The Psychological Impact of Critical Incidents - Essay Example

The Psychological Impact Of Critical Incidents Of Critical Incident This assignment is based arounda 79-year-old lady who had been admitted to the ward following her tripping over and falling down the stairs at home, whilst getting ready to attend her own birthday party. She had a fractured neck of femur. This lady (Norma, for the sake of confidentiality) had previously been of outstandingly good health, full of energy, rarely ill and always kept herself busy with looking after her house and visiting family. Whilst nursing her, I saw the condition of the inside of her mouth was extremely dehydrated. Her tongue looked like a bone-dry piece of leather and she had dysphagia. She had very small amounts of urine output and it's colouring was very dark, almost brown. From her mumblings, I could tell she was suffering from confusion. When I mentioned the poor condition of this lady, the SHO said, within earshot of the patient's family, ''well, at her age, we can't force her to drink, can we If she doesn't want to drink that's up to her''. I thought how insensitive this comment was and later on (in a private area, away from prying eyes and ears), I told him about how unnecessary and unprofessional he had been. The SHO then tried to defend his actions/words in a combative manner and became quite aggressive towards me. I stated that hydration could be given intravenously, avoiding actual 'drinking' anyway. Eventually, about 55 minutes later, the lady was hydrated using intravenous methods. It is well documented that critical incidents are stressful, possibly traumatic, for all involved: Health care professionals, patients, the patient's loved ones and casual observers. When a critical incident occurs it is necessary to engage in immediate action in a professional manner. What is more desired is the prevention of critical incidents in hospitals through better assessment and diagnostics, care, communication and support. The purpose of this essay is to examine the mentioned critical incident from a more holistic standpoint rather than strictly technical. The resources I have used are from various medical and psychological works from the UK, Canada, Australia and the U.S. In the case of 'Norma,' I was quite distressed when I examined her mouth and saw the telltale signs of dysphagia, then noted the status of her mental condition as protocol dictates in such cases, i.e., 'General factors such as body habitus, drooling, and mental status should be noted' (UTMB, Dept. of Otolaryngology 2001). I found it very disturbing that she was in such a dehydrated condition and that nothing had been done to alleviate it. Dehydration does occur, but it can be prevented, especially when one is hospital. Dehydration has a potentially dangerous effect on elderly people; when I saw the dried tongue, confusion and dark urine with Norma I was alarmed that no fluid had been administered. Upon alerting the SHO of her condition and his callous and unprofessional comment of, 'well, at her age, we can't force her to drink, can we If she doesn't want to drink that's up to her,'' I had several reactions at once: 1. I had no support in my evaluation and request for treatment. 2. The family was within earshot and heard the comments. 3. I feared for Norma's well being. This essay will be divided into several sections, discussing several factors of this incident from different perspectives. Stressor 1: Initial Dismissal of Request According to Jeanette Wick (1999), 'Once dehydration becomes a problem, the entire health care team must be involved in its resolution, and specific dehydration management strategies must be included on the resident's care plan.' Dysphagia being the condition of being unable to swallow, it should have been obvious to the SHO that in Norma's case, not wanting to drink was not the issue. She could not drink and another method of rehydration was in order. I feel that my recommendation was sound. Not only was I distressed that Norma was allowed to dehydrate, it was also distressing that the resolution of the problem was not employed for nearly an hour. This type of behaviour on the part of SHO's and other authorities within the health care system is demoralising and counterproductive. Over time it can damage the entire team of staff in terms of response to the needs of those in our care. This phenomenon has been a common complaint for decades, yet the problem still persists; in a study conducted by the University Of Western Ontario in 2004, more than half of the nurses in the field do not feel respected in their work place. Whilst this is old news and often cited as being rooted in rising costs of health care and less funding for staff, resulting in larger work loads, 'The nurses who felt respected had a sense of fair treatment by their managers, access to information, support, resources required to accomplish their work and opportunities to learn and grow. "Most of these are basic