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A study of critical incident analysis as a route to the identification of change necessary in clinical practice: addressing the theory–practice gap
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Article
A study of critical incident analysis as a route to the identification of change necessary in clinical practice: addressing the theory–practice gap Geoffrey W. Martin and Gordon Mitchell
This paper examines the analysis of critical incidents to assess to what extent post-registration students are able, through reflection, to identify areas of practice in need of improvement. Discussion centres on the students’ ability to reflect on their writing and link such reflection to ways in which changes can be facilitated. Concerns around the theory–practice gap are central to the research, and the use of this teaching strategy is discussed in relation to issues that arise from identification of the practice gap. Cormack’s (1983, 1996) technique of analysing critical incidents is used to classify the data, and the areas of discussion are grouped around three main headings relevant to the process of change. It is clear from the data that areas in need of change are identified, but it is more difficult to assess to what extent the process directly informs practice. The conclusion highlights the need for further research that examines whether or not change is apparent in the students’ practice area. © 2001 Harcourt Publishers Ltd Geoffrey W. Martin RGN, RMN, BSc(Hons), MA, Principal Lecturer, Gordon Mitchell RMN, Dip N, BSc(Hons), MA, Senior Lecturer, University of Teesside, School of Health, Middlesbrough TSI 3BA, UK. (Requests for offprints to GWM. Tel.: ;44 (0) 1642 384 966) Manuscript accepted: 18 January 2001
Introduction The aim of this paper is to assess to what extent we can say that qualified nurses are able to use reflection to identify changes which are necessary in their practice area. There has been wide discussion in nursing journals of the problems around the existence of the theory–practice gap. It was felt that, through the use of critical incident analysis, theory may become linked more closely to the student’s day-to-day practice. To this end, the nurses were asked to write and discuss critical incidents as part of their project work undertaken during participation in a set of diploma modules. These written papers were
© 2001 Harcourt Publishers Ltd doi:10.1054/nepr.2001.0006, available online at http://www.idealibrary.com on
then analysed to assess: (1) if it was possible to say that the education process facilitated the identification of care practices in need of change, and (2) if strategies for change were part of the critical incident analysis. By looking at the process of change, it was hoped that links between theory and practice could be identified. The nurses were asked to consider incidents from practice, and produce short reflective papers for discussion in classroom workshops. Relevant extracts from their writings have been utilized to demonstrate the concepts under discussion. The papers were only
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selected if they showed evidence of reflection and related such reflection directly to practice. This project can only be seen as a first stage of the research, and further work is necessary which addresses more directly the link between formal education and its role in practice development.
Critical reflection Reflection of critical incidents can be incorporated into a curriculum programme in an effort to make students apply what is learnt on a module to their day-to-day practice. Burnard (1989) reminds us that education suggests an evolving critical process that enables learners to make decisions for themselves through the exercise of rational thought. The approach that uses critical incidents allows the nurse to not only reflect on the event, but also become critical of practice in a safe environment. There have been several studies that have shown positive results when this strategy is employed in nurse education (Durgahee 1996, Martin 1996). The value of logs, academic diaries or journals have also been considered as a way to link education and practice (Holly 1987, Jordan 1998). Clearly there is a wide variation in the implementation and translation of critical incidents into a teaching and learning situation (Minghella & Benson 1995). However, there is a growing interest in the role of writing as learning where qualified nurses use writing as a tool to foster reflection on specific experiences, thus developing new skills, knowledge and attitudes (Parker et al. 1995). The process requires the student to learn through writing the critical incident for analysis, as well as reflecting on that writing. It is felt that reflection, if used correctly and sensitively, can bring about emancipation and empowerment, not only for the nurse but also as a way of influencing the practice of others. This can be seen in terms of nurse/patient interaction, clinical decision making and ethical debate (Rich & Parker 1995). With this process in place there may be the potential for a greater degree of practice development, and moves towards changing care environments. Nurses can consider the theory, which arises out of an examination of the clinical situation, and apply
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and reflect on the theory in an effort to identify changes necessary within their relevant practice settings (Rolfe 1997). The process has to be conducted in a supported environment, but one where it is possible to identify areas of good and bad practice which may then lead to identification of the need for change. The literature around the problem of the theory–practice gap reminds us that we may still be unable to apply learning in the classroom to care practices. Classroom teaching is thought to be idealistic and, as such, it may be that the theory–practice gap is a continuing cause for concern (Brereton 1995). It is useful, therefore, to examine the value of reflection and the problems that can arise from it. Schon (1987) reminds us that a ‘designer-like’ practice cannot be conveyed to practitioners wholly or mainly by classroom teaching. The important concept is being able to get in touch with the actual doing, the actual behaviour, in order to discover what the nurse is really doing. Schon felt that many practitioners were locked into a view of themselves as technical experts, and found nothing in the world of practice to occasion reflection. They have become too skilful at techniques of selective inattention, junk categories and situational control, techniques that they use to preserve the constancy of their knowledge-in-practice. For them, uncertainty is a threat, its admission is a sign of weakness (Schon 1983). Martin (1996) quotes one nurse in his study who argues that an over-reflective orientation could lead to an inability to act quickly when the occasion demands. The nurse valued the ability to act quickly when required over and above the ability to reflect before making decisions.
