This essay will reflect on critical incident which took place at my placement. It will outline how critical incident analysis is incorporated in the care provision of people with mental health problems particularly from a nursing perspective. I will also attempt to point out the weakness and the values of reflection and analyse care provision in a more structured therapeutic approach. Bandman and Bandman, (2002) suggest that in order to analyse an incident we need to think critically, reflecting on our beliefs, ideas, feelings and use of language. Gamble and Brennan, (2000) suggest that relationship between reflection and critical thinking emphasises the need for critical thinking to be based on reflective thinking. In this essay I shall also draw on Johns' Reflective Cycle (Pearson et al 1996) to give the reader a clear understanding and analysis of the incident, highlighting risk management as a major issue of concern. I will also highlight the daily risks, which Mental Health Nurses face in relation to the ethics, policies and procedures that guide them. All names have been changed for reasons of confidentiality Nursing and Midwifery Council, (2008).
Drawing upon an incident within my most recent placement, the discussion will reflect on the therapeutic intervention of family therapy as long-term psychotherapeutic intervention to treat an identified patient diagnosed with paranoid schizophrenia. It will also critically analyse the benefits and shortfalls of this intervention.
Reflecting on the incident described later in this essay, I found it more appropriate to use John's Reflective Cycle, (Pearson et al 1996) because it focuses on both the patient and the nurse unlike other models that lack a user focus reflection mainly on the nurse's feelings, ideas, beliefs and judgements. John's Reflective Cycle (Pearson et al 1996) places great emphasis on the feelings, emotions and insight of the client as well as the practitioner, which I feel is of greater significance as it offers a more objective perspective. The reflective cycle is also very clear, easy to follow, easy to understand and gives the reader a clear analysis of the incident which is very important in making sense of the whole reflective process. Johns' reflective cycle illustrates the following framework; first stage- phenomenon, second stage-rationale, third sage-causal essential factors, fourth stage-reflection, fifth stage-alternative actions, sixth stage-conclusion. Following this guideline it is that one can structure their reflection and bring out sense to the whole reflective process.
I chose to write about this incident because I feel it emphasizes the risks mental health nurses face when working with mentally disturbed people. It shows how policies and procedures can disempower professionals, placing them at increased risk of aggressive or disruptive behaviour. I also found it easy to use the critical incident analysis technique to evaluate possible therapeutic intervention in patient care.
The risk posed by the patient in this scenario could have been reduced if the nurses involved in the patient care used psychosocial interventions. The incident described in this essay call into question the policies and procedures used in Community Mental Health Services on dealing with crisis or emergency situation and the duty of care as a role the nurse. Legally and ethically nurses are not allowed to search patients in the community, (Thomas et al 1997) which places staff in a very vulnerable position which is very evident after reading and reflecting on the scenario.
Zack suffers from Paranoid Schizophrenia. Following is a brief summary on Schizophrenia in order to give the reader a picture of the patient's condition. Schizophrenia is a broad term given to group of mental illness which are traditionally characterised by thought disorder, auditory and visual hallucinations, delusional beliefs along with emotional and behavioural disorder leading to progressive deterioration and social withdrawal Ironbar and Hopper, (1989). This patient in-particular suffers from Paranoid Schizophrenia, distinguished by intense thought disorder, delusions and hallucinations, the sufferer having perceptions, beliefs and ideas of reference that things are being said about them and things being done to them which they believe may cause them harm Thomas et al (1997). Medical treatment involves long-term use of psychotropic medications such as anti-psychotic drugs and mood stabilisers. From a social model approach research has shown that long-term psychotherapy programmes such as family therapy have proven effective Thomas et al (1997).
Patient Profile and Context
Zack is 28 year old male outpatient known to the Mental Health Services since 2001 with a diagnosis of Paranoid Schizophrenia. Zack is an asylum seeker from Algeria and of Muslim origin, though he is not very strict with the religion. He visits the clinic every fortnight for his depot (Depixol) injection. When is unwell, he develops ideas that Jews and homosexuals are conspiring against him and believes he has special powers. Both his parents are alive; they believe he brings shame to the family due to his mental illness. There has been growing concerns about Zack's family not doing enough to help him through his illness and neglecting his needs. Staff has raised the need to engage the family in family therapy as a way of helping Zack and family cope with his illness but as yet no family members has agreed to this type of intervention.
The Depot clinic normally opens at eleven o'clock following the weekly Community Mental Health Team meeting. Zack was due for his depot injection that day but he arrived two hours early looking unkempt. The Community Psychiatry Nurse (CPN) and I went to talk to Zack and told him that we were having a meeting therefore he had to come back when the clinic opens. Zack said he wanted to have his injection early because he wished attend the Muslim celebrations taking place locally that day. He displayed signs of being mentally disturbed, talking and muttering to himself about apparently meaningless and strange things.
Zack appeared to be very hostile and provocative with fluctuating thoughts. The CPN insisted Zack had to wait but he was adamant on receiving the depot immediately. Zack became increasingly agitated, pacing up and down, raising his voice shouting abusive words to us. Zack began to make treats of arson, claiming he had a knife. He suggested he would stab one of us if we did not adhere to his demands. As soon as he said that and having observed his behaviour, I was perplexed on the one hand the need to do something about this patient who was clearly unwell and in need of support and treatment, while also being mindful of the risk to both the CPN and myself.