things that don't cost a lot of money," says Heather Laschinger, the study's principal investigator, professor of nursing and Associate Director, Nursing Research in the Faculty of Health Sciences at Western.' Further studies indicate that the increased workloads increase the chances of medically induced critical incidents; in the opinion of Dr. Mary Heye (2000), "Understaffing and multiple-patient loads are common today, and half of all critical incidents involve medications" (The News, University of Texas Health Science Center at San Antonio). Study after study on this issue reflects the lack of empirical evidence of such incidents, since the studies are reliant on subjective statements by nurses themselves. Yet awareness is being raised regarding simple things that can be done to improve working conditions and therefore prevent critical incidents due to lack of attention and proper care. If the health care worker is under undue stress, they themselves can become a problem; the signs of stress should be noted by the staff members themselves, so that they will know when to seek assistance: Normal stress reactions to traumatic, stressful events include (Antai-Otong 2002): Emotional: disbelief, shock, numbness, anger, sadness, depression Biological: sleep disturbance, poor appetite, headaches, muscle tension, GI disturbances, nightmares, startle response, fatigue Cognitive: confusion, forgetfulness, intrusive thoughts, fear of patients or co-workers Psychosocial: isolation, alienation, maladaptive coping (such as substance abuse) In my own incident, the psychological impact of the SHO's initial reaction was more serious for me than that of the incident itself. I knew what needed to be done and I feel confident in my assessment of Norma's condition and needs, yet the problem was unnecessarily escalated due to the factors of the SHO's attitude, statement and the family's near proximity. Stressor 2: Combative Nature of My Superior Upon attempting to express what I have learned whilst in nursing school about mutual respect and cooperation, making the patients' care the first priority, this SHO further inflated the issue with a combative and defensive attitude. Upon reflection of this incident I am compelled to understand the dynamics of this all too common occurrence in the workplace. Whilst the incident with Norma was not to the degree of a disaster or sudden attack, I feel it is good to implement some of the practices for coping with stresses for preparation of my own future and the capability to handle situations where an actual crisis occurs. My goal is to balance the technical learning with the ability to become proficient in self reflection; 'Since self-efficacy is task-specific, people who are highly efficacious about their abilities to meet their perceived expectations about emotional expression in their organizations are likely to experience more "positive emotional synchronization."' (Youssef, 2003) Ideally, I would have had many of the tools contained in this essay in processing/reflecting on this incident just after it occurred, such as is found in the information sheet published by the International Critical Incident Stress Foundation regarding signs and signals of stress as well as things to try: '- WITHIN THE FIRST 24 - 48 HOURS periods of appropriate physical exercise, alternated with relaxation will alleviate some of the physical reactions. - Structure your time; keep busy. - You're normal and having normal reactions; don't label yourself crazy. - Talk to people; talk is the most healing medicine. - Be aware of numbing the pain with overuse of drugs or alcohol, you don't need to complicate this with a substance abuse problem. - Reach out; people do care. - Maintain as normal a schedule as possible. - Spend time with others. - Help your co-workers as much as possible by sharing feelings and checking out how they are doing. - Give yourself permission to feel rotten and share your feelings with others. - Keep a journal; write your way through those sleepless hours. - Do things that feel good to you. - Realize those around you are under stress. - Don't make any big life changes. - Do make as many daily decisions as possible that will give you a feeling of control over your life, i.e., if someone asks you what you want to eat, answer him even if you're not sure. - Get plenty of rest. - Don't try to fight reoccurring thoughts, dreams or flashbacks - they are normal and will decrease over time and become less painful. - Eat well-balanced and regular meals (even if you don't feel like it).' (Critical Incident Stress Information Sheet handout, .pdf format) The above information was helpful for learning new ways I can cope with such incidents as lack of support or aggressive behaviour on the part of my superiors. The support of my co-workers is helpful; yet I feel that more can be done in the area of mutual support among professionals in this field. In reassessing the situation, I realise that I might have addressed