Engagement with a service user can be a challenging process which needs to be reflected upon by the individual nurse (van Os et al 2004). When a critical or unique incident arises reflection enables the practitioner to assess, understand and learn through their experiences (Johns, 1995). It was also suggested by Jarvis (1992) that reflection is not just thoughtful practice but a learning experience.
This assignment is a reflective critical incident analysis of an engagement encounter on a community placement recently using Gibbs (1998) Reflective Cycle (Appendix 1,3).
In maintaining confidentiality (NMC, 2004) and privacy, even for reflective pursuance (Hargreaves, 1997), pseudonyms will be used. I will also further reflect on a teaching session I contacted following this incident. Critical Incident analysis During a recent clinical placement with the local CMHT there was a distress call from parents of a client, Mat. An immediate visit by the two co-coordinators and me, followed without checking, or doing a risk assessment.
This visit resulted in aggressive and abusive encounter and Mat was then admitted to hospital, (Appendix 2).
This incident is critical to me as it presented a learning opportunity as well as a risk of physical harm to me and the nurses with me. As I look back on this incident there are several issues that relate to the role of the nurse. When I look back at this incident, I felt anxious but my thoughts were that this was a learning experience even when it was clear I was the main focus of the aggressive threats (Fazzone, et al, 2000) I knew I needed to remain calm and to assess for escape routes.
I made mental notes of these but still I was not sure and everything was happening so fast and my mentor was already telling us what to do. Being able to remain calm could have help and I feel this was a positive thing. As I reflect if I had panicked visibly this could have encouraged Mat to have a real go. It also helped us to remain in control as we walked out of the house. This could have reassured her parents that the nurses were confident of what they were doing. This incident was bad as an engagement with the client did not go well resulting with the client going into hospital.
This is usually distressing for most people although hospital is regarded as a place of safety in these circumstances. Even guidelines to the mental health act (MHA, 1983) acknowledge this that hospital can be distressing to others. On a positive note the situation was handled well and no physical harm was done to anyone. It was also a learning opportunity for me, as I gained an insight and now the opportunity to reflect on relevant issues related to risk assessment and management in the community. When the message was received about Mat, a decision was made promptly to visit.
On each planned visit I would get an update and I was expected to find out more about the client as well. This usually focused on risk and other necessary background information which would help me understand the intervention and interactions with that client. I took this to be good practice and put one in an informed position. I don’t recall Rita finding exactly what was going on from the parents neither did we check documentation on his file. There are protocols and guidelines on managing risk in the community and the local team had its own arrangements.
A good risk assessment through the CPA process will minimise distress to staff, carers and the patient in service provision in the community (Manthorpe and Alaszewski, 2000). All these are resources which are available and it is the nurse’s responsibility to use or adhere to them. Rita is a senior CPN and knew about this client. Maybe she decided to react straight on the basis of the cues she picked from her short conversation with the parents making use of her clinical experience and knowledge of the service user (Benner, 2001; DOH, 2007).
She could have considered the clinical need and prioritised and as this was an emergency, practice and theory rarely converge in these circumstances depending on what you perceive to be the link between practice and theory (Welsh and Swann, 2002). Mat could have felt provoked by three strangers walking into his place. Nurses are expected to respect the client and more so in their own homes. Manley and McCormack (1997) contended that the client should be respected and given autonomy and choice and some do feel aggrieved if this is breached.
The situation was different in this case as Mat lived with his parents who had invited us and opened the door for us. But this could appear Mat as clear case of invasion of his privacy or space. Although Mat was clearly unwell I feel seeing a crowd rushing into your house will make anyone uneasy and feel disrespected. When Mat was clearly aggressive Rita informed us to leave. This was logical for safety and as nurses are not to be subjected to abuse. The trust and across the NHS there are ‘zero tolerance policies’ (DH, 1999) on violence to staff.
