* Tel.: þ353E-mail addr

1 The writer ithe Neonatal UDublin 8, Irelan

1355-1841/$ -doi:10.1016/j.

Journal of Neonatal Nursing (2008) 14, 87e93

www.elsevier.com/jneo

The use of reflective practice on criticalincidents, in a neonatal setting,to enhance nursing practice

Alice O’Connor*,1

NICU, Womens and Infants University Hospital, Cork Street, Dublin 8, Ireland

Available online 7 March 2008

KEYWORDSPortfolios;Reflection;Personal development;Nursing;Neonates

1 8220395.ess: aliceoconnor3@eirs currently working as anit of the Coombe Wod.

see front matter ª 200jnn.2007.12.014

Abstract Portfolio development and the use of reflection as a tool to promote thedevelopment of critical thinking have become essential requirements in currentnursing education. In this article the writer has reflected on two critical incidentswhich occurred in a neonatal unit. The writer demonstrates how reflection has en-abled her to access, understand and learn, through a lived experience, and how thishelped to enhance the writer’s area of practice.ª 2008 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.

Introduction

A portfolio is a written document that presentsevidence of personal and professional growth byproviding critical analysis of its contents (McMullanet al., 2003). Having a portfolio is also useful forcareer planning and highlights transferable skills(Joyce, 2005). However, one of the strongest influ-ences for creating a portfolio has arisen from theneed for increasing professional autonomy andaccountability (An Bord Altranais, 2000). In thisportfolio I will begin by providing an overview of

com.netClinical Nurse Manager inmens Hospital, Cork St.,

8 Neonatal Nurses Association

reflection and mention the models used to guidethis process. I will then analyse two critical inci-dents and how they affected my practice. I willconclude by summarising my thoughts andreflections in developing this portfolio.

Reflection

Reflection is a tool to promote the development ofcritical thinking, which is essential to the intellectualelements of professional education and clinicalexpertise (Gustafsson and Fagerberg, 2004). How-ever, it might also challenge personal values andtaken-for-grantedviews, therebygenerating conflictand anxiety within the individual (Teekman, 2000).Engaging in critical reflection may lead to self-doubt,feelings of isolation and insecurity (Nicholl and

. Published by Elsevier Ltd. All rights reserved.

88 A. O’Connor

Huggins, 2004). Reflection enables the practitionerto explore, understand and develop meaning andhighlights contradictions between nursing theoryand practice (O’Callaghan, 2005). However, few em-pirical studies on reflective practice have been doneto evaluate its effectiveness in changing nursingpractice (Peden-McAlpine et al., 2005). This lack ofevaluation seems atoddswithcurrent thinking onev-idence-based practice and the need to provide em-pirical evidence for interventions (Paget, 2001).

Among the contemporary writings on reflectivepractice, the most significant has been Schon’swork (1983). In the nursing literature almost everypublication refers to Schon, an indication that hisconcepts are widely used today (Teekman, 2000).Schon (1983) distinguished between 3 differenttypes of reflection; knowing-in-action, reflection-in-action and reflection-on-action. Reflection-in-action occurs when the person reflects onbehaviour as it happens so as to optimise their im-mediately following actions. Reflection-on-actionoccurs after the event, allowing the practitionerto review, describe, analyse and evaluate the situ-ation, so as to gain insights for improved practice inthe future. However reflection-on action relies onmemory, which may lead to uncertainties in theaccuracy and recall of events, hindsight bias andanxiety (Andrews et al., 1998).

