Critical incidents in healthcare can be positive or negative experiences that happen

Critical incidents in healthcare can be positive or negative experiences that happen to a healthcare professional, patient or a family member, that may create risk or harm to the physical, mental, health and wellbeing of a person. Often an experience that makes the individual think and raise questions on their beliefs, attitudes and behaviours (Hannigan (2001). These events prompt reflection of the actions undertaken by those involved, and helps to be critical of those actions in order to learn and improve whilst out in practice. Reflection and analysis of critical incidents is widely regarded as a valuable learning tool for nurses (Alphonso, 2014).Bound et al (1985) defines reflection as “an important human activity in which people recapture their experience, think about it, and evaluate it. It is this working with experience that is important in learning”. Reflection can be used in all aspects of nursing; to reflect on a certain incident, and the actions thoughts and feelings associated with it (Gibbs (1988). Or everyday experiences by considering, analysing and critiquing the who, what, why and how of the events (Driscoll (2007). These mechanisms are known to improve nursing practice, however Rolfe (2014) argues that reflective practice has had a disappointing impact on nursing education and practice, he suggests that it is the poor interpretation and implementation of reflective practice, that results in this lack of progress. In defiance of this the NMC state that in order for nurses to renew their professional registration for successful revalidation, nurses must have five written reflective accounts in the three year period since joining or renewing onto the register. This demonstrates a key driver for understanding the importance of reflection in nursing, and the need for nurses to engage, in order to secure ongoing registration (NMC, 2019). Nurses and Midwives play a critical role in improving the health and wellbeing of patients whether in hospital, a community setting or social care, actively enabling co-production of decision making, at all levels of policy making and service provision. Having a ‘duty of care’ to protect the public whilst improving health outcomes, when issues arise that could compromise safety, quality and experience. Following the NMC Code and other NMC guidance (NMC, 2019).The NMC code (2015) contains the professional standards for nurses and midwives in the UK. Illustrating the professional attitudes and actions necessary for a high level of patient care and focuses on professional and practical aspects of nursing care. Divided into four sections the NMC code is based on the core professional values of nursing. These are, Prioritise people, practice effectively, preserve safety and promote professionalism and trust (NMC, 2015). Standards for competence applies to all fields of nursing and are set out in four main areas of professional nursing practice (NMC, 2019). Whilst these nurses must be accountable and use clinical governance to maintain and improve nursing practice. Professionals must be able to respond independently and with confidence to unplanned situations, taking care of themselves and others (NMC, 2019). . Communication in nursing is a core component of sound relationships, co operation and collaboration, which are essential aspects of professional practice. This interaction between patients and nurses has a huge impact on patient health outcomes, this can play an important role in patient health, education and adherence (Adair, J (2009). Effective Communication is central to the provision of compassionate, high quality nursing care enabling high levels of patient satisfaction, enhancing the ability of patients to self-manage their healthcare needs, and support shared decision making when planning treatment (Bramhall, 2014). According to Sibiya (2018) both effective communication and interpersonal skills can enhance professional nursing practice. Nurses communicate with people of different educational, cultural and social backgrounds and must do so in a caring effective manner whilst acting professionally to both patients and their families. Clear communication is transferred effectively between patients and nurses, however it has been recognised that this isn’t always possible and information can be misinterpreted, this barrier in communication can develop a breakdown in relationships and can lead to an obstruction in communication and care (Sibiya, M (2018). Heaven, 2006, states healthcare quality is strongly affected by nurse-patient relationship, and lack of communication skills may have a negative impact on services delivered to patients. Many problems are todo with the decreased amount of staff amongst hospitals and other community settings (Heaven, et al (2006). In accordance with the Nursing Midwifery Council (2015) confidentiality will be maintained throughout this sway and no details or individual information will be disclosed (NMC, 2015). Gibbs (1988) will be used throughout. This model is a theoretical framework compromised of six stages, most commonly used as a guide for reflection in clinical practice (Husebo, et al (2015) this model is well structured and easy to follow when reflecting on experiences such as a critical incident, in nursing care (Lawerence, 2008). Hospital discharge happens when patient’s are able to leave hospital as they no longer require inpatient care or treatment. Help and support is arranged for when the patient is discharged, and ongoing care will be transferred to other primary and community environments. This may include multiple healthcare professionals, such as district nurses, social workers and other specialists to ensure patient’s receive integrated and, importantly, safe care (Waring et al (2014). The inherent difficulty of co-ordinating a large number of patients frequently located in different organisations can contribute to the perception that hospital discharge can be a time-dependent, unstable and high risk episode in the patients journey (Ellins, 2012, cited in Waring 2014 p3). An example of this is ‘delayed discharge’, where the patient stays in hospital due to failure of appropriately coordinating care between multi disciplinary