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Critical Incident in Care Setting
There are numerous definitions as to what a critical incident is:
"Any situation that results in an overwhelming sense of vulnerability or loss of control" (Solomon),
"Any situation faced by emergency service personnel that causes them to experience unusually strong emotional reactions which have the potential to interfere with their ability to function either at the scene or later." (Mitchell, web source).
"...a factual incident, which may be defined as an observable and integral episode of human behaviour. The word "critical" means that the word incident must have a discernible impact on some outcome; it must make either a positive or negative contribution to the accomplishment of some activity of interest" (Pollit & Hungler 319-23)
Many situations can be critical incidents. What may be a critical incident for one person may not be for another. It depends on the perception of vulnerability, control over the situation, and the personal meaning of the incident. This does not mean that they are acute or major incidents or experiences, but that they stand out as being memorable and therefore having some potential for learning. Critical incidents are sudden and unexpected often disrupt your sense of control may involve the perception of life injuring threat involve you physically and or emotionally.
It is a common misconception for student nurses to think, "...it doesn't bother the other nurses, so it shouldn't bother me. If it does bother me, it means that I am weak and not cut out to be a nurse." in reality Part of the reasons people become nurses is because they can empathize with others, and can experience emotional reactions. Like everybody else, extraordinary situations can affect nurses. Critical incident stress is a normal reaction to abnormal situations. However, as you gain more experience you will be better able to handle situations with more control.
One such critical incident was experienced by me within an accident and emergency department. The incident in itself was not life threatening for the patient the consequences of the outcome could have been.
Eric Stewart a 69-year-old widower was brought into the A&E department by his son with lacerations to the left shoulder and forearm after a fall. On arrival, it was noted that he was inebriated. After seeing the triage nurse Stewart was escorted to a cubical for a more thorough examination of his shoulder. On removal of his T shirt it was noted by me that he had a colostomy bag fitted which was over full and leaking from one side. As the shoulder laceration was quite deep and would need thorough examination and closure by a doctor in the A&E department's clean theatre, it was necessary to change the colostomy bag to reduce any risk of introducing infection to the clean field within the theatre and thus increasing the risk of infection to the shoulder wound. After it was explained to him fully what needed doing and why he became very uncooperative and refused to change his bag for himself or have his bag changed by me, giving no explanation for why he didn't want it doing other than it was his job and he would do it when he got home. It was at this point after discussion with his son it was decided that his lack of cooperation was down to his inebriated state. Determining he had diminished responsibility due to his inability to fully understand the implications of his actions.
It would be necessary to change the bag with out his consent. A male nurse distracted his attention and held his hands out of the way so another nurse could change the bag and clean the surrounding area. He was then taken of to theatre to have his shoulder sutured.
The questions that need to be asked when looking at this incident are
One of the major reasons influencing the doctors decision to have the stoma sight cleaned and the colostomy bag changed was to limit the chances of cross infection between the excretions from the stoma area into the wound sight. Infection control, the prevention of spread of disease caused by infection, is fundamental to all nursing care. It is one of the most challenging aspects of care, as it demands both an understanding of the causes and self-discipline to apply the theoretical knowledge to a variety of practice settings (Gould, 34-39).Central to the concept of infection control is the frequently quoted statement 'Hospitals should do the sick no harm' (Nightingale, 67-70). Research indicates that one patient in every ten will develop an infection while in hospital (Meers et al., 198-201). Infection control is part of every nurse's clinical practice. It is necessary to recognize the sources and modes of spread of infectious micro-organisms and know how to apply practices to control infection.
An infection is caused by the invasion of a person's immunological defences by the deposition of infective agent's often micro-organisms within the body tissues. They are responsible for approximately half of all known human diseases (Could, 1987). Bacteria, viruses, fungi, protozoa and worms are the five main groups of organisms capable of causing disease. The main cause of hospital-acquired infections are bacteria. A good example of this is in the news at the moment is the rapid spread of the Gastro enteritis bug within the hospitals in the North West causing the closures of several wards.
The micro-organisms capable of causing disease are called pathogens, but the presence of a pathogen does not necessarily mean that an infection will ensue. Pathogens that can live harmlessly in a specific body site such as the gut or on the skin are called commensals. They only become pathogenic and cause an infection when transferred to an abnormal body site. The bacteria Escherichia coli lives harmlessly in the gut and aids digestion, but if this transferred to one of the wound sites in the arm or shoulder it could become pathogenic and cause infection and disease. Micro-organisms can enter and leave the body by several routes, which are often described as portals of entry and exit. They are often able to enter the body through the same routes that they can exit from.