Johns (1995a) suggests reflective practice re-quires both guidance and structure. Guidance inthe form of challenge and support. Structure inthe form of questions, which help practitioners toexplore the meaning of the experience. A suitablemodel and framework can be essential tools, aswhat passes for reflection is often not reflection.Contemplating an experience or event is not alwayspurposeful and does not necessarily lead to newways of thinking or behaving in practice, which isthe crux of effective reflective activity (Driscolland Teh, 2001). Platzer et al. (2000) identifiedthat learning through reflection is more potent ifthere is an understanding of frameworks that en-courage a structural process to guide the act ofreflection. Models of reflection offer probing ques-tions that stimulate thinking, feelings, behavioursand theories that may implicitly guide thinkingand doing. There are many theoretical models ofreflection to choose from such as The Reflective Cy-cle by Gibbs (1988), Cycle of Experimental Learningby Kolb (1984) and Model for Structured Reflectionby Johns (1995a) to name but a few. The emphasison models of reflection seem to be contrary toadvice from Heath (1998), who suggests that usinga model may produce uniformity and suppress crea-tivity and thinking. Reflective models have not beenadequately tested and more research is needed.

Critical incident 1

I have chosen to use Gibbs Reflective Model (1988)as a guideline as it is straightforward and encour-ages a clear description of the situation. It alsoidentifies the various stages people pass throughwhen learning from experience. I chose this emo-tional incident as I found it devastating at the timeand, although I have worked in neonatal medicinefor a long time, I never witnessed the suddendemise of a long stay baby just prior to discharge.Up to then I felt confident in my knowledge andexpertise but, following this incident, I questionedmy clinical skills and education and training com-petencies, which are essential requirements formy clinical practice. Competence and learningoutcomes are seen to be closely related concepts.Competence is concerned with knowledge, skillsand personal qualities that are required for par-ticular employment purposes (Huggins, 2004).

Description of incident

In the interest of confidentiality, I have usedpseudonyms when referring to the baby, theparents and nursing staff. John was born at26 weeks gestation to a primigravida lady calledMary. He was born by emergency caesarean sec-tion because of antepartum haemorrhage. Unfor-tunately, John did not receive the benefit ofantenatal steroids to improve lung maturity as ittakes 24e48 h to be effective (Peaceman et al.,2005). His birth weight was 600 g and his conditionwas poor at birth but he survived. He developedchronic lung disease (CLD) and was ventilator de-pendent for 12 weeks. John was then commencedon nasal continuous positive airway pressure(nCPAP) for another 8 weeks before he eventuallyweaned to oxygen via nasal prongs at 46 weeks ofage. It was decided that John was to go home onoxygen and was to be discharged the followingweek. His parents were very involved and compe-tent in his care and were comfortable, if appre-hensive, in taking him home on oxygen. They haddeveloped a good rapport with the staff due tothe length of John’s stay in the unit.

On the night of the incident I was looking afterJohn and 3 other low dependency babies. Theparents visited at 2100 hours (h) and bathed andfed John. He was active and alert and interactingwell with his parents. They left at 2300 h andJohn was asleep with his oxygen saturations levelsreading 92e94, which is acceptable for a baby withCLD (Kotecha, 2002). I had a busy but uneventfulnight until 0600 h. At 0500 h I fed John and puthim back to sleep. His vital signs were stable at

Reflective practice on critical incidents 89

that time and, apart from a few desaturationsduring the feed, he handled very well. At 0600 hhis saturation monitor alarmed and I saw that hisoxygen saturations levels had dropped to 60 andhis heart rate was 70 beats per minute (bpm). Iquickly went to his bedside and saw that his colourwas dusky. I checked that his nasal prongs were inplace and attached to the oxygen supply. Johnthen became apnoeic and his heart rate was unrec-ordable. I quickly initiated resuscitation and calledfor assistance, which came immediately. We trans-ferred John to the infant resuscitaire where theregistrar quickly intubated him and a full resusci-tation, using the Neonatal Resuscitation Protocolguidelines, was conducted (AAP, 2006). At thisstage I was going through the motions of assistingwith the resuscitation but felt I was not actually in-volved with it. Unfortunately, John did not surviveand was pronounced dead at 0630 h.

The consultant, who was called in from home,initiated a short debriefing session. All staff in-volved in the incident had an opportunity todiscuss their feelings and evaluate what hadhappened. He agreed that the correct action hadtaken place and thanked everyone involved. Hethen phoned the parents and broke the bad news.They arrived an hour later and were devastated. Itried to comfort them and answer their questionsto the best of my ability but, because of the way Iwas feeling myself, I felt I did not give them thesupport they needed at this tragic time.

