The Critical Incident: A Challenging Communication Encounter - Essay Example

?Reflective Paper The Critical Incident: A challenging communication encounter I was working as a nurse associated with the neo-natal ward in the hospital. The neo-natal ward had 4 pre-term babies at that point of time. There was a special case of one baby boy who was born at 26 weeks gestation and weighed about 1.5 pounds at birth. The neonatologist had given a probability of survival at only 50%. However, the parents were clear that they wanted the infant to survive. One fine morning, I rushed to the ward, hearing the screams of the mother. The mother was furious with someone and gesticulating wildly. I asked her to calm down and explain the situation. She was barely coherent, shouting at the interns and the nurses on duty. Apparently, the equipment was showing falling levels of oxygen saturation and no one was concerned enough to investigate the issue. Besides, some alarm was ringing inside the ward and the neonatologist was not summoned. The mother was really out of control and shouting at everyone. It took me more than half an hour to calm her down. In between I also got angry and tried to reason out the delay in nurses attending to the issue. She got more violent and began to throw a few things off the table. In the end we had to restrain her physically albeit for a few minutes. She broke down, sobbing. I kept a gentle arm on her shoulder and made her sit down. Meanwhile I ordered a cup of coffee at her request. It was handed over to her. Then I asked her if she had taken her breakfast. She replied in the negative. I ordered a quick but healthy breakfast from the hospital canteen. Once she consumed her breakfast, she was able to speak coherently. Even now, she was a bit loud and angry, but she was more logical and rational than before. I realized that there were shortcomings on the part of the nurses on duty also. Since the incident happened just before my shift was beginning, I was unable to understand the context fully. Structured Reflection Sometime later, I was trying to assess what had happened during the situation in the neo-natal ward. Firstly, what were the issues that were apparent on the surface? My reactions to the issues must also be analyzed. The primary issue was negligence on the part of the nurses and attendants on duty at the ward. The secondary issue was the tantrum thrown by the mother, though in hindsight, the tantrums were probably justified. On reaching the scene, I was initially angry and flustered. I reacted instinctively, trying to fight fire with fire. I was perhaps not successful. It only resulted in the argument getting louder. My feelings during the encounter ranged from anger to empathy. In the first instance, I perhaps started arguing and countering her on the various allegations raised. At this juncture, I was going by the gut. There was no thought on my part. I was merely reacting like a provoked child. Perhaps, my reactions were influenced by the nature of the encounter. Maybe, the situation was completely out of line with the otherwise quiet and brisk environment of the hospital. Possibly that made me angry. In a sense, I was trying to attack someone who was violating the sanctity of silence at the place. After the first ten minutes, I was able to pull myself back and this is where things started getting back to normalcy. I also need to question myself as to whether I responded in an adequate manner. My frank response is that I was brash and curt with the patient’s mother and it was pretty unreasonable behavior on my part. However, when analyzing the second part of my reaction, I can say that I moved towards the role of a care-giver – a person who is able to handle a lot of stress and can make peace in the midst of strife. What influenced me to change my stance? One reason could be that I realized the futility of arguing with someone whose dearest child was fighting for survival. Under such circumstances, anything could be excused. Perhaps I also empathized with her, trying to fit myself into her shoes. That changed my whole perception of the encounter. At this stage, I was moving towards mindfulness and my actions were influenced by the delicate nature of the situation and the need to minister unto the mother as a therapist. One also needs to understand the consequences of my action on the patient and others who were present during the situation. Firstly, I was looked upon for help and assistance. The fact that I was trying to contest the mother’s accusations added to the problem. It did not help soften the situation. Secondly, my anger was felt by the others who were present there. Again, it did nothing to appease the circumstances. Typically, the person in charge of a situation, an authority figure needs to be able to listen first with compassion and then proceed to action. I was definitely not following best practices. Yet, on coming to my senses, I calmed down and created a minor and pleasant diversion by asking the mother if she had taken her breakfast. This probably made her aware that I was now on her side and not fighting with her. The four-step method in which I structured my reflections has strong leanings towards Johns (2009) who advocated the approach with the view of the nursing profession. Whatever I thought in private and how I articulated my views in public were totally different (Cotton, 2001) and it was my responsibility to ensure that I behaved in an appropriate manner. A Critical Reflection In light of the described encounter, I felt a degree of stress and my instant response was definitely not the most appropriate one. I felt that the ability to reflect is as important as the ability to carry out duties subconsciously. In this demanding paramedical profession, reflection as I understand it can be a tool to retrospect carefully and analyze the situation (Rich & Parker, 1995). Considering the circumstances of the morning, I pondered deeply over my own motivations and sought answers therein. It is possible that in this profession I need to go beyond the role of instinct and curb any natural tendencies. How can that be accomplished? Obviously, there is no one-step solution. Was it just a case of an over-anxious mother worried about her infant, pre-term child? I feel that the other important parameters such as the authenticity of the complaint, whether there were any real gaps in neo-natal care also need to be addressed. For instance, going over the details later with the staff in charge, I found out that during that particular period, two of the staff were called to the administrative office on some earlier documentation