the family or engaged with them in some way. A nursing course at Bishop Community College, discussing nursing implications with family distress, says that 'The Seven Traits That Enhance Coping Of Family Members Under Stress are: communication skills, spirituality, cognitive abilities, relationship abilities, willingness to use community resources, individual strengths and talents.' The Importance of Psychological Support This has been largely ignored in many health care professions, yet after such disasters as '9/11' in the U.S. and the increased threat of terrorism it is recognised that the need is there: 'What's more, the constant threat of terrorist attacks means health care workers must always be prepared for the worst. Over time, the effects of this cumulative stress can take their toll,' (David Groves, RN, MSN, June 2004) Putting the fact aside that unprofessional behaviours occur every day in hospitals and other care facilities, it is, I feel, important for those workers who are dedicated to their profession to have the necessary tools to avoid burnout and demoralisation. 'Stress management and critical incident stress management have been shown to accelerate the recovery process for both acute and chronic stress, improve job satisfaction and performance, decrease absenteeism, and decrease health problems. Furthermore, programs for stress management have been shown to be effective in the reduction of burnout.' (Emergency Nurses Association, 2002). Difficulties In Implementing Critical Incident Stress Management The results of a pilot programme launched in Manitoba, Canada verify that psychological support for health care workers can be difficult to implement due to individual control issues in the workplace and a lack of empathy on the parts of individuals; a group of nurses surveyed after ten years in a facility implementing the Critical Incident Stress Management programme yielded that 'interventions can be effective for staff of any discipline and that CI's affect all staff differently. A reminder to all staff to be slow in harshly judging a colleague's response with "I don't know why they are so upset!" As most health care staff like being "in control", the sense of not having this frequently was discussed in interventions. The mental health nurses also learned the paramount importance of confidentiality so staff know it is okay and safe to talk about anything in an intervention' (Humphreys, L & Newton, L., 2005). Lest these ideas of Critical Incident Stress Management seem too one-sided and utopian, it must be understood that many methods have been tried over the years in an effort to support health care workers in all fields, from routine to emergency/response. Some worked better than others. One study explored both stress management and debriefing practices and found that the stress management practices which incorporated debriefing were the most helpful in the long-term (Brooks & Hammond, 2001). According to a resource page from the University Of Washington, a 'critical incident' is defined as: 'any event that causes an unusually intense stress reaction. The distress people experience after a critical incident limits their ability to cope, impairs their ability to adjust, and negatively impacts the work environment' (University of Washington Department Of Human Resources website). Critical Incident Stress Debriefing (CISD) is very different from Critical Incident Stress Management (CISM): 'Debriefing is a specific technique designed to assist others in dealing with the physical or psychological symptoms that are generally associated with trauma exposure. Debriefing allows those involved with the incident to process the event and reflect on its impact (Davis, Joseph A. 1998). It is pointed out in this study that lack of adequate understanding of the stress management/debriefing process, lack of proper infrastructure of such a programme and mistaking it for psychotherapy can be counterproductive when assisting health care/emergency personnel after a critical incident. Therefore, any organisation seeking to install such a programme should exercise great care. Whilst we are exploring the extremes of critical incidents, it should be understood that critical incidents of all scales induce stress and that with everyday health care workers it is imperative to maintain a balance between empathetic involvement and detached concern. Much of this depends upon the individual, yet the responsibility of nurses is the quality of care of the patients and as circumstances change with budget cuts, increased work loads, changes in insurance policies and hospital administrations, all levels of the health care profession are vulnerable to increasing stress and the likelihood of being the cause of a critical incident rather than a part of the prevention. The likeliest hurdle in implementing stress management programmes in institutions would be the utter disregard by management for their need. In Defence of CISM: The primary