Method In nursing practice, the critical incident technique has been widely used as a method of data collection, and has been defined as a ‘snapshot’ view of the daily work of nurses (Clamp 1980). Within nursing research, critical incident technique has been defined as a systematic, inductive, open-ended procedure for eliciting verbal or written information from respondents (Norman et al. 1992). An advantage of this technique is that it is a description of actual events, and is therefore
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more concerned with the real, rather than the imagined, world. It is important to note that it is real only so far as the perceptions of the respondents allow. Furthermore, the critical incident is a description of what the respondents think they do. (Cormack 1983, Cormack 1996). The disadvantage is its dependence on the memories of the respondents and their ability to recollect specific incidents. If the critical incident is sensitive to the participant, some participants might alter the facts of the incident, therefore the researcher might not receive an accurate description (Dachelet et al. 1981). From the literature, there appears to be two main methods of collecting data. Norman et al. (1992) and Cox et al. (1993) used interviews as a method to get the respondents to discuss the critical incident. The most popular method advocated by Parker et al. (1995), Rosenal (1995), Rich and Parker (1995), and Von Post (1996) is the use of written critical incidents. This method reveals the experiences of the nurse who writes them (Rosenal 1995). Therefore, reviewing the literature on critical incident technique, the researchers decided to use written critical incidents as participants may find it difficult to verbalize their feelings (Rich & Parker 1995).
Validity and reliability Validity can simply be defined as the instrument’s ability to measure what it supposes to measure (Avis 1995). In criticizing the traditional view of validity, Reason and Rowan (1981) argue that validity within traditional research is concerned with operationalization of the concepts for measurement. Therefore, these traditional notions of validity are about methods and not much about people. However, in reviewing the literature, Avis (1995) suggests that although qualitative research has different threats to accurate representation arising from its interactive methods, the same criteria for reliability and validity can be used to assess qualitative research findings. According to Anderson and Nilsson (1964), the categorization of critical incidents can be regarded as very subjective and difficult. It is possible that different people will categorize
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differently. Cormack (1983) acknowledges this potential problem, and suggests that an independent rater be used to classify the data, so having ‘inter-rater-reliability’. Both researchers, therefore, carried out the categorization independently and reached agreement on the main areas identified for discussion.
Data analyses Analysing the critical incidents involves an interpretative approach with similar contents being coded and categorized (Rosenal 1995). The data analyses involved examining the incident for similarities or common elements. This is what Dachelet et al. (1981) call ‘category formation’. Cormack’s (1983, 1996) technique for analysing critical incidents was used to classify the data. A classification system is constructed as the data is being analysed, rather than before (Cormack 1996). Cormack (1983) recommends that the researcher creates major areas related to common themes. Within each area there will be smaller categories, and within each category there may be a number of sub-categories. When nurses have mentioned a category more than once, the number of such references is recorded. Sims (1976) describes this as the grouping of similar behaviours together and writing specific descriptive statements to cover similarities of the incidents. Thereby the researchers will be able to see linkages to various concepts and themes (Cormack 1996). Following Cormack’s (1983) technique, three main areas were created: 1. Area A: Conflict around the process of change. 2. Area B: Complacency with the status-quo 3. Area C: Change identified as a central issue. Further sub-categories were created from within each of these three main areas. All the critical incidents were given a code and number to facilitate this process.
Sample A total of 75 critical incidents were collected over 1 year from four diploma modules that covered two specialist areas of nursing: care
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of dying patients and care of older people (ENB 931 and ENB 941). This process was based on work done by Gordon and Benner (1984), and the qualified nurses were given an outline of how to produce the work with headings to help them structure their critical incidents. The headings ‘What did you learn as a result of the experience?’ and ‘In a similar situation, how would you handle the incident?’ proved to be particularly useful in this research. In the event, just over half of the papers showed clear evidence of reflection on practice applicable to the research study (N:45).
Results From examination of the data, it was possible to identify the sub-categories (Table 1). There were some feedback sheets that showed evidence of more than one area, and this is why the totals add up to more than the 45 papers examined. Further categories arose out of the sub-categories listed above, and these will be referred to in the discussion when relevant. As can be seen from examination of the results, the largest categories were:
Change related to own practice (16 references) Conflict between nurse and doctor (12 references) Complacency with own practice (10 references).
It may not be surprising that these are the most frequently occurring areas given the nature of the research method. Asking the nurse to reflect on his or her own practice will inevitably lead to consideration of the individual’s actions. The highest frequency Table 1 Totals for each sub-category Area category
Sub-categories
No.
‘A’ Conflict
Between nurse and nurse Between nurse and doctor Between nurse and others With own practice With practice of others With culture of care Related to own practice Related to practice of others Related to culture of care
2 12 3 10 1 2 16 4 5
‘B’ Complacency ‘C’ Change
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is that related to change and, therefore, adds weight to the hypothesis that reflection on critical incident will raise crucial issues of change in practice, not only for oneself but also for others. A total of 25 references to change may encourage the use of this educational approach in that it holds potential for practice development and consideration of the gap between theory and practice.
