Take a few moments to think back over your nursing career, starting from your student days to the present, and identify some of the key ‘critical incidents’ that have happened to you. Use a broad definition of critical incidents to include anything that had a significant impact on you at the time; this could be the sudden and unexpected death of a patient, threats of aggression from patients or relatives, medication mismanagement, patient suicide, a personality clash with a colleague, having to tell a student that they have failed their placement, or a more routine clinical emergency. Once you have recalled two or three of these incidents, take a few more moments to reflect on how they affected you at the time and then how they have impacted on you and your development subsequently.
My first clinical placement as an 18-year-old student nurse was a surgical ward and I can still remember my physical and psychological reactions to a patient with advanced gangrene of his leg, who was nursed in a side room. Given the severity of his condition only more senior and experienced staff entered the side room and cared for him. But as part of my ‘training’ I accompanied the staff nurse one morning as she cared for the patient. The sight and smell of the decaying tissue could not be disguised, neither could the psychological despair of the patient. I can't remember how I responded while in the side room, but I know that my social and professional skills were totally inadequate. Another ‘incident’ 30 years later was while working as a senior nursing lecturer in a university. I took a 4-week sabbatical and spent it working in a hospice. I remember getting to know ‘George’ over a few days and then sitting with him one evening as he gently and peacefully died.
Both of those occasions in my nursing career have been key points in my development as a nurse. There have been many other ‘incidents’, some negative and some positive, but all having significant influence not only on my nursing development but also on my emotional and psychological wellbeing. I survived my nursing career, but many of my contemporaries and a number of my subsequent colleagues did not. Every nurse will encounter numerous critical incidents in their nursing career; some will be clinical emergencies, others will involve legal proceedings of coroner's courts or professional investigations by the Nursing and Midwifery Council, many will be personality clashes with colleagues, other healthcare workers, relatives or patients, and some may involve competency or procedural issues. Whatever the ‘incident’, it will uproot us from our daily routines and cause us to question what we are doing and where we are going.
Our initial response to any critical incident will be one of stress: we will feel worried and anxious about what happened and what the possible consequences for ourselves will be. That is likely to make us quite defensive trying to justify and rationalise any part we might have played in the development of the incident. Even if we were not at fault any investigation into the incident will make us feel exposed and at risk. The effects on our physical, emotional and psychological health and wellbeing will be evident with sleep disturbances, appetite changes, generalised anxiety, loss of self confidence and irritability with colleagues and family. If this happens too often then our resilience is weakened and we either leave the nursing profession to avoid further hurt or remain in the profession as a weakened and at times burnt-out carer.
Although it is important to say that we should reflect on, learn from and then build on the events that lead up to and were part of the critical incident, this in itself is too simplistic as an answer. No amount of reflection would have enabled me to learn from and build on my initial experience of the patient with a gangrenous leg. Whether a junior student should have been exposed to such a condition is debatable, but what was important in helping me cope with the realities of nursing care at that time, was the support of the nursing team in demonstrating how they approached the patient and undertook his care. Then subsequently giving me time to talk through the event with a caring staff nurse. I've never been involved in giving evidence at a coroner's court, but if it happened I would want the support and advice of the manager, the legal adviser to the Trust and my colleagues. Role play and simulation of the legal proceedings would be very helpful as the courtroom and the norms of behaviour would be unknown and frightening to me. If this is generalised to other types of critical incident, then what is needed is advice and support from people who have been there before and people who are experts in that area.
All nurses will be exposed to some form of critical incident during their career. Each incident will create some form of stress in the nurse and probably the whole healthcare team. This stress can be quite destructive, weakening self confidence and caring qualities. Reflection and immediate ‘coffee time’ support from colleagues are important, but it is crucial to provide expert advice and support if the incident progresses to areas of legal or professional investigation.