focus of current stress-management programmes in place is in the fields of emergency/critical care and emergency response teams of all disciplines. Whilst in the United States and Canada many programmes are in place, it seems that the UK is lagging. Part of this problem could be cultural; being British does have its peculiar social stresses, one of them being stoicism. Peggy Soderstrom, a stress specialist and assistant professor at Johns Hopkins University School of Nursing in Baltimore, Maryland (U.S.) recounted a horrendous incident of an emergency room shooting and the ensuing trauma experienced by the nurses and staff. According to Soderstrom, even during routine work, nurses (as well as people in general) often don't recognise that they are under stress (Beth Berk, 2002). In the same article, Bert McQueen, executive director of the Alaska Police Chaplains' Ministries attests to the unpredictability of human behaviour. According to his experience counselling hospital and emergency personnel, he states that 'You don't know when you'll have a significant reaction' (Berk, 2002). Learning stress management in university and practicing it in the field are two very different things; in the classroom things are fairly predictable; in the field, they are not. Yet learning these skills 'en masse' is enormously helpful in the field, since we are able to practice them upon each other in the event of no formal CISM in the facility. As noted by Jeffrey T. Mitchell, Ph.D., Certified Trauma Specialist, in a 2004 report, 'Research exists that peers can be even more successful in assisting one another than trained mental health professionals.' At a 1997 Teaching and Learning Forum in Australia, Michel Burgum and Catherine Bridge (School of Nursing, Curtin University of Technology), it was pointed out that from the standpoint of a student, 'working through a critical incident is both difficult and time consuming.' Not only did the student have to sort through their own issues around the critical incident, they also had to look at those of others involved in the incident. This is where the holistic perspective comes in; in my incident with Norma, I was well aware of her family's difficult position of hearing what the SHO said. I did not, however, have any empathy for the SHO. The Fine Art of Detached Concern There is no doubt in my mind that I was not detached in my incident with Norma, yet I was able to secure the necessary treatment for her by taking the SHO aside and telling him off. I may not have used the most professional demeanour, yet I did exercise the professionalism of talking to him in private. Still, my action provoked a defensive reaction from the SHO and was the result of my lack of practice in diplomacy in the field. A 2002 report from USA Today gives good advice regarding the type of personality required for health care: 'Health professionals, particularly those who work directly with patients, provide nurturing care to patients while maintaining a degree of emotional detachment. Professionals unable to strike this delicate balance will find it difficult to deal with the human suffering they routinely encounter at work.' Gaining the balance between involvement and detachment is difficult from Day One in the health care field. In thinking about my own emotional state on the day of the incident, I can see where the SHO and I were on opposite ends of a spectrum. This is where I would like to point to an interesting study conducted by Susan Harris from the University of Glamorgan Hensol Hospital. The following are direct quotes from the study: 'The study included two groups. Group A - a group of four staff nurses who had recently completed a traditional RGN programme. Group B - a group of four students in the last months of a pre- registration Diploma of Nursing in Higher Education programme.' And in brief, Mrs. Harris' findings, using direct quotes from the students themselves in the five key areas upon which the study focused: Emotional Involvement, Being Detached, Coping, The Effect Of Experience and Dealing With Relatives (again, direct quotes from the Susan Harris' study): '1. Emotionally Involved Group A "You are seeing their grief and you're feeling their grief with them because you think of your own life, your own partner and you know some people have been together for so long." Group B "I felt I was getting too attached and when I left, I was relieved. Its sounds awful but I thought shall I go back' but I couldn't because I was crossing that line. I had made too much of a friend." 2. Being Detached Group A "I felt I had to distance myself because otherwise I would get too attached to them, yet I felt they needed my support and I would have to be close to them, In hospice' they were all dying. Also, they wanted to talk. I couldn't just say Oh, I've got to go and see someone else because I can't face you." Group B "I felt detached at this point. I didn't feel the same closeness that I felt as a student and a newly qualified Staff Nurse. I don't know why this occurred but I knew that if I was to help these people, I had to keep my distance." 