Reflection on Three Critical Incidents in Practice

Introduction
Reflective practice promotes quality care as health and social care practitioners evaluate and analyse incidents and create action plans to improve current practice (Jones, 2010; Jasper, 2006). This essay aims to reflect on three incidents in practice using Taylor’s (2006) model of reflection. This model of reflection was chosen because of its holistic nature. The steps of reflection is presented through the acronym REFLECT. The reflective process begins with Readiness, Exercising thought, Following systematic process, Leaving oneself open to answers, Enfolding insights, Changing awareness and Tenacity in maintaining reflection. I will reflect on my learning and professional development from the three experiences in relation to the 9 domains of the Professional Capabilities Framework (The College of Social Work, 2013).
Incident One

Description of the Incident
I was requested to complete a social assessment for a service user who was about to be discharged from the hospital following a stroke. This service user has markedly reduced mobility. As part of the multidisciplinary team, healthcare team members requested that the care package should be increased from two calls to four calls per day.
Part of the assessment is to determine the degree of mobility of the patient and the need to provide additional support or changes in his home setting to facilitate mobilisation. This is necessary since the patient lives alone. In settings where the patient has very reduced mobility, a carer will be hired to provide additional support (NICE, 2008). However, if a family member can provide additional support, it is encouraged that care should come from an individual that the service user trusts and is comfortable with (NICE, 2008). Using this knowledge, I completed my assessment and concluded that the patient does not need an increase in his care package.
Meanwhile, I conducted a social assessment for the wife of the service user. Studies (Gordon et al., 2013; Fan, 2011; McCullagh et al., 2005) have shown that carers of patients with chronic conditions are at increased risk of depression. The demanding task of caring for a sick family member and seeing loved ones suffering from an illness are some factors that would increase this risk. Hence, it is suggested that carers should also receive social and emotional support to prevent depression (Gordon et al., 2013). Upon completing the assessment for the wife, I recommended social support for the wife. It has been shown that social support is important in preventing social isolation common amongst family members caring for those who are sick (Fan, 2011). Social support will also help carers interact with others who are experiencing similar situations. Engagement in a support group will help form friendships and relationships with people who are undergoing the same experience (McCullagh et al., 2005). Currently, a number of support groups for families of stroke survivors are available in the community. Membership in one of these groups could offer needed emotional and social support.
Patients surviving a stroke suffer from reduced mobility and disabilities (NICE, 2008). Studies (Langhorne et al., 2011; Rimmer and Wang, 2005) have shown the importance of improving cardiovascular fitness to prevent future stroke episodes. These studies also highlight the importance of social support as integral in the management of the condition and in the recovery of service users. Family members play crucial roles during the rehabilitation of these patients (Langhorne et al., 2011). As a social care practitioner, it is my duty to ensure that service users receive quality care and their needs are sufficiently addressed. However, on assessment, the patient does not require an increase in his care package.
Critical Care Incident
Following my social assessment, I found out that the patient does not require an addition to his care package. This critical care incident became a dilemma since I was torn between following my colleagues’ recommendations and pleasing them or presenting my findings that the service user does not need an increase in his care package. On reflection, I began to ask myself why I felt reluctant in discussing my findings with my colleagues. I realised that they did not insist that the care package should be increased. Instead, they were asking me to complete a social care assessment to validate their recommendations. On analysis, my reluctance was rooted in my desire to please my colleagues. This is not surprising since team members would want to create harmony in the group and avoid conflict. However, Clouston and Westcott (2005) explain that when managed properly, conflict might actually promote better outcomes for the group.
On reflection, I should have discussed my findings immediately with my team members and explained why the patient does not need an addition to his care package. Effective communication requires members to listen to both verbal and non-verbal messages of team members (Glasby et al., 2008). While we had no communication issues in the past, I could have eased my apprehensions and communicate my concerns with team members. Meanwhile, Collins (2009a) also emphasise that effective communication is needed to collaborate effectively with others. Since I will be collaborating with these team members in the future, I should use the lessons I learned from this incident to ensure that the patient receives optimal care. I also realised that I should observe the domains of professionalism and professional leadership when working with teams and in assessing service users. Professionalism is described as the ability of a health and social care practitioner to exercise his role based on the guidelines presented in his profession (Peck et al., 2008).
