Reflective Practice In Nursing: Analyzing A Critical Incident Using Gibbs Reflective Model

The purpose of this assessment is to reflect on a critical incident to enable you to 'reflect on action'. 

Choose a 'critical incident' from your clinical practice (or clinical placement, if applicable) that was significant to you, and analyse it using a critical reflection framework.

You are expected to refer to the NMBA (2016) standards for practice or your specialty practice standards throughout your reflection. 

Application of Specialty Knowledge to Practice

The main purpose of this essay will be to reflect on a critical incident which occurred during my work placement by analyzing my actions, reactions and feelings during and after the incident. The essay will cover key concepts related to tracheostomy and pressure area care. Reflective practice in nursing involves deliberately analyzing one’s actions and thoughts as part of the process of learning, critical thinking, documentation and coping with critical incidents (New Zealand Nurses Organization 2015, p.1). The model that will be used for my reflection is Gibbs Reflective Cycle which involves a description of the critical incident, what my feelings were, an evaluation of what was good and bad about the experience, an analysis of the incident and an action plan (2015, p.6). I will also discuss specialty knowledge, evidence-based practice and reflection under NMBA guidelines for standards of practice as well as reflect on what I learned to guide my future clinical practice.

Pressure ulcers are injuries that occur when there is a breakdown of skin over a period of time caused by continuous pressure on certain areas of the body. This constant pressure leads to ischemia of the underlying tissue because of lack of oxygen and blood to the area (Bhattacharya & Mishra 2015). Pressure sores usually develop in patients who are immobile and suffer from health conditions that require them to be confined to a bed or chair for extended periods of time (Cooper 2013). Pressure area care involves activities that are aimed at treating ulcers when they develop such as assessing the wound, removing necrotic tissue, cleaning and dressing the sore, relieving any pressure exerted on the wound (Osuala 2014).

Tracheostomy tubes are used to treat airway obstructions, manage secretions and treat patients who have chronic respiratory failure or sleep apnea that is severe and obstructive (Sebastian et al. 2015). The management of tracheostomies is a good example of multidisciplinary care within the healthcare system. Many medical, nursing and allied health staff such as pathologists, specialist nurses, neck surgeons and respiratory therapists are needed to provide effective care to tracheostomy patients (Bonvento et al. 2017).

The job duties of a tracheotomy specialist nurse include suctioning of the tubes, stoma care, checking if the cuff tubes have pressure, maintaining the patient’s airway patency, responding to and managing tracheostomy emergencies, changing tracheostomies of hospitalized and community patients, weaning and decannulation procedures, educating the patient and their family about tracheostomy care and selecting the right tracheostomy tubes. These nurses work in conjunction with other nursing staff in the unit to care for tracheostomy patients (Agency for Clinical Innovation 2013, p.6).

Analysis of Actions, Reactions and Feelings in Context of Professional Practice

The first step in Gibbs model is a description of what happened (2015, p.6). The critical incident that occurred is that my patient’s tracheostomy tube fell out as I was performing pressure area care. The patient immediately went into respiratory distress by struggling for breath. The ward person initiated oxygen therapy via nasal cannula to address this while pressing the emergency button to alert the nurses at the station. She next placed a trachemask that was next to the bed over the stoma to maintain its patency. Because the tracheostoma was less than a week old, there was a mad rush to insert a new tube before the stoma collapsed.  After this incident, the unit had a meeting and a new policy was introduced which required that an airway nurse be present when pressure area care is being performed for patients who are intubated.

In the stage of feelings, I was scared stiff because despite learning about tube dislodgements, I never expected one to come off when performing care. I was scared because I caused the dislodgement and I had put my patient’s life at risk by failing to exercise caution. What was good about the experience is that the wards person was able to act efficiently to maintain the integrity of the stoma and save the patient. The multidisciplinary team overseeing my patient’s tracheostomy was able to pull together quickly to reinsert the tube and also prevent the patient from going into respiratory arrest. What was bad is that I observed everything in a state of shock and I was unable to continue taking care of the patient until an incident report was filled and a meeting was called within the unit to discuss what happened.

