Critical Incident Analysis - Case Study Example

Critical Incident Analysis Introduction: In my previous placement in the mental health unit, I was assigned a patient, Jane. Her actual identity, and demographic details will remain undisclosed for reasons of confidentiality, and in this assignment, her pseudonym Jane will be used. Although Jane was the patient I was caring for, this incident is related to her mother. In this assignment, no information will be utilized which could violate the healthcare informatics confidentiality issues, such as anonymity, confidentiality, and data protection. This incident is critical in my opinion and interesting since this did not involve the patient. This incident was related to the patient, but involved her mother. In this assignment, I will perform a critical incident analysis of the incident that I am going to record briefly below. Jane was admitted here with a diagnosis of endogenous depression with suicidal attempt. She cut her wrists the day she was admitted here into this unit. Jane was complaining that her mother was too overpowering, and she was not able to live up to her satisfaction in any possible areas. This could have generated a sense of hopelessness and worthlessness, anxiety, nervousness, loss of sleep and appetite in her, and she was just not able to cope up with this stress. She was admitted after being treated in the emergency room for psychiatric stabilization. Jane was catching up, and I was able to build up a therapeutic relationship with her, and pharmacotherapy was observed to take its effect. She was advised pain medications when necessary. Since she was on antidepressant medications, the physician advised the nursing staff to hold pain medications as long as possible. It was afternoon on Sunday; I was posted in the nursing station on duty. Suddenly, I saw Jane's mother approaching the nursing station. She was looking very angry and aggressive. I smiled at her, and ignoring my smile, she started yelling at me. She was obviously verbally abusive. She was using words that were sarcastic, coercive, and blaming, and I understood, these were being used with the intent to hurt me. Of course, she was attempting to get my attention and wanted me to take some action. She stated that the nurses "don't care", are "lazy", and "should work harder". She also demanded that someone give her daughter the analgesic. She was not ready to listen to my side of the story. She was really much stressed. Stress plays a very important role in the physical and psychological status of human beings and is one of the most complex concepts in health and nursing. It is difficult to define and is a nonspecific response of an organism to any demand placed up on it. When these demands are of extreme nature, at least from the suffering person's perspectives, it would produce a state of heightened physical, cognitive, emotional, and behavioural arousal. Moreover, traumatic events of any magnitude can create both psychological and physiological threats that tend to disturb the person's interaction with the environment and life outcomes (Duxbury, 1999, 107-114). Any critical incident is stressful, and critical incidents can happen as a result of stress. When I am going to do a critical incident analysis, it is important to define a critical incident. A critical incident can be defined as any sudden and unexpected event that has an emotional impact, which can be sufficient to overwhelm the usual, effective, and sufficient coping skills of any individual or a group that causes a psychological distress in the usually healthy persons around or involved in the incident (Boudreaux and McCabe, 2000, 1095-1097). In case of Jane's mother, Jane's complaint of pain and no pain medication given in response to it threatened to overwhelm her ability to cope, and it produced an inordinately strong emotional, cognitive, and behavioural reactions in her. Theoretically, factors that can influence a person's response to an extraordinary situation includes a history of psychological impairment, personal values, the manner in which the threat is perceived, or the personal meaning of the event for the affected person, attitudes, existence of warning or lack of preparation time or inability to create some personal distance from the event. This discussion is important as a prelude to the critical incident analysis that I am going to present here, since this understanding would ultimately help me to create an intervention strategy. A critical incident is two dimensional. When a critical incident occurs, the aftershock of trauma may affect each participant's internal process of realization of the event and its repercussions. Moreover, it exerts a cumulative effect to even the observers and the remotely related persons to this incident. This ripple effect may take some time to set in since the immediate effect of any critical incident can cause the victims what appears to them as unimaginable loss (Duncan, Estabrookes, & Reimer, 2000, 13-14). As it is known that every individual has unique psychological makeup, immediately following a critical incident, its impact can carve unique pathways of suffering in the heart, mind, and memory. Although it is true that the typical reaction may change over time, immediately initially, a person may be so energized by the event that coping becomes impossible and may react in a manner in synchronization with the gravity of the incident as appreciated by him (Duxbury, 2002, 325-327). I am sure this could have been the case with Jane's mother. Critical incident analysis is a tool for learning where it would assist me in the learning process from the current practice by reflecting on the incident and my experiences, so I can anticipate future actions in such situations. Therefore, this would be a critical analysis of my personal experience in the given professional situation. It has been epitomized by the researchers that putting such situations of the practice settings would create an opportunity for me to analyze my experiences, and this could help developing my practice by reflection-on-action. Review of my response both expressed and felt can help me to critically examine my actions to know what had been done, what could have been