Discussion of findings A: Conflict It is important to discuss the issue of conflict and power, as there is a direct relationship between conflict and the potential for change. As Martin (1998) states, there are pressures on nurses to accept the status quo, which are directly linked to the power of the doctor to control the action of the nurses. The main area of conflict identified did, in fact, relate to that between the doctor and nurse; other areas of conflict were not as significant. There were three incidents of conflict between nurses and relatives, but in the main these were of a minor nature and showed evidence of resolution. If we examine one example of conflict between a community nurse and a general practitioner (GP), we can begin to understand the problem: The GP contacted (nurse) management the following day and complained that nurses did not have the authority to suggest possible omissions to patients and families. This incident concerned a community nurse who felt that recently prescribed pain relief was inadequate, and had discussed this with the patient and family before consulting the GP. From this extract, it is clear that the GP did not feel that the nurse had the right to discuss areas of prescribing that were traditionally the domain of the doctor. The nurse faces conflict here that may mean that she is unable to extend her role in this area of practice because of the power of the doctor. A further example demonstrates the beginnings of reflection on a process of change directly related to conflict with the doctor: … the patient stipulated that she was not to be given any diamorphine of
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any sort … I did not want her to have the (iv) diamorphine as prescribed. Therefore, I explained this to the doctor over the telephone … on his arrival to Coronary Care he went to Margaret and began loudly saying that she could not refuse to go for the tests. I went over and informed the doctor that Margaret had at no point refused to go for the tests, that I had said that I did not want to give her the diamorphine … On reflection the problem could probably have been handled more professionally than a doctor and nurse having a heated discussion at the patient’s bedside. Although based on a misunderstanding, it would seem that this arose because the nurse was ignored by the doctor and she had to assert herself in a way she later felt to be unprofessional. The nurse is recalling the event, describing her feelings and interpreting the actions taken. She has identified the problem with the situation and now needs to reflect further on what solutions could be applied in future. For it to move from mere reflection to an identification of the need for change, the nurse needs to analyse the problem and apply the options to her clinical area. Hugman (1991) highlights the situation of the nurse in the health care hierarchy. He feels that sometimes nurses have difficulty in identifying their state of subordination to others. If we consider the next area, the results of this lack of insight may become more apparent.
B: Complacency Unless nurses accept the limitations of their role and seek to bring about a change of culture within the hierarchical structure, it will be difficult for them to instigate change without agreement from doctors and other professionals with power over them. The culture of care needs to be questioned if there is to be any real and lasting change (Martin 1997). The following short comments from nurses in this study show how they perceive their situation: I don’t believe any real neglect occurred. On reflection I know I did the right thing.
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I didn’t really learn anything new. I think this is her (the patient’s) personality and very little will change. It is possible that some of the situations were satisfactory, but the inability on the part of the nurse to reflect on this may show that he/she has been unable to envisage alternatives to the care practices in place. If this is the case, then change in such a culture is difficult. The process of critical incidents analysis within an educational setting, remote from the practice area may, therefore, be the forum to challenge complacency and identify alternatives to the status quo.
C: Change The process of change identification can be broken down to three stages, related directly to the written reflections. They are: 1. Reflection on practice 2. Reflection in writing 3. Reflection on writing. The third stage is the crucial process if real change is to become possible. The nurse in the example of ‘Margaret’ above has worked through the first two stages, but still needs to undertake stage three to ensure that practice is improved. According to Jarvis (1992), learning is intimately bound up with action. A potential learning situation arises only when action cannot be performed unthinkingly. The nurse’s feelings, expressed in the extract, are clear, but what is not clear is whether learning has taken place which could be applied to a new situation should it arise. Work carried out in the classroom can begin this process, but important ongoing reflective work, perhaps as part of a clinical supervision situation, needs to take place for real change to become a possibility. When attending to feelings, Mezirow (1981) uses the term ‘perspective transformation’. As one becomes critically aware of ritual ways of thinking and acting which limit practice and relationships, a sudden insight into the whole structure or a growing awareness may occur. The change of thinking can be disturbing and should not be underestimated for the individual concerned. The question arises as to whether the teacher should take responsibility for the results of changes and the problems that may arise for
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the nurse. Rich and Parker (1995) remind us that lecturers will not be there when nurses attempt to use the reflective process in practice. The teacher must, therefore, take some responsibility for the consequences of potential conflict around change, and needs to develop links with practice areas to ensure ongoing support and advice is provided. A further example from the research demonstrates how a nurse may feel vulnerable when uncertainty arises: The doctor did not approve of the nurse’s actions and this would be remembered if a similar situation arose in the future, i.e. the nurse would perhaps be reluctant to become an advocate for a patient to prevent a confrontation. The nurse is aware that confrontation with the doctor will undermine her ability to practice effectively. The teacher will need to encourage the nurse to address the critical incident and explore, through reflection, a way forward. It may be that such confrontation will enhance the nurse’s ability to practice effectively and such conflict needs to be addressed rather than avoided. One nurse involved in the research stated that she would not be prepared to advocate for the patient if it would lead to disciplinary action or dismissal. However, many nurses felt able to confront others on matters where they felt that their judgement was in the patients’ interests: I found that I became a stronger person emotionally and felt that I could handle this situation better in the future. From this extract, and through an examination of other similar comments, it is possible to conclude that critical incident analysis by the student has the potential to lead to a process of change though reflection on and application of theory to the clinical area. The act of writing out, reflecting and discussing the critical incident may be enough to identify and perhaps develop changes related to practice for the student involved in the process. The nurse who reflects on a critical incident is likely to begin re-evaluating that experience by a process of validation: a rehearsal of the ideas by thinking through the steps that would have to be taken for change. To work effectively, the process needs to be a personal one in which
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something is learnt about the individual as well as their practice. The outcome of the self in relation to reflection should ideally be a changed conceptual perspective (Boyd & Fales 1983). It is this fundamental process that is the key to change in action, and is dependent on the capacity of the nurse to explore his or her experiences. According to Boud et al. (1985), the success of adopting this approach is affected by the context in which the individual is learning and the level of support, encouragement and facilitative intervention he/she receives. A further example demonstrates this: When the doctor came onto the ward I produced Emily’s medication sheet, pain chart and nursing records. He looked and said she was on maximum dosage without oversedating. I told him what she wanted and explained her fears. I asked him to listen to her cries and look around at the distress it was causing [others]. If there was no cure for Emily, then to keep her pain-free at all times was paramount. The doctor eventually agreed to review the medication. According to Schon (1987), the professional can display their artistry in practice situations. From a cumulative body of personal knowledge, that may include a range of strategies that the nurse can adopt appropriately should the need arise, such professional knowledge needs to be tapped to provide a body of knowledge that is directly relevant to the realities of practice. In this way, the problems related to conflicts can be addressed. Nurses who are able to effectively reflect on critical incidents maybe more able to challenge such value conflicts. This is an essential process if change is to be addressed as part of the reflection of critical incidents. Within a clinical supervision situation or in a classroom seminar, areas of practice development can be explored and interventions planned more easily within this type of supportive setting.
