Introduction
Human beings learn and improve from experiences, but the process requires reflection and introspection. It is not enough to encounter something to progress; one must consciously think about the actions for personal growth. The Gibbs Model provides a tool to understand the learning process from past incidents (Galli and New, 2022).
The model consists of six steps: description, feeling, evaluation, analysis, conclusion, and action plan (Ingham-Broomfield, 2021). The first three steps focus on what happened during the scenario, while the remaining three focus on improving for similar future situations. In this context, the tool is used to structure my thoughts and develop the capability to get a better outcome based on my involvement with a patient who fell out of bed and sustained life-threatening injuries.
Description
Working as a student nurse for the first time was an intriguing adventure in my nursing practice. A patient who was hospitalized at my workplace was experiencing episodes of confusion and had just received a lung cancer diagnosis. As a precaution, the patient was physically restrained in his bed by the doctor’s instruction. The physical confinement functioned as intended for the first few days after admission to the hospital. Nevertheless, to assess his delirium, a CT scan was required. After the scanning, he was transferred to a new medical floor. Since I assisted another junior nurse in charge, I received the patient on arrival.
When the patient was brought into the new room, I missed the restraining orders that required the patient to be secured to his bed. It was a busy night shift, and neither my colleague nor I had enough time to review this patient’s document. Besides, there was no communication with nurses from the previous level about the directive to restrain the patient. Therefore, the patient was checked at the hourly rounding, as is standard procedure. During the next round of check-ins, the patient was located unconscious on the floor, with substantial bruising around the face and head. When trying to get out of bed, the patient tripped, fell, hit his head, and sustained significant head injuries. He lapsed into a coma and spent several days in the ICU, but eventually recovered and was returned to his ward.
Feelings
It was a bustling ward with only two night-shift staff in charge. Given the workload, I was only two hours into the shift, but it was a long stretch. The handover by the radiology transporter was routine since I had familiarized myself with the standard transfer protocol. A brief overview of the sheet also appeared normal; therefore, I presumed this was a regular admission like any other. Since the patient was deep asleep, no indicator or major incident was encountered while admitting him into his new room. The next round was approaching, so I assisted my colleague with the check-ins. Unfortunately, the patient’s restraint requests were ignored, resulting in the accident.
A breakdown in communication between the receiving floor nurse, the radiology transporter, and the preceding floor exacerbated the event. How the process was carried out breached NMC rule 8.6, which requires medical workers to “share information to identify and reduce risk” (Nursing and Midwifery Council, 2018). Although everyone concerned admitted to making mistakes without assigning blame, I felt guilty for the irresponsibility. The supervisor delegated the verification of reallocations because I had become accustomed to the processes. As a result, the charge nurse and the radiology technician were at ease with how I handled the matter. After the incident, everyone was disappointed for failing to communicate appropriately and felt guilty about the patient’s condition.
Evaluation
The days following the transfer of the patient to the ICU were intense and filled with anxiety, mainly for the junior nurse in charge, myself, and the radiology transporter. According to research, such ethical conflicts in clinical practice create a significant degree of anxiety and moral stress (Jiménez-Herrera et al., 2020). Therefore, I believe the others experienced anxiety and moral stress as well because the situation arose as a direct or indirect action of staff from the previous. The coincidental arrival of the patients at the start of the next rounding was unfortunate because it might have contributed to the lack of concentration on the minor details of the transfer. Accordingly, the patient would be checked on during the next round, which prolonged the duration in which the accident could be discovered.
However, once the patient was found unconscious, the level of coordination, assessment, and transfer to the ICU was executed efficiently. The quick reaction by the floor staff and physicians played a critical role in saving the patient’s life. The day following the incident was crucial in my career because the staff were supportive and kind despite the error. Moreover, the error reporting and disclosure process overseen by the immediate nurse practitioner in charge was professional and encouraging.
According to research, an organizational culture that prioritizes safety above blame generally dispels care providers’ fear of lawsuits and their self-perception of ineptitude (Indriani, Kusumapradja, and Anindita, 2022; Brborović et al., 2019). Despite the best efforts by my superiors and colleagues to dispel the situation, I experienced the psychological trauma of living with the consequences if the outcome was worse. Finally, disclosing the error to the family and the patient went well without a lawsuit after the full recovery.
Analysis
Accidentally harming a patient by overlooking some instructions or by communication mistake is serious because it contradicts the nursing objective of caring for and assisting the sick. Human error is a fact of life, and faults attributed to lack of or miscommunication are common in healthcare practice (Vaismoradi et al., 2020; Brennan and Oeppen, 2022; Bindra, Sameera, and Rath, 2021). The incident is critical to reflect on since I realized life-threatening situations result from too much familiarity with a process. From experience, it is easier to overlook some instructions when some functions become too routine because the mind becomes conditioned to predict a familiar pattern. Lack of experience with patients undergoing delirium combined with work stress and a series of unfortunate events also contributed to the incident.
Furthermore, poor hand-off communication was another major flaw that contributed to the accident. Many studies show that miscommunication of crucial information regarding a patient’s symptoms or condition and inadequate patient documentation are practitioners’ most frequent communication breakdowns (Street et al., 2020; Kim, Lee, and Kim, 2020). Handover is undoubtedly the most important and regular communication process between clinicians in patient care. Since the incident happened during handing over and was linked to miscommunication, it is critical to evaluate how nurses follow procedures. Mainly, these breakdowns in information relay occur due to the urgent, changing, and unpredictable nature of care provision (Raeisi, Rarani, and Soltani, 2019; Pun, 2021; Chien et al., 2022). My concern is that some errors can result in being too familiar with the process, so one becomes prone to overlook the minor details.
Conclusions
The first causality of miscommunication or overlooking the order sheet is the patient, and the second is the responsible nurse who must live with its consequences. One will probably go back to that situation repeatedly, beating oneself up for making mistakes and going through doubts and feelings of guilt (Montgomery et al., 2020). Sleeping disorder, hallucinations, and reputational damage worries are among the symptoms of post-traumatic stress disorder that can arise from unresolved psychological trauma following the incident.
I noticed that inadequate clinical handover can quickly occur when staff, departments, or facilities cannot communicate effectively. Factors that can cause miscommunication during handover include an insufficient preliminary review of records or procedures, poor handwriting, and a lack of open communication between staff or providers (Raeisi, Rarani, and Soltani, 2019). For instance, skipping some details when they are not eligible is more manageable, and the workload is high. Every nurse should seek clarification, even for minor information, regardless of whether they are working under pressure.
Action Plan
Personal responsibility and accountability are critical in patient safety, even for the most straightforward task. After carefully reviewing the incident, I resolved to read through all the information in an order sheet. As an extra precaution, I will verify with the nurses previously in custody of the patient to establish underlying medical status before transferring. Concerning NMC code 8.5, it will be essential to work with colleagues to preserve the safety of the patients (Nursing and Midwifery Council, 2018).
Second, optimizing communication technology, such as patient record systems administration, ensures dependable and frequent access for patients and healthcare providers. I would quickly check up on critical information about the patient if they were available via a health communication technology without straining about handwriting or retrieving vital information. Finally, errors can occur regardless of the level of expertise. Therefore, the optimal solution should be pursued in case of a fatal accident, such as elevating the situation as quickly as possible. Further actions include owning up to the mistake, providing accurate accounts of the incident, and seeking help from colleagues whenever you need counseling.
Reference List
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