done to make things better, what worked, and what else or what more could have worked better. An isolated situation of such incident is just an example where the learning can be transferred to several such situations in the future practice. This can really be a medium of understanding the events and processes taking place, and thus it can help exploring alternative ways of responding to the clients (Privitera et al., 2005, 480-486). I know from my experience that anger, aggression, and violence are influenced by experience, beliefs, culture, and gender. Individuals and groups develop their own views of acceptable and unacceptable words and actions (Berkowitz, 1989, 59-73). When Jane's mother was abrupt in her behaviour and expression, although hurt initially, when my emotions settled down, I could understand that there had been a serious interruption in the steady state or equilibrium in Jane's mother. She was obviously in a state of emotional turmoil. I did not know whether it would be an emotionally significant event in both of our lives. However, I was certain that her verbally abusive behaviour was a reflection of her values, and she did never mean to downplay it. On the lighter side, it was an opportunity for me to explore in what condition Jane had succumbed to suicidal attempts (Allen, 1999, 36-42). It was obviously a tremendous challenge for me as to how I would be able to intervene and control her angle to bring her into a stage of reconciliation. She was appearing so much beyond control that I was doubtful whether I would be able to apply the nursing process approach in her case. I must accept the fact that, with her initial approach, I also lost control over myself and for a moment, I forgot that I am a professional nurse, and I should prevent at any cost my personal emotional reactions to take upper hand over my professional responsibilities. To start with I was also angry and was thinking that being a responsible mother of an admitted patient she must not behave like this and she should control herself. Later I understood that it was wrong on my part, since in this scenario, my role and responsibility would be to prevent and de-escalate this situation in order to prevent her verbal violence and aggression (Frey & Weller, 2000, 607-609). Anger is a strong, uncomfortable emotional response. The provocation that happened to this family member of my patient through omission of pain medication was unwanted by her. Moreover, omitting a pain medication dose to her daughter might have been incongruent with her own values, beliefs, or rights (Gerloff, 1997, 5-7). She was angry, but this could not be termed as hostility, since she did not persist to demonstrate a more enduring negative attitude. Although it could appear that her anger was leading to her aggressive approach, I could find out that her venting of the anger could prevent her aggression and would possibly help me to resolve the situation, and I decided to accept this outburst as an expression of annoyance, frustration, temper, resentment, and rage. On deeper thought, this anger could also be Jane's mother's transient expression of the personality trait. Thus this was a situation ideal for therapeutic intervention since in my eyes her anger and aggression were interlinked in the sense that anger was her feeling and aggression was her behaviour, although both resulted from innate instinct. Her desire about the treatment or care of her daughter failed to be met, and this threat could have resulted in her instinctive response of anger (Koh, Kim & Park, 2002, 486-492). Although initially upset, I could immediately regain my professional stature to quickly understand that this outward expression should not be blocked, or else this instinctive reaction can turn inward to result in depression. Moreover, this anger could well be the resultant of feelings of hurt or anxiety. On second phase of thought, I felt without knowing the reality she had been justified to be angry since anger, I have learned earlier, is an affective state experienced as the motivation to act in ways that warn, intimidate, or attack those who are perceived as challenging or threatening. It occurs most often when there is a threat, delay, thwarting of a goal, or conflict between goals (Leahey & Harper-Jaques, 1996, 133-151). For me this is a critical incident for many reasons. The person who is reacting is my patient's mother. The essential environmental denominator for Jane's suicidal act is her mother's behaviour to her. Her stress, anxiety, hopelessness, helplessness, all point towards her mother. It was an opportunity for me to understand Jane's situation and environment, her post discharge support, and risks of recurrence. Moreover, analysis of this incident might throw some light on her personality, psyche, and behaviour (Harris & Morrison, 1995, 203-210). If I could enter into a relationship with her through the analysis and possible intervention, this might as well help me to shape up the home environment for Jane. Apart from these practical reasons, this could provide a chance to explore my errors, identify them where I can take appropriate actions to improve practice. While doing that, I can at the same time, integrate theoretical learning and practice. I could use this momentary life experience to draw out something that could be used in the long range to help Jane out. This is an incident worth analysing since this would allow in-depth reflection and analysis of this specific event and interaction (Lewis, 2002, 57-63). I am sure I would be able to unpack significant factors that contributed to what happened. Furthermore, this learning could be used in my future practice. If this incident constitutes past experience, it is important to link past experience with learning and with future actions and would ensure continuity and transfer of learning over different contexts of similar nature. For me, this event signaled a cue to study the subjective component of the anger. It was evident that it did not arise from specific neurologic damage or biochemical imbalances. I took this anger episode as a social event. Obviously, its meaning to me would develop from the belief I held about anger and the interpretation given to the