The NMC has also emphasised the need for employers and government to consider the human rights of the nurses while the Healthcare Commission has called for a balanced between protecting the healthcare staff and protecting patients’ rights. (Healthcare Commission, 2007). Without a prior risk assessment this decision could have been meant to create pace and time for risk to be considered. The space created may have been meant to allow space and time for Mat to calm down as well.
Under the Health and safety at work (1974) we had responsibility to follow the employer’s safety procedures. I did not see explicit measures and effort being put to de-escalate the situation at that moment. I am of the opinion that this could have helped and saved the stress of involving police and the hospitalisation which followed. I think this way, as by the time they got to hospital I was informed that Mat was apologetic for his attack especially on me. Maybe with a bit of time he could have calmed down.
The decision taken by the nurse could have been based on the need to protect the safety not only of the staff and the parents who appeared vulnerable but also for Mat’s safety. Rita could have felt the need to fulfil that requirement of her role duty of care as a nurse (NMC, 2004) and moral duty towards the vulnerable parents. In all this I assumed a back seat role. This was in line with my position as a student as I had to be aware of my limitations (NMC, 2006). I was not sure of how to react, whether to wait for cues from my mentor or to take the initiative was on my mind.
On reflection I have to agree with Irving and Hazlett (1999), who observed that working with people with challenging behaviour puts strain on the nurse’s interpersonal skills and weaknesses in this area are more evident in such situations. This could also have helped as I could have reacted in a way to aggravate the situation as I was target in this aggression. Working in a team requires professionals to be aware of each individual’s role and not to contradict one another so I acknowledged that Rita was taking the lead role.
In light of the risk posed by Mat a decision was made to involve the police. This is not an easy decision to make if one considers the impact this will have on the client. Even the staff’s time consumed by this can be enormous. In this case Rita had to spend the rest of her day involved on this issue. My mind kept telling me that there could have been an alternative approach somewhere, but Rita could have made the right choice as after MHA (1983) assessments carried out by other professionals; a consultant and ASW, it was felt there was a need for Mat to be in hospital.
In decision making Rita might have considered the vulnerability and the stress the parents could have been going through. Nurses also have to look after the interest of the public or carers as in this case (NMC 2004). After reflecting on what transpired on this day I feel there are things that could have been done differently. This does not suggest that anything was done in any wrong way, neither that my suggestions are better. Most of my suggestions are grounded in the benefit of hindsight which might not have been available to Rita at the time.
The staff could have taken their time and risk assessed before rushing out to see the client. Rita could have explored about the risk posed from the parents (DH, 2007). This could not have breached any confidentiality and eventually could have helped reduce further distress on all involved. This could clearly have quantified the level of risk and appropriate arrangements for interventions made. This could have involved a full MHA (1983) assessment with the right personnel in attendance. If the risk was high for the parents police could have been involved in the first instance to minimise risk.
Policies and procedures are there to give guidelines and they could have proved to save the day in this incident. It is the responsibility of staff to adhere to them (NHS SMS, 2005). Once we were at Mat’s place more effort could have been put to de-escalate the situation or to give him more space to calm down. Mat appeared prepared to talk to Rita and not the rest of us, even if it was on racial grounds. This issue could have been addressed later after he was composed highlighting how his behaviour was inappropriate. NHS SMS, (2007) has emphasised on this in nits guidelines.
Since he was unwell benefit of the doubt could have allowed Mat to speak to appropriate staff in the situation and this could have saved hospitalisation or involvement of other professionals. Such positive risk (Morgan 2004) taking could have saved distress on the part of the client and carers and resources of time and number of agencies and professionals involved. Further to positive risk taking, staff from CMHT could have involved the Home Treatment Team. This could have helped Mat to remain at home with an increased level of support as Mat settled down fairly quickly once in hospital.
It was also realised that his level of medication was quite a low dose and there were other factors triggering a relapse. HTT team could have given support and assurance to the parents in line with holistic care and moral agency, (Manley and McCormack, 1997). A discussion with the parents could have been considered to ascertain how they felt about Mat staying home with the support from HTT. After being involved in this incident and reflection I have considered several issues as regards my professional position and development. I have identified that risk assessment is varied and circumstantial to the environment.
