What is critical incident? Critical incident has been defined in different ways depending on the nature of the incident and the environment or setting where it took place. Tripp (1993) defines critical incidents as a “commonplace events that occur in routine professional practice” Incidents may relate to range of issues amongst which issues of communication, relationships, moral beliefs and ethical values, knowledge, culture or emotions. The definition I like best is that a critical incident need not be a dramatic event, but it is an incident which has significance for us. It is often an event which made us stop and think, or one that raised questions for us. One that may have made us question an aspect of our beliefs, values, attitude or behaviour. It is an incident which in some way has had a significant impact on our personal and professional experience and learning (MU).
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Curiosity is a basic human emotion. The psychologist William McDougall states that “The instinct of curiosity is at the base of many of man’s most splendid achievements … “. As humans we all have the drive to find rational explanation of lived events and our surrounding. We do that though trying to examine or reflect on our experiences. According David A. Kolb (1984) reflection is an inseparable part of the learning process. This is the part during which by analysing given event we enhance our knowledge, enrich our practical experience and prepare for new and challenging situations.
Different frameworks have been developed to aid the development of critical reflection. Most prominent are the models of Kolb (1984), Gibbs (1988), Atkins and Murphy (1994), Johns (2000), Rolfe et al (2001) and Lister and Crisp (2007). Lister and Crisp explain that “critical incident analysis has developed as a tool to aid critical reflection in practice, in health and social work”. It has been used to enable students to describe and explore issues from their practice (Nygren and Blom 2001), (Montalvo 1999).
PoDAIT describes that “Critical Incident Analysis is an approach to dealing with challenges in everyday practice.” and that “As reflective practitioners we need to pose problems about our practice, refusing to accept ‘what is’. We need to explore incidents which occur in day-to-day work in order to understand them better and find alternative ways of reacting and responding to them.” Therefore it is safe to conclude that critical incident analysis can enable professionals to reflect on their practice and to explain and justify it.
During my placement at a south London CMHT I had short period of working with the duty team. This was when I and the MH nurses Q met Miss X for an initial assessment.
Several days following Miss X’s assessment her case was discussed at a clinical review with one of the team consultants DR G and it was decided that the dosage of her medications is to be altered. When I informed her GP of the above I was told that her medications have already been adjusted and that the dosage is different from the one given on her referral. This created the need for reviewing Miss X’s case second time. In the meanwhile Dr G left the team and was replaced by Dr V.
By that time I had finished my period of duty work and despite the fact that I had recorded all information on the internal database and that Miss X was still a duty client I was asked to present her case at Dr V’s next clinical review. I had no objections as I had knowledge of the client, and especially as Q was not present. At the review was decided that Dr. V will offer Miss X another appointment. I recorded the outcome on the internal database and also reported to Q who happened to be on duty shift. I also informed him of the need for Miss X to be notified of her appointment.
On the agreed appointment date Miss X did not attend and when contacted by phone she stated that she was not notified of it. Dr V asked me to offer her a new appointment for the following week. I had no obligation to liaise with the Miss X or do any work on the case as she was a duty client and I no longer had formal involvement with her. Nevertheless, I notified her of the new appointment did both over the phone and in writing.
When the second appointment came Dr. V asked me to attend the assessment with her. I was not required to, however I accepted. I decided that while Miss X would be more comfortable with a familiar person during the meeting, I would have good learning opportunity attending an assessment conducted by one of the team consultants.
When Miss X arrived I introduced Dr V to her. During the assessment Miss X said that her medications have not helped and that she cannot cope. During the assessment she was wringing her hands and became tearful. Dr. V identified that Miss X had not been taking her medications at the appropriate time and that sleeping in the afternoons could be contributing to Miss X’s difficult night sleep. During the assessment Dr. V suggested that she can prescribe Miss X a number of different sleeping aid medications. However, at the end Miss X’s medications were not changed and she was told to continue with her current ones, but to take them at the prescribed times. Dr V informed Miss X that she will offer her a follow up appointment in two weeks time, in order to assess her progress and to change her medications as and if necessary.
Following the assessment I went to the duty workers and asked them to come for an update from Dr. V. Two of them were busy and the third one Z who is a MH nurse was dismissive. As I could not get anyone from the duty team to come I went to the doctor’s office for final discussion and planned to record the outcome of the assessment and any decisions on the internal database. While we were discussing Miss X’s action plan Z entered the office. It was jointly agreed that Miss X will be offered follow up appointment in two weeks time.