My analysis of the situation was that I was ill prepared and uncomfortable in handling tube dislodgements. A study done by Pritchett, Rietz and Ray (2016) to assess the role of nurses in managing pediatric tracheostomies in emergencies showed that nurses who had experience working in ICU settings were more comfortable in handling accidental decannulations in tracheostomies that were either new or mature. Because they managed emergency health issues on a more frequent basis, they had a higher comfort level with complex medical conditions. Nurses with experience of less than five years were more uncomfortable with tracheostomy management and accidental decannulations (Pritchett, Rietz & Ray 2016). I should have been more prepared before performing pressure care by reading up on tracheostomy care and how to handle emergencies. In the future, part of my action plan will be to be conversant with tracheostomy care and how to respond to such emergencies quickly.

Evidence-Based Practice and Professional Standards in Reflection Process

One of the major complications of tracheotomies is tube dislodgements which inadvertently lead to a loss of airway. Tube dislodgements can be caused by accidental displacement when performing nursing care, turning the patient (Sebastian et al. 2015), the presence of edema in the patient’s neck and airway, forceful and excessive coughing and a tube that is too short for the respiratory tract (Morris, Whitmer & McIntosh 2013). If a tube becomes dislodged, the tracheostoma can collapse quickly especially if the healing time has been under one week. It therefore becomes an emergency and all healthcare professionals are required to act promptly to ensure the stoma does not collapse (Sebastian et al. 2015).

Under the NMBA standards of practice for 2016 (NMBA 2017), standard three requires all nurses to maintain their scope of practice by being accountable for their actions, behaviors and decisions. I took accountability for what happened and explained this during the incident report meeting with the unit manager. My actions during the emergency incident were below standard but I attributed this to my lack of confidence and knowledge with managing tracheostomies. According to Rajendram, Khan and Joseph (2017), anyone who takes care of a tracheostomy patient should have clinical knowledge of tube dislodgements or displacements and respond to them immediately.

Practice standard six of the NMBA requires nurses to provide safe, appropriate and responsive care to their patients. The nurse should ensure that they are providing safe and quality care, are practicing within their scope and are using the appropriate protocols to report potential and actual health risks to the relevant authorities (NMBA 2017). I understood that part of my duties when taking care of this patient was to provide safe and competent care while taking care of their tracheostomy but I failed in this regard when the tube fell off. Displaced tracheostomy tubes are a life-threatening emergency and a delay of a few seconds could lead to death. Staff have to communicate efficiently and clearly during such emergency situations to ensure the proper execution of life saving procedures (Rajendram, Khan and Joseph 2017).

What I learned from the critical incident is that I need to improve my response to emergency situations as part of my scope of practice. Being effective reduces the rate of mortalities and it improves the reaction time of the multidisciplinary team in the unit. The experience also identified a learning gap in my knowledge of handling emergency dislodgements and displacements. I believe this training is important for all nursing staff without having to specialize in tracheostomy care. The numbers of specialist nurses trained in this field are few and the majority of staff who take care of such patients are general nurses. Research evidence has shown that specialist nurses who offer support in caring for the tracheostomy patient have reduced the incidence of complications that arise with these patients and have reduced cases of readmissions especially to the ICU (Bonvento et al. 2017).

Reflection on Learning to Guide Clinical Practice and Improve Patient Outcomes

Tracheostomy care is a high risk-low incidence skill which means that nursing staff without specialty training take care of patients with tracheostomy tubes on an infrequent basis. The incidence of patients with tracheotomies especially in general wards is low which is why many nurses may lack the skills to provide effective care to these patients (Paul 2010, p.78). Nurses who practice in different specialties should have the knowledge and skills to perform all aspects of tracheostomy care such as resuscitation in the event of respiratory arrest, cleaning the stoma, suctioning and maintenance of the equipment (Paul 2010, p.78).