The CPN decided to minimise the risk by agreeing to give Zack his injection and getting him out of the building as quickly as possible. I felt this was a risky decision because if Zack did have a knife we were potentially placing ourselves in greater danger by engaging with him further. I pulled the CPN to the side I let my feelings known. The CPN responded by informing me that Zack did not have a history of violent or aggressive behaviour nor was he known to carry knives. I felt we needed to make sure Zack was not carrying any knives or sharps before we went into the clinical room to give him his injection.
The CPN then asked Zack calmly and politely if he was carrying the knife at this point Zack produced a knife from inside his jacket. We followed the Trust policy for dealing with armed and dangerous patients that you must call for back-up; we pressed the alarm alerting other staff for assistance. The police were called and arrived very quickly they seized the knife Zack was also found to be carrying a screwdriver. He was taken to an acute admissions ward of a nearby hospital under Section 2 of the Mental Health Act (1983) for further assessment of his mental state. His family were informed but they seemed not to be concerned.
Family therapy involves the whole family in the treatment process based on the understanding that a particular symptom or group of symptoms, exhibited by a family member. Reflecting on Zack's relationship with his family it is important to note that due to their culture the family had negative attitude towards the illness and they felt it brought shame to the family. By educating the family, which is a major component of family therapy, it helps gain understanding into the illness, how they can monitor, support and supervise the patient which contributes to the development of insight and helps reduce risk of relapse and hospital admission. Fadden, (1999) cited by (Gillam 2002, p106) defines psycho educational interventions as "those interventions where the patient and family members are seen together, where is acquisition component in addition to a didactic element where the primary aim is reduction of relapse in the patient" It has been shown that those patients who have family who are willing to engage in the patient's care in a supportive manner have an enhanced probability of maintaining stability in their mental state.
Therefore, use of family therapy as a long-term psychosocial intervention reduces the risk of relapse, which is what happened in this scenario with Zack. Engaging with the patient is very important in providing care and monitoring people with schizophrenia and it would be very important for the patient and his family. The family also feel supported by the therapist who works with them to help develop an understanding of the illness and reduce their fear and misguided prejudices.
As a nurse/therapist it would be important to understand effects of culture in this situation and try to bring awareness to the family that mental illness is very common and maybe show the family statistics on how many people live with mental illness. It would also be important to educate the family on understanding the improvement rate for people who engage into family therapy and benefits. Evidence based practice would be very important when working with this family as it shows proof that treatment can actually work and has been proven to do so in many cases. Family therapy has been found to be effective, as an adjunct to drug therapy in the management of schizophrenia Birchwood, (1994), therefore the family should monitor that patient is taking medication as required. By encompassing family therapy, psycho education it encompass the involvement and support of family members in the care of an individual Gillam, (2002) which is very important in this scenario. This helps the family gain understanding into the illness and accepts it even though this might be difficult due their cultural beliefs.
Staffs are always at risk of aggressive patients and therefore there is great need for risk assessment. Clinical risk is concerned with the danger in which an individual might pose to themselves or others Gamble and Brennan, (2000). Research has identified that the occurrence of violence, arson and homicide depends on additional situational factors and their accumulation lead to increased risk. In this situation having observed the incident from the beginning, I observed Zack's escalating behaviour, presentation such as speech, voice tone, gestures and they determine a lot in ones mental state Gamble and Brennan, (2000).
There are other precipitating factors leading to this incident such as the psychosocial environment and stimuli in this case the day of the depot coinciding with the celebrations. If it was a different day, maybe Zack would not been very paranoid and carrying a knife. Also the fact that staff could not meet his needs, it made him more aggressive and in a way no one would have known he was carrying a knife. Psychiatry nurses face importance of risk assessment due to the restrictions they have in searching people who they suspect to be dangerous. The fact that Mental Health Clinics have no enough security measures to detect people who bring in weapons, it increases the risk. Staffs are limited in the procedures of working with patients and it is illegal and unethical to go through patients' things or searching them without their consent Thomas et al, (1997).
Mental illnesses can manifest in a way that can cause distress to both the patient family and carers but with the help of such therapies as family therapy I recommend it.
I believe that Zack could benefit more from it. This intervention has been proven useful by research in the management of schizophrenia Gamble and Brennan, (2000), therefore it is useful to use such therapies inform our care as part of evidence based practice. Rowland and Goss, (2000), writes about evidence based practice as the aspirations nurses should deliver care and therapy based on procedures that are known through research to be effective. Family therapy help the patient cope with their condition and improve their quality of life. Relatives and carers also benefit and by empowering the patient, the family members help the patient change their behaviour Slade and Haddock, (1996) cited by Gamble and Brennan (2000). Research carried out in the last twenty years on high Expressed Emotion (EE) by the Social Psychiatry Unit at the Institute of Psychiatry provided evidence of negative impact of high (EE) on the course of the family of a schizophrenic patient Gamble and Brennan, (2000). Families find distress in copying with the condition but they are also showed hostile behaviour by the sufferer and eventually become emotionally over involved. These developments led to the development of family therapy intervention.