related issue. The attendant was taken ill and had to be administered medication. Hence there were a few unforeseen circumstances that led to the encounter. Besides, I also found out that the mother had arrived early to the ward. According to her usual practice she turned up at around 10 a.m. On this particular day, she had turned up at 9 a.m. itself. Considering the situation that prevailed when she arrived, it is quite understandable regarding the turn of events that transpired. Next, I proceeded to analyze my own reactions in greater detail. I looked back to my education and I wondered briefly as to why I chose to become a nurse. I had set my heights on becoming a doctor and then after a while, due to lack of credible academic accomplishments, I ventured to still adopt the medical profession although in the subordinate role of nursing. I paused at this stage and thought over why nursing should be considered inferior? Is it possible that doctors and patients routinely look down upon our fraternity? I consider the practitioners, mainly the doctors to engage in cognitive activities whereas there is stronger research urging nurses to become aware of their intellectual leanings and apply them in practical situations (Kuiper & Pesut, 2004). I admit that to a great extent, we did have a lot of learning during our education that reflective practice is an integral part of nursing education (Mann, Gordon & MacLeod, 2009). Yet I fail to see why the nursing profession needs to engage in cognitive processes. Aren’t we called to just serve? I firmly believe that nurses follow their calling to serve and most of them consider mere execution of job roles as their responsibilities. They are not urged to think. Nor is their calling suited to providing emotional, empathetic support. Often, the nursing fraternity is more in attendance especially in terms of the hours spent visiting the bedside of patients, checking vital signs, recording measurements and reporting to doctors. Under these circumstances, when we spend more time with patients than doctors, I feel that we should be capable of providing emotional support and not just provide medicines, get IV lines fixed and update the charts. We perhaps need to move beyond the call of mere action as a mode of compliance to support and care as a mode of service. This point of view is coherent and in alignment with Lynn (1998) who asserted that the paramedical profession, in particular nurses could be trained in reflective thinking. This thinking, according to her could effectively bridge the gap between following orders and empathizing with the patients, providing emotional succor. So, what do I find to be the essence of nursing practice? Addressed in a more relevant context, how do I see myself reacting to circumstances as the one described before? I see myself transcending the defined roles and moving onto a greater facilitative and supportive role, a role in which task execution is a small fraction of the potential gamut of responsibilities. Mantzoukas (2007) suggests that Evidence Based Practice (EBP) has lot of parallels with reflective practice. Arguably, nurses and doctors adopt EBP, yet while reflective practice is possibly a self-assessment, ex-post detail, one needs to agree that this method is something that calls for a multi-faceted understanding of circumstances, especially relating to a crisis situation. It is in this realm of reasoning that reflective practice has helped me brush aside notions of lower-hierarchy and other such demeaning phrases that have haunted the paramedical profession. Strategies for Improvement Having witnessed the incident and acted in it, I moved onto analyzing it critically. I considered how I had acted and how I should have acted. The next step is in framing a set of processes that would help me improve my behavior and my handling of the situation. In this regard, I proceed, to examine and understand some of the facets under consideration that would assist me in my growth, not in the materialistic sense, but in the sense of personal fulfillment and self-esteem. While some authors have provided to give a balanced view of reflection as a practice in nursing (Hannigan, 2001; Kim, 1999), there are others (Burton, 2000) who have questioned the efficacy of reflective practice. Kim (1999) argues that reflection could actually help increase the knowledge base of nursing practitioners. In different situations, the learnings vary. Accordingly, upon reflection, the in-depth understanding of self and the situation would go a long way in assisting the nursing practice. Burton (2000), in his forceful essay suggests that reflection as a practice in nursing has not been empirically proved and tested. He posits that one needs to critically evaluate the efficacy of reflective practice in nursing. Though he does not advocate giving up the practice altogether, he is strongly in favor of a balanced, well-informed decision in this aspect. The professional side of nursing practice faces challenges of a different nature. For instance, nurses are often treated as second-class citizens in the medical fraternity. Doctors get prime treatment. This is not justified, but it is how the hierarchical structures have evolved. Under such a situation, calling upon nurses to engage in reflective practice is deemed to be a tough challenge. On one side, the demands of the profession call for continuous presence and discharge of duties, on the other hand, they are requested to engage in reflective practice. There are other perspectives to improvement in reflective practices. One of the core issues is communication. How does one communicate effectively in a situation? During periods of stress the nursing profession is beset with workload of the highest order. Doctors are not expected to be in attendance throughout the day. They can take short breaks from work, although they cannot get away from the hospitals for an extended duration of time. Under duress, nurses are called upon to maintain an atmosphere of serenity, support patients and care-givers during moments of heightened tensions and assist them in routine duties. Communication skills are very important here. A balance of firmness and emotional support needs to be conveyed to the patients and care-givers. While it is clear that nurses encounter critical communication situation with patients more than doctors, how can they engage in fruitful encounters when they are not in the upper rungs of the hierarchy? A possible suggestion is that through careful engaged behavior, they could gain the trust of patients and care-givers. In several cases, close family and kin