Critical incidents are snapshots of something that happens to a patient, their family or nurse. It may be something positive, or it could be a situation where someone has suffered in some way (Rich & Parker 2001). Reflection and analysis of critical incidents is widely regarded as a valuable learning tool for nurses. The practice requires us to explore our actions and feelings and examine evidence-based literature, thus bridging the gap between theory and practice (Bailey 1995).
It also affords us the opportunity of changing our way of thinking or practicing, for when we reflect on an incident we can learn valuable lessons from what did and did not work. In this way we develop self-awareness and skills in critical thinking and problem solving (Rich & Parker 2001). Therefore, to ensure his reflection was productive, in terms of encouraging synthesis, analysis, critical thinking and evaluation, along with guidance on the reflective journey, I chose Gibbs (1988) reflective model as a framework for my reflective practice on a clinical incident happened in my organization.
Gibbs model of reflection incorporates the following: description, feelings, evaluation, analysis, conclusion and an action plan. I have chose this Gibbs (1988) model because I believed his cyclical process provides a structured analysis, highlighting the reflective journey as a continual process, in which reflective skills grow and develop as new situations arise and the context of practice changes. DESCRIPTION It is a Sunday morning; I was on duty as an on call manager for the day. I have been called by a junior nurse from maternity ward to set a peripheral line for her patient under her care.
As a junior nurse she is not confident to set a line by looking at patient condition that is very weak. Without delaying, I went to visit that particular patient to help my nurse. This patient is a 40 years old Malay lady, who had done Total Abdominal Hysterectomy and Bilateral Salpingo-Oopherectomy (TABHSO). According to the nurse in charge; after the operation patient had small bowel syndrome due to complication raised during operation. Patient general condition was very weak and lethargic. Her oral intake was poor too.
The consultant in charge has started treatment on Total Parental Nutritional (TPN) daily for 18 hours. This TPN is given via a peripheral line for about two days. Other than that they also use the same line to infuse other intravenous medication (antibiotic). According to the nurses, they have suggested to the consultant to put central venous catheter (CVC) since the patient have many intravenous (IV) medication to be infused. The consultant refused putting CVC and according to him it just for few days only. He doesn’t want to incur cost and prevent potential complication of CVC insitu.
He just ordered the nurses to transfused TPN via peripheral line. Without further arguing the nurses just follow his instruction. They didn’t do closed monitoring of the particular hand with peripheral line for any early sign and symptom of IV line complication. So at the end on that day (Sunday), the line is blocked due to thrombopheblitis . FEELING Initially the nurse in charge didn’t acknowledge me about this patient condition and the purpose of setting a peripheral line which is basically to transfuse TPN. I was thought that as usual to give intravenous medication or solution.
When I looked at the patient, she looks so weak and lethargic in other word look like a septicemia patient. I was wonder; how can a patient who had done TABHSO in this situation! When I assess her hand, I was shocked to look at her hand skin condition (previous on cannula), which looks swollen and skin blue black in colour – Thrombophlebitis and patient complain of pain when touch. I query how it could happen to this patient. Then I notice at patient bed site there was a balanced TPN solution is hanged.
I wonder, “Is this solution been given via peripheral line” because I didn’t notice any central venous catheter (cvc) or long line with patient. It thinker me and I asked the nurse whether patient on TPN and which line she used to transfuse. She replied that she and other nurses in her department use peripheral line as ordered by consultant and that is why she called me. I was very disappointed, stopped the cannulation procedure, give a smile to patient and excused my self from her and walked out from the room with the nurse. I felt very upset with nurses for not acknowledging me this situation ealier.
What could the patient feel? I really felt sorry to the patient for having Thrombophlebitis on her hand due to poor observation. In fact she is in pain. I felt very pity to the patient who doesn’t know any thing about what is going on with her, and thought of due to her diagnosis she is getting blue black to her hand. I am very annoyed with the nurses and doctor, they aware of patient having thrombophlebitis after transfused TPN, yet they still want to continue at another peripheral line without thinking patients suffering.
However, I felt very pity to the nurses who felt no rights to the patient due to infinity and lack of knowledge and power. EVALUATION I asked the nurse why she didn’t acknowledge me the purpose of this peripheral cannulation for TPN. I told them they should be open and honest, act with integrity and uphold the reputation of their profession. They must inform someone in authority if they experience problems that prevent them working within their code of nursing or others nationally agreed standards.