Feelings (what was I thinking and feeling)

My immediate feelings following this incidentwere guilt and remorse. I started to question mycompetency in clinical expertise in relation towhat I had missed. Questions of what I did wrongor what I had missed to allow a ‘well’ baby tocollapse and die in my care was foremost in mythoughts. I also contemplated the fact that,because John was in the unit for so long andready to go home, I did not expect any problemsand, therefore, may have missed something bytaking habitual care of him. Professional practicecomprised largely of routine and habitual action isnon-reflective. The routine practitioner acceptsthe realities of daily practice and concentrates ondiscovering the most effective way of solvingproblems, often missing opportunities for reflec-tion (Williams, 2001). Andrews et al. (1998) de-bate the extent to which reflection derives frompractice, due to the repetitiveness of certain nurs-ing skills which they claim are undertaken as a re-sult of habit, rather than a conscious analysis ofaction. The situations that professional nurses

find themselves in are usually so complex thatthe notion of routine practice should be pre-cluded. To engage in competent practice, nursesneed to consider the contextual variables ineach interaction, mindful that each encounter isunique and that there is usually more than onedesired outcome (Williams, 2001).

I also felt disbelief and grief that the outcomewas death. I was surprised at my level of caring as Ihave been around death and dying for so long.However, John was in the unit for a long time and Ihad become attached to him and his parents.Nursing, in the pursuit of technical knowledge,has tended to denigrate the value of caring skills.In fact, as nurses have become more experiencedthey have tended to give away the more caringaspects of their work to more junior or unqualifiedstaff. Caring should be central to nursing practice(Johns, 1996). After all we are human beings firstand nurses second.

I also felt powerless which has been closelylinked to suffering. Personalization with the familywas probably a contributing factor to my suffering.Suffering has been identified as a factor that candiminish autonomy and remove the person’s abilityto fulfil goals and best interests (Jezuit, 2002).Literature has identified 3 phases of suffering;the mute phase, which occurs when, an event isso overwhelming, or so unexpected, that the per-son is rendered speechless; the expressive phaseallows expression of the suffering; the final phaseis the new idea phase, during which the personcan establish a new identify and regain autonomy(Jezuit, 2002). I went through those phases. Ini-tially, I could not express my feelings to anybody.Because I was a senior I was afraid that it wouldseem that I was unable to cope with a difficult sit-uation. Smith and Kirsten (2005) suggest there isa blame culture in nursing practice, which possiblyacted as a deterrent to expressing myself. Also,the culture of the unit, at the time, did not en-courage expressing feelings. All too often, in thepast, reactions have been repressed and musthave contributed significantly to stress amongpractitioners (Burns and Bullman, 2000). Eventu-ally, I was able to express myself to colleagues,which helped me to resume my autonomy. Raeside(2000), in her descriptive study on bereavement,interviewed 76 nurses to assess grief responses,and highlighted the need for staff support and al-lowing them the opportunity to work through theirgrief.

I also felt very guilty that I could not give theparents the support they needed. Breaking badnews can be emotionally demanding for bothparents and staff (Reynolds, 2003). When they

90 A. O’Connor

arrived I went with the doctor to speak to them butdid not spend as much time as I should have be-cause of my own emotions. In showing my feelingsand becoming emotional they appreciated that Iwas empathising with them in their time of grief.Maybe my extreme emotions could be attributedto burn out, which is closely linked to stress, lackof support and isolation (Gillespie, 2003).

Evaluation (what was good and bad aboutthe situation)

Evaluation of my perceived failure of keeping Johnalive and not giving adequate support for hisparents had both a positive and negative outcome.In relating to the negative outcome, John had dieddespite our best efforts to save him. Even though Iparticipated fully in the resuscitation I did not feelthe satisfaction of doing it well, resembling in thepast, even when the outcome resulted in death.While I was doing-in-action I was not reflecting-in-action. This detached, objective stance woulddeny the fundamental notion of ‘involvement’,which is central to caring practioners (Johns,1996). Involvement is contrary to the current sys-tem, which protects nurses from affective distress-ing components of their action (Perry, 2000).Nurses, like other people in all aspects of living,do not think through in detail their every action.Such actions can sometimes be likened to ‘workingon autopilot’, in which set patterns are followedthat governs and directs nursing actions (Driscolland Teh, 2001).