3. Coping Group A "Now I do feel that I cope better. It's important to get the right balance; not too friendly, not too involved." Group B "I see these senior Staff Nurses and Sisters and see how well they cope with everything that is thrown at them. They don't show any emotion but they show concern and they show compassion. They also appear to be completely in control and I think this is what I want to be like." 4. The Effect of Experience Group A "... and you can only do it as a professional if you have control of your feelings and, once again, that only comes with experience." Group B "I will think it's hard, once qualified, not to get involved but, then again, I think that we should. There is a conflict there!" 5. Dealing with Relatives Group A "... you're trying to reassure them (the relatives) and you're trying not to tell them everything's going to be all right, because you can't do that. But you are seeing their grief and you are feeling their grief." Group B "... although I didn't really do anything, the family made it clear that they did appreciate it and, you know, it felt a privilege to be able to share that time with them."' Reading Mrs. Harris' study helped me enormously in reflecting upon my own attachment to Norma and her family. Whilst there is a huge chasm between concerned detachment on the outside and intense involvement emotionally, we can never truly know where the fulcrum of balance should be at any given moment without the benefit of feedback and support, over time. In learning about Critical Incident Technique and concluding this section I offer a quote by Michelle Byrne, RN (2001): 'A common attribute of critical incident technique is that it elicits aspects of best and worst practices.' In my desire to focus on the best practices, I have heeded the advice of a report stating that self-reflection not only aids the patients but also advances the nurse's career as a researcher (Harper 2005) Putting It All Together In this document I have attempted to thoroughly explore different dynamics of my chosen field of study and profession, based on one key incident. The process has been helpful for my own enrichment as well as my desire to analyse the critical incident from a more holistic perspective. Working on one's self at the same time as assisting others with their emotions is a continual process of reflection, evaluation and attention. As stated by Costantino Battistina (2005), 'Work involving observation/perception is also work on oneself; this is certainly more intense, the greater the challenge to one's emotions and therefore forms a significant part of such jobs. The expression "emotional labour" denotes this work on oneself, in the officially accredited usage -in psychoanalytical language - in order to process/digest one's own emotions within oneself. The expression is also used for inner, spiritual searching.' In using the mapping method of self-reflection (Day, Christopher & Leitch, Ruth, 2001), I can see where my approach and conduct in the critical incident with Norma could have been improved through practicing immediate self-reflection in the moment. The second encounter with the SHO could have been different and possibly could have resulted in a more positive outcome. Conclusion This has been a valuable project for me as I have been forced to look beyond my own professional mind set and extend myself to others around me, no matter how loosely tied to a critical situation. Thanks to a last minute search, I have learnt the difference between a 'quality' work place and a 'healthy' work place (Susan Wagner, 2002). I feel that this will greatly assist me in exploring my own role in the prevention of and ability to cope with critical incidents. References Antai-Otong, Deborah, MS, RN, PMHNP, CS, 2002, 'Overwhelming Stressful Events: Proactive Response Key to Coping,' The American Nurse |Online| Available at: http://www.nursingworld.org/tan/janfeb02/coping.htm Battistina, Costantino (August 2005), 'What Is Emotional Labour' Dipartimento di Scienze Sociali, Universit di Torino, Via Sant'Ottavio 50, 10131 Torino Italia |Online| Available at: http://www.thrivingandhome.com/emotional_labour.htm Berk,Beth (6 September 2002), 'Surviving Stress,' NurseWeek |Online| Available at: http://www.nurseweek.com/news/features/02-09/stress.asp Bishop State Community College, Individual/Family Considerations r/t Health, p. 21, |Online| Available at: http://www.bishop.edu/health/consideration.pdf. Brooks, Jill & Hammond, Jeffrey, (06 November 2001), 'The World Trade Center Attack: Helping the Helpers: The Role of Critical Incident Stress Management,' Critical Care Forum |Online| Available at: http://ccforum.com/content/5/6/315 Burgum, M. and Bridge, C. (1997), 'Using Critical Incidents In Professional Education to Develop Skills of Reflection and Critical Thinking,' Proceedings of the 6th Annual Teaching Learning Forum, Murdoch University, February 1997 (Australia) |Online| Available at: http://lsn.curtin.edu.au/tlf/tlf1997/burgum.html Byrne, Michelle, RN, (2001), 'Critical incident technique as a qualitative research method,' AORN Journal: October 2001 Research Corner, |Online| Available at: http://www.aorn.org/journal/2001/octrc.htm Davis, Joseph A. Ph.D., LL.D.