teams. According to Victor et al, (cited in Waring, 2014) , nearly 30% of older people experience a delay in their discharge. This exposes patients to additional hospital – related risks, creates physical and emotional dependency and incurs additional hospital costs, whilst restricting the availability of hospital beds. In addition to this, early discharge or discharge without the appropriate arrangements can lead to patient recovery complications. Analysing the causes of these delays, Tierney et al (1993) identify a range of common factors including, low health and social interaction ie communication; Lack of assessment and planning for discharge; insufficient confirmation of discharge; inadequate involvement of patients and families; and lack of attention to vulnerable patients. Healthcare professionals need to be aware of the steps involved in transferring the care of a patient from hospital to home, and how best to facilitate this processes, recognising the patients deteriorating condition and communicate with the patient and their families. An individually tailored care plan and package of care to support the patients needs is key for communication. Healthcare professionals must respect the patients needs and wishes with preferred place of care and death and liaison with the appropriate community services. As with any important decision making, the mental capacity of the patient must be assessed, and if the person lacks capacity, decisions need to be made and documented clearly using the Best interests framework. (Department Of Health, 2005,, cited in British journal Of hospital medicine, 2017, p98) .Care planning meetings with the multidisciplinary team gives a chance to discuss in full the patients current and future needs, risks involved in a quick discharge at the end of life stage can cause limitations such as availability and the appropriate use of services. It is imperative that useful communication is delivered to GP practices, primary care, district nursing teams, care agencies and the community specialist palliative care team, this will achieve the best possible outcome for the patient. (Borrill, (2017).Palliative care is an approach that improves the quality of patients lives when facing a life threatening illness, whose disease is not responsive to curative treatment. Controlling pain symptoms and of social, physical, psychological and spiritual problems is highly important. To facilitate adjustment to the many losses they will face, and to attain a dignified death, with minimum distress. Palliative care is interdisciplinary in its approach and includes achieving the best possible outcome for patients and their families. (Dougherty, 2015).Palliative and end of life patients when given the choice would prefer to spend their final days at home (Gomes and Higginson, 2006, cited in British Journal Of Hospital Medicine, 2017, p97). Helping people achieve this can result in a more enjoyable experience for the patient and their families. (Department of Health, 2008, cited in British journal of Hospital Medicine, 2017, p97). Palliative care consultants in hospital can provide support and information on patient prognosis, ensuring symptoms are managed. However once patients are discharged Palliative care teams need to continue to play active roles in patient care, addressing any social and psychological concerns “ Gaps in discharge planning” decrease quality of life and a lack of support is offered (Benzar, et al (2011). Community-based palliative care teams include GP’S, district nurses and doctors, helping to manage symptoms, provide education, co-ordinate care and provide additional help and support (Bakitas et al, 2009). NICE guidelines on improving supportive and palliative care for adults with cancer advise that commissioners should ensure that an appropriate range of specialist palliative care services are available to meet the needs of patients. This includes advice and support on a 24 hour, 7 days a week basis. Seow et al. (2014) found that when community based palliative care teams collaborate integrated care to patients is delivered. Ever since 1859 palliative care has been fundamental to district nursing. (Toofany, 2007) cited in international journal of palliative nursing). District nurses play a crucial role in the primary healthcare team, visiting patients in their own homes every day. Providing care for patients and families. Playing a vital role in keeping hospital admissions low and ensuring patients can stay at home as long as possible. (Nursing times, (2009). In terms of patients dying at home it is often district nurses that provide care and support to patients and their families. District nurses have been identified as central to palliative care, who offer holistic medical treatment, pain management, emotional support and co-ordination of patient and family services. (Dunne, K et al (2005).Benner (2001) explains the typical behaviour of a novice is limited and inflexible. Students are known as novices as they have limited or no experience in situations they may face, they are guided in performance and given rules to follow from a nurse that has worked in that area and has experience. However the rules given can not always be used in an actual situation of practice. Nurses can also been seen as a novice if they are expected to work in an unfamiliar area. For example a nurse in adult critical care would be classed as novice stage working in neonatal intensive care. (Benner, 2001).Patient non-compliance is a persistent concern for nursing practice. Research on compliance focuses on ways that nurses should intervene with patients to encourage them to follow health care recommendations. Good holistic nursing practice means nurses must identify the social factors that make patients non compliant. When patients are non compliant, an approach based on the recognition of social fears can provide a more in depth understanding as to why, they may feel like this and why they are non compliant to care and treatment. (Russell, et al, 2003). When patients decline care this gives an opportunity for nurses to develop and build relationships (Russell et al, 2003). Playle and Kelley (1998) argue that non compliance can be seen as a behaviour that challenges professionally- held beliefs, expectations and norms. The