Critical Incident Analysis - Nursing Assessment Answers

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Introduction

Different professions are faced by varying challenges every day at their place of work. It is therefore necessary to analyse the problem that occur during provision of services in order to understand the cause and how it can be avoided in future. This document provides a critical incident analysis of a scenario whereby several parties failed to perform their duties effectively. It outlines the problem faced and the suggested cause of the challenges and how the activities would have been performed to eliminate the occurrence of the incident.

Section 1

In the field of nursing, a critical incident is one of the activities that can happen due to either a positive or a negative reason. After the incident takes place, the person concerned reflects on what happened to him or her and in some cases rethink about the event that took place. In this field, analysis of any critical incident is important as it helps to facilitate reflective practice and learning whereby the nurses explore their feelings on the subject involved. It also acts as a medication error and is significant for the people involved. On the other hand, the critical incident analysis revolves around an event whereby the analysis of the circumstances surrounding it are included, the actions of the people involved as well as responses and outcomes of the event. Thus, in the scenario discussed here, the analysis helps in identification of professional capabilities of the student and the RN that can help one to increase knowledge as well as improving patient care outcomes (Vachon & LeBlanc 2011, p. 896).

This essay will focus on critical incident analysis, which occurred at a placement of a nursing student. The student was working in an environment whereby the need for critical care services has been on the rise as people seek for medical care to improve survival from surgery (McIntyre et al, 2013, p. 135). The aspects of the critical incident will be explained in order to point out weaknesses that may have resulted to the problem that arose in the scenario. In this essay, reflective thinking is applied to provide a clear understanding as well as analysis of the scenario highlighting assumptions and factors that resulted to judging behaviour and in return undermining good nursing practice as the major issues of concern (Vachon & LeBlanc 2011, p. 900).

Basing on the incident described in this work, it is necessary to use the reflective cycle, which focuses on the situation of both the patient and the nurse. This is in contrast to other modes of analysing an incident that focuses on the feelings, beliefs, as well as the judgment of the nurse only. The reflective cycle emphasises on feelings of the different parties involved, and the problem can be identified immediately since it offers an objective perspective. It can be followed easily and understood very fast, and the reader can follow the clear analysis of the incident. For instance, the reaction of the patient at the end helped the registered nurse to detect there was a problem and acted accordingly (Raju 2014, p. 4).

There are codes of ethics that need to have been exercised and could have minimised the occurrence of the incident. The codes have been set aside in this case although they serve different purposes such as guiding ethical decision-making and providing the nurses with reference point from which to reflect on their conduct and that of others. Besides, they help to identify fundamental ethical standards as well as values to which the profession is committed. Firstly is the aspect of nurse value quality care provided for all people. This involves accepting accountability by the RN with regard to standard nursing care they provide as well as taking action when unacceptable nursing care arise. In this case, the correct procedure would have been the need of the RN to recognise the accountable that fall for the decisions made regarding the patients care and practice within the professional role boundaries. The nurse was also entitled in ensuring that the students are supported during their placement in order to gain experience. Secondly, it involves the act of the nurses valuing informed decision-making. This means that the RN need to value peoples interest when making free and informed decisions. For this scenario, the nurse was supposed to make the decision of assigning the tasks to the students basing on contemporary and well-founded knowledge and information. Thirdly is whereby a nurse is expected to value a culture of safety in nursing together with health care. It emphasises on valuing a culture of safety involving the need of the nurses to actively engage in the development of shared knowledge. The RN was supposed to share the knowledge and develop the knowledge of the student before assigning the tasks which helps in understanding the crucial importance of health care. The patient needed much more attention from the RN although she ignored this and got involved in other activities leaving the person under the care of the student. Fourthly, the nurses were to be guided by the code of valuing a socially and economically sustainable environment which promotes both health and wellbeing. The RN would have been involved in attending to the patient together with the student. Lastly, the RN did not value respect and kindness for the patient. She was to look after the patient as the sign of value for the life and wellbeing of the person.