Conclusion Critical incident analysis is explored here as one way of allowing the student to identify
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changes in practice at either a micro or macro level. What remains problematic is whether reflection holds the potential for lasting change (Day 1993). Perhaps all we can say is that the process may hold that potential, but further work is needed. We need to look at development and change from a practice, as well as a theoretical, perspective, perhaps through portfolio work as part of an ongoing education programme. It is the notion of critical reflection within a broader educational framework that needs to be understood. Through the use of critical incident analysis, the processes of change may come about. However, in the case of the diploma modules examined here, the identification of potential areas of change, which is the first stage of that journey, may be all we can see. To develop this process, we should attempt to direct the reflective process within a theoretical perspective in an effort to raise consciousness in the student to problems and solutions that may arise in practice. The theory–practice gap remains an ongoing problem. However, through the use of teaching strategies that attempt to bring the clinical experience of qualified nurses into the classroom setting, it may be possible to undermine the culture which denies that ‘idealistic’ theoretical dimension in favour of a ‘common sense’ approach to critical incidents. Educational programmes need to build strategies into the curriculum which will serve to narrow the theory–practice gap and build on such strategies in an effort to monitor and facilitate real change at the practice level. The potential for practice development is evident, but only if the teacher is willing to become more centrally involved in areas of practice not only as a support resource but also as an advisor and facilitator of good practice. In this way the theory/practice gap can be challenged. References Anderson BE, Nisson SG 1964 Studies in the reliability and validity of the critical incident technique. Journal of Applied Psychology 48(6):398–403 Andrews M, Jones PR 1996 Problem-based learning in an undergraduate nursing programme: a case study. Journal of Advanced Nursing 23(2):357–365 Avis A 1995 Valid arguments? A consideration of the concept of validity in establishing the credibility of research findings. Journal of Advanced Nursing 22:1203–1209
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Boud D, Keogh R, Walker D (eds) 1985 Reflection: turning experience into learning. Kogan Page, London Boyd EM, Fales AW 1983 Reflective learning: key to learning from experience. Journal of Humanistic Psychology 23(2):99–117 Brereton ML 1995 Communication in nursing: the theory-practice relationship. Journal of Advances Nursing 21(2):314–324 Burnard P 1989 Developing critical ability in nurse education. Nurse Education Today 9(4):271–275 Clamp C 1980 Learning through incidents. Nursing Times 76(40):1755–1758 Cormack DFS 1983 Psychiatric nursing described. Churchill Livingstone, Edinburgh Cormack DFS 1996 The research process in nursing (3rd ed.) Blackwell Science, London Cox K, Bergen A, Norman IJ 1993 Exploring consumer views of care provided by the Macmillan Nurse using the critical incident technique. Journal of Advanced Nursing 18:408–415. Dachelet CZ, Wamett MF, Garling EJ, Craig-Kuhn K, Kent N, Kitzman HJ 1981 The critical incident technique applied to the evaluation of the clinical practicum setting. Journal of Nursing Education 20(8):15–31 Day C 1993 Reflection: a necessary but not sufficient condition for professional development British Educational Research Journal 19(1):83–93 Durgahee T 1996 Promoting reflection in post-graduate nursing: a theoretical model Nurse Education Today. 16(6):419–426 Gordon G, Benner P 1984 Guidelines for recording critical incidents. In: Benner PE (ed.) From novice to expert: excellence and power in clinical nursing practice. Addison-Wesley, London, pp229–302. Holly ML 1987 Keeping a personal professional journal. Deakin University Press, Geelong Hugman R 1991 Power in caring professions. Macmillian, Basingstoke and London Jarvis P 1992 Paradoxes of learning: on becoming an individual in society. Jossey-Bass, San Francisco Jordan S 1998 From classroom theory to clinical practice: evaluating the impact of a post-registration course. Nurse Education Today 18(4):293–302 Martin GW 1996 An approach to the facilitation and assessment of critical thinking in nurse education. Nurse Education Today 16(1):3–9 Martin G 1997 Changing the culture of care for dying patients. Professional Nurse 12(7):498–500 Martin GW 1998 Ritual action and its effect on the role of the nurse as advocate. Journal of Advanced Nursing 27:189–194. Mezirow J 1981 A critical theory of adult learning and education. Adult Education 32(1):1–23. Minghella E, Benson MA 1995 Developing reflective practice in mental health nursing through critical incident analysis. Journal of Advanced Nursing 21: 205–213 Norman IJ, Redfern SJ, Tomalin DA, Oliver S 1992 Developing Flanagan’s critical incidents technique to elicit indicators of high and low quality nursing care from patients and their nurses. Journal of Advanced Nursing 17:590–600
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Parker DL, Webb J, D’Souza B 1995 The value of critical incident analysis as an educational tool and its relationship to experiential learning. Nurse Education Today. 15(2):111–116 Reason P, Rowan J (eds) 1981 Human inquiry. John Wiley, Chichester Rich A, Parker DL 1995 Reflection and critical incident analysis: ethical and moral implications of their use within nursing and midwifery education. Journal of Advanced Nursing. 22:1050–1057 Rolfe G 1997 Beyond expertise: theory, practice and the reflexive practitioner. Journal of Clinical Nursing 6(2):93–97
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Rosenal L 1995 Exploring the learner’s world: critical incident methodology. The Journal of Continuing Education in Nursing 26(3):115–118 Schon DA, 1983 The reflective practitioner: how professionals think in action. Basic Books, New York Schon DA 1987 Educating the reflective practitioner. Jossey-Bass, San Francisco Sims A 1976 The critical incident technique in evaluating student performance. International Journal on Nursing Studies. 13:123–130 Von Post I 1996 Exploring ethical dilemmas in perioperative nursing practice through critical incidents. Nursing Ethics 3(3):236–249
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Article
A study of critical incident analysis as a route to the identification of change necessary in clinical practice: addressing the theory–practice gap Geoffrey W. Martin and Gordon Mitchell