Another negative aspect of the incident was myfailure to be a support person for the parents. I leftit to other staff members to help them, eventhough I had a closer relationship with them. Thischallenged me to consider personal concerns thatinterfered with me being available to help them. Ihad just lost a close family member, and thisincident brought all the raw emotions back, and Idid not want to deal with other people’s grief.

On the positive side I evaluated the care I hadprovided to John and, I believed, I had honouredmy principles of care. These principles are foundedon non-maleficence and beneficence (Boxwell,2000). I discussed the incident in detail with theconsultant and he concurred. I had done my bestbut was my best good enough and, if not, how couldI change to achieve this? I had rated myself highlyas a neonatal nurse because of my years of experi-ence working in the field, however, there weregaps in my knowledge. Experience may be a barrierto learning if it becomes routine (Johns, 1996). Re-flection can only occur when one challenges thevalidity of prior learning (Burton, 2000). I became

aware of my discomfort at my lack of knowledgeof the long-term outcomes of babies with CLD. Up-dating knowledge and skills in response to changingwork practices is essential to deliver evidence-based care (Huggins, 2004). As I am accountablefor my own knowledge and skills I wanted to em-power myself by extending my knowledge base,and I went back to college to achieve this. Ques-tioning one’s knowing and understanding in prac-tice is an integral aspect of reflection (Driscolland Teh, 2001).

Analysis (how can you make sense of whathappened)

My past experiences and expectations had anoverall influencing effect on my reactions. Be-cause I had not encountered an incident like thisbefore I assumed that nothing was going tohappen. Past experiences provide professionalswith a stock of practical knowing, a storeroom ofmemorized situations, which could be accessed toevaluate the current situation (Teekman, 2000).Having reviewed the literature on CLD followingthis incident, I discovered that pre-term babieswith CLD have more severe episodes of hypoxae-mia after feeding which puts them at higher riskof sudden infant death syndrome (SIDS) (Kotechaand Allen, 2002). This usually occurs at homebut, because John was in the hospital for an ex-tended time, it happened in the hospital setting.I felt assured that I had not missed anything inmy care of John.

Johns (1996) suggests that practitioners whobecome over-involved with their commitment totheir clients override the therapeutic regime andcloud professional judgement. This results in feel-ings of entanglement, which may cause anguishand distress to the practitioner. Through reflectionI now realise this was true in my case, as I had be-come very involved with John and his parents. Yetwe are only human and must accept the fragilitiesof being human (Johns, 1996). I have come toterms that I cannot help all babies all of thetime, and I was too hard on myself.

Conclusion (what else could I have done)

On reflection I now feel that there was nothingmore I could have done in taking care of John thatnight. I reacted quickly and appropriately when hecollapsed. However, I should have spent more timewith his parents, which would have been beneficialfor both of us. I felt vulnerable when I was trying toreflect on this incident. I focused on my perceivedfailings for a long time and could not focus on the

Reflective practice on critical incidents 91

good aspects. Selective memory and vulnerabilitycan make reflection seem like a negative process,if it focuses on the gaps in skill and knowledge(Smith and Kirsten, 2005). While it is therapeuticto reflect on the ‘bad’ it is also good to focus onthe ‘good’.

Critical incident 2

This incident took place 6 months after the previ-ous incident. It is due to the reflection on that in-cident that I have chosen to write and analyse thisevent. Both incidents are similar but with differentoutcomes. However, this incident was dealt withdifferently due to reflection on the first.