Family therapy reduces the effect of schizophrenia such as hospitalisation and relapse Ironbar and Hooper, (1989). If Zack's family was involved in care, this incident might not have happened. Family therapy also improves patients functioning and lowers the burden on the family. If one receives support from family, he is more likely to improve adherence to medication, less violent and lower negative family effect. A component of family therapy includes engagement of families and patients, behaviour, self-management, maintenance of skills, dealing with violence, risk management, assessment, cultural issues, over involvement and interpersonal boundaries, Gamble and Brennan, (2000). In Zack's situation all the above on family therapy would be helpful and it involves issue on culture hence Zack's family feels he is a disgrace to the family, which is part of their cultural beliefs. Making them understand the illness would be more helpful in coping with Zack's illness. Research has also found out that these psychosocial interventions are more useful than taking routine medication treatment and not only benefit patient, but also family carers and relatives Ironbar and Hooper, (1989). In helping this patient, this type of intervention should help him gain insight and doing individualised care with the nurse in the therapy it can be achieved. Gillam, (2002) suggests the importance of using drug treatment therapy in conjunction with family therapy for maximum benefit to the patient, family and carers.
Reflecting more on this scenario, it brings out issues of concern and critical incident analysis would be very important to guide the whole reflecting process. Developing skills on reflecting enables one to learn more effectively from practice situation and identify what you have learned in practice John, (2000). There is also emphasis that reflection is related to a complex and deliberate process of conscious thinking about interpreting experience in order to learn from it.
In this incident I used my knowledge on risk management to lower the risks Mental Health Nurses face in working with mentally ill patients. I was trying to minimise the occurrence of an event that would be dangerous. Considering the importance of critical incident analysis to analyse this scenario was because it gives me an understanding and appreciation of the whole Clinical Incident Analysis (CIT) process. I also chose family therapy because as noted before the family could offer a lot of help to the patient, but only if they can engage with the patient and understand the mental illness and how they can lower the fear and prejudices of living with somebody with a mental illness.
Before this incident happened, I felt very nervous that being a student nurse involved in such a difficult situation. However, my feelings changed later when Zack was found to be carrying a knife. Having not emphasised on the nurse to check if the patient actually had the knife, this could have lead into someone getting hurt or even killed by the patient. This was also a learning process for me I learnt that besides taking medication like in this situation, the patient was on medication, there are other therapeutic interventions which can be used to lower the stresses in the family of a schizophrenic patient and help the patient manage and cope with his own illness.
Critical incident analysis was very important in giving structure to the whole reflection process and gain appreciation to therapeutic interventions that nurses can use in managing schizophrenia. On the other hand I knew it was unethical and illegal to search this patient, but I felt in such incident, nurses should have the power to search thought to be dangerous or threatening to staff. Evidently, according to reports from Department of Health (DH) (2008), there has been an increase in the violent incidents involving staff working with patients with mental health problems.
The issue of risk management, risk assessment is something not to ignore in Mental Health Nursing. Risk management is intended purpose of assessment process, reducing severity of identified risks though they vary over time and circumstances Gamble and Brennan, (2000). Gates et al (2000) identifies clinical risk assessment as an established tenet of Psychiatry Nursing treatment. The establishments of National Service Framework and Guidelines (DOH, 2008) have emphasised on practitioners on the importance of risk assessment. There have been a large number of tragedies and homicidal incidents involving psychiatry patients therefore there have been high expectations in considering risk assessment as a major tool in mental health nursing.
In this incident I felt I had to remind the CPN on the danger Zack was posing to us, reflecting on practice Thomas et al (1997). This is achieved by assessing situations and judge how dangerous they could be or how best you can deal with them in a professional and ethical way. NMC, (2008) states that professionalism and accountability in all our practices and by being accountable, you have a good cause to justify your actions in this situation safety was a priority.
In future if I face the same situation, I would act quicker and take precautions to safety in time. I would also use good interpersonal skills to try and talk to the patient. I would also use my knowledge of risk management and safety precautions since nurses have a duty to look after themselves as well as public, than just looking after the patient Stern and Drummond, (1995). I would also consider that when working with people with schizophrenia there is great need to engage into psychotherapy interventions, family therapy a priority adjunct to drug therapy.
In conclusion, the essay clearly considers the values of family therapy as a possible psychotherapeutic intervention to be used in the management of schizophrenia. It also gives appreciation of the whole process. The essay also demonstrates the importance of ongoing clinical supervision and the role of a Psychiatry Nurse. Evidently throughout the essay, it is clear that mental health nurses face a great risk in their day to day practices in working with mentally ill patients. Highlighted is the importance of reflecting and using Clinical Incident Analysis (CIT) process as a major tool to help the whole reflective process. The stages of John's reflective cycle were used in the essay as it enabled the writer to identify the phenomenon. The need for risk assessment and critical thinking you are able to analyse and reflect on an incident and bring more sense to the reader.