This paper examines the analysis of critical incidents to assess to what extent post-registration students are able, through reflection, to identify areas of practice in need of improvement. Discussion centres on the students’ ability to reflect on their writing and link such reflection to ways in which changes can be facilitated. Concerns around the theory–practice gap are central to the research, and the use of this teaching strategy is discussed in relation to issues that arise from identification of the practice gap. Cormack’s (1983, 1996) technique of analysing critical incidents is used to classify the data, and the areas of discussion are grouped around three main headings relevant to the process of change. It is clear from the data that areas in need of change are identified, but it is more difficult to assess to what extent the process directly informs practice. The conclusion highlights the need for further research that examines whether or not change is apparent in the students’ practice area. © 2001 Harcourt Publishers Ltd Geoffrey W. Martin RGN, RMN, BSc(Hons), MA, Principal Lecturer, Gordon Mitchell RMN, Dip N, BSc(Hons), MA, Senior Lecturer, University of Teesside, School of Health, Middlesbrough TSI 3BA, UK. (Requests for offprints to GWM. Tel.: ;44 (0) 1642 384 966) Manuscript accepted: 18 January 2001
Introduction The aim of this paper is to assess to what extent we can say that qualified nurses are able to use reflection to identify changes which are necessary in their practice area. There has been wide discussion in nursing journals of the problems around the existence of the theory–practice gap. It was felt that, through the use of critical incident analysis, theory may become linked more closely to the student’s day-to-day practice. To this end, the nurses were asked to write and discuss critical incidents as part of their project work undertaken during participation in a set of diploma modules. These written papers were
© 2001 Harcourt Publishers Ltd doi:10.1054/nepr.2001.0006, available online at http://www.idealibrary.com on
then analysed to assess: (1) if it was possible to say that the education process facilitated the identification of care practices in need of change, and (2) if strategies for change were part of the critical incident analysis. By looking at the process of change, it was hoped that links between theory and practice could be identified. The nurses were asked to consider incidents from practice, and produce short reflective papers for discussion in classroom workshops. Relevant extracts from their writings have been utilized to demonstrate the concepts under discussion. The papers were only
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selected if they showed evidence of reflection and related such reflection directly to practice. This project can only be seen as a first stage of the research, and further work is necessary which addresses more directly the link between formal education and its role in practice development.
Critical reflection Reflection of critical incidents can be incorporated into a curriculum programme in an effort to make students apply what is learnt on a module to their day-to-day practice. Burnard (1989) reminds us that education suggests an evolving critical process that enables learners to make decisions for themselves through the exercise of rational thought. The approach that uses critical incidents allows the nurse to not only reflect on the event, but also become critical of practice in a safe environment. There have been several studies that have shown positive results when this strategy is employed in nurse education (Durgahee 1996, Martin 1996). The value of logs, academic diaries or journals have also been considered as a way to link education and practice (Holly 1987, Jordan 1998). Clearly there is a wide variation in the implementation and translation of critical incidents into a teaching and learning situation (Minghella & Benson 1995). However, there is a growing interest in the role of writing as learning where qualified nurses use writing as a tool to foster reflection on specific experiences, thus developing new skills, knowledge and attitudes (Parker et al. 1995). The process requires the student to learn through writing the critical incident for analysis, as well as reflecting on that writing. It is felt that reflection, if used correctly and sensitively, can bring about emancipation and empowerment, not only for the nurse but also as a way of influencing the practice of others. This can be seen in terms of nurse/patient interaction, clinical decision making and ethical debate (Rich & Parker 1995). With this process in place there may be the potential for a greater degree of practice development, and moves towards changing care environments. Nurses can consider the theory, which arises out of an examination of the clinical situation, and apply
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and reflect on the theory in an effort to identify changes necessary within their relevant practice settings (Rolfe 1997). The process has to be conducted in a supported environment, but one where it is possible to identify areas of good and bad practice which may then lead to identification of the need for change. The literature around the problem of the theory–practice gap reminds us that we may still be unable to apply learning in the classroom to care practices. Classroom teaching is thought to be idealistic and, as such, it may be that the theory–practice gap is a continuing cause for concern (Brereton 1995). It is useful, therefore, to examine the value of reflection and the problems that can arise from it. Schon (1987) reminds us that a ‘designer-like’ practice cannot be conveyed to practitioners wholly or mainly by classroom teaching. The important concept is being able to get in touch with the actual doing, the actual behaviour, in order to discover what the nurse is really doing. Schon felt that many practitioners were locked into a view of themselves as technical experts, and found nothing in the world of practice to occasion reflection. They have become too skilful at techniques of selective inattention, junk categories and situational control, techniques that they use to preserve the constancy of their knowledge-in-practice. For them, uncertainty is a threat, its admission is a sign of weakness (Schon 1983). Martin (1996) quotes one nurse in his study who argues that an over-reflective orientation could lead to an inability to act quickly when the occasion demands. The nurse valued the ability to act quickly when required over and above the ability to reflect before making decisions.
