This essay will be a reflective essay focussing on a critical incident that took place whilst being at practice placement earlier in the year. A critical incident is defined as a ‘learning technique that breaks an event down into its main components for the purpose of reflective analysis’ (Hoystonard, and Simpson, 2004) The essay will give a critical analysis of an event with an acutely ill adult and will use Gibbs model of reflection (1988) to do so. For the purpose of this essay, the patient will be referred to as Mrs Smith.
The reflective model I have chosen to use is Gibbs model of reflection (1988). Gibbs model of reflection incorporates the following: description – what happened?, feelings – what were you feeling?, evaluation – what was good or bad about the experience?, analysis – what sense can be made of the situation?, conclusion – what else could you have done?, and an action plan – if the situation arises again what would you do?. The model will be applied to the essay to facilitate critical thought, relating theory to practice where the model allows.
This incident occurred in the middle of my 10 week placement on the ward. My reason for using this critical incident is because of the impact that it had on me. I did not expect to see my mentor in a situation which she did not appear to be able to cope with, principally through lack of communication.
Mrs Smith is a 46 year old lady suffering from acute myeloid leukaemia (AML). In order to provide treatment for this disease, it was decided that a Hickman line would be the most appropriate type of access for the patient, so this procedure was performed in theatre under sterile conditions. Mrs Smith was well enough to go home just a few hours after the procedure but started to feel unwell the following morning. She was experiencing extreme pain at the wound site so returned to hospital. When Mrs Smith returned to the ward it was clear this event was serious as her neck and chest were very red and inflamed looking and she was showing all the signs and symptoms of a severe infection, i.e. temperature of 38+C, heart rate greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute and white blood cell count greater than 12,000. These combined symptoms are known as the Systemic Inflammatory Response Syndrome. This, in conjunction with a confirmed infection is known as Sepsis.
My mentor and I immediately began the process of managing the infection, keeping Mrs Smith stable and preventing further deterioration in her condition. Although we managed to prevent Mrs Smith from progressing to septic shock, I felt the management of the situation could have been handled better by my mentor, enabling me to provide better care. This is the issue which I would like to reflect on.
My thoughts and feelings towards this event were initially fear ,as I had not dealt with such a seriously ill patient before and I was worried that my mentor would expect more from me than I was capable of giving. I felt under pressure as things had to be done quickly and I did not want my mentor to think I was not capable in a critical situation. I also did not want the patient to feel that I was not able, and that she was not in safe hands. Durbin (2004) has said that critically ill patients may experience many unpleasant and frightening events, so the use of reassuring mannerisms and honest communication improves patient comfort. My mentor started to become flustered and was not staying calm which was what was needed in this situation. I felt that procedures were being rushed and not done as well as they could have been owing to the pressure of the situation. My mentor was trying to do everything herself and not communicating with either myself, the patient or other staff members, causing uncertainty and confusion. Houston (2009) states that keeping calm under pressure will enable you to make good decisions, have a better judgement, and be able to deal with patients and their families better. I was trying to think and plan ahead for Mrs Smith’s care but knew I was not achieving this because of the lack of communication from my mentor. I wanted to ask my mentor to calm down as it was not helping the situation, and I imagined that it was making the patient feel worse and more anxious seeing this lack of control from the nursing staff who were supposed to be helping her. Mrs Smith just needed to be reassured and kept calm during this initial crucial hour, but I could see that we had not achieved this and she looked very worried. McCabe (2003) states that patient-centred communication is vital to encourage and support both nurse and patient in a critical situation and Radcliffe (2006) is a firm advocate of improving communication with patients .
As blood cultures and urine samples were taken and the administering of antibiotics began, the patient eventually stabilised and vital signs began to improve which was a great relief as we both now felt more in control of the situation. It was not until then that my mentor began to deliver better care and I started to plan ahead for what would be needed next. Gillie and Thorman (2008) state that having a positive attitude will let you be more in control of a critical situation, and that being positive shows you have the strength to stand up to a negative situation. I did not go into this event with a positive attitude as I had never experienced this before and initially just felt panicked and under pressure. However, in future I will always have a positive attitude when going into a new and difficult situation as it will have a greater effect and better outcome for all involved.