Description of the Incidents

The case involved a first year registered nurse who had in the past six months been serving patients in the intensive care unit. There was a post-operative patient who needed care after being admitted from the theatre following the thoracic surgery and suffering from issues that needed close attention (Ferraris et al. 2011, p. 947). The patient had an indwelling urinary catheter, oxygen therapy, wound drains, and a central venous line for fluids and antibiotics. In addition, there was an underwater seal drain ventilating to the air and swinging on inspiration. However, due to many activities taking place in the health care facilities, late shifts were usually busy, and a nurse required some help from others in order to keep an eye on the patients and take note of their improvements or deterioration of their conditions. Here, two third year nursing students who were on their placement for two days ago in this unit contributed to the critical incident outlined. Although the patient was stable because the pain was under control, the conditions became worse after Bethany, one of the students volunteered to help him. Before assigning her any responsible, it was necessary to enquire if she had emptied wound drains together with a urinary drainage bag before as she claimed to have done in the previous surgical placement. Moreover, when asked about the whereabouts of the equipment and where to chart the drainage volume she gave a positive feedback and went ahead to carry out the task. The trained nurse was seated at the end of the patient bed entering data from the shift as Bethany carried out the tasks. Contrary to the expectations, the patient gasped for breath as Bethany completed the roles since she had emptied the underwater seal drainage bottle of the patient. Since the chest drainage tubes were not drained using the correct procedure, this exposed the patient to some discomfort and was seen gasping for air. Instead, the student would have used the following procedure when changing an UWSD. This process is to be conducted when there are indications for it to be changed, if the chest drain chamber is ¾ full or if the UWSD system sterility is compromised through accidental disconnection. These were some of the factors that the student could have considered before emptying the drainage system. On the other hand, the following equipment should have been assembled and used in the exercise which includes new UWSD, gloves, eye protection together with dressing pack. After all these issues have been considered, then the following procedure would have been applied. Firstly would have been to perform hand hygiene and ensure that personal protective equipment is used to protect the attendant from body fluid exposure. Once this is complete, an aseptic technique would have been used to remove the unit from its packaging and latter placed adjacent to old chamber. Secondly, would be to connect tubing as well as connectors when necessary and ensure that the manufacturer’s instructions are followed concerning insertion of water to create water seal. Suction is then turned off, chest drain clamped close to the drainage unit, and precaution should be taken to protect the tubing when dealing with metal clamps through placement of gauze between the clamps and the tube. This is to prevent sucking of air back to into chest. Thirdly would have been to disconnect the old chamber through holding down the clip connected to the in-line connector in order to pull the tubing from the chamber. The tubing was to be inserted into the newly clamped chamber until it click and then unclamp the chest drain which would have been back on suction. On completion of this exercise, the old chambers are to be placed into yellow infectious waste bag which is tied ready for disposal. The nurse is then supposed to perform hand hygiene. Lastly, the nurse can do the documentation. The use of this correct procedure together with supervision would have helped in elimination of the occurrence of the problem that arose.

From this scenario, there are different aspects that can be depicted here. One of them is the violation of the code of professional conduct that guides the nurses. Firstly, all nurses are expected to practice in a safe and competent manner. The RN was supposed to be aware of the risk of undertaking activities outside the scope of practice may in some instance compromise the safety of the patient. The scope based on the student’s education, knowledge and extent of experience could have been considered first. In addition, the delegation was not supposed to compromise the quality of care of the patient. Secondly, the RN was to practice in accordance to the set standards of the profession. This implies that the RN are responsible for ensuring that the standards of the service they provide conforms to the professional standards such as provision of supervision to the students. Some of the standards that were left out in this scenario include lack of engagement in professional development activities. The RN was to guide the student by demonstrating nursing leadership. Thus, the nurse neither evaluated the effectiveness of the nursing care provided by the student nor understood the diversity in practice community. Although the student claimed to have dealt with patients before it was not enough information as different patients seek different medical attention. Thirdly, the nurse was to practice and conduct herself in accordance with laws well known to her relevant to the nursing profession. Delegating of all nursing activities to the students is prohibited by the law and thus should have been avoided and the nurse to take part in the process. Another professional conduct that could have been considered is the nurses practising nursing reflectively and ethically. The nurse was to comply with the codes of ethics discussed earlier and to learn from experience and contribute to professional practice. The RN was also to contribute to the professional development of Bethany and the colleague by offering quality-nursing advice (Zeng, Ng, & Thong 2016, p. 331).

Another aspect would be the focus on education of the placement students in different services of the hospitals. This focuses on promoting consistency among the staff members on training in order to avoiding conflicting information when dealing with patients. For instance, Bethany claimed to have dealt with other patients before but probably not with a similar case of the patient in the intensive care unit. The nursing professional conduct demands that nurse provide honest and accurate information and thus Bethany should have been open to clearly state whether even the underwater drainage system was familiar (Walton & Barraclough 2011, p. 7).

Section 2

The situation stated earlier occurred because of different players failing to play their roles effectively as expected of them thus resulting to an emergency. In Australia and any other health care offering region, nurses together with other health workers in need of employment in either primary health care or general practice settings need to be competent in the field with a range of qualifications and professional experience and adhere to nursing rules. Failure to adhere to these rules in most circumstances has a negative impact on the patients, and it is necessary for the practitioners to observe them and save the lives of the service seekers (Iyer & Yadav 2013, p. 60).

