- Email: [email protected]
Toward a Reflective Practice: Using Critical Incidents
Teaching and Learning in Nursing (2013) 8, 33–35
EDUCATE, EXCITE, ENGAGE www.jtln.org
Toward a Reflective Practice: Using Critical Incidents Rojann R. Alpers PhD, RN⁎, Kay Jarrell MS, RN, Roxena Wotring MS, RN Arizona State University College of Nursing and Health Innovation Phoenix, AZ 85004, USA
Nursing's lexicon includes a number of significant and important words in describing who we are and what we know and do; words such as genuineness (Rosendahl, 1973), bearing witness (Naef, 2006), stewardship (Murphy, 2009), and reflection (Benner, 1984), but how can we inculcate these action words into our student's professional practice? As master teachers, we all use a variety of strategies to draw these reflections (critical thinking) out of our students and their clinical experiences. Discussions and seminars are valuable tools but require more on-the-spot thinking that tends to lack real depth and thoughtfulness. Journals can also be constructive but often regress to a recounting of a day's events and superficial musings. For me, a helpful assignment, one that has generated significant reflection from students, is having them write a guided critical incident from their past of current clinical encounters (Benner, 1984; Gordon, 2000). Before the assignment is made, a general overview of the reflective process is discussed, and readings are assigned. I have found both Rodriquez (1988), “Writing an Exemplar (Clinical Narrative)” (https://nursing.ynhh.org/ Portals/0/RCAP_Writing%20an%20Exemplar.pdf), and Somerville and Keeling (2004), “A Practical Approach to Promote a Reflective Practice Within Nursing” (http://www. nursingtimes.net/nursing-practice/clinical-zones/educators/ a-practical-approach-to-promote-reflective-practice-withinnursing/204502.article), to be helpful to students in preparing to select and write their own critical incidents. In general, when I mention a writing assignment to students, their anxiety becomes palpable, their complexions
⁎ Corresponding author. E-mail address: [email protected] (R.R. Alpers).
pale, and a visible tremor radiates across the classroom; that is until I tell them that it can only be two pages long and that they only have to respond to three questions! It is the perfect set up for such an assignment; three questions and two pages seem eminently possible, and it “soothes a savage breast” (Congreve, 1697) reaction to the word writing. The critical incident assignment asks students to think about a patient care event, incident, encounter, or experience they have had this semester or in a past semester in nursing school. The patient care event must be one that elicited an emotion in the nursing student such as fear, anger, joy, relief, and others. They are then to describe it and provide essential context and why this particular event or encounter evoked such emotion. Next, they are to think about what they learned from the situation. The format used (the three questions) include the following: WHAT? A brief description and context of the nursing encounter/event. SO WHAT? How has this experience informed/transformed/changed your nursing practice? NOW WHAT? What are the specific lessons learned from this patient care encounter, and what would the student do differently if the situation could be repeated. This section of the assignment also requires the student to read and reference a nursing journal article that addresses one of the lessons learned or supports an alternative intervention or approach to the situation (I always make it clear that nursing journals are those publications that are peer refereed). As always, my writing assignments have the information tag that this is a scholarly article and that it is to represent their most elegant and eloquent professional language and writing style. In an effort to help get students started on their critical incident (and to give them an example), I shared a critical incident of my own:
1557-3087/$ – see front matter © 2013 Published by Elsevier Inc. on behalf of National Organization for Associate Degree Nursing. http://dx.doi.org/10.1016/j.teln.2012.10.002
34
Educate, Excite, Engage
1. Tiffany's Story It's early December, and the pediatric unit is already decorated for the upcoming holidays. Even though this is a tertiary care hospital and only the sickest of the sick children come here, you can still sense the joy and anticipation of the holidays from the children, their parents, and the nursing staff. Every so often you can hear the sounds of Christmas music drifting in from one of the patient's rooms, and if you listen closely, you may hear some of the parents and staff humming along. Tiffany is a 5-year-old brown hair, blue-eyed beauty. She is tall for her age but very svelte; she is a ballerina in the making. In fact, she has danced with the touring ballet company the last 2 years in their production of the Nutcracker Suite. She has been in the hospital since midNovember and has deteriorated rapidly since diagnosis. Tiffany has a Wilm's tumor, stage four; chemotherapy has done little except create nausea and hair loss… Tiffany is going to die…very soon. Last week, when I and my nursing students were on site, Tiffany was still visiting with her family, finger dancing across her bed linens to the Dance of the Sugar Plum Fairy (her favorite piece of music) and giggled at her daddy's silly faces…today she is lying still, very still, no longer talking, certainly no giggles are heard, and worse yet, she is getting blood drawn and she not moving, pulling away, crying, or asking her parents to ‘make it stop.’ She has withdrawn completely, and nothing seems to engage her. Her parent sit stricken at her bedside, faces are flushed, and eyes filled with tears, nothing they do, coaxing, cajoling, promising anything and everything, seems to bring their child back from her isolation. The nursing students are trying their hardest to reconnect with Tiffany…their best hugs and tickles, funny faces, and sounds…it all seems to no avail. My students have a growing sense of futility and sadness. We step out into the hall and have a candid conversation about the situation, its ultimate and rapidly approaching outcome and what we can do for this family to try and make these last few days together a happier and more peace-filled time. We all agreed we will do whatever it takes. That's when it happened, a clear, precise, luminous…and dare I say it…brilliant idea occurs. We rush to the linen cart and remove draw sheets, we scurry to the utility room for tape, gauze, and safety pins and ‘…then what to my wondering eyes should appear…’ but the most extraordinary line of pirouette-ing sugar-plum fairies imaginable! We ran to Tiffany…actually, we 'pas de deux'ed, to her room, turned on her Nutcracker Suite cassette, and proceeded to do our interpretation of the Dance of the Sugar Plum Fairy. The staff and parents looking in from the door were aghast, Tiffany's parents speechless and astonished, but most importantly, Tiffany was amused! At first, there was a half smile that bloomed in to a full-fledged grin, and then her soft giggle grew to a guffaw. We all felt a sense of satisfaction and knew, at least today, we had made a difference. Tiffany died the following evening, but her parents made a point of letting us know that her last day was filled with
laughter and singing together, and they were able to say their goodbyes. She died in her mother's arms listening to the Nutcracker Suite.
I think, providing a personal critical incident opens communication with the students and also invites them to share some of their more intimate experiences and emotions. Over the last few semesters, I have received some of the most inspiring, courageous, passionate, and gut-wrenching tales from the field. It is not unusual for me to be in tears when I read these extraordinary stories and absolutely beam with pride and confidence for the future of the nursing profession. It is also essential to share these reactions with students—if they have taken a genuine risk in sharing these experiences and lessons, we must, in return, share our reactions and delight. Finally, the following rubric is used to reinforce the assignment criteria and to evaluate the final product.
2. Assignment Criteria and Evaluation Rubric Table 1
Critical Incident and Final Paper Criteria
Critical incident selection
Selected an important incident (1)
Journal selection
Used at least 1 refereed/ scholarly nursing article (2) Complete with appropriate context of incident (2) Complete Adequate and thorough description description (1) (2)
Description of critical incident
Description of informed/ transformed change in practice Description of lessons learned and their use in own practice Writing style
Complete and thorough description using firstpersonvoice (3) Correct grammar and spelling, elegant and eloquent progression/ presentation of ideas (3)
Did not select an important incident (0) Used a nonrefereed/ scholarly nursing article (1) Adequate context of incident (2)
Adequate description using firstperson voice (2) Correct grammar and spelling, logical progression/ presentation of ideas (2)
–
–
Used no articles (0)
–
Superficial context of incident (1)
–
Superficial description (1)
Absent description (0)
Superficial description using firstperson voice (1)
Absent description/ failure to use firstperson voice (0) Multiple Minor grammatical/ grammatical/ spelling spelling errors and/ errors and/ or inconsistent or difficult to follow progression/ progression/ presentation presentation of ideas of ideas (1) (0)
Educate, Excite, Engage
35
Table 1 (continued) American Psychological Association (APA) format
Consistent and accurate use of APA format (3)
Total points
–
Inconsistent and/or inaccurate use of APA format (0) –
–
–
–
–
References Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Congreve, W. (1697). The mourning bride. Retrieved October 8, 2012 from http://www.britannica.com/EBchecked/topic/395036/The-MourningBride.
Gordon, J. M. (2000). Congruency in defining critical thinking by nurse educators and non-nurse educators. The Journal of Nursing Education, 39, 349−351. Murphy, N. S. (2009). Nurse leaders as stewards: The beginning of change. Retrieved October 1, 2020 from The Open Journal, 3, 39−44. http://www.benthamscience.com/open/tonursj/articles/V003/ 39TONURSJ.pdf. Naef, R. (2006). Bearing witness: A moral way of engaging in the nurse– person relationship. Nursing Philosophy, 7(3), 146−156. Rodriquez, L. A. (1988). Writing an exemplar: Clinical narrative. Retrieved October 1, 2012 from https://nursing.ynhh.org/Portals/0/ RCAP_Writing%20an%20Exemplar.pdf. Rosendahl, P. L. (1973). Effectiveness of empathy, non-possessive warmth, and genuineness of self-actualization of nursing students. Nursing Research, 22(3), 253−257. Somerville, D., & Keeling, J. (2004). A practical approach to promote reflective practice within nursing. Nursing times.net. Retrieved October 3, 2012 from http://www.nursingtimes.net/nursing-practice/clinicalzones/educators/a-practical-approach-to-promote-reflective-practicewithin-nursing/204502.article.
