Elderly Patient on Psychotic Depression ward

In this assignment I will be carrying out a ‘Critical Incident Analysis’ on an incident taken from my portfolio that was encountered whilst in practice placement. This type of analysis was first used to analyse flying missions by pilots, as a way of raising their performance (Flanagan, 1954), in more recent years Norman et al. (1992) and Perry (1997) described this type of analysis as being an important and valid tool for use in nurse training, as it allows the student to choose and use an incident that made an impact on them, from their practice placement that was either positive or negative, so that they can analyse, reflect on and learn from it, showing their development as a practitioner and a person whilst linking theory to practice and helping them move from novice to expert, as outlined by Benner (1984) .

Model used for reflection

For the purpose of this assignment I have selected the Gibbs (1988) reflective framework model which is an iterative model meaning it is cyclical in nature, the six points covered by this model are:

Describe the activity or experience in objective detail.

Discuss and explore any feelings you were having at the time of the experience.

Evaluate the experience: What really happened? What was good about it? What was bad? What factors contributed to the event?

Analyse the experience: What can you learn from it?

Conclusion: What could you have done differently? Anything you wish you had done? Wish you hadn’t done?

Action Plan: What can you plan on doing in the future?

(Bethann, 2004, p167)

This is also the model I use in my portfolio as along with critical incident analysis, it centres on reflective practice, an essential skill in nursing practice allowing situations to be analysed in detail, identifying areas of potential change, Jasper (2003) and reinforcing the need for certain practices by highlighting their benefits. I also find the logical, straightforward structure of this framework allows the reflection to be written clearly, providing opportunities to look at incidents from different perspectives.

The Critical Incident

Stages one and two of Gibbs model of reflection are covered here, where the incident is described along with my feelings at the time of the incident.

I chose this particular incident as it put me in a very challenging position where I had to think on my feet, it made me test my abilities as a communicator and a nurse under stress, whilst highlighting the importance of some of the more basic nursing techniques like non-verbal communication through touch, educating patients to help themselves, looking out for physical signs that can indicate a patient is in distress and how working closely with a patient can earn their trust whilst building up the therapeutic relationship

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In order to keep the patient and the practice placement confidential, as indicated in the NMC Code of Professional Conduct (2002) and the N.M.C. guide for students (2002), the practice placement is kept anonymous and the patient will be referred to as ‘Tom’. The patient’s consent was also obtained, as it is the patient’s right to choose whether or not they wish details to be written about them, highlighted by Johnston and Slowther (2003) also outlined in section – 3.7 of the N.M.C Code of conduct (2002) with reference to patients who suffer from mental illness.

The patient, ‘Tom’ a 72 year old man, was admitted to my practice placement suffering from Psychotic depression and anxiety, my placement is at a Psychiatric admissions ward, for patients over sixty five years old.

On assisting Tom with his ‘activities of daily living’ (A.D.L’s), (Roper et al, 1980) after, rising one Monday morning, It became apparent when helping Tom dress that his right arm was causing him pain, in the area of his right shoulder, I relayed this to the nursing staff who explained Tom had fallen unobserved on the Friday night and had been seen by the Doctor who on examination felt no other investigations were needed.

On further discussion about his arm and the fall, between myself and Tom, he eventually admitted to having also fallen on the Sunday night and had not told anyone about it, once I had explained this to the nursing staff the Doctor was again consulted and felt that Tom should have an X-ray to rule out any broken bones.

I accompanied Tom as an escort to the x-ray department where he became increasingly agitated, anxious and was mumbling to himself with delusional content of speech evident, concerning the N.H.S. which had not been known about, as Tom had only recently been admitted, he felt ‘they’ (the N.H.S) were going to cause him, bodily injury (a persecutory delusion – Gamble & Brennan, 2003) due to his ‘doing them out of money’ when he was younger, I did my best to give constant reassurance that I would not let anyone harm him, but when someone holds a delusional belief it can be very firmly maintained and difficult to dissuade from, in particular when they are in a state of high anxiety like Tom, as indicated in Stuart and Laraia (2001). I was quite worried about how the situation was going and that I might be out of my depth as I did not know Tom very well and felt a little awkward trying to reassure someone who was this distressed, feeling I was doing little or no good for him.