research on compliance is concerned with improving healthcare and involves issues of professional control and beliefs about nurse patient relationships. Non compliance can be seen as a label used by professionals to maintain power and control over patients (Russell, et al 2003). Adherence to care and treatment is a serious problem that affects both the patient and the healthcare system. Healthcare professionals have a significant role in their daily practice to improve patient adherence. (Beena & Jose, 2011). Medication adherence is defined by the World Health organisation (2003) as “the degree to which the persons behaviour corresponds with the agreed recommendations from a healthcare provider”. Compliance is not only thought to be in the patients interest but is associated with a ‘social good’. (Mulaik, 1992, cited in Journal Of Advanced Nursing, 2003). However we argue that the dominant view of non compliance fails to take into account the social context of patients lives. Non compliance isn’t always about patients choosing not to follow advice, it is recognised that choice may be constrained by the circumstances patients live in, they may be fearful, worried or anxious of their diagnosis or are finding it hard to accept what is happening. (Russell et al, 2003). Knowing patients have different circumstances as to why they are non compliant will allow nurses to work and adapt to that specific patient. (Lannon, 1997, cited in journal of advanced nursing, 2003). This gives the nurse a potential role to show leadership in how care is delivered. Learning more about patients lives and situations will encourage nurses to bring information regarding healthcare decision making. This may be more helpful and meaningful to the patient and develop therapeutic adherence. (Lutfey & Wishner, 1999, cited in Journal of Advanced Nursing, 2003). Florence Nightingale developed a modern perspective on nursing, and since then it is within the nurses profession to be engaged in the care of vulnerable patients. This, vulnerability is considered an important aspect of nursing. (Morse (1997) cited in Journal Of Clinical Nursing, 2016), the goal is to increase patients capability to meet their own needs and protect from harm. Flaskerud and Winslow (1998) states that Grouping people as ‘Vulnerable’ is based on demographic factors, health threatening circumstances such as poverty, abuse, chronic illness, physical or mental illness, or other socioeconomic disadvantages. Usually one disadvantage situation leads to another, such as being chronically ill may have a negative impact on their job and financial situation, their worries and concerns potentially impairing ability to cope with the illness, often creating the need for professional help in relation to health behaviour and self care.(Danish health authority (2006), cited in journal of clinical nursing, (2016). The illness itself identifies vulnerability in the patient and the experience may be so unfamiliar that the patient may feel misunderstood, engendering a feeling of loneliness, and lack of usefulness. The patient may come across non compliant with care however feelings need to be considered, some patients who behave unpredictably can be seen a threat, and nurse professionals are expected to provide the care needed and witness the patients problems, nurses have their vulnerability exposed in caring for the patient. Shame is a well known experience for nurse professionals who think they should of done more to reduce the patients discomfort and lifestyle making the nurse feel insecure, powerless and ashamed this may have an impact on the nurses professional performance. (Strandberg, (2003) cited in journal of clinical nursing, 2016). .The NHS cancer plan (2000) states that ‘the care of all dying patients must improve to the level of the best’, good communication between healthcare professionals and patients is central to receiving this. After Obtaining and documenting consent I was able to ask the patient questions and take into account any factors such as their social situation, this helped identify what could be put in place for the patient, to encourage help and support. Assessing the patients capacity to make each decision using the principles in the Mental Capacity Act (2005) full capacity was identified. Although the patient has the right to make informed choices, the nurse stated the patient no longer had the ability to manage their own care, self management and lifestyle choices. The NMC state that all healthcare professionals have a duty of care to ensure patient safety and best interest are at heart. Offering support and respecting their views is key to engage effectively. However Nice (2019) state many patients wish to be active in their own healthcare, and self care and self management are particularly important for people with long term conditions.The experience was good as the nurse and I were able to review and evaluate the patients care and contact services to tailor the patients needs, preferences and values (NMC, (2019).This helped ensure the patient was receiving effective, appropriate care. Raising concerns and putting in place other members of the multidisciplinary team Including Marie curie to help with overnight stays so the patient wasn’t alone. Marie curie is a major UK charity for people with terminal illnesses who offer care and support to help patients with the time they have left. (Marie Curie, (2019). Care assistants throughout the day were put in place to help with medication, personal care and nutrition. Accurate documentation of patients care and treatment should be shared with other members of the team to provide the best continuing of care (Benzar et al (2011). All healthcare professionals have a ‘duty of candour’ to protect patients and must be open and honest with a patient when something goes wrong with their care, or has the ability to cause them harm or distress. The nurse was able to apologise to the patient and offer remedy and support. Following organisations policy the nurse was able to report the incident of the patient having no continuing healthcare (chc) in place, this will ensure patients are protected in the future and any near misses or adverse incidents from occurring. ( NMC, 2019).

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