episode. When I started to analyse what had happened to Jane's mother, I thought professionally I would analyse her thinking process. It could have followed this model, "I wanted something, I did not get what I wanted, I feel frustrated, it is awful not to get what I want, others should not frustrate me, other are bad since they frustrate me, bad people should be punished." In this model, it was quite normal for her to experience this normal human emotion, that I understand, but to begin with I was quite perplexed with her inappropriate expression of anger that was actually threatening to me, and of course to herself (Lewis, 2002, 57-63). At the time of this incident, I did not know the other biological factors that could have precipitated such behaviour on her part. Theoretical analysis of her feelings, emotions, and expressions of behaviour would lead to possible presence and interactions of several factors. Biologically, the adverse event of no pain medications to Jane would have triggered a negative response, and the emotional circuit between the limbic system and frontal cortex was affected temporarily, leading to low serotonin levels. I remembered last time when I was angry; in fact, I was trying to understand what Jane's mother was going through. I know people differ in reactions when they are angry. There is a whole list of body sensations when people become angry. From my own experience of being angry, I can tell that expression of anger must be facilitated. Difficulties in expression of anger have often been associated with health problems in other dimensions. Anger turned inward has been implicated as a contributor of mood disorders, especially depression. For her it was an event of refusal of demands for her child, and she needed more intense attention to her problems. The triggering of the adverse event has I ignited the emotional circuit between the limbic system. The hypothalamus that synthesizes the input from throughout the nervous system is part of the limbic system, and the limbic system mediates primitive emotions and basic drives to produce behaviours for survival, and anger is one such response (Miller et al., 2003, 57-97). In her case, as it happens in most of the cases, cognitive appraisal is not involved in these rudimentary feelings of fear or anger, while Jane's mother felt this stimulus at first, I am sure, cognitive appraisal was not involved in these rudimentary feelings of fear that something will happen to her daughter, or anger that her daughter had not been getting appropriate attention. Over time, high-order cognitive processing quickly began to take over. Her brain then associated her current experience of unfulfilled desire and physiologic sensations with memories, ideas, and previously experienced motor expressive reactions. I indeed understand this since for my own experience of anger I felt earlier, that it then interprets and differentiates the experience. Depending on prior experience and associations, the response may be intensified and suppressed. It is in this phase, the intervention may work out. It is to be remembered that these experiences and their interactions would be designed by the social stature of the subject. The social factors that could be related to such an expression would be competition and success oriented society, inequities in relationships, learned response, and mainly a combination of instinctive impulses and environmental events. In Jane's mother's case, this event could occur due to her psychological urges, interference with or blockage of a goal, internal and external stimuli perceived as intentional and dangerous, negative emotions leading to an irrational behaviour, and her innate coercive style of interaction (Morrison & Carney Love, 2003, 146-155). Anger among people in psychiatric settings is the same as anger in other settings. Therefore, the subject's behaviour should be considered a social problem and responded to on that basis. People with interactional styles that were argumentative or coercive were more likely to engage in aggressive or violent interchanges. Aggression, violence, and anger often arise from one party's belief that his or her view of a situation is the only correct one. The first party considers other views wrong and in need of changing. A second party's refusal to give in to the view of the first may lead to an episode. People may use aggression and violence as ways to get what they want. They may resort to violence to force change or to regain or maintain control. Rewards from violence include attention from nursing staff. Nurses bring their own perceptions and reactions to clinical settings. They respond to the behaviors of the patients and families for whom they care. Patients and families, in turn, react to nurses. Nurses' beliefs about themselves as individuals and professionals will influence their responses to aggressive behaviors. For example, the nurse who considers any expression of anger or aggression inappropriate will approach an agitated patient in a manner different from that used by the nurse who considers agitated behavior to be meaningful (Limacher & Wright, 2003, 130-150). This may create a bias in interpreting the situation and reacting to it and is ethically in appropriate and should be avoided. In this incident there were no such issues involved. There were no different levels of activities involved in this incident, and that was my initial perception. When I had a chance to interact with Jane's mother, and when I then analysed the situation, no variability in levels was identified. However, now, when I am analyzing this incident, I find that there were at least three different levels involved in it, which was mix of different components of biological, social, and psychological levels of her interaction with the environment. When I am analyzing it now, long after the event, I see that there was a bias from my end that was involved in dealing with this situation. Now I can clearly recollect that for Jane's clinical situation, depression, and distress, I was holding her mother responsible, and I was thinking that it is her mother's behaviour and attitude towards her that was responsible for such suicidal behaviour in Jane and her admission. This could