A critical incident is an incident which has prompted reflection of the actions undertaken by all involved and being critical of those actions in order to learn and improve practice (Perry, 1997 cited by Elliott 2004). Therefore, a critical incident is personal to each individual and requires critical thinking skills; critical thinking skills utilise the ability to reflect in order to decide upon the best outcome (Norris and Ennis, 1989 cited by Fisher, 2011). When applying critical thinking, the nurse must consider their own emotions, values and beliefs to develop an objective conclusion (Price et al, 2010); the conclusion may contribute to an improved awareness of learning needs and self. Reflection may aid these developments. "Reflection is the process of critically analysing practice to uncover underlying influences, motivations and knowledge" (Taylor, 2000 cited by Hilliard, 2006:35); therefore the ability to critically analyse and reflect are intertwined and crucial for the nurse to be able to learn from and develop their own practice.
To analyse the chosen critical incident I will be using John's model of structured reflection (Palmer et al, 1994 cited by Jasper, 2003) implicitly throughout this essay. John's model consists of five questions to prompt reflection, these include; description of the incident, reflection, factors which may have influenced the outcome, possible ways in which the situation may have been improved and resultant learning (Palmer et al, 1994 cited by Jasper, 2003). Learning is divided in five sub-categories of knowing, these incorporate; care delivery, personal emotions, ethical considerations, underpinning theory and how personal development has contributed to the outcome compared to past situations (Price et al, 2010). The sub-categories of knowing implicitly apply Brookfield's (1987) components of critical thinking which consist of challenging assumptions, recognising the importance of learning, how a potentially biased attitude may hinder learning, and contemplating and analysing potential interventions (Rolfe et al, 2011). John's model of structured reflection (Palmer et al, 1994 cited by Jasper, 2003) was chosen as different aspects of the situation can be critically reflected upon, including how the actions of others may have contributed to the outcome; the sub-categories of knowing allow a thorough exploration of the experience from a personal and professional perspective.
The critical incident I have chosen occurred during placement within an adult community learning disability team. The learning disability nurse, Georgina, received a referral for a 36 year old gentleman named Christopher. Christopher has a moderate learning disability, Down's syndrome and currently resides within a large residential home. Christopher has no living family and communicates with the use of some signs.
Staff reported that Christopher remains in bed throughout the day on a daily basis; whilst in bed Christopher will extract and smear faeces in his bed and on his bedroom walls.
Georgina explained that other health care professionals have reported that the care provided is unsatisfactory. Georgina and I met with the new manager of the home to discuss issues the residential staff were experiencing and Christopher's wellbeing. The manager explained that the staff had reacted to Christopher's behaviours by locking him out of his bedroom and leaving his bed without any bed clothes on. Staff hoped this would prevent Christopher from remaining in his bed and smearing faeces. Christopher responded by entering other residents' bedrooms, getting into their bed and smearing faeces in their bedroom.
When Georgina and I met Christopher, he was lying in his bed with his back to the door, facing the wall. Christopher ignored all attempts of interaction and continued to face the wall.
This experience was a critical incident for me as I allowed another individual to influence my opinion over a service prior to visiting; this resulted in me entering into the service with a biased, negative attitude. This may have been portrayed to the staff through my body language, facial expressions or tone of voice which would not be conducive to working with the staff to promote Christopher's holistic wellbeing. This experience has highlighted the importance of working together with the staff to begin to improve the care provided to Christopher. Appearing judgemental and negative may contribute to reduced staff morale and possibly a negative attitude towards me and other professionals.
When I started the learning disability nursing course I did not consider how my non verbal communication may be interpreted by other individuals and the impact of this. I have since become very aware of this and am fully aware of the need to appear objective and approachable. It is apparent from this critical incident that I need to become more aware of and in control of my non-verbal communication. Appearing objective, professional and approaching all situations with an open mind may contribute to a good, collaborative working environment to influence change to promote holistic health.
The key processes for reflection from this experience include the potential reasons for Christopher's behaviour, the impact this behaviour has had on staff, organisational issues and the importance of collaborative working. I will now go on to critically discuss Christopher's behaviours, exploring the factors which may contribute to these.
Prior to attributing Christopher's behaviours to challenging behaviour, potential physical and psychological health issues, social and emotional causes should be ruled out (McSherry et al, 2012); best practice states physical and mental health needs should be maintained and improved in order to promote holistic wellbeing (DH 2007c). This may prevent diagnostic overshadowing from occurring. Diagnostic overshadowing occurs when behaviours are wrongly attributed to an individual's learning disability (Mencap, 2007); Christopher's behaviours may be attributed to his moderate learning disability or Down's syndrome. As Christopher does not communicate verbally and is choosing not to engage with staff this will contribute to the difficulty of detecting a potentially treatable cause to Christopher remaining in his bedroom and evacuating and smearing faeces. The Department of Health aim to work with the appropriate professional bodies to include the issue of diagnostic overshadowing in training and standards (DH, 2007a).
