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 andimportant words in describing who we are and what we knowand do; words such as genuineness (Rosendahl, 1973),bearing witness (Naef, 2006), stewardship (Murphy, 2009),and reflection (Benner, 1984), but how can we inculcatethese action words into our student's professional practice?

As master teachers, we all use a variety of strategies todraw these reflections (critical thinking) out of our studentsand their clinical experiences. Discussions and seminars arevaluable tools but require more on-the-spot thinking thattends to lack real depth and thoughtfulness. Journals can alsobe constructive but often regress to a recounting of a day'sevents and superficial musings. For me, a helpful assign-ment, one that has generated significant reflection fromstudents, is having them write a guided critical incident fromtheir past of current clinical encounters (Benner, 1984;Gordon, 2000). Before the assignment is made, a generaloverview of the reflective process is discussed, and readingsare assigned. I have found both Rodriquez (1988), “Writingan Exemplar (Clinical Narrative)” (https://nursing.ynhh.org/Portals/0/RCAP_Writing%20an%20Exemplar.pdf), andSomerville and Keeling (2004), “A Practical Approach toPromote a Reflective Practice Within Nursing” (http://www.nursingtimes.net/nursing-practice/clinical-zones/educators/a-practical-approach-to-promote-reflective-practice-within-nursing/204502.article), to be helpful to students in prepar-ing to select and write their own critical incidents.

In general, when I mention a writing assignment tostudents, their anxiety becomes palpable, their complexions

⁎ Corresponding author.E-mail address: rojann@asu.edu (R.R. Alpers).

1557-3087/$ – see front matter © 2013 Published by Elsevier Inc. on behalf ofhttp://dx.doi.org/10.1016/j.teln.2012.10.002

pale, and a visible tremor radiates across the classroom; thatis until I tell them that it can only be two pages long andthat they only have to respond to three questions! It is theperfect set up for such an assignment; three questions andtwo pages seem eminently possible, and it “soothes a savagebreast” (Congreve, 1697) reaction to the word writing.

The critical incident assignment asks students to thinkabout a patient care event, incident, encounter, or experiencethey have had this semester or in a past semester in nursingschool. The patient care event must be one that elicited anemotion in the nursing student such as fear, anger, joy, relief,and others. They are then to describe it and provide essentialcontext and why this particular event or encounter evokedsuch emotion. Next, they are to think about what they learnedfrom the situation. The format used (the three questions)include the following:

WHAT? A brief description and context of the nursingencounter/event.

SO WHAT? How has this experience informed/trans-formed/changed your nursing practice?

NOWWHAT?What are the specific lessons learned fromthis patient care encounter, and what would the student dodifferently if the situation could be repeated. This section ofthe assignment also requires the student to read and referencea nursing journal article that addresses one of the lessonslearned or supports an alternative intervention or approach tothe situation (I always make it clear that nursing journals arethose publications that are peer refereed). As always, mywriting assignments have the information tag that this is ascholarly article and that it is to represent their most elegantand eloquent professional language and writing style. In aneffort to help get students started on their critical incident(and to give them an example), I shared a critical incident ofmy own:

National Organization for Associate Degree Nursing.

34 Educate, Excite, Engage

1. Tiffany's StoryIt's early December, and the pediatric unit is already

Table 1 Critical Incident and Final Paper Criteria

Criticalincidentselection

Selected animportantincident

(1)

Did notselect animportantincident

(0)

– –

Journalselection

Used at least1 refereed/scholarlynursingarticle

(2)

Used anonrefereed/scholarlynursingarticle

(1)

Used noarticles

(0)

–

Descriptionof criticalincident

Completewithappropriatecontext ofincident

(2)

Adequatecontext ofincident

(2)

Superficialcontext ofincident

(1)

–

Description ofinformed/transformedchange inpractice

Completeand thoroughdescription

(2)

Adequatedescription

(1)

Superficialdescription

(1)

Absentdescription

(0)

Description oflessonslearnedand theiruse in ownpractice

Completeandthoroughdescriptionusing first-personvoice

(3)

Adequatedescriptionusing first-personvoice

(2)

Superficialdescriptionusing first-personvoice

(1)

Absentdescription/failure touse first-personvoice

(0)Writing style Correct

grammarand spelling,elegant andeloquentprogression/presentationof ideas

(3)

Correctgrammarandspelling,logicalprogression/presentationof ideas

(2)

Minorgrammatical/spellingerrors and/or inconsistentprogression/presentationof ideas

(1)

Multiplegrammatical/spellingerrors and/or difficultto followprogression/presentationof ideas

(0)

decorated for the upcoming holidays. Even though this isa tertiary care hospital and only the sickest of the sickchildren come here, you can still sense the joy andanticipation of the holidays from the children, theirparents, and the nursing staff. Every so often you canhear the sounds of Christmas music drifting in from oneof the patient's rooms, and if you listen closely, you mayhear some of the parents and staff humming along.

