, 2013). Before a vaginal examination is done, the nurse or midwife should obtain consent from the patient. Code of Professional Conduct requires all nurses and midwives to obtain consent from patients before providing any treatment or care (ANMAC, 2010). The Royal College of Midwives (2012) highlights that performing a medical procedure without consent from the patient is comparable to actual assault. Muliira et al (2013) supports this and argues that no pregnant woman should undergo any form of treatment or assessment without consent and that for a consent to be valid; the individual should be mentally capable of consenting, the person should be provided with adequate information and lastly the person should willingly give consent (Muliira et al, 2013). Shepherd & Cheyne (2013) explain that research based evidence recommends the regularity and acknowledges that vaginal examination is valuable and an essential strategy of managing labor. Dixon & Foureur (2010) however argue that vaginal examinations are carried out since guidelines stipulate so and not because they are necessary. Nonetheless, since healthcare providers are supposed to give evidence based practice (ANMAC, 2010) justifying the practice of routine vaginal examinations when women are in labor is difficult. Bjertness et al (2012) explains events when it is necessary to carry out vaginal examinations in order to get vital information. Nevertheless, in this critical incident there was no obvious indication as to why the RN carried out the two vaginal examinations in hour’s duration and also the RN did not make any documentation for carrying out the vaginal examinations. Singata et al (2013) argues that investigations because of probability of litigation have increased. They further emphasized that such defensive practices if litigation occurs have grave connotations on standards care because people are no longer being handled as human beings. Muliira et al (2013) support this by explaining that the fear of litigation is a key aspect that influences how patients are offered choices or how the choices are withheld. Probably this is one of the reasons why the patient was not offered any explanation before vaginal examinations were carried out (Muliira et al, 2013). One of the reasons as to why the midwife and the student nurse carried out vaginal examinations on the patient might be because they presumed that the progress of the patient’s labor was slow. Nonetheless, the midwife and the student nurse informed hospital’s senior personnel regarding the incident and after the incident was studied the verdict was that there was no indicating that the patient was having a slow labor and hence vaginal examination was not necessary. Additionally, in case the fear of a lawsuit was the reason as to why the RN kept on performing vaginal examinations, the RN is supposed to have documented the findings of the examinations in the notes (Frosch et al, 2014). The RN could have used other procedures to assess how the patient’s labor was progressing. For instance, the nurse could have evaluated the patterns of uterine contractions as well as the flexion of the fetal head which can be established through abdominal palpation (Bjertness et al, 2012). But there is shortage of empirical research supporting reliability of these other methods and hence it can be argued that midwives and nurses fail to use these other less invasive methods because they do not trust their diagnostic capacity and probably they do not have adequate skills and knowledge about them (Siwe, Wijma & Swahnberg, 2011). However, as ANMAC (2010) indicates, all healthcare providers have the responsibility of ensuring that they update their knowledge and skills throughout their working careers. By doing this, healthcare practitioners are able to avoid giving care that might be outdated or harmful to the patients. In this critical incident, the patient was distressed and in so much pain during the second vaginal examination that the nurse carried out. Studies indicate that patients term vaginal examinations as traumatic, distressing, mortifying, painful and can also elicit sexual problems particularly if the woman has ever been abused sexually (Dixon & Foureur, 2010). This therefore implies that healthcare providers should treat women in labor with sensitivity and respect. In this view, perhaps the RN was desensitized to the intrusive nature of vaginal examinations and was not aware of the weight her actions carried. However, vaginal examinations have been termed as intimate, private and sexual and this indicates the requirement for healthcare providers handling women in labor to be sensitive to the likely distress and discomfort that result from vaginal examinations. This highlights the significance of communication skills in implementing this. As Frosch et al (2014) stipulates, effective communication with patients is the foundation to provision of quality healthcare. In this critical incident the RN ought to have used communication skills to communicate with the patient to not only seek informed consent but to also enquire regarding the patient’s continuity of care (Frosch et al, 2014). Singata et al, (2013) emphasize the significance of developing a trustful relationship between the midwife and the mother to make sure that the vaginal examination procedure is less distressful. In this incident, the patient did not know the RN because the RN did not even introduce herself and also they had not created a relationship between them. Singata et al (2013) further highlight the importance of providing holistic care to ensure the experience o childbirth is a positive one. However in this incident the patient was not offered any psychological support or consideration from the RN who assisted the patient into childbirth. To give women in labor holistic care, it is important to make sure that psychological factors are integrated into