Since I have the necessary background to conduct a social assessment, I should be confident in my findings and share this with the group. It is also part of professionalism to accept suggestions from my colleagues in order to improve current practice (Barrett et al., 2005). Further, one of the 9 domains of the PCF is knowledge. I should be able to use my knowledge on social assessment for stroke survivors in informing my team that the service user does not need additions to his care package. Next, I should also exercise professional leadership, which is also another domain of the PCF. In social care, leadership means the ability of social care workers to lead the management and care for service users (Barrett et al., 2005). Since leadership is a skill that is learned through constant practise, I should seek for opportunities where I can exercise leadership skills. In this incident, I should be able to lead the care of the service user following the findings of the social assessment.
Changing Awareness
The specific critical care incident in this case is my reluctance to discuss with my team members the findings of my social assessment. Reflecting on this incident, I realised that as a qualified worker I should demonstrate my knowledge and leadership when assessing the needs of the service users. I should not fear that my colleagues would not respect my findings. I also realised that I need to improve my self-esteem to effectively advocate for my service users. To continue my professional development, I should engage in trainings on how to communicate effectively with team members. I should also improve my knowledge on social assessment to help me decide on the most appropriate care for my service user.
Since this incident, I began to be make changes in my practice. I improved my learning on social assessment and also began to be more confident in sharing my findings with the team and leading care. Developing my knowledge and leadership skills was essential since this would help me achieve two of the domains in the PCF. During supervision, I discussed this incident with my supervisor. Supervision plays an essential role in increasing job satisfaction of social care workers and in helping them become more effective in their areas (Carpenter et al., 2012). These meetings were important since it helped me clearly identify the problems of my service user and reflect on the best solution for his circumstances. I also felt on our meetings that I was allowed to critically thing through the problem and create a solution that is feasible for the client and my team.
Incident Two
Description of Incident
A social care assessment was completed for a service user who underwent hip replacement after suffering from a fall at his home. After careful consideration, the team decided to transfer the patient from the hospital to a step down bed to allow for mobility rehabilitation. A physiotherapist completed a home visit to ascertain the type and level of support that the service user will need. The aim of the team is to restore normal living and independence for the patient as soon as possible. However, the physiotherapist reported that the service user’s home was unfit for habitation. There was no heating and a side lamp in the lounge remains as the only source of light. The house was filthy with black trash bags strewn in the kitchen. There was no food in the refrigerator. The house smelled of urine with the bed covers looking visibly soiled while the toilet also needs plumbing.
The National Institute for Health and Care Excellence (NICE, 2013) guideline for fall prevention has emphasised the need to assess the conditions of the home and make changes to facilitate easier mobility of the service user. As the environment is physically adjusted to the needs of the patient, this will prevent recurrent falls and will help improve mobilisation of the patient (NICE, 2013). On analysis, the patient was living alone and had difficulty maintaining the cleanliness of his home prior to his fall. This would suggest the need for assistance in the activities of his daily living. Although the patient refused any help, health and social care workers can act on the best interest of the patient and make changes on the patient’s home to make it safe and liveable (Glasby et al., 2008). The NICE (2013) guideline also states that home hazard assessment should be performed to allow safety interventions and home modifications. Consistent with the experience of the service user of this incident, the home assessment was part of discharge planning. In addition, the NICE (2013) guideline emphasises that home modifications should be carried out within the agreed time frame between the patient and appropriate members of the healthcare team. However, it should be noted that home hazard assessment is not effective when follow-up and interventions are not introduced. The physical modification of the house alone is also not effective in preventing a recurrent fall. House modification should be supported with appropriate interventions for the patient.
Critical Care Incident
The service user is only allowed to stay for six weeks at the rehabilitation unit. Since the house needs repair and deep cleaning, there would be not enough time for the service user to move to his house after his discharge. The service user also refused to have carers since he feels that he is capable of taking care of himself. He explicitly stated that he does not want additional support to assist him with activities for daily living (ADL) and made a verbal request to the rehabilitation team to help him return to his home. For this particular case, the critical care incident involves respecting the wishes of the patient or acting on the best interest of the patient. As a qualified worker, I have to convince the patient that he could not immediately return to independent living since his house has to be repaired. In the meantime, we have to find a suitable place for him to stay before he can go home. Since the patient was adamant in returning home, I have to decide between acting on the best interest of the patient or respecting patient autonomy. This means, I either have to follow the patient’s wishes of returning him to his home even if it is still not fit for his condition or convincing him to stay in a temporary shelter. I consider this as an incident since social care workers should respect patient autonomy. However, this is difficult to follow especially if respecting the patient’s autonomy would not be for his best interest.