of patients are key people who raise alarms and give out distress signals when they perceive a breach of service. Under such conditions the practice of reflection helps nurses respond to them in a more proactive and mindful manner. While we adopt the perspective of therapeutic care, nursing assumes larger significance in the healthcare profession. O’Connell (2008) discusses the role of nurses as therapists while they attempt to serve the needs of diverse and difficult customers. While their immediate customer may be patients, often they need to cater to the needs of the extended customer, who is represented by the patient’s family and friends. Moving beyond mere critical incidents as a tool to aid in reflective practice, Griffin (2003) supports the role of additional, enhanced job responsibilities for the nursing community. We also look at more approaches for improvement. Firstly, how can nurses be trained to engage in reflective practice? While it is assumed that all nurses come armed with requisite capabilities of reflective practice, real-life scenarios and the demands of a high-paced work environment often does not allow the nursing profession the luxury of reflecting upon incidents and trying to improve their responses to future, critical encounters. Under such circumstances, we advocate a different methodology to study this aspect. We need to have a defined structure for reflection and critical incident analysis, especially considering that these have not been empirically tested and validated (Freshwater & Rolfe, 2001; Carney, 2001). According to these researchers, providing a better structure to critical incident analysis and reflective practices would make the process of reflection more fruitful. It becomes more methodology based. In the absence of a clear set of processes, it is interpreted in a host of myriad ways by the nursing fraternity. This could prove to be harmful to them in the long run. A collaborative effort is also needed in healthcare. For instance, while we consider the medical profession, there is no island of activity. The different departments and the organizational actors such as doctors, nurses and medical assistants come together, ensuring patient care and administration of various facilities. Here, nurses also need to collaborate with others while administering their duties. While we have established reasonably well that reflective thinking could be an innate, ingrained process adopted by nurses (Teekman, 2000), there could be greater benefits in molding personality to suit the role of a therapist (Edwards & Bess, 2009). A therapeutic use of self requires a greater collaborative effort. It is not just important to set aside time for reflective practice, but it is equally important to consult experts in the field as the nursing practice moves towards therapeutic care in critical communication encounters. Towards the concluding part of my discussions, I would set forth a few practical examples in terms of how I would handle future critical incidents or communication encounters. In this last part of my essay, I plan to approach the topic through simple everyday examples backed by theory or academic underpinnings; earlier research also would help me in this regard. I am keen to learn from my own critical incident which I listed in the very first section of this essay. Firstly, I would move towards a role of therapeutic assessment of self. Based on earlier research where Taylor, Lee, Kielhofner & Ketkar (2009) did a nationwide study where it was clearly suggested that a therapeutic mode is essential for a keen understanding of how the nursing practitioner responds in an emotional encounter with a patient or care-giver. Earlier research in this realm has suggested that for a medical context, the nurse-patient relationship moves from a service-provider-customer role to that of a therapist-patient role (Roter, 2000). Effectively I would be more keen to listen first before making judgments. I would not react to harsh, fast language. I will patiently wait for the person and divert her attention in a very polite way so that she calms down. Secondly, I would make internal changes to my own mind-set. Earlier I used to consider myself inferior to doctors and specialist practitioners of medicine. Now I have understood that the power equations could be anything, but what matters in the context of healthcare is the need for greater concern and a keen sense of empathy. These follow after adherence to discipline in all manner of day-to-day activities. So far, I believe I have been merely a student of reflective nursing. Now I plan to put it into practice. Some of the research in this field has been oriented towards reflective thinking as an ingrained, innate activity (Rodgers, 2002) and as a panacea for all education needs of nursing (Burton, 2000). To a possible question that arises now, ‘how do you plan to implement it?’ I would reply stating that I plan to keep a reflective thinking journal where I jot down the critical incident of the day along with my reactions, the situation, my feelings and emotions relating to the encounter and how the other person probably felt and responded during the communication encounter. This would help me learn and be proactive in subsequent interactions at my workplace Thirdly, I have been impressed by the concept of single-loop and double loop learning especially as it applies to reflection (Greenwood, 1998). In this the author has attempted to interpret the concept in terms of a continuous process of learning. The essence here is that in any learning activity which calls for cognitive skill development, an iterative method could help in the first stage, which has parallels with single loop learning. At an advanced stage, the nursing practitioner would be able to anticipate the situation and proactively develop likely responsive scenarios and act accordingly. This is analogous to double loop learning. In practical situations, this theoretical concept can be applied with good results. Finally, I would conclude by stressing upon one important point. This relates to professionalism in the nursing practice. I mean that just like any other profession, there needs to be strict adherence to policies and laid out rules. Additionally, the challenge arises in my case due to the need to respond to patients, medical practitioners and care-givers. In most cases I need to face their complaints, praise and abuse in an equally receptive manner. Hence I feel that the challenge is more to do with developing the right kind of response and being able to think on my feet. 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