Description of incident

Adam was born at 34 weeks gestation to a 28-year-old woman called Anne. There was prolongedrupture of membranes (PROM) for 36 h prior to de-livery. At birth he weighed 2 kg, which is appropri-ate for gestational age. He developed moderaterespiratory distress syndrome (RDS) at 2 h of ageand was placed on nasal CPAP ventilation. WhenAdam was 8 h old, I came on duty and was in chargeof the unit. I allocated Joan, a nurse who had beenin the unit 5 months, to look after Adam. She hadnot worked in the intensive care part of the unitfor very long and I asked her if she was comfortablein looking after Adam. She assured me that she wasand had looked after other babies on CPAP in thepast. I also spoke to her mentor who had orientatedher and was assured that Joan was capable of theallocation.

Four hours into the shift I noticed, in passing,that Adam was pale and had increased respiratoryeffort. I asked Joan if this was new and she saidthat it was. I contacted the doctor to assess Adamand before the doctor arrived Adam becameapnoeic, and required bag and mask ventilation.He then required intubation and commenced onendo-tracheal ventilation. During the incident Joanbecame very upset and was unable to participate inthe stabilisation of Adam. Seeing how upset shewas I reassured her, and told her to go for a cup ofcoffee to calm down. When Adam had stabilised Iallocated him to another nurse and contacted theparents to inform them of Adam’s condition. I thenwent to see Joan to reflect on the incident.

Feelings (what was I thinking and feeling)

Immediately after the incident I was relieved thatAdam was now stable on ventilation. However, I

also had feelings of guilt. I knew Joan had limitedexperience in neonates and still allocated hera ‘moderate risk baby’. I questioned my compe-tency of providing indirect care to Adam. Nursesare accountable for their decisions to delegatework to others, and for ensuring that the task hasbeen carried out. The nurse must also decide forherself whether she should accept the delegationand, if she does accept, she is accountable (Rowe,2000). I had reflected-before-action by discussingwith Joan and her mentor her capabilities andwas assured she was capable. I was exercisingthe competency of clinical focus by doing this. Ialso had feelings of guilt that the situation hadturned into an emergency. Maybe, I should havesupervised Joan better, but the unit was busyand I was occupied elsewhere.

I also felt uncomfortable that Joan may think Iinterfered in her care of Adam and underminedher judgement. However, on reflection, I feltobliged to intervene and act quickly to provideadequate care for Adam. In this situation I wasreflecting-in action. One of the most importantskills in professional practice is the ability toexercise professional judgement (Rush et al.,2000). I was concerned how this incident couldaffect Joan’s confidence, and I could empathisewith her because of the similar incident I was in-volved in previously. Empathy provides the bestdata on how to help another person solve theirown problems. When a person believes that theother person appreciates how it feels to be intheir shoes, then they will be more trusting to-ward the other person (Gustafsson and Fagerberg,2004). However, I had more experience in dealingwith this type of emergency and could handle itbetter. Following my reflection on the first inci-dent I made sure I helped her to reflect and tomove forward. Sharing experiences, reflectingwith, and learning from others would also improvecommunications between nurses. This improvedcommunication would help to consolidate goodpractice and improve the patient care.

Evaluation (what was good and bad aboutthe experience)

The fact that Adam had survived an emergencysituation and was now stable was a good outcome.Everybody had worked together as a team to goodeffect. The bad aspect was that Joan did not stayand participate in the stabilisation of Adam.Experience in nursing is obtained by observingand being involved in unique situations (Rowe,2000). Maybe I should have supported her better,but I was focusing on the emergency situation.

92 A. O’Connor

Each learner needs to be considered as an individ-ual and the work place needs to be an environmentwhere learning is encouraged and supported byeveryone (Huggins, 2004).

Analysis (what sense can you make of thesituation)

To analyse this incident I will utilize Carpers (1978)four patterns of knowing: the empirical, thepersonal, the ethical and the aesthetic. This willenable the reflective process to be more focusedand effective.

