Critical Incident Report
Critical reflection is an essential skill for nursing practice, reflection can be used as a method that connects knowledge and experiences and it can be argued that nurses who use reflection can be better positioned to provide excellent patient care (Japan Journal of Nursing, 2013, 170-179). This report will focus on values and a range of influences that affect them, styles of leadership and the benefits or disadvantages of them and the importance of quality assurance and of reporting incidents. In this report I am going to critically reflect on an incident that occurred on my placement on a specialist medical ward. During this placement I encountered a patient who had been transferred from Intensive Care following a drug overdose and query suicide attempt, the patient was a known intravenous drug user and was HIV positive and Hepatitis C positive. As a patient on the ward she experienced some discriminatory behaviour and experienced dehumanisation from members of staff due to her diagnoses of HIV and Hepatitis C, this was predominantly through staff gossiping and unprofessional conduct. This eventually led to the patient getting quite upset and agitated causing her to lash out at members of staff. I was part of the care team working alongside the patient from when she was transferred up until she left the ward, during this time I had to report the staff behaviours to the ward leader.
There were multiple influences and factors that led up to the incident, many of these revolved around values. Values are deep-seated beliefs about what is right or wrong and about what is important or unimportant, they are considered as principles, standards or qualities that people care about and that contribute to behaviour. Personal values are supported by a set of unwritten rules or norms regarding what is socially acceptable. Values are a part to professional identity and many professionals have shared sets of values through their regulatory bodies and trust values (Baillie and Black, 2018, 12-14). It is essential to be able to understand and integrate these values into practice, giving consideration to organisational, social and political factors and how they influence health and social care. Social factors could be considered as one of the largest influences leading up to the incident. As mentioned, the patient experienced some discriminatory attitudes and labelling from members of staff during her stay on the ward, certain staff members refused to treat the patient and others made comments about her. The discrimination may be a result of the stigma around intravenous drug users and the belief that all those who inject drugs are HIV positive. This stigma could have developed from the increased risks of HIV in those who take drugs intravenously, this is noted by Avert (2018) who state “people who inject drugs are 22 times more at risk of HIV compared with the general population.” The discriminatory behaviour came from a range of staff including doctors and staff nurses, both of which have set codes of conduct that contain organisational values. The General Medical Council (GMC) code of conduct sets out guidelines and expectations that should be followed by those registered. Principle three discusses ‘objectivity’ and states that ‘holders of public office must act and take decisions impartially, fairly and on merit, using the best evidence and without discrimination or bias” (GMC, 2018). I found it concerning that there was a great lack in compassion for the patient, particularly as our organisational values with the National Health Service promote the Compassion in Care strategy using the 6C’s. The 6C’s are a way of articulating the values which need to underpin the culture and practise of organisations delivering care and support and underpin quality social care provision too (NHS England, 2019).
It is also important to look into the political influences on both personal and professional values and how they may have influenced the behaviour during the incident. Political factors such as government policies like the Equality Act (2010) and the Human Rights Act (1998) have indirect influences on our behaviours and values as professionals but also members of society. The discrimination experienced by the patient can be considered as unmoral but also unlawful as The Equality Act (2010) makes discrimination of any kind unlawful, and anyone diagnosed with HIV has the same protections as disabled people, regardless of their health status.
Leadership is essential for a variety of reasons in health and social care settings, particularly for the safety of patients and the management of incidents and elicit effective performance from staff. The Hay Group (2006) found that where nurses demonstrated and used their transformational leadership skills, wards experienced fewer safety incidents. The NHS Leadership Academy (2013) has developed a Healthcare Leadership model in order to describe what should be seen in leaders and how an individual could develop their role, the model is made up of nine leadership dimensions which include ‘Leading with Care’ and ‘holding to account’, this is important to recognise as it shows the NHS taking steps to ensure that their leaders are of the highest standard. Initially there was no leader that was managing the incident, the ward leader in the environment had adopted a ‘laissez-faire’ style of leadership. Laissez-faire leadership is a laid back approach in which the leader has little control or direction over the staff and what they are doing (Royal College of Nursing, 2013), however this leadership style is generally noted as ineffective and although it is recognised as a distant form of leadership it does not mean that team members may take any action they choose, but rather that they stay within certain guidelines and boundaries. The deputy sister on the ward adopted the leadership role for the management of the incident, she used a situational leadership approach, which is where effective leaders adapt their leadership style to manage situations. For the incident she used an autocratic approach to the situation. Autocratic leadership is a form of transactional leadership and uses good structure in order to determine what needs to be done. This was effective for the management of the situation as it meant a resolve could be met and the staff involved were managed in a suitable manner. Through the use of autocratic leadership, the deputy sister spoke to all members of staff, and made it clear that it was unacceptable for any type of discrimination to be present on the ward and reminded them of the NHS and local Trust values. Furthermore, over the course of a week the deputy sister created learning packs around HIV in order to improve staff understanding and remove the stigma around the condition, which had the potential to result in changes in personal values.
Critical incident reporting is essential in proving patient safety and care standards (British Journal of Anaesthesia, 2010) and is key to maintaining quality assurance. When errors are being made repeatedly, it is a gross failure of care, and through the use of incident reporting, these mistakes can be minimised (Journal of General Internal Medicine, 2005, 1063-1067). The term ‘quality assurance’ refers to maintaining a high quality of health care by constantly measuring the effectiveness of the organisations that provide this (WHO, 2018). Reporting incidents is paramount to ensuring that situations do not reoccur and that we learn from the incidents in order to improve the quality of care provided. The incident that I experienced was reported through the trusts internal systems, this was investigated by the ward staff and also more senior members of staff. This is beneficial to improving healthcare standards as it gives an insight into situations that should not be occurring, and it allows senior management to investigate into the reasoning behind the occurrence. Organisations such as the Nursing and Midwifery Council (NMC) have clear guidelines about our role in quality assurance, for example, in the Code of Conduct the section ‘Promote Professionalism and Trust’ clearly highlights the importance of nurses ‘continuing professional development’ and also upholding the values set out in the code of conduct (NMC, 2018). The lack of understanding and compassion that led to the discrimination could suggest that the staff involved may require more training to gain a better understanding of conditions such as HIV, thus allowing them to be more objective and evidenced based with the care that they provide. It is essential that reporting of incidents should be used in order to learn and develop care standards and used for the evaluation of care in order to help improve the systems and practice seen within the National Health Service.
To conclude, through this critical incident report I have considered the significance of reflective reporting and discussed the importance of integrating values within practice giving consideration to organisational, social and political influences on health and social care whilst reflecting on an incident that I have experienced in practice. From the incident that I have reflected on it is clear to see the difference that personal values can have on professional practice, however it is important to consider that organisation’s have their own set of values that should be followed, regardless of personal values. The report has also considered the importance of political influences such as the Equality Act (2010) and how they affect incidents and values. Furthermore, I have looked into a variety of leadership styles including the transactional and laissez-faire methods that were used by different leaders during the incident. Finally, through reflecting on the incident I have been able to discuss the importance of monitoring quality assurance and evaluation of healthcare both in general and also throughout the incident, this has allowed me to consider what was learnt from the incident and how to prevent situations such as this from happening again.
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