After he had his x-ray and I was assisting him to get dressed in the x-ray cubicle the Radiologist came in and told us that Tom’s shoulder was broken and that we would need to go round to casualty to be seen by a Doctor there.

This news made Tom’s level of panic escalate considerably and he began to have a panic attack in the cubicle, most likely a ‘situationally predisposed panic attack’, which occurs on exposure to a situational cue or trigger (DSM-4) Tom had become quite pale and began to perspire profusely, along with his breathing becoming very shallow and rapid to the point that he was panting, I found it quite distressing to see Tom in this condition.

I had never encountered someone quite as panicked as this and I felt quite concerned. I thought calling out for someone to help might only panic him more, so I decided to try some deep breathing exercises to relax and calm him down first, then if that did not work I would seek help. I knew from reading Tom’s notes that he did not have a heart condition or other health problem that would have been causing these symptoms and it had been recorded that Tom suffered from panic attacks, although I was still watchful for any change in his symptoms that might indicate an alternative medical reason for his condition.

Initially I sat beside Tom with my arm around him, asking him to take slow deep breaths, but with his level of panic and no eye contact meant he was not concentrating on me, so I knelt down on the floor in front of him took his hands, spoke to him gently but firmly using his name and with direct eye contact got him to focus on what we were doing.

I explained his symptoms were due to his panic attack and the breathing exercises we were doing would help relax him, calm him down and make him feel better. Tom started to comply and began with my instruction, breathing in slowly through his nose holding it for a moment then breathing out slowly through his mouth.

In a relatively short time his breathing began returning to normal and he started to relax, enabling us to go on to the casualty department to see about his shoulder. In the casualty department Tom still required reassurance not only verbally but also with touch as he asked me to hold his hand, bringing home the importance of this simple yet significant form of non-verbal communication and despite needing another brief set of relaxation breathing in the casualty cubicle Tom was notably calmer.

I felt privileged that he had put his trust in me and that we had moved on further in our therapeutic relationship, as while waiting in casualty Tom who had hardly spoken to anyone let alone myself, began discussing how scared he had been and talked about some of his delusional beliefs, which helped me empathise with how terrified he must have been. I was also able to discuss what Tom told me with the qualified nurses on return to the ward giving a deeper insight into his condition.

Critical Discussion of the Incident

For this section of the Critical Incident Analysis stages three and four of Gibbs reflective framework are covered, allowing me to look at what was good and bad about the incident along with contributing factors (Gibbs 1988), I am going to discuss, analyze and reflect upon three key issues: Panic attacks, the relaxation technique of Deep breathing and Touch therapy, that were encountered during the incident and that I felt were of significant importance.

Panic attacks

I felt this topic was important to the critical incident as it is a common condition closely linked to anxiety which a great number of mental health patients experience often along with their main diagnosis but most commonly alongside depression as in Tom’s case, Clayton (1990) and Merikangas et al (1996) stated that comorbidity between panic and depression is the single strongest type of anxiety-mood comorbidity found in both treatment and in the general public. Panic attacks are often talked about and appear in patient notes but this critical incident brought home for me how absolutely terrifying and totally debilitating the panic attack was for Tom and how distressing it can be to witness a patient in this condition.

Anxiety is a normal healthy reaction to the stresses of everyday life as suggested by Trevor Powel (2001) and even necessary for us to perform at our best as ‘Yerkes-Dodson’s Law (1908)’ explains, illustrated in the graph below. Here levels of anxiety are referred to as ‘arousal’ and a direct correlation to performance is demonstrated, it tells us that if we have low levels of ‘arousal’ then our performance becomes decreased (distress, as introduced by Seyle (1956)), at medium levels our performance levels peak (eustress as described by Seyle (1956)) and when our ‘arousal’ levels become high our performance levels and subsequent ability to function drop again (resulting in distress) as seen in Tom’s situation.

(Yerkes & Dodson 1908)

Peplau (1963) defined anxiety in four levels:

Mild anxiety- everyday life stress.

Moderate anxiety- Immediate concerns focused on, with narrowed perceptual field, although able to function when necessary.

Severe anxiety- Greatly reduced perceptual with difficulty focusing on anything except what is causing anxiety.

Panic- Person feels terror, dread as is unable to reason with the ‘threat’ causing anxiety blown out of all proportion, making it almost impossible to communicate or function, with little or no control over themselves – causing panic attack.