The empirical may be described as the scienceof nursing, based on observations or experience,rather than theory or logic (Carper, 1978). Theobservational skills, which I had learned from expe-rience, enabled me to ascertain that Adam’s condi-tion had deteriorated and needed intervention. Iwas able to critically analyse the situation andmake a clinical judgement. Benner (1984) wouldequate this with the expert nurse being able to‘zero in’ and not waste considerable time on differ-ent answers. Benner (1984) described a hierarchy offive proficiency stages of practising nurses as nov-ice, competent, advanced, proficient and expert.Because Joan could be classed as a novice shemay not have recognised the significance of the his-tory of PROM. Babies with a history of PROM havea higher risk of infection initiating pneumonia andbacteraemia (Boxwell, 2000). Nurses at the bedsideare in a unique position to use their expertise toquickly detect the subtle, initial signs of sepsis inthe newborn (Rubarth, 2003). Joan may not haverecognised the signs of Adam’s distress that maybe apparent to an expert practitioner.

Interlocked with experience, intuition is de-veloped as part of the personal knowledge. Theexpert nurse has a broad range of experiencethat allows an intuitive grasp of the situation andresponds to a problem quickly and efficiently. Intu-ition is a skill that develops subconsciously overtime as a result of experience gained and is some-thing that cannot be thought. Intuition is thereforea skill that affects the quality of patient care out-comes. Because of this, its place as one of thetools applied to the scope of practice must beacknowledged (McCutcheon and Pincombe, 2001).However English (1993) disputes this and suggeststhat, in this climate of accountability, the conceptof intuition is unacceptable and an insult to nurses.However, I disagree with his statement. Knowledgegained through experience is often difficult toarticulate and may be described as knowing (Smithand Kirsten, 2005). This makes it difficult for juniorstaff to understand its importance or significance

in nursing practice. Maybe a more experiencednurse may have intuitively picked up some signsprior to Adam’s deterioration.

Ethical knowledge described by Carper (1978) isthe quest for doing what is right and good in theclinical situation. I became Adam’s advocate in ap-plying the principle of non-maleficence and benef-icence by intervening in his care to prevent furtherdeterioration.

Aesthetic knowledge relates to the skill ofgrasping and responding to a situation with appro-priate action. Johns (1995b) envisages ‘this as theart of nursing which includes a set of principles ofcaring and commitments embodied in the nursingprofession’. I demonstrated this by acknowledgingJoan’s distress and providing support in the after-math of the incident.

Conclusion (what else could I have done)

The only way that Joan is to gain experience is byworking in the ICU environment, to develop herskills and knowledge. Adam was the best baby togive her at the time as all the other babies were onfull ventilation. Therefore, I felt justified in allo-cating her Adam. However, because of her lack ofexperience, I should have allocated a senior nurseto supervise her. Clinical supervision offers an idealmilieu for the guidance of reflective practice. Thissymbiotic relationship is concerned with enablinga practitioner to develop increasing therapeuticcompetence, sustaining effective work and ensur-ing the maintenance of high-quality clinical skills(Titchen, 2003). This incident highlighted somegaps in my managerial skills and the allocation ofskill-mix in the unit. I needed to attend furthermanagerial courses to update my skills.

Conclusion

There appears to be a general agreement in theliterature that reflection has the potential to assistpractitioners to tap into knowledge gained fromexperience, and connect theory to practice (Nich-oll and Higgins, 2004). Psychological stress can beassociated with reflection and recall may be dis-torted by repression. Accuracy may be an issuebut the process itself can be therapeutic. It shouldbe done as soon as possible after the event (Smithand Kirsten, 2005). Portfolios, ideally, encouragenurses to develop self-reflection and take chargeof their own life long learning. It will encouragepractitioners to accept accountability, increasefeelings of self-esteem and confidence (McMullanet al., 2003).

Reflective practice on critical incidents 93

When I started on this reflective journey I foundit very difficult to transfer my private thoughts topaper but, as time went on, I found it cathartic. Ihad bottled up a lot of feelings about the incidentsand reflection helped me to release those feelingsby giving me a structure to do so. It also revealedthe gaps in my knowledge and spurned me intofurthering my education. It also made me aware ofthe after effects of critical incidents and theimportance of reflecting after such incidents. Inow make sure all staff are supported and areencouraged to reflect.

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