The critical incident discussed earlier emerged because of the failure of people to attend their responsibilities. In Australia, the nursing workforce is regulated by the Nursing and Midwifery Board of Australia under the Health Practitioner Regulation National Law, which outlines what, is expected of every practitioner. The nurses are expected to practice independently as the case of the one in the intensive care unit and takes responsibility together with accountability for the services they provide to the patients since they possess adequate skills required to perform all the assigned duties. Moreover, when offered some support by the enrolled nurses or any other health care worker, he or she takes responsibility for that delegation and ensure that they control all the activities to be performed. This implies that the registered nurse should consider the education of the juniors who join their medical providing facilities, their level of training, and scope of practice and the context of care before assigning any responsibility to ensure that the new members can be assigned duties they are competent in their line of duty. For instance, the RN was supposed to evaluate outcomes based on the set goals in this scenario. Furthermore, another practice emphasises on provision of appropriate and responsive nursing practice. The RN ought to have provided effectively timely direction as well as supervision to ensure the delegated practice is not only safe but also correct (Nursing & Federation 2014, p. 30). This did not arise in the case of Bethany, and the nurse in charge asked a few questions without carrying out enough evaluation to allow the student attend to the patient.

Another matter that may have contributed to the happening of the situation is the unaccountability act of the registered nurse. This could have been necessary, as she could not have had a chance to attend to such condition before by herself. Similarly, the nurse was supposed to be accountable for the decision to assign the role to Bethany. Also, the nurse would have ensured that the person delegated is responsible for the offer, and the actions that may emerge because of the act. This failed in this incident and Bethany would not be blamed or any action taken since there was no proof of accountability (Nursing & Federation 2014, p. 20).

On the other hand, the failures of enrolled nurses may have contributed to the scenario. These people also come to the field after completing an accredited education program. They are also expected to demonstrate the ability to meet all the standards as laid down by the Nursing and Midwifery Board of Australia which has developed supervision guidelines for nurses. In this scenario, there were principles of supervision that were neglected and led to the incident discussed earlier although they were supposed to be applied to the supervision. Firstly, every supervisee is obliged to work only within the limits of competence. The student has the responsibility of assessing and determining learning needs with the help of the supervisor although this failed in the case of Bethany. Secondly, both the type and level of supervision was to be matched to several factors; they include purpose of supervision, needs of the supervisee, and their capabilities as well as level of risk associated with delegated position. The RN should have considered these aspects. Thirdly, there is always a need to enter into a supervision agreement that involves the supervisor, the student, and the registration committee of the NBMA. These discussions help to identify who is to be involved where as well as the responsibilities of the supervisor and the students. Fourthly, another principle that was violated was the allocation of a principal supervisor. In case the person is not available, a secondary one is to be appointed to provide supervision and ensure that they have adequate time for the role. RN failed in this field as she was to be there to help the student and provide the feedback to the core supervisor. When these standards are adhered to, the supervisor is able to provide the expected supervision. One of these standards is with regard to supervision whereby these nurses are supposed to work either under direct or indirect supervision by the registered nurses who play key roles. For the case of direct supervision, the RN plays the role of taking both direct and principle responsibility of providing treatment to the patient. In this situation, the registered nurse was supposed to be present in the work place together with the student and observe all times as Bethany provided clinical care as per the requirements of the supervised practice plan. Furthermore, the student was supposed to consult with the RN before delivering any care. For this case, the students were supposed to request the RN to observe how the draining processes were conducted since the new students are not supposed to perform the duties on their own. Apart from their presence, the experienced nurse should be available to offer immediate support and advice that may be required at the point of need by the nursing students. In this situation, the registered nurse was present but engaged in other duties while the student did not bother to ask for advice concerning the different systems in the patient before working on the wrong one and causing problems. Bethany did not utilise the supervisor fully and instead relied on her own understanding. This direct supervision is very important to both the student and the supervisor. It helps in determining the level of competence of the nurse in order to inform further levels of supervision as outlined in a supervised practice plan. On the other hand, the RN nurses also play key roles in indirect supervision. Similar to direct supervision, the RN can be contacted easily after the responsibilities of the individual patients are shared between the supervisee and the supervisor. Under this supervision, the RN can be contacted easily, observes, and is available to discuss the nursing care provided by the student. The nurse was to be present when the student was attending to the patient and the student was supposed to inform the RN at agreed intervals the details about management of the patient. This mode of supervision is also necessary in hospitals (Cherry & Jacob 2015, p. 162). Due to the critical condition of the patient in this scenario, the most appropriate standard of supervision was to ensure that the RN is present, observes what the student does, and provide directions of what is to be done at every stage. Thus, this kind of supervision would have ensured that the patient receives attention from all the nurses while the supervisee also learns from the experienced nurses in the hospital. The RN could have spared time to observe what the new student does and provide directions of how to do the drainage. Such activities would have controlled the occurrence of the emergency case that arose.