Tiffany is a 5-year-old brown hair, blue-eyed beauty. Sheis tall for her age but very svelte; she is a ballerina in themaking. In fact, she has danced with the touring balletcompany the last 2 years in their production of theNutcracker Suite. She has been in the hospital since mid-November and has deteriorated rapidly since diagnosis.

Tiffany has a Wilm's tumor, stage four; chemotherapyhas 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 dancingacross her bed linens to the Dance of the Sugar Plum Fairy(her favorite piece of music) and giggled at her daddy'ssilly faces…today she is lying still, very still, no longertalking, certainly no giggles are heard, and worse yet, she isgetting blood drawn and she not moving, pulling away,crying, or asking her parents to ‘make it stop.’ She haswithdrawn completely, and nothing seems to engage her.

Her parent sit stricken at her bedside, faces are flushed, andeyes filled with tears, nothing they do, coaxing, cajoling,promising anything and everything, seems to bring theirchild back fromher isolation. The nursing students are tryingtheir hardest to reconnect with Tiffany…their best hugs andtickles, 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 conversationabout the situation, its ultimate and rapidly approachingoutcome andwhat we can do for this family to try andmakethese last few days together a happier andmore peace-filledtime. We all agreed we will do whatever it takes. That'swhen it happened, a clear, precise, luminous…and dare Isay it…brilliant idea occurs. We rush to the linen cart andremove draw sheets, we scurry to the utility room for tape,gauze, and safety pins and ‘…then what to my wonderingeyes should appear…’ but the most extraordinary line ofpirouette-ing sugar-plum fairies imaginable!

We ran to Tiffany…actually, we 'pas de deux'ed, to herroom, turnedon herNutcracker Suite cassette, andproceededto do our interpretation of theDance of the Sugar PlumFairy.The staff and parents looking in from the door were aghast,Tiffany's parents speechless and astonished, but mostimportantly, Tiffany was amused! At first, there was a halfsmile that bloomed in to a full-fledged grin, and then her softgiggle grew to a guffaw. We all felt a sense of satisfactionand knew, at least today, we had made a difference.

Tiffany died the following evening, but her parents madea point of letting us know that her last day was filled with

laughter and singing together, and they were able to saytheir goodbyes. She died in her mother's arms listeningto the Nutcracker Suite.

I think, providing a personal critical incident openscommunication with the students and also invites them toshare some of their more intimate experiences and emotions.Over the last few semesters, I have received some of the mostinspiring, courageous, passionate, and gut-wrenching talesfrom the field. It is not unusual for me to be in tears when I readthese extraordinary stories and absolutely beamwith pride andconfidence for the future of the nursing profession. It is alsoessential to share these reactions with students—if they havetaken 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 theassignment criteria and to evaluate the final product.

2. Assignment Criteria and Evaluation Rubric

Table 1 (continued)

AmericanPsychologicalAssociation(APA) format

Consistentand accurateuse of APAformat

(3)

Inconsistentand/orinaccurateuse of APAformat

(0)

– –

Total points – – – –

35Educate, Excite, Engage

References

Benner, P. (1984). From novice to expert: Excellence and power in clinicalnursing practice. Menlo Park, CA: Addison-Wesley.

Congreve, W. (1697). The mourning bride. Retrieved October 8, 2012 fromhttp://www.britannica.com/EBchecked/topic/395036/The-Mourning-Bride.

Gordon, J. M. (2000). Congruency in defining critical thinking by nurseeducators and non-nurse educators. The Journal of Nursing Education,39, 349−351.

Murphy, N. S. (2009). Nurse leaders as stewards: The beginning ofchange. 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. RetrievedOctober 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. NursingResearch, 22(3), 253−257.

Somerville, D., & Keeling, J. (2004). A practical approach to promotereflective practice within nursing. Nursing times.net. Retrieved October3, 2012 from http://www.nursingtimes.net/nursing-practice/clinical-zones/educators/a-practical-approach-to-promote-reflective-practice-within-nursing/204502.article.