Conclusion

An analysis of the situation and existing literature has shown that not many nurses, myself included, have the skills to deal with a tracheostomy dislodgement. This is a medical emergency that needs an effective response from all healthcare personnel. A future recommendation is to have a specialist nurse trained in tracheotomies to be present when an untrained nurse is performing pressure area care so that they can react quickly in case of an emergency. The recommendation that my unit made of having an airway nurse present is also good as they can react immediately the patient has respiratory distress.

References

Agency for Clinical Innovation 2013, Care of adult patients in acute care facilities with a tracheostomy: clinical practice guideline, viewed 16 November 2018, <https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/181454/ACI_Tracheostomy_CPG.pdf>.

Bhattacharya, S & Mishra, RK 2015, ‘Pressure ulcers: current understanding and newer modalities of treatment’, Indian Journal of Plastic Surgery, vol. 48, no.1, pp.4-16, viewed 16 November 2018, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4413488/>.

Bonvento, B, Wallace, S, Lynch, J, Coe, B & McGrath, BA 2017, ‘Role of the multidisciplinary team in the care of the tracheostomy patient,’ Journal of Multidisciplinary Healthcare, vol.10,  pp. 391-398, viewed 17 November 2018, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5644554/#b68-jmdh-10-391>.

Cooper, KL 2013, ‘Evidence-based prevention of pressure ulcers in the intensive care unit,’ Critical Care Nurse, vol. 33, no. 6, pp.57-66, viewed 16 November 2018, <https://ccn.aacnjournals.org/content/33/6/57.full>.

Morris, LL, Whitmer, A & McIntosh, E 2013, ‘Tracheostomy care and complications in the intensive care unit,’ Critical Care Nurse, vol. 33, no. 5, pp. 18-30, viewed 16 November 2018, <https://ccn.aacnjournals.org/content/33/5/18.full>.

Nursing and Midwifery Board of Australia (NMBA) 2017, Registered nurse standards for practice, NMBA, 1 February 2017, viewed 16 November 2018, <https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx>.

New Zealand Nurses Organization (NZNO) 2015, Reflective writing. NZNO Education and Professional Development Guideline, viewed 19 November 2018, <https://www.nzno.org.nz/LinkClick.aspx?fileticket=3oTgEOEbXws%3D&portalid=0>.

Osuala, EO 2014, ‘Innovation in prevention and treatment of pressure ulcer: nursing implication,’ Tropical Journal of Medical Research, vol. 17, no. 2, pp. 61-68, viewed 16 November 2018, <https://www.tjmrjournal.org/article.asp?issn=1119-0388;year=2014;volume=17;issue=2;spage=61;epage=68;aulast=Osuala>.

Paul, F 2010, ‘Tracheostomy care and management in general wards and community settings: literature review,’ Nursing in Critical Care, vol. 15, no.2, pp. 76-85, viewed 17 November 2018, <https://pdfs.semanticscholar.org/6b94/b25f5c1bc2e88dc3249851ab4f370a883e74.pdf>.

Pritchett, CV, Rietz, MF & Ray, A 2016, ‘Inpatient nursing and parental comfort in managing pediatric tracheostomy care and emergencies,’ JAMA Otolaryngology Head and Neck Surgery, vol. 142, no. 2, pp. 132-137, viewed 17 November 2018, <https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2478313>.

Rajendram, R, Khan, MF & Joseph, A 2017, ‘Tracheostomy tube displacement: an update on emergency airway management,’ Indian Journal of Respiratory Care, vol. 6, no. 2, pp. 800-806, viewed 16 November 2018, <https://www.ijrconline.org/article.asp?issn=2277-9019;year=2017;volume=6;issue=2;spage=800;epage=806;aulast=Rajendram>.

Sebastian, FB, Mahajan, B, Folch, E, Caviedes, I, Guerrero, J, & Majid, A 2015, ‘Tracheostomy tube placement: early and late complications,’ Journal of Bronchology and Interventional Pulmonology, vol. 22, no. 4, pp.357-364, viewed 16 November 2018, <https://journals.lww.com/bronchology/Fulltext/2015/10000/Tracheostomy_Tube_Placement__Early_and_Late.19.aspx. [16 November 2018>.