On reflection, I began to question how I offered support to the patient after he expressed that he wants to go home after attending the six-weeks rehabilitation. It is understandable that patients who suffer from a fall do not want to be a burden to others. The NICE (2013) guideline notes that patients do not want to become an added burden to the staff when they want to ask help for mobilisation. On the other hand, I also have to inform the patient about his condition and why he needs to return to a home that is clean and modified for his needs. Hence, there is a need to introduce multidisciplinary management when caring for patients who have undergone hip fracture surgery. For instance, the NICE (2011) guideline for hip fracture expresses that a patient should be involved in a hip fracture programme that addresses all his health needs. Specifically, the guideline states that multidisciplinary teams should aim for recovery of mobility, functions and independence.
The same guideline also reiterates that multidisciplinary teams should enable return of service users or patients to their residence and ensure the long-term wellbeing of this group. On analysis, our multidisciplinary team is following measures to ensure that the service user will return to a home that is safe and modified for his needs. This reflects values and ethics, one of the 9 PCF domains. The value of patient safety and ethics when caring for patients are demonstrated in our actions of helping the patient return to a safe environment following his discharge from the rehabilitation unit.
Changing Awareness
I had to consider the best interest of my patient even if he insists on returning to his home immediately after his discharge from the rehabilitation unit. Barrett et al. (2005) express that social care workers should always place the safety and best interest of the service user when deciding on appropriate interventions for the patient. This is consistent with the ethical principle of non-maleficence and beneficence (Runciman and Merry, 2012). The primary role of social care workers is to do no harm. Since the patient refused to receive additional support for ADL, I am aware that returning him to an unmodified home will increase the risk of recurrent fall.
Although the patient was deemed as having the capacity to perform the activities of daily living, I felt that his current house is unsafe. Adding a challenge to the service user’s case was his refusal to have a carer to look after his needs and assist him with daily living. As noted previously, patients want to feel that they are still needed and they still have the capacity to perform ADL (NICE, 2011). Surrendering one’s independence to a carer is perceived as demeaning and also depressing (NICE, 2011). Hence, I sought the manager’s approval to transfer the service user to a residential home temporarily until his house has been deep cleaned and modified. On analysis, patient-centred care is important to improve patient satisfaction and increase adherence to a care plan. However, there are cases where social care workers have to intervene in the best interest of a patient (Collins, 2009a). This case exemplifies this exception and shows the influence of social care workers in making meaningful decisions for the health and wellbeing of services users.
Incident Three
Description of the event
I completed a social care assessment for an elderly female patient who suffered from a fall in her home. She was transferred to the rehabilitation care home following her admission from the hospital. Healthcare team members recommend the restarting of the previous care package and increasing the package. On the completion of my assessment, my recommendations were identical to that of the healthcare professionals in my team. I recommend increasing the care package since the service user is experiencing poor health and has difficulty eating independently.
The patient and her family members were very reluctant to accept the additions to the care package. Family members contacted my team and arranged a meeting with all health professionals involved in the care of the patient. The purpose of the meeting was to determine the type of support that the service user needs and to identify any additions in her care package. During the case conference, health and social care professionals explained why the patient needs modifications in her home and a carer to assist her in her ADL. For instance, it was explained to the family why the service user will need a stair lift and a pendant alarm. Additionally, the health and social care team agreed with my recommendations to provide the patient with support in preparing meals, intake of medications and personal hygiene. Although the family was apprehensive about the additional cost, they finally agreed to the increase.
Critical Care Incident
The service user was very reluctant to return to her home after a consultation was made on why her care package will be increased from two calls to four calls per day. She was also informed to hire one carer to support her needs and to assist her with ADL. Considering the cost implications of an added carer and increasing the number of calls each day, the service user declined the addition in the care package. The critical care incident in this case is the need to convince the patient that she needs the additions to her care package. This became a dilemma since this request entails that the patient and family members will have to make out-of-pocket expenditures. This could mean an added burden to the care of the patient. To convince my patient, I have to consider my knowledge on elderly care after hip surgery. This means I should give sufficient information about her condition and why she needs the additions to her care package.
Since I am practicing patient-centred care, I gently reasoned out with the patient why she needs a carer once she returns home. The Department of Health (2008) reiterate that the patient should be involved in healthcare decision-making about their care and discharge. While I recognise the service user’s rights to refuse treatment, one should also consider that social care workers have to work in the best interest of their patients. Hence, I tried to convince the patient that she needs an addition to her care package to ensure that she is safe in her home and receives adequate nutritional support.