Method In nursing practice, the critical incident technique has been widely used as a method of data collection, and has been defined as a ‘snapshot’ view of the daily work of nurses (Clamp 1980). Within nursing research, critical incident technique has been defined as a systematic, inductive, open-ended procedure for eliciting verbal or written information from respondents (Norman et al. 1992). An advantage of this technique is that it is a description of actual events, and is therefore
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more concerned with the real, rather than the imagined, world. It is important to note that it is real only so far as the perceptions of the respondents allow. Furthermore, the critical incident is a description of what the respondents think they do. (Cormack 1983, Cormack 1996). The disadvantage is its dependence on the memories of the respondents and their ability to recollect specific incidents. If the critical incident is sensitive to the participant, some participants might alter the facts of the incident, therefore the researcher might not receive an accurate description (Dachelet et al. 1981). From the literature, there appears to be two main methods of collecting data. Norman et al. (1992) and Cox et al. (1993) used interviews as a method to get the respondents to discuss the critical incident. The most popular method advocated by Parker et al. (1995), Rosenal (1995), Rich and Parker (1995), and Von Post (1996) is the use of written critical incidents. This method reveals the experiences of the nurse who writes them (Rosenal 1995). Therefore, reviewing the literature on critical incident technique, the researchers decided to use written critical incidents as participants may find it difficult to verbalize their feelings (Rich & Parker 1995).
Validity and reliability Validity can simply be defined as the instrument’s ability to measure what it supposes to measure (Avis 1995). In criticizing the traditional view of validity, Reason and Rowan (1981) argue that validity within traditional research is concerned with operationalization of the concepts for measurement. Therefore, these traditional notions of validity are about methods and not much about people. However, in reviewing the literature, Avis (1995) suggests that although qualitative research has different threats to accurate representation arising from its interactive methods, the same criteria for reliability and validity can be used to assess qualitative research findings. According to Anderson and Nilsson (1964), the categorization of critical incidents can be regarded as very subjective and difficult. It is possible that different people will categorize
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differently. Cormack (1983) acknowledges this potential problem, and suggests that an independent rater be used to classify the data, so having ‘inter-rater-reliability’. Both researchers, therefore, carried out the categorization independently and reached agreement on the main areas identified for discussion.
Data analyses Analysing the critical incidents involves an interpretative approach with similar contents being coded and categorized (Rosenal 1995). The data analyses involved examining the incident for similarities or common elements. This is what Dachelet et al. (1981) call ‘category formation’. Cormack’s (1983, 1996) technique for analysing critical incidents was used to classify the data. A classification system is constructed as the data is being analysed, rather than before (Cormack 1996). Cormack (1983) recommends that the researcher creates major areas related to common themes. Within each area there will be smaller categories, and within each category there may be a number of sub-categories. When nurses have mentioned a category more than once, the number of such references is recorded. Sims (1976) describes this as the grouping of similar behaviours together and writing specific descriptive statements to cover similarities of the incidents. Thereby the researchers will be able to see linkages to various concepts and themes (Cormack 1996). Following Cormack’s (1983) technique, three main areas were created: 1. Area A: Conflict around the process of change. 2. Area B: Complacency with the status-quo 3. Area C: Change identified as a central issue. Further sub-categories were created from within each of these three main areas. All the critical incidents were given a code and number to facilitate this process.
Sample A total of 75 critical incidents were collected over 1 year from four diploma modules that covered two specialist areas of nursing: care
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of dying patients and care of older people (ENB 931 and ENB 941). This process was based on work done by Gordon and Benner (1984), and the qualified nurses were given an outline of how to produce the work with headings to help them structure their critical incidents. The headings ‘What did you learn as a result of the experience?’ and ‘In a similar situation, how would you handle the incident?’ proved to be particularly useful in this research. In the event, just over half of the papers showed clear evidence of reflection on practice applicable to the research study (N:45).
Results From examination of the data, it was possible to identify the sub-categories (Table 1). There were some feedback sheets that showed evidence of more than one area, and this is why the totals add up to more than the 45 papers examined. Further categories arose out of the sub-categories listed above, and these will be referred to in the discussion when relevant. As can be seen from examination of the results, the largest categories were:
Change related to own practice (16 references) Conflict between nurse and doctor (12 references) Complacency with own practice (10 references).
It may not be surprising that these are the most frequently occurring areas given the nature of the research method. Asking the nurse to reflect on his or her own practice will inevitably lead to consideration of the individual’s actions. The highest frequency Table 1 Totals for each sub-category Area category
Sub-categories
No.
‘A’ Conflict
Between nurse and nurse Between nurse and doctor Between nurse and others With own practice With practice of others With culture of care Related to own practice Related to practice of others Related to culture of care
2 12 3 10 1 2 16 4 5
‘B’ Complacency ‘C’ Change
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is that related to change and, therefore, adds weight to the hypothesis that reflection on critical incident will raise crucial issues of change in practice, not only for oneself but also for others. A total of 25 references to change may encourage the use of this educational approach in that it holds potential for practice development and consideration of the gap between theory and practice.