midwifery care (Dahlen et al, 2013). Regarding the informed consent; an informed consent can be obtained verbally or in a written form. Informed consent is a legal and ethical aspect during nursing care and hence during childbirth women should be empowered through respect, giving information and providing them with choices regarding their treatment. During childbirth, healthcare providers attending the patient are supposed to inform the mother regarding all aspects of any intrapartum procedure that the mother undergoes (Collins, 2010). Additionally, the healthcare provider is supposed to get consent prior to carrying out any treatment. In this case, the RN did not adhere to this. What’s more the RN did not adhere to the Code of professional conduct which requires all healthcare providers to always seek informed consent (ANMAC, 2010). Section 3 After the delivery, the first response would be to give my opinion to the RN for the patient to undergo psychological debriefing and be given appropriate intervention to prevent a traumatic reaction to the distressful childbirth. Collins (2010) explains that psychological debriefing is a means of risk management after labor since feeling traumatized by a birthing experience can result to trauma symptoms. Therefore, this indicates that the need for the patient to undergo debriefing which is a structured intervention aimed at mitigating and preventing acute stress reaction to a traumatic childbirth process (Collins, 2010). Therefore, it would be necessary to ensure that the necessary measures are taken for debriefing of the patient to take place. This should include offering the mother an opportunity to talk about and review her childbirth experience. Studies indicate that offering women with a chance to make sense of their childbirth experiences provides them with psychological strength (Hassan, 2012). Accordingly, a discussion of the birth experience should be encouraged where an accoucher or a properly experienced healthcare practitioner ought to explain and discuss the events of labor and birth with the woman and this is supposed to be done in an understandable manner to the woman. During the discussion the healthcare provider should listen to the woman emphatically. Articulation of the childbirth experience should be encouraged and finally a documentation of summary of the discussion and explanations availed to the woman should be done within the case notes (Hassan, 2012). The second response would be to report the incident to the appropriate authority. Reporting this incident to the authority would ensure that the appropriate measures are applied to ensure women in labor are handled with respect and care they deserve. This would ensure that every healthcare provider in the institution follows the hospital guidelines which include seeking consent before a vaginal examination is performed and also ensuring that other methods of assessing labor progress are used. This is because as studies indicate that there are potential risks allied to infection risks with vaginal examinations (Singata et al, 2013). For instance, infection can be introduced through the uterine cavity and to the fetus as well. Evidence indicates that there is a link between the number of vaginal examinations performed on a woman during childbirth and the risk of puerperal sepsis (Singata et al, 2013). Basically, puerperal infection is manifested after 24 hours after childbirth and can go without been documented and can be really risky especially if the woman is not given antibiotics. Even in developed countries where antibiotics are readily available, there are concerns due to overusing antibiotics to treat infections and hence any elevated risk of untreatable puerperal infections should be taken into consideration. Chlorhexidine has been utilized for long as an anti-infective drug during labor and normally during vaginal examinations and delivery time. Nonetheless, trials have not indicated any decrease of infection risk when chlorhexidine is used (Singata et al, 2013). In addition as indicated, during vaginal examinations, there is a risk of possible allergy to gloves used on the healthcare providers or women in labor (Dahlen et al, 2013). This indicates the significance of reporting the incidence to avoid all issues that can arise due to vaginal examinations, especially without a patient’s consent. Report regarding the critical incident will be hand written and this will be forwarded to the head nurse as well as the manager of risk department for the appropriate actions to be carried out. Conclusion Some women view vaginal examinations as embarrassing, painful and distressful as well. Therefore, it is necessary for the healthcare provider attending the women to respect the women as individuals and maintain their dignity as this can alleviate the feelings of distress and embarrassment. If the patient was in this incident was informed before vaginal examinations were performed this would have assisted in determining the patient’s wishes on frequency and timing of the vaginal examinations and perhaps alleviate the distress and the pain she underwent during childbirth. The response includes assisting the patient through debriefing after childbirth to ensure she recovers from the traumatic birth experience. Reporting should follow for the proper measures to be implemented to prevent recurrence of such incident again. Bibliography Australian Nursing and Midwifery Accreditation Council (ANMAC), 2010, National competency standards for the registered nurse, Melbourne: ANMAC. Bjertness E, Hassan SJ, Sundby J & Husseini A, 2012, The paradox of vaginal examination practice during normal childbirth: Palestinian women’s feelings, opinions, knowledge and experiences, Reproductive Health, 9(16). Collins, R., 2010, What is the purpose of debriefing women in the postnatal period? 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