The student failed because she was not responsible for the individual practice of mishandling the patient in the intensive care unit. On the other hand, the registered nurse did not meet the requirements of the practice when delegating duties to the juniors together with maintaining the safety of the patient. Regardless of the patient being in a critical condition, the registered nurse failed to consider the risk of having the person being handled by inexperienced individuals, and this contributed to the incidence of grasping for breath. Several factors such as the student’s knowledge, skills, competence, as well as the nature and complexity of the care needed would have been considered (Gilligan, Outram & Levett-Jones 2014, p. 2). Altogether, the players in this scenario failed in one way or another resulting to the dangerous situation to their patient. The student had more confident in herself and thought she could perform the tasks easily on her own. She was not keen on the patient, as she did not take note of her mistake until the instructor took notice of the struggles of the patient. It is necessary to be keen and note any changes and report to the most experienced people who are supposed to immediately come to the rescue of the victim (Iyer & Yadav 2013, p. 63).

Section 3

To ensure the life of the patient is safe, it is necessary to deal with the emergency case and stabilise the condition. In this case, the RN did not determine the level of experience as well as the knowledge of the student. Instead, she played the role of a delegator without observing the rules that govern the delegation process. The RN was supposed to supervise and educate the student in providing safe patient care. The process is expected to take place only in circumstances where the delegated role is appropriate to the level of competence of the doer. In this case, this failed as the student did not manage to drain the assigned systems appropriately (Cherry & Jacob 2015, p. 280). Afterwards, the nursing students involved in the incident need to have been informed about the mistake they committed in order to avoid repeating it. The behaviours of the negligence of the registered nurse need to be condemned. The nurse should be reminded about their responsibilities especially when dealing with critical conditions of patients who need much of their attention.

While on placement, the students have some rights, which are of great significance although in this scenario they never enjoyed them. According to these rights, the students should receive support of an instructor or mentor during the time of placement for at least 40% although the RN was committed in other duties. In case the mentor was busy, the student had the right to receive support from another experienced member of staff although it also failed in order to offer supervision. In addition, the students have the right to not only be aware of the possibility of any failure arising but also be given a chance to address the problem with the nurse in charge. For the case of Bethany, the RN did not exercise this and instead instructed her to carry on the assigned duties. Moreover, the students should always perform the duties with the member of staff rather than being left alone to deal with patients in critical conditions (Gilligan, Outram, & Levett-Jones 2014, p. 3). During the placement period, the students are required to ask for supervision from the RN nurses at their workplace. In this case, the new student played key role after violating the rule of working under supervision of a senior staff. She played the role of a competent nurse in the field although she was supposed to use the placement period as a learning session for her. She did not consider some important collaborative practice standards for the nurses. As such, Bethany was to communicate effectively with the RN and share the information of what she did at every stage. Through this mode, the nurse would have identified when she was about to mess.

Apart from the rights, the students ought to have been aware of the policies and procedures, which facilitate adherence with set professional practices and serving as a source for new members in the environment. Some of these policies are related to the rights of the students whereby one of them include incorporate training whereby new members are to be engaged in orientation programs and the senior being held accountable. In addition, the policies involve implementation of feedback mechanism and the RN was supposed to report the case to the management so that such cases can always be addressed in order to minimise the harm that could arise in the affected patient (Cherry & Jacob 2015, p. 238).

In order to eliminate the occurrence of incidences such as the one discussed here, several issues need to be put into consideration. The nursing students should be evaluated first before being assigned duties. When performing their tasks, the nurses in charge should take them through and educate them about what is expected of them in the field. This improves what is learnt earlier in class and accountability of all parties emphasised so that one is keen on what he or she does. In this scenario, it was noted that the RN was busy during the night shift. This is because she had to ensure the patient was improving and stable, and make records about the progress of the patients. These commitments facilitated the failure of the student and necessary steps such as keeping a schedule of how each activity could have been done was necessary. Moreover, it can be appropriate to ensure there is enough support to the new students. For instance, the number of nurses in the shift can be raised to ensure all the activities are attended to unlike in this case whereby there was only one registered to perform all the tasks. Due to different complications of different patients, it is necessary to educate the new nurses and brief them on the situation of the victims they are about to handle. In addition, the type of treatment the patients are going through in order to avoid tempering with life supporting systems the students would not have been exposed to before as it happened in the case of Bethany.

Conclusion

In summary, the issue of a limited number of trained nurses in the health care facilities is one of the main challenges. The situation has resulted to the delegation of some responsibilities to the nursing students with limited skills, which in such cases result to some serious conditions amongst the patients. It is therefore the responsibility of the registered nurses to be keen on some aspects like accountability, especially in direct supervision and avoid making assumptions and judgments when dealing with new nurses in hospitals who may not have been exposed to such working environment before. Moreover, in the case of busy shifts, more trained individuals should be involved to ensure all activities run smoothly. Such steps will help to ensure that juniors improve their skills in their field of specialisation, as they will be nurtured by other nurses through support and guidance.