Mrs Smith was now being managed for sepsis and my mentor had removed the source of infection which was proven to be the Hickman line, and inserted a urinary catheter to monitor Mrs Smith’s urinary output as she had not passed urine at all that day. She was given IV fluids to maintain her circulating volume and I continued to monitor her vital signs and assess Mrs Smith’s mental state. The antibiotic therapy should have been started earlier, but owing to my mentor not contacting the doctor quickly enough, this delayed the patient being stabilised quicker. If my mentor had remained calmer then she would have been more focussed on what was a priority. Prioritising what has to be done first, is an essential skill nurses need in order to provide a good level of nursing care, Castledine (2002). I felt this was a negative aspect of my experience as I knew myself that we had not prioritised and that antibiotic therapy should be started shortly after diagnosis of sepsis to prevent further deterioration. However, positive aspects of the experience were that I learned that I was calm under pressure and was able to reassure the patient when I did not think I could. Another positive aspect was that my mentor and I managed to control the sepsis before the patient went into septic shock. She was however, already showing signs of severe sepsis as her kidney function had altered.
On looking back and analysing the situation, it was a worthwhile exercise as it was a good learning curve for me on how not to act in a critical situation. I did not want to be like my mentor who was flustered and panicking and therefore not thinking properly, as I saw how it affected the situation. Because of this critical incident occurring, I learnt valuable skills that I will use in other situations, should they arise. Skills such as, staying calm and not panicking, communicating with the patient to reassure them they will be ok and communicating with relatives as they need to know what is going on as well. Acting quickly under pressure, but not too quickly which may cause mistakes to happen. Also, very importantly, to ask for help when required.
If this situation was to happen again, I feel I am more prepared and would not have the initial feeling of worry and fear, as I know what to expect and am capable of carrying out what may be asked of me. On making sense of the situation, I realise I am more confident now not only in this situation but other tasks that are asked of me in the practice placement.
This incident began as what should have been a straightforward case of managing sepsis, but soon turned into a worrying case of possible severe sepsis and losing control of this situation all down to panic, lack of forward planning and lack of communication. Robson and Daniels (2008) discuss how the Sepsis Six Bundle could have been used in this situation, as it has been introduced in 2007 for cases exactly like this, reducing mortality rates by 25%. Six simple steps to be followed within the first hour and severe sepsis will be avoided. Mitchell et al (2004) looks at the changes made to the patient’s care if sepsis is managed well and how one of the roles of the nurse in this situation must be to keep the patient reassured as much as possible. Reassurance would have kept Mrs Smith from becoming more panicked and would have made the event slightly easier for myself and my mentor. Once the initial hour had passed and the management of the sepsis was under control, Mrs Smith became more stable and was relieved to have her pain under control. After a few days on a course of antibiotics, Mrs Smith’s infection soon cleared. On reflection, I now know what was good and bad about this event and what to take from it.
If a situation like this were to occur again, the first thing to apply would be a positive attitude leading to a more controlled and calmer management of a critical incident. Being more in control of the situation makes forward planning easier to do and better nursing care can be achieved. The patient would benefit greatly and a lot more quickly than a rushed, uncontrolled environment. Fewer mistakes would occur and simple tasks would not be missed as the nurse involved would be more focussed. Proper communication is a huge factor in how any incident turns out. Anderson (2009) states that ‘breakdown in communication can cause negative outcomes’, and warns about poor communication, especially with patients and their families. Lack of communication can lead to lack of trust and mean that any future communications could well be disregarded. Egan (2007) states that the face and body are very communicative and in this situation the patient was picking up my mentor’s uncertainty and panic even through her non-verbal communication, making her worried and ill at ease. McCabe and Timmons (2006) stress how important communication is in establishing rapport with the patient, again building up trust. Coulehan et al (2001) also note how communication, using empathy helps to establish a relationship with both patient and relatives.
In a future situation I would ensure proper communication with all involved – especially the patient, to put them at ease and reassure them that the staff knows what they are doing. Now that I have had this experience and learnt from it, I have gained a lot more confidence in how to better manage a patient in a similar situation, not just a critical incident. Being more confident lets the patient know that you are in control and can put their mind at ease, Penzien and Rains (2007). I would know not to show fear, as there was not anything to fear and the last thing the patient needed was to feel worried she was not in safe hands.