Tom’s anxiety level was clearly at the ‘panic’ stage which cannot be allowed to continue indefinitely as being in a panic attack state is not compatible with living, as described by Stuart and Laraia (2001), who believe if prolonged can result in total exhaustion or in extreme cases even death.

Panic attacks affect between 3 and 5 percent of the population at some point in their lives (Lynch E, 2005). The findings of an American study carried out this year showed that people suffering from panic attacks account for around 25% of those attending casualty departments or G.P’s. (Ham, P. et al, 2005) often having trouble breathing properly as found with Tom, with most people suffering from panic attacks, stating hyperventilation as being one of their main symptoms (Holt and Andrews, 1989), or with patients believing they are having a heart attack.

Tom’s panic attack was mainly evident by the physical symptoms he displayed, described previously, physiological symptoms often being the only visible signs of a panic attack as described by Stuart and Laraia (2001).

In this instance, although Tom’s Psychotic Depression was the likely reason for his anxiety with the resulting panic attack, I felt trying to deescalate his anxiety levels, by getting the panic attack and hyperventilation under control was my main priority, there would have been no point in me trying to deal with his delusional beliefs at this point as this takes time and experience, of which I had neither, plus Tom’s panic levels were so high it was difficult for him to concentrate. Therefore it seemed logical to concentrate on something which it was perhaps possible to change.

I hoped that using the deep breathing technique would be successful in helping return Tom’s body systems to normal which would stop the hyperventilating making Tom feel a lot better and knew that breathing techniques could be very effective but did not want to put Tom at any risk by doing so, I had to make a judgment call about how I was going to handle the situation and decided I was going to try and deal with it using the breathing exercise.

Relaxation Techniques – Deep breathing

The next topic I am going to cover is Relaxation Techniques and the technique of Deep Breathing in particular, I feel it is important to cover this topic as it was a key factor in the outcome of the incident as by guiding Tom through the breathing technique, enabled him to control his breathing resulting in his panic attack and hyperventilating coming to an end.

Tom’s physical symptoms indicated that he was hyperventilating or ‘overbreathing’, the mental health handbook (Trevor Powell, 2001) tells us this is a normal response to threat by our bodies to bring more oxygen to the muscles, preparing us for ‘Fight or Flight’, but if the extra O2 is not needed by the muscles, i.e. the situation is only an imagined threat as in Tom’s case, the normal level of gases in the blood and lungs becomes out of balance, due to breathing in to much oxygen (O2) and pushing out too much carbon dioxide (CO2), this causes the blood to become alkaline which brings on many of the unpleasant symptoms Tom was suffering from.

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There are several ways of overcoming hyperventilation, possibly the most commonly referred to, is breathing into a paper bag to facilitate the breathing back in of the carbon dioxide being breathed out, as explained in the Nursing Times article, Facts: Panic Attacks (2003), which also acknowledges the importance of controlling the patients breathing, Stuart and Laraia (2001) also agree that relaxation techniques are an accepted therapeutic intervention in the treatment of anxiety.

Since I had no paper bag with me, I decided to use the three stage deep breathing technique to retrain Tom’s breathing which, Risser and Murphy (2005) agree, improves panic symptoms and associated disability, this type of breathing which is commonly used in yoga helped to slow down and control Tom’s breathing which also stopped him hyperventilating, it is carried out by:

Inhaling slowly and deeply through your nose.

When you’ve taken in a full breath, hold it for a moment and then…

Exhale slowly through the nose or mouth, depending on your preference.

This action although different to the paper bag technique brings about the same desired effect, in the case of ‘Deep Breathing’ carbon dioxide is not being re-breathed but the rate it is expelled by is being slowed down along with holding it a little longer in the lungs which results in the levels of carbon dioxide in the blood rising, correcting the acid/alkaline balance in the blood, which relieved Tom’s unpleasant symptoms, bringing his breathing rate back to normal and making him feel calmer.

At the time of the incident I really hoped that the breathing technique would be successful although I was not entirely sure whether to trust my instincts and try it out. On reflection I was very impressed at how effective such a simple procedure could be and was glad not only for Tom’s sake but also my own that I had decided to try it out, as it gave me more confidence in my abilities as a nurse even though at the time I was carrying it out, although outwardly calm, I had felt quite anxious.