The source of infection may be determined by knowing the site of infection, the organism involved and the mode or route of spread. This allows an assessment of the degree of risk and the planning and immediate initiation of preventive measures. In the incident, it was obvious the source of the potential infection was from the stoma sight. Implementing the use of appropriate infection control practices to reduce the risk of infection needs to include all who are at risk from exposure to the infective organism patient, family, friends and all health care personnel. Safe practice should ensure that the chain of infection is broken, thereby preventing the transmission of pathogens to potential sites of infection. Reservoirs of infection can be eliminated, sites of entry and exit controlled, and modes of spread minimized by actions such as disposal of body fluids, wearing protective garments, effective hand washing and aseptic procedures.
In recent years, the concept of a comprehensive approach to infection control that promotes the use of safe practices to ensure protection to everyone from blood borne infections has been introduced into some hospitals and health authorities (Wilson & Breedon, 1990). Called 'Universal Precautions', it embraces the notion that all blood and certain body fluids are potentially infectious and therefore such practices are to be used with all patients at all times, regardless of whether they are known to have a blood or body fluid infection. The impetus for the introduction of Universal Precautions began in the USA as a result of the problems of identifying individuals with HIV infection. Universal infection control precautions have been identified as explicit policies for hand washing, broken skin, sharps, protective clothing, spillage, waste and excreta (Wilson & Breedon, 1990). These practices are applied to all patients in all health care settings whenever there is contact with blood and certain body fluids rather than only being introduced when I consider the patient to be a high risk. One argument for implementing such precautions is that they not only protect me from known diseases, but also protect against those that are as yet unknown.
Whilst cleaning the stoma and wound area it was vital for me to use aseptic techniques. Aseptic means that the procedure or technique 'will be done in such a way as to avoid introducing micro organisms into a vulnerable site' (Ayliffe et al., 81-83). The method and equipment for a specific procedure varies from hospital to hospital and health authority to health authority, but the principles of asepsis remain. The principles should include suitable hand washing, the use of sterile packs, equipment and solutions, the appropriate use of gloves, maintenance of a sterile field throughout the procedure. In addition to the maintenance of an aseptic technique while carrying out the procedure, it is important that the site (shoulder and arm wounds) is cared for to prevent the entry or exit of infection.
Accurate documentation is required at each stage of the Nursing Process. An evaluation of care given is particularly important to provide other nurses with a baseline for future comparative situations. There are many Personal and professional issues which are clearly stated in the Code of Professional Conduct (UKCC, 1992). When used in the context of infection control some of the clauses in the code show that nurses clearly have several areas of direct responsibility as follows:
In the control of infection, nurses have the responsibility to educate and inform others, including both the patient and their family. After several attempts to discuss the risk of infection with Stewart, I, then addressed the importance of the colostomy change with his son to see if the son could have more influence over his father. When this approach did not seem to work, it was necessary to educate his son towards the issues of diminished responsibility and consent Mr. Stewart expressed the opinion that if his father were not so drunk then he would have understood the need to change the bag and would have cooperated fully.
Wherever patients and clients are receiving care, poor practice might put control of infection in jeopardy, therefore there need to be policies and guidelines. These need to be written, available for referring to, and put into practice by all staff (nursing, medical and ancillary). Such policies and guidelines require regular monitoring by staff and management to ensure that they are current and in line with new national and European legislation and policies. I need deliberately to weigh up the potential harm and potential benefit of certain actions for that particular patient at that particular time, and reach a decision, which is then documented in the notes on which action gives the most benefit and least harm. In the case of harm resulting, they can then argue logically as to how the decision was reached.
My job is to do their best for the patient, given the Resources at their disposal. Indeed, this is more than their job; it is their legal and moral duty once the patient has been accepted as a patient. In addition, it is hard to see how the patient, unless in some way incapacitated, can object to this. After all, is it not one of the informal tests for how sensible and rational someone is that they should want the best for themselves? Why should we also need their consent?
In law to touch someone against their wish is battery, for everyday treatments like having a tooth filled or an eye examination, consent is both presumed and implicit in the patient's simply being there. For more complex, unusual or potentially dangerous interventions, more formal procedures are needed to establish consent. To consent in any real sense one must know what one is consenting to, and one's consent must be genuine, i.e. unforced. A patient must understand the nature of the treatment proposed if any verbal or written declarations are to count as genuine consent. As stated earlier it was obvious that Stewart did not understand what we were trying to do. Consent also matters because people can be wrong and in particular, they can be wrong about what is good for another person. If the patient chooses the actions to be taken with regard to their own care then they bare the consequences whereas if somebody else chooses the actions to be taken it is still the patient that bares the consequences. This means that the patient must have the opportunity to decide what treatment to receive and that they must be of sound enough mind to be able to make that decision for themselves. In English and American law, patients have the right to refuse treatment. Treatment carried out without consent is usually accountable. What is less clear is how far patients have the right to decline treatment when such treatment is likely to be for the patients good. It might be seen that without consent treatment can't be carried out but in practice the refusal of treatment is often regarded as evidence of an inability for rational thought choosing a course of action which will result in doing harm to yourself seems inconsistent with what is accepted in everyday life e.g. rational thinking people would always use oven gloves to take something hot out of the oven.