I have to be aware of the risk considerations and then to equip myself with the right skills and tools to meet my responsibilities (Rew and Ferns, 2005). The tools provided such as policies and procedures are there to complement and minimise risk and not to hinder our work. It is my professional duty to be aware of these and make use of them where they are available. As I go into my last clinical placement I will make sure I am aware of these polices and adhere to them. Following the critical incident I carried out a teaching session during my clinical placement which I will reflect upon also using the Gibbs’ Reflect Cycle.
Teaching session reflection I planned for a teaching session on Risk Management as an issue I had identified in the incident I reflected upon. This was also a rare incident with this CMHT. Violence to anyone is distressing so when I looked at the role of the nurse as a teacher, RCN (2006) statement on violence and the professional expectations, I felt the need to share my knowledge on the topic. I delivered a presentation on the topic of risk management with focused reference to the incident. The participants were all the 8 staff members who attended the staff meeting for that afternoon.
In preparation I encountered encouragement and support from some team members but challenges were also there. In planning the teaching I looked at the subject area and relevance to the prospective audience. The language in terms of jargon and the method of teaching was considered looking at my position as teacher and learner as well as the adult professional participants. I had hoped to use power point but this was not available. The room and timing of the session were determined by doing the session during a weekly staff meeting which provided for teaching or presentation session (appendix 5).
From the onset anxiety set in as I was trying to decide what exactly I was going to focus on (Haward, 2004). This was mainly so as I was going to deliver a teaching to people who I was sure knew the subject matter better than me. Awareness of my limitations was glaring me in the face. The subject of risk is such a vast area and being specific can be a mammoth task. This happened early on in my placement and I was still getting familiar with the team. My confidence was low at the start of preparations and on delivering the session. The participants were from different professions including the team manager.
It was more difficult as most of my support was from my mentor who happened to be in hospital on the day. On the day of the incident I was given time to reflect on what had happened. This was good for me as this set the ball rolling for the planning and delivering of the teaching session. As part fulfilment my studies I was aware that I needed to present a teaching session (appendix 4). This was good as it helped me decide on what to do. This reflection also helped me understand that one of the most important issues in mental health if not heath and social care at large is risk management.
I got support and encouragement from my mentor and another newly qualified staff. Positive feed back and realising how my confidence had grown in those twenty minutes I had delivered the teaching felt very rewarding for my efforts. The challenges of deciding on the subject and planning of the teaching were unnerving. I was aware of my disadvantaged position that I was going to teach people who in all probability knew and had more experience on the subject than me, which who did not help my confidence regardless of what Thompson, (2004) suggested.
This was not helped by one member of staff who encouraged me to abandoning the teaching on the last point. He was not clear on his reasons but maybe felt he was doing me a favour. The timing of the teaching at the end of a staff meeting was not favourable and conducive for such a topic which could be very dry. The planned media of delivery of power-point was not available although contingency plans were in place. See appendix 5. Teaching requires preparation. The first consideration was who I was to teach. Knowing that I was going to teach experienced practitioners in their own area of practice was un-nerving.
When you teach something you need to impart some knowledge and you want to make worthwhile the student’s time. I was not sure what I should teach on. I had to find a topic which I would be able to research on and give some interesting knowledge that would be valued by my audience. This was partly achieved by basing my teaching on the critical incident that everyone was aware of. Reflective learning was achieved by the presentation which focussed on a known incident allowing the participants to discuss issues around that incident and relate it with the theory.
Cropley (1981) contends that adults learn best when encouraged to relate learning to their experience. Baud, et al (1985) also talked about leaning being enhanced by the use of experience, ideas and the reflective process and looking at the outcomes. In a group with nurses and other professions social workers, occupational therapists, doctors and psychologists as well as an administrator the language was important (Haward, 2004). This is an issue I had not seriously considered initially on the basis that this was one team which had been together for a long time.