Touch Therapy

The final key issue I wish to highlight from the critical incident is the benefit of touch as a therapy, which I felt was vital as a way of communicating with Tom during his panic attack along with giving him reassurance that I was there for him, empathising with his situation and helping him focus on what we were trying to do.

There are several terms used to describe the different types of touch used in nursing, some of which are: ‘necessary touch’ which covers ‘task’ and ‘instrumental touch’ that is mostly used when a procedure or task needs to be carried out on a patient as opposed to ‘non-necessary touch’ which is described as spontaneous and emotional physical contact between the nurse and patient, introduced by Routasalo (1996), ‘expressive touch’ comes under the ‘non-necessary touch’ umbrella with the same type of nurse patient contact, described by McCann & McKenna (1993) which is similar again to ‘caring’ and ‘protective touch’ highlighted by Estabrooks (1989) and finally therapeutic touch, which is an alternative therapy similar to reiki, discussed by Meehan (1998).

Nesbitt-Blondis and Jackson (1982) agree that touch is probably the most important of all non-verbal communications that we use in nursing and can be particularly useful in cases like Tom’s panic attack where his ability to understand and communicate was diminished, when patients are unable to communicate verbally or understand verbal communication for reasons such as dementia, those with learning or cognitive difficulties and in panic attack situations like Tom’s, touch can be an excellent means of communication.

Unfortunately, McCann & McKenna (1993) reported that in the U.K. there is little use of expressive, non-necessary or caring touch by nurses. Many nurses see touch as just something that is used when a procedure or task needs to be carried out on a patient, but Tutton (1998) suggests that touch in nursing and the powerful expressions it conveys to patients are sadly underutilised. Routasalo (1996) also suggests that non-essential touch although not absolutely essential, can be extremely important and necessary to the patient.

The benefits of this type of touch in nursing are strengthened further by Moore & Gilbert (1995) who found patients interpreted the use of touch by nurses as a display of affection and attention which they greatly appreciated, with patients interviewed in Routasalo & Isola’s (1996) study, describing touch by nurses as extremely comforting.

Davidhizar & Giger (1997) whilst acknowledging the important role that touch can play in the nurse patient relationship, also points out that the value of touch is not appreciated by all health professionals or considered appropriate or desirable by some patients. Bearing this in mind as long as the correct manner of touching is employed, and there is no way it could be seen as being inappropriate with the patient’s personal and cultural beliefs being taken into account, it is one of our most valuable communication nursing tools.

The extent of physical contact carried out in a society is governed by sets of well-defined behavioural norms for whatever circumstance we find ourselves in (Pratt & Mason 1981). Jourard (1966) recognised that the incidence of touching within our Western society declines from childhood onwards but Montagu (1986) discovered that the need for touch did not reduce with age. It is felt that the level of touch common in childhood can return in situations of sickness or incapacity (Barnett 1972). This may mean that, the need for touch in illness might be more important than our ideas of ‘proper’ behaviour.

I felt the touch element in this incident: my taking of Tom’s hands to help him focus, get his attention and convey my empathy, was extremely important and was in fact the turning point in the whole incident which allowed me to gain Tom’s trust and initiate the breathing technique which stopped him hyperventilating. I feel that without the touch element it would have been almost impossible for me to ‘reach’ Tom and the outcome of the incident would have been very different.

Implications for Professional and Personal Development

In this final section of the Critical Incident Analysis, the two final stages of Gibbs model of reflection (1988), five and six are covered, here we look at what was learned from the incident, what could have been carried out differently or should not have been done, along with what was missed out concluding with a plan for future action.

I found in utilising the Gibbs (1998) reflection tool, the impact the incident made on my personal and professional development was made much clearer.

Through carrying out this Critical Incident Analysis I have been able to see what I have learned through reflection, as the Department of Health (1999) states, reflective practice is necessary in order to further our continued personal and professional development and leads to a greater understanding of our own needs. Described as a form of self discovery by Freshwater (2004) with a deeper understanding of the needs of the patient and improved patent care highlighted by Davies (1995).

From this I feel the analysis made me examine my communication skills on a deeper level for although I feel that I am a natural communicator, and have had many years experience working with people suffering from dementia, I had not fully thought about the use of touch or the great importance it has in communicating with patients .