A point to bring up is the relationship between both knowledge and understanding. Clearly, a patient cannot be said to have consented to something they are kept in ignorance of, misled about or simply fail to understand, its nature. Doctors, who have specialist knowledge, are capable of explaining something in such a way that no non-specialist could hope to understand. This is much rarer than it used to be and many doctors are now trained in communication skills. But it is not always easy to explain a complicated matter in terms, which are both clear to the layperson and, accurate and complete. Patients are not always good at admitting that they have not understood a word and would like it explained again. It is always possible, for anyone to give apparent consent, which is undermined by lack of knowledge or genuine understanding but There are, classes of people for whom consent will be a problem. These are people who, in legal terminology, lack the capacity to give consent, not because they do not understand but because they cannot and cannot be brought to understand.
Authoritative guidance on how patients should be approached was made available by the Court of Appeal (Tingle & Cribb 110-15). Medical teams should start from the presumption that patients have the capacity to reach their own decisions. Patients are entitled to make irrational or foolish choices. Scope for overriding their wishes arises only when there is evidence of impaired mental functioning. Pain, shock, medication, fatigue and drugs may induce temporary loss of competence. The refusal of treatment can only be properly understood in terms of a moral unease about the decision taken and/or the reasons for it. Though there are good moral reasons for wishing to oppose such a decision, it may well be that there are equally good policy reasons for not giving that opposition proper consideration. We may in other words, disagree perhaps profoundly, with the decision without thinking that it would be right to enforce another course of action on the patient's behalf.
As mentioned above, it can happen that patients are no longer capable of consenting to treatment. This may be because of mental or physical deterioration or both. In such cases, treatment becomes a matter of what the health care team consider to be in the patient's best interests. Ordinarily it might be thought that such a situation would be eased if there exists what has come to be called an 'advance directive'. This could take the form of anything from a simple statement of the patients wishes taken when the patient is still of sound mined to the much more formal living will. As Stewart was only drunk this did not apply to him.
From the patient's point of view, the concept of negligence is an important one. The patient must be able to rely on me as a nurse to take care to avoid harming them. An ill patient is vulnerable for so many reasons, from his illness and from unavoidable effects of treatment. His need for safe care is supported not merely by my professional behaviour of but also by the wish to avoid litigation. However, there are several drawbacks to the patient's reliance on the law of negligence. Firstly, for an award of compensation, there must be resultant harm. This part of a case is often difficult to prove conclusively even when breach of duty exists. In addition, if harm is sustained, but not as a result of a negligent act, there will again be no award. The notion of no fault compensation has been suggested on a number of occasions (Tingle & Cribb 110-15) but it still seems unlikely that this will be introduced in this country. A second difficulty is the inaccessibility of the English legal system to the majority of people. A legal dilemma also arises when there is a pressure on the professional to gain the patient's co-operation to certain treatment or care. Not surprisingly, some professionals find the ethical approach required difficult to accept.
In conclusion it can be said that the critical incident described was a near miss. There were several things which could have been handled differently, many of which could have altered the possible outcome some for better some for worse. We can only speculate as to what some of those outcomes could have been and whether they would have resulted in improved care for Mr Stewart. An example of this would have been if we had respected his wishes to not change his colostomy bag and it had continued to leak the wound may have had infection introduced to it making Stewart both ill and his healing time longer. If the fact that he refused to have it be incorrectly documented then he would have had cause so take action for negligence.
The question arises of what is the relevance to care to the law. It is clear that the law, acting as a broad reflection of the moral values held by society, provides a framework within which care is provided: 'As far as the law is concerned there must clearly be a close connection with morality since they have concepts in common such as justice, rights, rules, responsibility, and many others' (Downie and Caiman 171-80). The regulatory effect of the law is seen when the professional carer or support worker is in breach of the rules. They may find that they are liable to be prosecuted under criminal law, sued under civil law.
Determining whether the patient has given a valid consent or refusal may be one of the most simple tasks that I have to undertake or it may be one of the most complex leading to conflict with other practitioners treating that patient. The law provides a framework for professional practice to operate but on certain issues the scope of liability remains undecided. Even where legal principles are set out in decided cases the practitioner is left with considerable discretion as to how to act in a particular situation. In the area of consent to treatment, as in other areas, with the development of the role as practitioner and as patient advocate me will be faced with increasingly hard choices.
Nurses have a vital role to play in the area of respect for consent to treatment within the A&E department. Nurses a valuable contribution to make in ensuring that patients understand the significance of the consent they are asked for, and the obstacles that might lie in the way of their giving it. Clinical governance can be seen as a positive move by the Government to ensure that both Trusts and individual practitioners are more accountable and are held to be responsible for the quality of the care they deliver.
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