Critical Incident Analysis

In nursing a critical incident is considered to be an incident within practice where the practitioner's intervention made a difference to the outcome whilst demonstrating the essence of the work undertaken. Historically Aristotle (350 BCE) alluded to critical inquiry suggested pro-positional knowing or formal logic that refers to abstract ways of knowing. Schon (1983) discussed theories of reflection that have a historical foundation in learning, supported by Dewey (1938), Lewin (1932), and Piaget (1929), each of whom theorised that learning is dependent upon the integration of experience with reflection and of theory with practice. Benner (1984) discussed how nurses could move from novices to experts by the acquisition of knowledge and application of theoretical understanding to practice. To identify an incident that was significant to a practitioner they could examine an extract from their reflective journal (Schon, 1983). A reflective journal is generally a record of a practitioner's perceived emotional state and thoughts at the time closest to the incident. At a later date they should be able to expand on this record without losing the essential essence of what took place. All adults could reflect, but not all reflection will result in learning, mental reflection may occur spontaneously, 'written reflection is not a natural process, but has to be learned and practiced' Jasper (1989). Critical thinking can enable the examination of and challenge of assumptions, resulting in imagining and exploring alternatives (Brookfield, 1987).

Critical reflection focuses on interrelated processes; the process by which practitioners question and then reframe an assumption; the process when practitioners take alternative perspective on ideas, actions, and forms of reasoning and the process whereby practitioners come to recognise the dominant cultural values (Brookfield, 1987). Meizirow (1990) discussed learning as being the process of using a prior interpretation of an event to construct a new or revised meaning of the experience and guide future actions. A criticism of Mezirow's (1990) theory is its emphasis upon rationality and a view of transformative learning as an intuitive, creative, emotional process is now emerging in the literature (Taylor, 1998) This alternative view of transformative learning is based primarily on the work of Boyd and Myers (1988), who developed a theory of transformative education based on analytical (or depth) psychology, as fundamental change in personality involving the resolution of a personal dilemma and the expansion of consciousness. Mezirow (1990) saw the ego as playing a central role in the process of perspective transformation, whereas Boyd and Myers (1988) use a framework that moves beyond the ego with the emphasis on reason and logic to a definition of transformative learning that is more psychosocial in nature.

Meizrow (1991) describes a transformational theory of adult learning, transformation being a process where meaning structures are transformed through reflection. In a collaborative learning environment reflection and analysis is encouraged, which could result in effective problem solving strategies emerging and become part of organisational activities (Meizrow, 1990).
Mezirow (1991) suggested the role of the educator as being to:

· help the learner focus on and examine the assumptions that underlie their beliefs, feelings and actions
· assess the consequences of these assumptions
· identify and explore alternative sets of assumptions
· test the validity of assumptions through effective participation in reflective dialogue
· encourage the learner to use transformative learning to become more reflective and critical
· discuss the learner being more open to the perspectives of others
· suggest the learner be less defensive and more accepting of new ideas

An critical incident analysis [CIA] is chosen due to the effect it has on the practitioner at the time and subsequent to the event. It is useful to include the context of the event, timing and who was involved, then the practitioner can clarify the incident for discussion. One method is to use the categories: concerns; thoughts; feelings; accomplishment; difficulties; satisfying and disturbing; importance; learning and changes to future practice.

Choose a critical episode:
· This would be something that stands out for you, e.g. a successful or unsuccessful learning incident, a problem presented to you by clients, which made an emotional impact.

Describe the incident to include:
· When and where it happened (time of day, location and social context)?
· What actually happened (who said or did what)?
· What you were thinking and feeling at the time and just after the incident?
· What were the significant factors?

Interrogate your description to include:
· Why did this incident stand out?
· What was going on?
· Did you bring personal bias or a particular mindset to the event?
· Could you have interpreted this event differently from another point of view?
· What can you learn from the episode about the context, your colleagues and yourself?
· Is there any useful theory you can apply to this incident?

Ongoing Critical Incident Analysis
. Find a friend or colleague to:
· Share your account of the episode
· Discuss your interpretation
· Modify your analysis, where necessary, in the light of peer suggestion, advice and perspective.

Another method of analysis is that of 'Reflexive Critique' (Winter, 1989) using an interpretation of an event to consider what its origins were in the underlying general values, professional values and theoretical assumptions.

Clarification of Critical Incident.
General Values
Anti-discriminatory practice: race, age, sexuality, gender, religion, disability, and social class. Personal experiences, professional experiences and their perception of current societal views.

Professional Values
Professional values will be based on professional knowledge and clinical expertise.

Theoretical Assumptions
Professional knowledge informs clinical practice. Critical examination of significant events will improve practice and identify training specific needs. The practitioner should use their general values; professional values and theoretical assumptions to inform their analysis of critical incidents.