Without the use of reflective practice I would not have researched into the concept of touch so fully or really understood its relevance and consequences in my nursing practice. Or recognised the significance touch played in the successful deescalating of Tom’s panic attack and hyperventilating in this critical incident. This Critical Incident Analysis has definitely taught me to have more faith in my abilities as a nurse but has also taught me I have more to learn as a communicator.

Similarly with the topic of panic attacks which I was obviously familiar with and had some knowledge on, having been through the incident with Tom and then carrying out the reflection on the incident, allowed me to see the field of panic and anxiety disorders with a deeper understanding and much more from the patients viewpoint. Having witnessed the real distress and levels of disability it can inflict will enable me to really empathise with patients like Tom going through this type of disorder when I come across them in my future career.

The area of relaxation breathing was something which I had used myself in yoga practice and did know of its benefit in anxiety situations, but I had not expected to have to start teaching it to a patient that day in the X-Ray cubicle. I was quite shocked when Tom had began hyperventilating but on reflection I should have perhaps saw it coming with his rising levels of anxiety after our arrival at the hospital, especially after I had read only that morning that he had a history of panic attacks. Again on reflection I could have asked the nursing staff the best way to deal with it should the situation arise. I have learned from this that I could have been better prepared before escorting Tom by asking questions and having a plan of action to use if necessary.

I had been worried about putting Tom at risk by trying the breathing technique with him as I stated earlier, and perhaps it was wrong of me to have tried it in the first place, but I had made a judgment in an emergency situation, and I did not make the decision lightly, being aware that help was nearby should it be needed. I did not want to distress Tom further by calling out, resulting in people rushing into the cubicle and in conclusion felt the breathing exercise was worth a try, but I would have called for help quickly if it did not appear to be working.

On discussing the incident and my actions back on the ward, my mentor also felt I had made the right choice. This made me think about the fact that as a nurse there are times when it is up to you to make judgment calls regarding patient care and that it is important to remember that you are accountable for your actions. To carry this level of responsibility demands a sound knowledge of practice and an ability to think calmly and clearly even under stress.

I was both relived and delighted that the breathing technique worked so well for Tom and felt honoured that he decided to put his faith in me. As stated earlier, this prompted Tom to confide some of his fears to me, which showed trust on Tom’s part and fostered a deeper understanding of his condition on mine. This advancement of the therapeutic relationship between Tom and I has continued during my placement where I have worked quite closely with him and where I have taught him how to practice the breathing techniques when he feels calm making it easier for him to utilise in panic situations, which he has been doing with good effect.

As a follow on from this incident and after seeing the efficacy of relaxation techniques in action, at my practice placement I asked my mentor if it would be possible to carry out some relaxation groups with carefully screened groups of patients who had anxiety problems. My mentor and other nursing staff thought this would be a good idea both for the benefit of the patients and for my personal and professional development. After researching the subject and finding appropriate music along with compiling a script, the groups were initiated with great success and are now regularly used on the ward, which has given me some sense of achievement and helped build my confidence in my abilities as a nurse.

Along with being very beneficial in analysing this particular incident the use of reflective analysis has definitely improved my practice in placement, and although I have used this model of reflection in my portfolio for some time now, it has made me re-examine the importance keeping and using a portfolio to further my professional and personal development. I also feel this helps me to benefit more from my placement as I fully understand the concept behind reflection and use it positively as a tool rather than a task I need to perform.

When using reflection now I am able to draw more insight from my experiences on placement, while previously I had only skimmed the surface of the subjects when carrying out reflection. This has increased both my self awareness and my ability to link theory and practice together. Overall, I can see clearly how reflection is a useful tool in helping nurses to focus on their skills and behaviour which consequently enables them to provide the best care possible for patients, as discussed by Somerville (2004).

Action Plan

Preparing and utilising action plans is an important way of improving both our personal and professional development as nurses, whilst building on improved nursing practice.

To be prepared for this kind of scenario in the future I have identified the following plan of action:

Make sure I know and understand all relevant information regarding patients.

Have good communication with other members of staff about patients.

Have a plan of action thought out for any incidents that may arise.

Remain calm and consider actions carefully.

Empathise with the patient by trying to understand what it would be like to be in that situation.

Where possible help the patient to help themselves, i.e. by educating them to use breathing techniques so when a panic situation arises they are in a better position to take control themselves.