Later in the day Z came to me and asked me whether I have recorded the appointment in the duty diary. I informed her that I have not as my understanding was that this is consultant’s appointment rather than a duty one, which is normally not recorded in the duty diary. Nevertheless, she insisted that I do so. As I recorded the appointment in the diary, which I found on Z’s desk, Z came and asked me not to make the appointment for the agreed date but for the day after. She explained that the appointment fell on a day which should be free of duty appointments. I was obviously confused as the date was chosen by Dr V and the other 2 previous appointments were both booked for the same day of the week without that being a problem. Z said that she has spoken to Dr. V regarding the appointment already. While trying to be helpful, having been given ambiguous information and the fact that Miss X was not my client to start with, I decided to step back and asked Z to clear any confusion with Dr. V.
On the following day during Dr. V’s clinical review meeting Z presented Miss X’s case with suggestion for her to be discharged back to GP. To my big surprise Dr. V agreed with the suggestion. The rest of the team approved her decision silently. As the team had moved onto discussing other client I did not want to interrupt and did not speak out until the end. Having considered the distressed and tearful state in which Miss X presented, during the two assessments, her reports of feeling hopeless and without support, and her previous suicidal ideation, I asked if we could have another look at her case and perhaps offer her one more appointment before discharging her from the team.
Dr. V said that she had reconsidered her yesterday’s decision and assert that Miss X presented low risk; therefore she did not require further input from a consultant. In principle I agreed that Miss X may not have to be seen by a consultant. Nonetheless, I still felt that it would have been appropriate and an example of good practice for a member of the team to see Miss X before discharging her, especially after she was told to expect further support. Z suggested that I should take the case on. I explained that without my placement tutor’s permission I am unable to accept any new clients. Z suggested that keeping her as a client for an extra week or two puts strain on the duty team and suggested that as alternative to face to face appointment I can call the client. I agreed to that, but highlighted that due to my student capacity I would still have to be supervised by a team member. One of the senior social workers commented that I “will be given credit towards my competencies”, for advocating for the client. My request was left unanswered and Z said that she would deal with the case. Following the meeting another member of the team also a MH nurse spoke to me and said that I should not have brought up this question and contested the decision made by the consultant.
I provided my practice assessor with a report of the situation however, it never went any further.
I tried to look at the whole process and the outcome from Miss X’s perspective and tried to explore her feelings.
Removal of formal and informal power barriers between the su and s providers
Did not feel like I could change the decision and speaking to the cons. Would not have been benefitial.
I was surprised if not even shocked by the consultant’s decision. Earlier I had observed (noticed) a certain level of indecisiveness as whether to prescribe different medication s or not have offered a range of different meds however did not stick to any of her own suggestions. Reflecting on that I tried to justify her behaviour accepting the fact that along the assessment different new information came to light. (reflected on her actions and decisions made)
Power dynamics, my student and consultant
Being familiar with the details ot the case I felt it was morally and ethically unjust to remain silent and not bring the matter up
Being assertive but not argumentative
in this situation my believes and values clashed with the decision taken What was the right thing to do. Keeping in mind my status in the team as student on placement, without extensive social work experience and not familiar with the power dynamics within the team I was double minded as to whether to Express my disagreement by suggesting an alternative approach to the situation and in this way challenge the decision taken by the consultant or to remain silent. In this situation the final decision about the care of the patient was being made. I (felt) was aware that once the decision was made speaking in private with any of the participants would not be constructive or bring positive results.
No one likes being challenged and when this happen some people may become self-protective and resistant to accept others’ views which may also impair future joint working. It is important to highlight that by challenging certain decision it is only the decision being challenged and not the person. After all the joint goal is the wellbeing of the client and not proving who is right or wrong.
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Be aware of office power dynamics and be mindful that some professionals may be strongly opinionated and confronting their views on a particular matter has to be made with care and in non confrontational approach. Sensitively approach and challenge others opinions try to (prevent from happening) diffuse charged emotionaly situations (to be diplomatic) When analysing a critical incident, it is useful to ask yourself questions such as:
- Why do I view the situation like that?
- What assumptions have I made about the client or problem or situation?
- How else could I interpret the situation?
- What other action could I have taken that might have been more helpful?
- What will I do if I am faced with a similar situation in the future?
Atkins, S & Murphy, K (1994) Reflective Practice Nursing Standard 8 (39) pp49-54
Evans, D. (1999) Practice Learning in the Caring Professions, Aldershot, Ashgate.
Gibbs G (1988) Learning by doing: A guide to teaching and learning methods. Oxford Further Education Unit, Oxford.
Johns C. (1995)Framing learning through reflection within Carper’s fundamental ways of knowing in nursing. Journal of Advanced Nursing 22 p. 226-234
McDougall W. (2003), “An Introduction to Social Psychology”, Courier Dover Publications
Rolfe G., Freshwater D., Jasper M. (2001), Critical Reflection in Nursing and the Helping Professions: a User’s Guide. Basingstoke: Palgrave Macmillan
KOLB D A (1984) Experiential Learning: experience as the source of learning and development New Jersey: Prentice-Hall
ProDAIT – http://www.prodait.org/approaches/cia/ [accesedâ€¦â€¦â€¦.]
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