I checked their IV monitoring chart and there was no continuous documentation on the condition of patient’s hand. I believe thrombophlebitis won’t occur immediately. Firstly there will be sign and symptom upon development of thrombophlebitis. If the nurses have done their practice promptly, I am sure they would have detect it earlier and not wait till today with very bad thrombophlebitis. when I asked why they didn’t document in monitoring chart and detect ealier,they looked bluer. It is really a poor nursing care practice.
They have no self responsibility and dignity to conduct their duties. They just are being a follower. I enquire to that particular nurse and her colleagues, what they know about TPN infusion. Their answer gave me an idea of their level of knowledge and skills towards TPN treatment are very scanty. It could be their level of experience with minimal handling or care of patient with TPN. However I felt it’s not the matter, learning is life long, and they need to update their knowledge to ensure best practice and care given to their patient.
I reinforce to them that TPN is a large molecule solution and it should be given via CVC line and shouldn’t be use the same line to transfuse any other drugs. I told them the complications of TPN transfuse via a peripheral line – thrombophlebitis. They aware of it but not confidence to argue with consultant since he ordered even though they have highlighted to him about the current complication. In fact he told them to get help from nursing sister to set the line, since he is at home. He doesn’t want to incur cost. It is very bad, they just be the follower.
Either they or consultant didn’t view on patient perception, how she is suffering with thrombophlebitis. There was no ethical consideration between both. This complication showed how bad the nursing care is given to that patient without her knowledge. They were not impartial. ANALYSIS Even though I know this patient required TPN infusion; without delay, I stopped to put a peripheral cannulation for her because I believe this going to put the patient at risk again. I want to avoid the nurse to continue the TPN at peripheral line which later will end with another thrombophlebitis.
I need to make them realize this is a wrong practice. As a professional, and aware of my personal accountable for actions and omissions in practice ,I told the nurse to inform the consultant that I refused to set a peripheral line for TPN infusion to prevent further harm to the patient. I suggest to put a CVC to ease the work flow whereby with many lumens, they can administer other drugs in order to maintain standard of care. Since it is Sunday, and he is not around, I suggested to get help from the anesthetist who is available that moment.
This definitely won’t cost much compare to treating the complication which may require extra management and prolonged patients length of hospitalization. I believe that any commercial considerations must not be influenced in order to make right judgment towards maintain high standard of care. I believed my decision will drill the consultant mind awake and not abuse our privileged position for own ends. It comes true, whereby since the patient condition required the treatment immediately and myself decision not bothering his ordered, he came in the evening, inserted CVC line and ordered treatment for the complication.
Inspite he also wants to maintained his patient and family respect and belief on him towards his management so called “perfect and caring”. I have reinforced to the nurse on duty to do close monitoring towards this patient and provide a high standard of practice and care at all times. In example they need to ensure the monitoring chart is documented the condition of CVC and the affected hand sincerely. Any complication symptom develop need to take action immediately to avoid further harm to patient. I have reported this matter to my superior.
I expressed my concern to patient’s health and my junior nurse’s knowledge and skills and empowerment in making decision towards patients care. She was very impressed with my decision and further planning where by, I have schedule a continuous nursing education(CNE) talk on TPN and IV care by the nurses who involved in this incident. This will enhanced them and other nurse’s knowledge and skills up to date throughout working life and safe and effective practice when working without direct supervision and maintain and develop their competency and performance.
I do arranged CNE session on ethics, patient’s rights and code of nursing practices for all nursing staff. This will enhanced them act with integrity demonstrate a personal and professional commitment towards quality nursing care. CONCLUSION I still believe my decision had save the patient from further harm happened to her.
Even though it is not easy for me to put things right, by arguing with consultant, explained and make the nurses involved in the incident to accept their wrong practice and make them to follow the right way; however at the end I am happy have overcome the critical situation and safe the patient well being. I am proud of my self for not being follower and stand on my right follow code of nursing. This encouraged my junior nurses to act with integrity and uphold the reputation of their profession and treating all patients as an individual and respecting their dignity. It make them sense to think they have all the right to take an actions and omissions in practice provided with evidence based towards maintaining high standard of care to patient avoid putting them in risk.
The consultant view on nurses, they have high standard on our knowledge and skill and our authority to make decision in patient care. This I notice whenever the particular consultant see me, he really showed the respect to me and used to discuss patient care to me. ACTION PLAN Since this type of incident is common and could be happen in future, I ensure the CNE session related to this incident is been continuously done in order to alert the nurses on enhanced their knowledge and uphold their professionalism followed code of nursing and to continuously provide high standard of practice at all time towards patient care.