Discussion of findings A: Conflict It is important to discuss the issue of conflict and power, as there is a direct relationship between conflict and the potential for change. As Martin (1998) states, there are pressures on nurses to accept the status quo, which are directly linked to the power of the doctor to control the action of the nurses. The main area of conflict identified did, in fact, relate to that between the doctor and nurse; other areas of conflict were not as significant. There were three incidents of conflict between nurses and relatives, but in the main these were of a minor nature and showed evidence of resolution. If we examine one example of conflict between a community nurse and a general practitioner (GP), we can begin to understand the problem: The GP contacted (nurse) management the following day and complained that nurses did not have the authority to suggest possible omissions to patients and families. This incident concerned a community nurse who felt that recently prescribed pain relief was inadequate, and had discussed this with the patient and family before consulting the GP. From this extract, it is clear that the GP did not feel that the nurse had the right to discuss areas of prescribing that were traditionally the domain of the doctor. The nurse faces conflict here that may mean that she is unable to extend her role in this area of practice because of the power of the doctor. A further example demonstrates the beginnings of reflection on a process of change directly related to conflict with the doctor: … the patient stipulated that she was not to be given any diamorphine of
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any sort … I did not want her to have the (iv) diamorphine as prescribed. Therefore, I explained this to the doctor over the telephone … on his arrival to Coronary Care he went to Margaret and began loudly saying that she could not refuse to go for the tests. I went over and informed the doctor that Margaret had at no point refused to go for the tests, that I had said that I did not want to give her the diamorphine … On reflection the problem could probably have been handled more professionally than a doctor and nurse having a heated discussion at the patient’s bedside. Although based on a misunderstanding, it would seem that this arose because the nurse was ignored by the doctor and she had to assert herself in a way she later felt to be unprofessional. The nurse is recalling the event, describing her feelings and interpreting the actions taken. She has identified the problem with the situation and now needs to reflect further on what solutions could be applied in future. For it to move from mere reflection to an identification of the need for change, the nurse needs to analyse the problem and apply the options to her clinical area. Hugman (1991) highlights the situation of the nurse in the health care hierarchy. He feels that sometimes nurses have difficulty in identifying their state of subordination to others. If we consider the next area, the results of this lack of insight may become more apparent.
B: Complacency Unless nurses accept the limitations of their role and seek to bring about a change of culture within the hierarchical structure, it will be difficult for them to instigate change without agreement from doctors and other professionals with power over them. The culture of care needs to be questioned if there is to be any real and lasting change (Martin 1997). The following short comments from nurses in this study show how they perceive their situation: I don’t believe any real neglect occurred. On reflection I know I did the right thing.
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I didn’t really learn anything new. I think this is her (the patient’s) personality and very little will change. It is possible that some of the situations were satisfactory, but the inability on the part of the nurse to reflect on this may show that he/she has been unable to envisage alternatives to the care practices in place. If this is the case, then change in such a culture is difficult. The process of critical incidents analysis within an educational setting, remote from the practice area may, therefore, be the forum to challenge complacency and identify alternatives to the status quo.
C: Change The process of change identification can be broken down to three stages, related directly to the written reflections. They are: 1. Reflection on practice 2. Reflection in writing 3. Reflection on writing. The third stage is the crucial process if real change is to become possible. The nurse in the example of ‘Margaret’ above has worked through the first two stages, but still needs to undertake stage three to ensure that practice is improved. According to Jarvis (1992), learning is intimately bound up with action. A potential learning situation arises only when action cannot be performed unthinkingly. The nurse’s feelings, expressed in the extract, are clear, but what is not clear is whether learning has taken place which could be applied to a new situation should it arise. Work carried out in the classroom can begin this process, but important ongoing reflective work, perhaps as part of a clinical supervision situation, needs to take place for real change to become a possibility. When attending to feelings, Mezirow (1981) uses the term ‘perspective transformation’. As one becomes critically aware of ritual ways of thinking and acting which limit practice and relationships, a sudden insight into the whole structure or a growing awareness may occur. The change of thinking can be disturbing and should not be underestimated for the individual concerned. The question arises as to whether the teacher should take responsibility for the results of changes and the problems that may arise for
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the nurse. Rich and Parker (1995) remind us that lecturers will not be there when nurses attempt to use the reflective process in practice. The teacher must, therefore, take some responsibility for the consequences of potential conflict around change, and needs to develop links with practice areas to ensure ongoing support and advice is provided. A further example from the research demonstrates how a nurse may feel vulnerable when uncertainty arises: The doctor did not approve of the nurse’s actions and this would be remembered if a similar situation arose in the future, i.e. the nurse would perhaps be reluctant to become an advocate for a patient to prevent a confrontation. The nurse is aware that confrontation with the doctor will undermine her ability to practice effectively. The teacher will need to encourage the nurse to address the critical incident and explore, through reflection, a way forward. It may be that such confrontation will enhance the nurse’s ability to practice effectively and such conflict needs to be addressed rather than avoided. One nurse involved in the research stated that she would not be prepared to advocate for the patient if it would lead to disciplinary action or dismissal. However, many nurses felt able to confront others on matters where they felt that their judgement was in the patients’ interests: I found that I became a stronger person emotionally and felt that I could handle this situation better in the future. From this extract, and through an examination of other similar comments, it is possible to conclude that critical incident analysis by the student has the potential to lead to a process of change though reflection on and application of theory to the clinical area. The act of writing out, reflecting and discussing the critical incident may be enough to identify and perhaps develop changes related to practice for the student involved in the process. The nurse who reflects on a critical incident is likely to begin re-evaluating that experience by a process of validation: a rehearsal of the ideas by thinking through the steps that would have to be taken for change. To work effectively, the process needs to be a personal one in which
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something is learnt about the individual as well as their practice. The outcome of the self in relation to reflection should ideally be a changed conceptual perspective (Boyd & Fales 1983). It is this fundamental process that is the key to change in action, and is dependent on the capacity of the nurse to explore his or her experiences. According to Boud et al. (1985), the success of adopting this approach is affected by the context in which the individual is learning and the level of support, encouragement and facilitative intervention he/she receives. A further example demonstrates this: When the doctor came onto the ward I produced Emily’s medication sheet, pain chart and nursing records. He looked and said she was on maximum dosage without oversedating. I told him what she wanted and explained her fears. I asked him to listen to her cries and look around at the distress it was causing [others]. If there was no cure for Emily, then to keep her pain-free at all times was paramount. The doctor eventually agreed to review the medication. According to Schon (1987), the professional can display their artistry in practice situations. From a cumulative body of personal knowledge, that may include a range of strategies that the nurse can adopt appropriately should the need arise, such professional knowledge needs to be tapped to provide a body of knowledge that is directly relevant to the realities of practice. In this way, the problems related to conflicts can be addressed. Nurses who are able to effectively reflect on critical incidents maybe more able to challenge such value conflicts. This is an essential process if change is to be addressed as part of the reflection of critical incidents. Within a clinical supervision situation or in a classroom seminar, areas of practice development can be explored and interventions planned more easily within this type of supportive setting.