Sensory impairment may be a contributory factor to Christopher's change in behaviour, as the behaviour may be providing sensory stimulation. Impairment of hearing in individuals with Down's syndrome may be due to a build up of wax in narrow ear canals or impairment of vision possibly due to cataract, or glaucoma (NHS, 2005). Christopher may be evacuating and smearing faeces due to being constipated; constipation, in comparison with the general population, is more common in individuals with a learning disability (RCN, 2006). Constipation could be masking an underactive thyroid which is more common in individuals who have Down's syndrome (RCN, 2006). Furthermore, dementia or depression may be wrongly attributed to hypothyroidism (NHS, 2005).
Depression is more commonly diagnosed in individuals who have Down's syndrome (NHS, 2005); difficulties in problem solving, coping with stress, including limited opportunities to socialise and limited life experiences may contribute to this (McGillivray et al, 2007). Dementia is more prevalent amongst individuals who have Down's syndrome compared to the general population (The British Psychological Society, 2009). Best practice suggests that all individuals who have Down's syndrome should be screened for dementia from the age of thirty to ensure an appropriate baseline assessment is available (Turk et al, 2001 cited by The British Psychological Society, 2009). Christopher has not been screened for dementia, this is not mandatory and may not be part of routine screening locally.
Social changes, including staffing changes, routine, environment or a traumatic experience should be considered. Christopher's home is experiencing a high turnover of staff; it is possible that a particular member of staff whom Christopher had a good therapeutic relationship with has left, thus leaving Christopher to cope with a loss. By Christopher experiencing this loss regularly he may experience difficulties accepting new staff in the future.
The process of investigating Christopher's behaviours should incorporate a capacity assessment to determine Christopher's ability to consent to a holistic health assessment, appropriate interventions and whether Christopher understands the implications associated with his behaviours. If it is decided that Christopher does not have capacity, the reasoning for this should be accurately documented, including all efforts to aid understanding, and reviewed regularly (MCA, 2007). Person centred planning should be followed if any decision is to be made on behalf of an individual who lacks capacity, this must be in their best interests (MCA, 2007). A best interests meeting will be required with an advocate present to support Christopher's rights. It could be argued that Christopher has been deprived of his liberty by being locked out of his bedroom and receiving unsatisfactory, non-personalised care. The European Court of Human Rights stated that if an individual looses autonomy due to being subject to continuous supervision and control then this could contribute to deprivation of liberty (MCA, 2007). Deprivation of liberty should only be considered to protect an individual from harm, if there is no less restrictive option of providing appropriate care (MCA DOL safeguards, 2008: CQC, 2011).
Christopher may have been subjected to institutional abuse as there appears to be rigid daily routines focused around staff shift times and meal times and a need for training to improve staff's knowledge (DH, 2000). Although, had Christopher's hygiene not been maintained that would be considered neglect, thus causing a dilemma for staff (DH, 2000).
Within social care, issues such as a high turnover of staff, inadequate training and knowledge of health needs has led inconsistent care delivery due to staff being unaware of their role in health facilitation (DH, 2008). Valuing People Now (DH, 2009) acknowledges that people with a learning disability should receive annual health checks and have a health action plan, but not everyone has received this yet. Health checks are not undertaken systematically as they are not currently integrated into routine within primary care settings in England (Michael, 2008). If annual health checks are integrated into routine within primary care this may increase the number of individuals receiving them. Training on health requirements and health action plans may raise awareness of health needs amongst individuals with a learning disability.
The residential staff have the responsibility to recognise ill health and ensure Christopher is able to access appropriate services (DRC, 2006); this may be difficult due to a high staff turnover. Staff may prefer to avoid Christopher possibly due to finding the evacuating and smearing of faeces unpleasant (Whittington et al, 2005). This may impact on the staff's emotional wellbeing and their willingness to implement interventions recommended by specialists (Tynan et al, 2002: Dudman et al, 2012). The Royal College of Nursing highlighted organisational factors which may impair the quality of care provided; these factors include ignorance and fear as a result of inadequate knowledge and training (Michael, 2008). A high staff turnover may affect the dynamics of the staffing team. The residential staff may be in the forming stage of Tuckman's model (1977, cited by Goodman et al, 2010) due to new staff, such as the manager. Therefore, the individuals within the staffing group may have been attempting to get to know the new staff members, whilst the new staff members may have been attempting to understand cliques and communication methods within the group (Goodman et al, 2010). The factors which may be preventing the group from developing into an effective team include morale, communication and a clear understanding of their group identity (Goodman et al, 2010). Effective leadership is essential if the staff are to perform efficiently; essential leadership qualities include having a commitment to provide high quality care with the ability to motivate others, this will involve optimism, risk taking, creativity, and strong morals (Bishop, 2009).