(hon), 1998, 'Providing Critical Incident Stress Debriefing (CISD) to Individuals and Communities in Situational Crisis,' The American Academy Of Experts In Traumatic Stress |Online| Available at: http://www.aaets.org/arts/art54.htm Day, Christopher & Leitch, Ruth (2001), 'Reflective Processes in Action: mapping personal and professional contexts for learning and change,' Journal of In-Service Education, Volume 27, Number 2, 2001 |online| Available at: www.triangle.co.uk/pdf/validate.aspj=bji& vol=27&issue=2&year=2001&article=Leitch_JISE_27_2 - 27 Aug 2005 Emergency Nurses Association, 2002, Emergency Nurses Association Position Statement: 'Stress Management Strategies,' |Online| Available at: http://66.102.7.104/searchq=cache:_jto215AlVEJ:www.ena.org/about/position/PDFs/StressManagement.PDF+critical+incidents+in+nursing&hl=en Groves, David RN, MSN, 01 June 2004, 'Critical Incidents Call for Team Response,' Nursing Spectrum |Online| Available at: http://community.nursingspectrum.com/MagazineArticles/article.cfmAID=12078 Harper, John Lawrence (2005), 'Releasing The Nursing Knowledge Embedded In Nursing Practice Through Mentorship, Reflection On Practice And Clinical Supervision,' ICUS NURS WEB J ISSUE 21 Online JANUARY - MARCH 2005, Available at: http://66.102.7.104/searchq=cache:fKkIe1d-9-kJ:www.nursing.gr/LHarper.pdf+critical+incidents+in+nursing&hl=en Harris, Susan (January 1998), 'Getting the Balance Right: Are Nurses Socialised Into Expecting The Growth Of A Detached Concern For Their Patients As A Requirement Of Their Professional Development' Development Of Professional Practice Research Training Fellowships: Occasional Papers |Online| Available at: http://66.102.7.104/searchq=cache:LiCeZfX41TgJ:www.hpw.org.uk/images_client/Susan_Harris.pdf+critical+incidents+in+nursing&hl=en Heubeck, Elizabeth (19 November 2002), 'Key Personality Traits Essential for Health Care Jobs,' USA Today |Online| Available at: http://www.usatoday.com/money/jobcenter/workplace/healthcare/2002-11-19-personality_x.htm Humphreys, Linda & Newton, Linda, June 2005, 'Ten Years, Lessons Learned: Critical Incident Stress Management and Mental Health Nursing.' Nursing News, Vol. 18, Issue 5 |Online| Available at: http://66.102.7.104/searchq=cache:R032R78E0s4J:www.hsc.mb.ca/nursingpractice/pdf/NN0605.pdf+critical+incidents+in+nursing&hl=en Richards, D. (2001). 'A Field Study of Critical Incident Stress Debriefing Versus Critical Incident Stress Management,' Journal of Mental Health, 10, 351-362. Office Of Public Affairs, University of Texas Health Science Center at San Antonio, 6 November 2000, 'Nursing Faculty Use 'Critical Incident' Teaching Strategy,' The News, Volume XXXIII,No. 37, |Online| Available at: http://www.uthscsa.edu/opa/issues/new33-37/nursing.htm International Critical Incident Stress Foundation, Inc. Handout: Critical Incident Stress Information Sheet (Adobe Acrobat .pdf format) Includes: "Signs and Signals", "Things to Try" and "For Family Members and Friends". |Online| Available at: http://www.icisf.org/articles/ Mitchell, Jeffrey T. Ph.D. (2004), 'Crisis Intervention and Critical Incident Stress Management: A defense of the field,' International Critical Incident Stress Foundation, Inc. |Online| Available at: http://www.icisf.org/articles/ University Of Washington Human Resources, 'What Is a Critical Incident' Critical Incident Stress Debriefing (CISD) |Online| Available at: http://www.washington.edu/admin/hr/pol.proc/work.violence/cisd.info.html University of Western Ontario, 'Study Shows More Than Half of Nurses Feel Lack of Respect at Work,' Media Newsroom 21 September 2004 |Online| Available at: http://66.102.7.104/searchq=cache:gslPDxF7D2wJ:publish.uwo.ca/hkl/respectpressrelease.pdf+how+nurses+feel&hl=en UTMB, Dept. of Otolaryngology (November 2001), 'Dysphagia,' Grand Rounds Presentation |Online| Available at: http://www.utmb.edu/otoref/Grnds/Dysphagia-2001-11/Dysphagia-2001-11.htm Wagner, Susan (August 2002) 'A Catalogue: Current Strategies for Healthy Workplaces', Canadian Nursing Advisory Committee commissioned report |Online| Available at: http://www.hc-sc.gc.ca/hcs-sss/pubs/care-soins/2002-cnac-cccsi-final/cnac-cccsi-a3_e.html Wick, Jeannette Y. 'Prevention and Management of Dehydration,' The Consultant Pharmacist August 1999 |Online| Available at: http://www.ascp.com/public/pubs/tcp/1999/aug/prevention.shtml Youssef , Carolyn M. (Ph.D Dissertation 2003)), 'BEYOND EMOTIONAL LABOR Positive Emotional Synchronization,' Organizational Behavior, |Online| Available at: http://:www.midwestacademy.org/Proceedings/2003/papers/youssef2.doc Read More