Conclusion Critical incident analysis is explored here as one way of allowing the student to identify
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changes in practice at either a micro or macro level. What remains problematic is whether reflection holds the potential for lasting change (Day 1993). Perhaps all we can say is that the process may hold that potential, but further work is needed. We need to look at development and change from a practice, as well as a theoretical, perspective, perhaps through portfolio work as part of an ongoing education programme. It is the notion of critical reflection within a broader educational framework that needs to be understood. Through the use of critical incident analysis, the processes of change may come about. However, in the case of the diploma modules examined here, the identification of potential areas of change, which is the first stage of that journey, may be all we can see. To develop this process, we should attempt to direct the reflective process within a theoretical perspective in an effort to raise consciousness in the student to problems and solutions that may arise in practice. The theory–practice gap remains an ongoing problem. However, through the use of teaching strategies that attempt to bring the clinical experience of qualified nurses into the classroom setting, it may be possible to undermine the culture which denies that ‘idealistic’ theoretical dimension in favour of a ‘common sense’ approach to critical incidents. Educational programmes need to build strategies into the curriculum which will serve to narrow the theory–practice gap and build on such strategies in an effort to monitor and facilitate real change at the practice level. The potential for practice development is evident, but only if the teacher is willing to become more centrally involved in areas of practice not only as a support resource but also as an advisor and facilitator of good practice. In this way the theory/practice gap can be challenged. References Anderson BE, Nisson SG 1964 Studies in the reliability and validity of the critical incident technique. Journal of Applied Psychology 48(6):398–403 Andrews M, Jones PR 1996 Problem-based learning in an undergraduate nursing programme: a case study. Journal of Advanced Nursing 23(2):357–365 Avis A 1995 Valid arguments? A consideration of the concept of validity in establishing the credibility of research findings. Journal of Advanced Nursing 22:1203–1209
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Boud D, Keogh R, Walker D (eds) 1985 Reflection: turning experience into learning. Kogan Page, London Boyd EM, Fales AW 1983 Reflective learning: key to learning from experience. Journal of Humanistic Psychology 23(2):99–117 Brereton ML 1995 Communication in nursing: the theory-practice relationship. Journal of Advances Nursing 21(2):314–324 Burnard P 1989 Developing critical ability in nurse education. Nurse Education Today 9(4):271–275 Clamp C 1980 Learning through incidents. Nursing Times 76(40):1755–1758 Cormack DFS 1983 Psychiatric nursing described. Churchill Livingstone, Edinburgh Cormack DFS 1996 The research process in nursing (3rd ed.) Blackwell Science, London Cox K, Bergen A, Norman IJ 1993 Exploring consumer views of care provided by the Macmillan Nurse using the critical incident technique. Journal of Advanced Nursing 18:408–415. Dachelet CZ, Wamett MF, Garling EJ, Craig-Kuhn K, Kent N, Kitzman HJ 1981 The critical incident technique applied to the evaluation of the clinical practicum setting. Journal of Nursing Education 20(8):15–31 Day C 1993 Reflection: a necessary but not sufficient condition for professional development British Educational Research Journal 19(1):83–93 Durgahee T 1996 Promoting reflection in post-graduate nursing: a theoretical model Nurse Education Today. 16(6):419–426 Gordon G, Benner P 1984 Guidelines for recording critical incidents. In: Benner PE (ed.) From novice to expert: excellence and power in clinical nursing practice. Addison-Wesley, London, pp229–302. Holly ML 1987 Keeping a personal professional journal. Deakin University Press, Geelong Hugman R 1991 Power in caring professions. Macmillian, Basingstoke and London Jarvis P 1992 Paradoxes of learning: on becoming an individual in society. Jossey-Bass, San Francisco Jordan S 1998 From classroom theory to clinical practice: evaluating the impact of a post-registration course. Nurse Education Today 18(4):293–302 Martin GW 1996 An approach to the facilitation and assessment of critical thinking in nurse education. Nurse Education Today 16(1):3–9 Martin G 1997 Changing the culture of care for dying patients. Professional Nurse 12(7):498–500 Martin GW 1998 Ritual action and its effect on the role of the nurse as advocate. Journal of Advanced Nursing 27:189–194. Mezirow J 1981 A critical theory of adult learning and education. Adult Education 32(1):1–23. Minghella E, Benson MA 1995 Developing reflective practice in mental health nursing through critical incident analysis. Journal of Advanced Nursing 21: 205–213 Norman IJ, Redfern SJ, Tomalin DA, Oliver S 1992 Developing Flanagan’s critical incidents technique to elicit indicators of high and low quality nursing care from patients and their nurses. Journal of Advanced Nursing 17:590–600
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