Identification of Specifics of the Incident
Concerns: what concerns did the practitioner have at the time of the incident?
Thoughts: what were the practitioner's thoughts as the incident took place?
Feelings: how did the practitioner feel at the time of the incident?
Accomplishment: what did the practitioner want to achieve?
Difficulties: what were the practitioners difficulties regarding the incident?
Satisfying and Disturbing: what were the satisfying and disturbing parts of the incident?
The Importance: what was the importance of the incident?
Learning: what did the practitioner learn from this incident?

The practioner should be aware of what training needs or changes in client care have been identified? One opportunity to discuss CIA's and their likely impact on practice is during clinical supervion sessions.

Clinical Supervision

Clinical supervision is a suggested method of supporting reflection on practice and as a way for nurses to contribute to the healthcare agenda as recommended in 'Vision for the Future' (Department of Health, 1993). Now that we are in the twenty first century most Trusts have policies for clinical supervision and clinical support for their practitioners. Clinical supervision has been defined as: 'an exchange between practice professionals to enable the development of professional skill' Faugier and Butterworth (1994). Clinical supervision will be part of the ongoing development of students whilst in practice and is a reflective process that they should continue after qualification.

Clinical supervision can be considered a 'safe' venue where practitioners are encouraged to examine practice issues critically, either within a group or one to one. However, practitioners should be made aware of the agreed rules for clinical supervision and the pathway of subsequent action that could be taken if practice issues are identified, either from a negative or positive perspective. Clinical supervision will use critical thinking as a means of exploring alternatives; it can facilitate the examination and challenge of assumptions. Pat Benner (1984) suggested a novice to expert view of the practitioner, in that as we all move backwards and forwards along a continuum we are at different stages of professional development, so would bring different experiences to supervision. One aim of supervision can be to understand the client better and move towards an understanding of their expressed health needs (Bradshaw, 1972). Mattison (1981) suggested a triangle of supervision in that case discussion theoretically involves three participants: supervisor, practitioner and service-user.

In Mattison's (1981) triangle the supervisor represents line management authority and accountability; the practitioner brings their experience of direct work with service-users, professional needs and the service-user with needs, capacities, demands and rights. For supervision to be effective supervisors should be acceptable to supervisees; be able to share clinical expertise; received training in the management and delivery of supervision as well as attending regular updates. Hagler and Mcfarlane (1991) identify behaviours that were most favoured in supervisors: benevolence, confidence in practitioner; empathy; encouragement; positive reinforcement; promotion of patient care and role modelling. A supervision session should have a structure, the session can move from an introduction; to a process of information sharing; a question period; a clarification of points, with feedback from the supervisor; identification of key points and a reflective break, to consider options; a response statement from the practitioner, on the ideas and process analysis, as to what could happen next. Clinical supervision usually occurs as a one to one although could be as part of a group.

King (1981) suggested a conceptual framework for examining 'health beliefs' in groups consisting of three interacting systems: personal systems, interpersonal systems and social systems. An alternative method is that developed by John Heron of Six Category Intervention Analysis (1986, 2001). The categories are : prescriptive; informative; confrontative; cathartic; catalytic and supportive. The six styles were then further broken down into two basic categories: authoritative and facilitative.

Authoritative Interventions
Prescriptive: The supervisor explicitly directs the supervisee by giving advice or direction.
Informative: The supervisor intends to provide information, to assist the supervisee.
Confrontative: The supervisor challenges the beliefs or behaviour of the supervisee. Such confrontation does not imply aggression, it encourages the supervisee to consider some aspect of their work or themselves that was perhaps previously taken for granted.

Facilitative Interventions
Cathartic: The supervisor attempts to help the supervisee move on through the expression of thoughts or emotions previously unacknowledged or unexpressed.
Catalytic: Interventions are focused on helping the supervisee become increasingly self-directed and reflective. They aim to move forward the developmental level of the supervisee as a professional.
Supportive: The supervisor attempts to reinforce the confidence of the supervisee through focusing on their areas of competence, and attending to what they did well.

Clinical supervision is a confidential facilitative process although if clinical practice issues are identified the supervisee should be aware that appropriate action will be taken. The Allitt Inquiry (Clothier et al. 1994) highlighted to the public the limited protection afforded to vulnerable patients, should a nurse be determined to cause deliberate harm. The Clothier Report (1994) gave recommendations related to the screening of staff by occupational health departments, and to systems designed to support increased vigilance and inter-professional observation of staff, one such system was that of clinical supervision. Ideally clinical supervisors should be able to offer practitioners sufficient time and a non-judgemental objectivity, each session should be planned and be protected time. Supervisors could also incorporate Faugier and Butterworth's (1994) concept of clinical supervision as being an exchange between practitioners that allow the development of professional skills, for the supervisor and supervisee.




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