have created a bias in me due to my attachment to Jane, and this could have been expressed unethically in my behaviour towards Jane's mother. This was not professional, since from my position as a nurse, I was required to maintain a neutral attitude to all the events. When I talked about this to my other colleagues, they however relieved me of this guilt; I came to know that it had happened quite frequently with them. The nurse's ability to maintain personal control is challenged when faced with angry, provoking patients. I was feeling very vulnerable, and I became very defensive. I was also angry in response, but I forgot when nurses lose control of their own responses, the potential for punitive interventions or the use of threats or sarcasm is greater. I did not expect this from the mother of a patient, although at that time, I forgot what Jane's mother was going through due to Jane's illness, for which she might have been felling herself responsible (Morrison, 1998, 21-31). I could have been more assertive in dealing with Jane's mother. I needed to understand her angry emotions better. I wish I knew better how to prevent anger and aggression and her verbal violence. I needed to be more assertive. My senior colleagues when discussing with me regarding this event advised me to be more assertive in dealing with such situations. They told me to have a communication style that is open, honest, direct, and confident. If i were assertive, I could express my emotions in a manner that assumed responsibility. It would allow placement of boundaries and prevent acceptance of inappropriate aggression or eruptions of anger from others. What I learned from this incident is that Jane's mother's anger was natural given her state of affairs. A cool and impartial assessment of the behavioural expression is necessary, and for that her history is probably the most important predictor of potential for expression of anger. These include previous episodes of rage and violent behavior, escalating irritability, intruding angry thoughts, and fear of losing control. I should analyze all assessment data across the biologic, psychological, and social domains to understand the dangers that her behavior poses for self or others. The most common nursing diagnoses for patients experiencing intense anger and aggression are Risk for Self-Directed Violence and Risk for Other-Directed Violence (NANDA, 2003). The outcome focus should be aggression control without any bias. Moreover, to control such situation, assertiveness is necessary. For resolution of this problem, it is important to develop a partnership between me and her, with a plan to work together to find solutions to prevent the recurrence of explosive episodes and to de-escalate volatile situations. When I decided to intervene from within the context of the therapeutic relationship, I had to recognize her situation, thought process, emotional turmoil, and had to create a fit for the particular intervention. My action was based on her response. Her affective, behavioral, and cognitive responses to the intervention did provide information about its effects and guided my next response. I was, although with difficulty, able to collaborate with her to find a solution and together attempted to find out any alternative to her aggressive and violent outbursts. I expressed empathy to her cause and expressed my understanding that norms for behavior are created within the context of a particular environment and are influenced by the patient's history and culture. My present learning is that I should have viewed her from the perspective of acknowledging that she had solved problems before and is only temporarily in need of help (Wright, Dixon, & Tompkins, 2003, 557-562). There is no particular theory that can be useful in this context. However, the basic learning had been of paramount importance. A nurse needs to establish basic trust and rapport with the person and also need to use calm, reassuring approach. It needs also a collaborative approach where a joint determination needs to be made about appropriate behavior expectations for expression of anger, given the life events she was going through at that time. It would be necessary to limit her access to frustrating situations until she can express anger adaptively. Lastly, she needs to be reassured that nursing staff shall assist when necessary. There is a need for collaborative identification of source of anger, function that anger, frustration, and rage serve for the person; consequences of inappropriate expressions of anger. If I had enough knowledge, I could also assist her in planning strategies to prevent the inappropriate expression of anger through identification of the benefits of expressing anger adaptively and nonviolently. As my colleagues stated, I could have also established an expectation that she can control her behavior and instructed her on use of calming measures (Thomas, 2001, 41-48). Moreover, since Jane's situation is at stake, I could have taken the avenue of mobilizing her feelings and emotions towards reason such that she can develop appropriate methods of expressing anger to others. Reference List Allen, L. A. (1999). Treating agitation without drugs. American Journal of Nursing, 99(4), 36-42. Berkowitz, L. (1989). Frustration-aggression hypothesis: Examination and reformulation. Psychological Bulletin, 106(1), 59-73. Duncan, S., Estabrookes, C. A., & Reimer, M. A. (2000). Violence against nurses. Alberta RN, 56(2), 13-14. Boudreaux ED., and McCabe, B., (2000). Emergency Psychiatry: Critical Incident Stress Management: I. Interventions and Effectiveness. Psychiatr Serv; 51: 1095 - 1097 Duxbury, J. (1999). An exploratory account of registered nurses' experiences of patient aggression in both mental health and general nursing settings. Journal of Psychiatric and Mental Health Nursing, 6(2), 107-114. Duxbury, J. (2002). 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Philadelphia: Author Privitera, M., Weisman, R., Cerulli, C., Tu, X.,and Groman, A., (2005). Violence toward mental health staff and safety in the work environment. Occup. Med.; 55: 480 - 486. Thomas, S. P. (2001). Teaching healthy anger management. Perspectives in Psychiatric Care, 37(2), 41-48. Read More