For Christopher's wellbeing to be promoted, care plans should be reviewed regularly to determine their effectiveness and appropriateness regarding Christopher's dynamic needs (CQC, 2010). The results of a study undertaken by Adams et al (2006) showed that those with a high quality person centred plan spent more time participating in meaningful activities. Currently, Christopher does not participate in meaningful daytime activities; Valuing People Now (DH, 2009) stated that services should provide their staff with training on topics such as how to develop a person centred plan. When this does not happen or the quality of training is poor, factors relevant to Winterbourne View such as poor care planning and lack of meaningful daytime activities may contribute to a diminished wellbeing, neglect or institutional abuse (DH, 2012b).
To promote Christopher's holistic wellbeing, the residential staff may benefit from support and training. For the staff to be able to develop high quality care plans, they should develop a therapeutic relationship with Christopher to get to know him well (DH, 2007a). This may contribute to Christopher having his health needs understood and a healthy lifestyle promoted (DH, 2007a). By staff feeling valued and supported, this may reduce the high staff turnover and improve morale, leading to a more consistent, dignified approach to care. When dignity is promoted Christopher may feel valued and in control of decisions, compared to potentially feeling humiliated and devalued (RCN, 2010b).
A learning disability nurse should provide relevant interventions and education such as supporting Christopher to be understood and supporting staff to communicate effectively with Christopher to establish coping strategies and ensure Christopher's health is promoted (Sheerin, 2008: DH, 2007 c). Collaborative working between health and social care professionals is required to ensure Christopher's needs are met (RCN, 2011).
Primary healthcare professionals such as nurses and GP's should be able to implement and develop health action plans with the support of learning disability nurses (DH, 2008). Health action plans need to be outcome focused with monitoring of progress and achievements, monitoring is required to ensure good quality health action plans (DH, 2008). Good quality health action plans may support a key objective of Valuing People Now (DH, 2009) by facilitating appropriate healthcare for individuals who have a learning disability to live longer, healthier lives (DH, 2009).
Annual health checks are not yet routine practice within primary care settings (Michael, 2008), but are thought to be an effective intervention in promoting the wellbeing of individuals with a learning disability (DH, 2007a). By introducing financial incentives for GP practices to undertake annual health checks, it is hoped this will encourage primary healthcare services to assess an individual's health and provide appropriate interventions (DH, 2007a). Alternatively, introducing penalties for each individual who is not offered a health check may be a more ethically sound incentive. However, the aim of everyone with a learning disability being registered with a GP and with a health action plan has been unsuccessful to date due to these aims not being built into the targets of mainstream, primary healthcare (DRC, 2006). Best practice states that the nurse should use their skills to train and influence mainstream health staff to support them in providing person-centred care (DH, 2007c). Recently, it has been acknowledged that "changes to people's lives require action at a local level, with local commissioners and providers working together, change of this scale, ambition and pace requires national leadership" (DH, 2012c: 15). Collaborative working is critical to effectively adopt a proactive approach for improved holistic wellbeing and reduced health inequalities amongst individuals who have a learning disability (DH, 2006).
Upon reflection, I entered into the service believing they were doing wrong which was impacting on Christopher's wellbeing; I did not consider factors which contributed to the level of care being delivered. I should have dealt with this experience in an objective, professional manner and considered how my facial expressions and body language may be perceived by the staff; thus conforming to the NMC Code (2008) by being impartial. I should have considered how it would affect the staff's morale and potential for collaborative working had the staff picked up on my negativity. From this experience, I am more aware of the need to control my non-verbal communication which has been continually developed throughout the course and will continue to be developed through working with individuals who have a learning disability, their families, carers and other professionals. The importance of collaborative working with other health and social care professionals in order to promote the wellbeing of an individual has been highlighted. In the past I have taken a blinkered approach of working with the individual in order to promote their wellbeing, however, in this instance the service and staff have required support and education in order to promote Christopher's wellbeing. This realisation will enable me to consider the bigger picture and factors which may be contributing to the situation prior to developing a conclusion; this will ensure I support those I care for to access appropriate services (NMC, 2008).
In summary, Christopher's needs are not currently being met; in order to meet Christopher's needs collaborative working between the residential staff and appropriate professionals needs to occur. Working with Christopher's home and staff may improve the standard of care being delivered and ultimately improve Christopher's holistic wellbeing. Collaborative working at a local level is fundamental to begin to improve standards. Although, this will need to be monitored to ensure Christopher is receiving appropriate, person centred care.
In conclusion, a critical incident prompts critical reflection in order to develop and learn from the experience (Perry, 1997 cited by Elliott 2004). This incident prompted reflection of my own actions, the actions of others, and the implications of those actions. The residential staff require support and education in order to improve their practice to benefit Christopher's wellbeing. This will need to be monitored to ensure Christopher is treated in a dignified, person centred manner with his human rights promoted. My practice will continue to develop through using different reflective tools, maintaining a reflective portfolio and regular supervision in practice. This will ensure my practice is underpinned using the best available evidence to ensure I provide appropriate care and work collaboratively with other health and social care professionals to adopt a holistic, person centred approach. This will ensure I work within my level of competence and continue to conform to the NMC Code (2008) by upholding the reputation of learning disability nurses. (Word Count, 3000)