EDUCATE, EXCITE, ENGAGE www.jtln.org
Toward a Reflective Practice: Using Critical Incidents Rojann R. Alpers PhD, RN⁎, Kay Jarrell MS, RN, Roxena Wotring MS, RN Arizona State University College of Nursing and Health Innovation Phoenix, AZ 85004, USA
Nursing's lexicon includes a number of significant and important words in describing who we are and what we know and do; words such as genuineness (Rosendahl, 1973), bearing witness (Naef, 2006), stewardship (Murphy, 2009), and reflection (Benner, 1984), but how can we inculcate these action words into our student's professional practice? As master teachers, we all use a variety of strategies to draw these reflections (critical thinking) out of our students and their clinical experiences. Discussions and seminars are valuable tools but require more on-the-spot thinking that tends to lack real depth and thoughtfulness. Journals can also be constructive but often regress to a recounting of a day's events and superficial musings. For me, a helpful assignment, one that has generated significant reflection from students, is having them write a guided critical incident from their past of current clinical encounters (Benner, 1984; Gordon, 2000). Before the assignment is made, a general overview of the reflective process is discussed, and readings are assigned. I have found both Rodriquez (1988), “Writing an Exemplar (Clinical Narrative)” (https://nursing.ynhh.org/ Portals/0/RCAP_Writing%20an%20Exemplar.pdf), and Somerville and Keeling (2004), “A Practical Approach to Promote a Reflective Practice Within Nursing” (http://www. nursingtimes.net/nursing-practice/clinical-zones/educators/ a-practical-approach-to-promote-reflective-practice-withinnursing/204502.article), to be helpful to students in preparing to select and write their own critical incidents. In general, when I mention a writing assignment to students, their anxiety becomes palpable, their complexions
⁎ Corresponding author. E-mail address: [email protected] (R.R. Alpers).
pale, and a visible tremor radiates across the classroom; that is until I tell them that it can only be two pages long and that they only have to respond to three questions! It is the perfect set up for such an assignment; three questions and two pages seem eminently possible, and it “soothes a savage breast” (Congreve, 1697) reaction to the word writing. The critical incident assignment asks students to think about a patient care event, incident, encounter, or experience they have had this semester or in a past semester in nursing school. The patient care event must be one that elicited an emotion in the nursing student such as fear, anger, joy, relief, and others. They are then to describe it and provide essential context and why this particular event or encounter evoked such emotion. Next, they are to think about what they learned from the situation. The format used (the three questions) include the following: WHAT? A brief description and context of the nursing encounter/event. SO WHAT? How has this experience informed/transformed/changed your nursing practice? NOW WHAT? What are the specific lessons learned from this patient care encounter, and what would the student do differently if the situation could be repeated. This section of the assignment also requires the student to read and reference a nursing journal article that addresses one of the lessons learned or supports an alternative intervention or approach to the situation (I always make it clear that nursing journals are those publications that are peer refereed). As always, my writing assignments have the information tag that this is a scholarly article and that it is to represent their most elegant and eloquent professional language and writing style. In an effort to help get students started on their critical incident (and to give them an example), I shared a critical incident of my own:
1557-3087/$ – see front matter © 2013 Published by Elsevier Inc. on behalf of National Organization for Associate Degree Nursing. http://dx.doi.org/10.1016/j.teln.2012.10.002
34
Educate, Excite, Engage
1. Tiffany's Story It's early December, and the pediatric unit is already decorated for the upcoming holidays. Even though this is a tertiary care hospital and only the sickest of the sick children come here, you can still sense the joy and anticipation of the holidays from the children, their parents, and the nursing staff. Every so often you can hear the sounds of Christmas music drifting in from one of the patient's rooms, and if you listen closely, you may hear some of the parents and staff humming along. Tiffany is a 5-year-old brown hair, blue-eyed beauty. She is tall for her age but very svelte; she is a ballerina in the making. In fact, she has danced with the touring ballet company the last 2 years in their production of the Nutcracker Suite. She has been in the hospital since midNovember and has deteriorated rapidly since diagnosis. Tiffany has a Wilm's tumor, stage four; chemotherapy has done little except create nausea and hair loss… Tiffany is going to die…very soon. Last week, when I and my nursing students were on site, Tiffany was still visiting with her family, finger dancing across her bed linens to the Dance of the Sugar Plum Fairy (her favorite piece of music) and giggled at her daddy's silly faces…today she is lying still, very still, no longer talking, certainly no giggles are heard, and worse yet, she is getting blood drawn and she not moving, pulling away, crying, or asking her parents to ‘make it stop.’ She has withdrawn completely, and nothing seems to engage her. Her parent sit stricken at her bedside, faces are flushed, and eyes filled with tears, nothing they do, coaxing, cajoling, promising anything and everything, seems to bring their child back from her isolation. The nursing students are trying their hardest to reconnect with Tiffany…their best hugs and tickles, funny faces, and sounds…it all seems to no avail. My students have a growing sense of futility and sadness. We step out into the hall and have a candid conversation about the situation, its ultimate and rapidly approaching outcome and what we can do for this family to try and make these last few days together a happier and more peace-filled time. We all agreed we will do whatever it takes. That's when it happened, a clear, precise, luminous…and dare I say it…brilliant idea occurs. We rush to the linen cart and remove draw sheets, we scurry to the utility room for tape, gauze, and safety pins and ‘…then what to my wondering eyes should appear…’ but the most extraordinary line of pirouette-ing sugar-plum fairies imaginable! We ran to Tiffany…actually, we 'pas de deux'ed, to her room, turned on her Nutcracker Suite cassette, and proceeded to do our interpretation of the Dance of the Sugar Plum Fairy. The staff and parents looking in from the door were aghast, Tiffany's parents speechless and astonished, but most importantly, Tiffany was amused! At first, there was a half smile that bloomed in to a full-fledged grin, and then her soft giggle grew to a guffaw. We all felt a sense of satisfaction and knew, at least today, we had made a difference. Tiffany died the following evening, but her parents made a point of letting us know that her last day was filled with
laughter and singing together, and they were able to say their goodbyes. She died in her mother's arms listening to the Nutcracker Suite.
I think, providing a personal critical incident opens communication with the students and also invites them to share some of their more intimate experiences and emotions. Over the last few semesters, I have received some of the most inspiring, courageous, passionate, and gut-wrenching tales from the field. It is not unusual for me to be in tears when I read these extraordinary stories and absolutely beam with pride and confidence for the future of the nursing profession. It is also essential to share these reactions with students—if they have taken a genuine risk in sharing these experiences and lessons, we must, in return, share our reactions and delight. Finally, the following rubric is used to reinforce the assignment criteria and to evaluate the final product.
2. Assignment Criteria and Evaluation Rubric Table 1
Critical Incident and Final Paper Criteria
Critical incident selection
Selected an important incident (1)
Journal selection
Used at least 1 refereed/ scholarly nursing article (2) Complete with appropriate context of incident (2) Complete Adequate and thorough description description (1) (2)
Description of critical incident
Description of informed/ transformed change in practice Description of lessons learned and their use in own practice Writing style
Complete and thorough description using firstpersonvoice (3) Correct grammar and spelling, elegant and eloquent progression/ presentation of ideas (3)
Did not select an important incident (0) Used a nonrefereed/ scholarly nursing article (1) Adequate context of incident (2)
Adequate description using firstperson voice (2) Correct grammar and spelling, logical progression/ presentation of ideas (2)
–
–
Used no articles (0)
–
Superficial context of incident (1)
–
Superficial description (1)
Absent description (0)
Superficial description using firstperson voice (1)
Absent description/ failure to use firstperson voice (0) Multiple Minor grammatical/ grammatical/ spelling spelling errors and/ errors and/ or inconsistent or difficult to follow progression/ progression/ presentation presentation of ideas of ideas (1) (0)
Educate, Excite, Engage
35
Table 1 (continued) American Psychological Association (APA) format
Consistent and accurate use of APA format (3)
Total points
–
Inconsistent and/or inaccurate use of APA format (0) –
–
–
–
–
References Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Congreve, W. (1697). The mourning bride. Retrieved October 8, 2012 from http://www.britannica.com/EBchecked/topic/395036/The-MourningBride.
Gordon, J. M. (2000). Congruency in defining critical thinking by nurse educators and non-nurse educators. The Journal of Nursing Education, 39, 349−351. Murphy, N. S. (2009). Nurse leaders as stewards: The beginning of change. Retrieved October 1, 2020 from The Open Journal, 3, 39−44. http://www.benthamscience.com/open/tonursj/articles/V003/ 39TONURSJ.pdf. Naef, R. (2006). Bearing witness: A moral way of engaging in the nurse– person relationship. Nursing Philosophy, 7(3), 146−156. Rodriquez, L. A. (1988). Writing an exemplar: Clinical narrative. Retrieved October 1, 2012 from https://nursing.ynhh.org/Portals/0/ RCAP_Writing%20an%20Exemplar.pdf. Rosendahl, P. L. (1973). Effectiveness of empathy, non-possessive warmth, and genuineness of self-actualization of nursing students. Nursing Research, 22(3), 253−257. Somerville, D., & Keeling, J. (2004). A practical approach to promote reflective practice within nursing. Nursing times.net. Retrieved October 3, 2012 from http://www.nursingtimes.net/nursing-practice/clinicalzones/educators/a-practical-approach-to-promote-reflective-practicewithin-nursing/204502.article.