But during my presentation I quickly realised that this was not the case when I had to elaborate or explain certain terms as well change substitute some terms as I continued. This lack of consideration could have left the participant uncomfortable or miss to fully benefit from the session. When teaching adults you need to treat them as adults and the same treatment should be expected from them (Knowles, 1984) making choose the androgogal approach. Although I was the one teaching my position was peculiar as I was aware that I could be the one with the least knowledge on the subject in the room.
I managed to realise and accept this short coming in knowledge on the basis that I cannot know everything. I also accepted that preparing and delivering this session makes me a learner and teacher at the same time. My learning was not limited to the researched material but also the discussions during the session and the experience of delivering the session, increasing my confidence (Thompson, 2004). One important consideration was the environment. The need to ensure basic intrinsic needs (Maslow, 1987) of physiological comfort and safety could not be overlooked.
This was initially not an issue as the room was prepared for the meeting. But as the time dragged on tiredness might have become a factor although this was not explicit. I was aware of this; I can recall trying to go through my presentation before anyone excused themselves. The timing of the session at the end of the meeting was good in that the largest audience was available after the team meeting and the meeting room was prepared already. Also this did not affect the work of any staff as they were all scheduled to be available at that time.
Initially there was passivity but progressively participation improved as questions were discussed among the participants. My fear was that this will be centred on me as the teacher (Quinn, 2000). Being aware of my limitation my audience could have missed out on those areas I could not fully articulate. Handout were prepared and used for this session. Personally I would have preferred to use power point for two reasons. Firstly I am used to using power point and I can manipulate the presentation (Sammons, 1997). I am someone who likes to use the latest technology and aids available especially with environmental awareness on my mind.
The second reason is that power point will help to divert some attention from me the presenter. This was topic so crucial that the student and mentor should work closely in partnership. In this way I will have gained more from getting a closer insight into what informed the mentor’s actions and a practical view of the issues at hand. The rest of the team members will also benefit more broaden view point (Jasper, 2003). With hindsight I could have discussed with the staff member who was discouraging me from carrying the teaching, challenging his position.
Some practitioners are only concerned about doing the minimum to do the job, treating education as an extra to necessity, described by Conway (1996) as ‘traditionalists’ and by Houle (1980), as ‘Laggards’ who resist both learning and new ideas. The topic of risk assessment is such a vast topic and given the opportunity I had on this occasion I could do justice to this important issue. I could revisit my ability to set work towards realistic goals that are achievable within my personal and professional life (Cropley, 1981). This was a learning opportunity which I will nurture and utilise to develop myself and other professionals.
Critical incidents are learning opportunities for everyone concerned staff and clients alike. My role as nurse requires me to be an educator and a health promoter. To this end a teaching session on such an incident should include experienced staff and clients in preparations and delivery where possible (Manthorpe and Alaszewski, 2000). I will also consider delivering a similar teaching to educate the clients as well especially those who were part of such an incident (NHS SMS, 2007). Conclusion After this process of reflection I can realise the importance of life long learning (DH, 2001).
In nursing there are many challenging situations which are so varied; one is expected to fully appreciate the need to continuous update and keeping one self abreast with skills and knowledge. Challenging situations occur on a daily basis and unless we are prepared for them the quality of care will suffer. Some of these incidents will leave staff at the ‘end of their wits’ and may affect their confidence. More skills and knowledge will become hand especially in challenging engagement situations where there will not be time to look up things. Clinical supervision will form a big part in maintaining and improving competency.
Competency as a nurse is critical and justifies need for PREP (NMC, 2004a) for transition for newly qualified nurses and need for life long learning requirements of KSF standards (DH, 2003) Reflection will help one to identify areas for personal and professional development. This will go a long way helping the KSF and clinical governance requirements (Scally and Donaldson, 1998). All these factors to enhance the nurse’s knowledge and skills are prerequisites for responsibility and authority which underpin accountability. Skills and knowledge in professional practice brings the ability to exercise professional judgement.
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