I used my knowledge in elderly malnutrition in informing the patient why she needs an addition to her care. For example, I informed her that since she is an elderly, she is at risk of malnutrition compared to the general population. Malnutrition in the elderly is defined as a basal metabolic index (BMI) of <18.5 (Harris and Hboubi, 2005). This condition could be corrected with appropriate diet, nutrition and support (Harris and Hboubi, 2005). Further, malnutrition is a significant deterrent to optimal health and wellbeing (Age UK, 2010). Patients recover slowly or not at all when they are suffering from malnutrition. Hence, it is important to address malnutrition at this stage. Apart from malnutrition, there is also the issue of adherence to medications. There is evidence that adherence to medications might not be high amongst elderly patients (Maclaughlin et al., 2005). It is suggested that cognitive functions of this group are in decline. Hence, there is a need to introduce medication prompts to remind patients when to take their medications.
Since the patient remains undecided after our consultation, I asked her to confide to her family and seek their advice. Engagement of family members in the treatment and care of patients has been shown to be effective in improving health outcomes (Glasby et al., 2008). One of the reasons for this effect is that family members are more committed to improving health outcomes of patients.
Changing Awareness
This incident helped me understood the domains of rights, justice and economic well-being in the PCF. It is the right of all service users to receive equitable care (Department of Health, 2008). Justice is not satisfied when service users do not receive equal access to healthcare services. However, the economic well-being of the patients should also be taken into account when recommending additions to care packages. It should not become an added burden to a family who might have suffered from financial difficulties as a result of the patient’s illness. It was evident from the case that the family has difficulty supporting the service user.
The cost implication of an addition in care package could act as a deterrent to access in health services. For instance, the family of the service user was initially reluctant to support the addition to the patient’s care package due to its cost implications. While support from social care services is available for different groups of service users, financial support is limited. Hence, this could be an important deterrent to care. In my future practice, I should ensure that al additions to a patient’s care package should be well justified, especially if the NHS does not cover these additions. For my professional development, I should always act on the best interest of the patient in ensuring that care is cost-effective and does not require patients and their family members to make out-of-pocket expenditures. On reflection, the incident was a learning experience since I need to be more acquainted on the economics of care. I evaluated my actions after arriving at the decision to request for additions to the care package and discovered that I was acting on the best interest of the patient. I learned that as a social care worker, I should always be an advocate for the patient. In my future practice, I will follow the same actions I made for this case. I will improve my communication skills with my patients to help them feel that I empathise with them and only wants the best care for them.
Conclusion
The three incidents presented in this brief illustrate the importance of patient-centred care when providing support for service users. Lessons from these incidents could be used to improve my current practise. Specifically, there is a need to communicate effectively with team members to ensure optimal and quality care of the patients. In incident one, I learned the importance of exercising my leadership and professionalism when acting on behalf of the best interest of the patient. I also learned the importance of facilitating normalisation and independence amongst my service users. Maintaining their independence would help improve their self-worth. In incident two, the values of patient safety and independence were exemplified. A home hazard assessment will improve patient safety since homes will be modified to suit the needs of the patient. In incident three, I learned to empathise with patients and to evaluate the cost-effectiveness of additions in care packages. Although the patient’s family was reluctant to spend for additions in care packages, the family eventually agreed to these additions.
This reflective brief shows that a holistic approach should be made when addressing the needs of services users. This approach would view the issues of a patient’s case based on the social, environmental and political contexts. In this brief, health policies in the UK and NICE guidelines were used to support the discussions in this brief. The NICE guidelines serve as an important resource for information on how to manage patients with different health conditions. Social care workers could collaborate with inter-agencies to ensure that quality care is provided for each service user.
As part of my professional development plan, I will continue to seek for opportunities to work with other professionals and practice positive communication. I also learned that I should respect the wishes of the service users and facilitate their independence and promote return to normal activities. I also learned that allowing my service users to regain their independence, their self-worth will increase and they will become more empowered. I also have to show empathy when addressing the needs of my patients, especially if they are concerned about the additional financial costs of additions in their care packages. Reflection has allowed me to become a better social care worker. In my future practice, I will use the lessons learned from the incidents to improve care for my service users
References
Age UK (2010) Seven Steps to end malnutrition, London: Age UK.
Barrett, G., Sellman, D. & Thomas, J. (2005) Interprofessional working in health and social care: Professional perspectives, London: Palgrave Macmillan.
Carpenter, J., Webb, C., Bostock, K. & Coomber, C. (2012) SCIE Research briefing 43: Effective supervision in social work and social care [Online]. Available from: http://www.scie.org.uk/publications/briefings/briefing43/ (Accessed: 12th December, 2013).
Clouston, T. & Westcott, L. (2005) Working in health and social care: an introduction for allied health professionals, London: Elsevier Health Sciences.
Collins, S. (2009a) Effective communication: A workbook for social care workers, London: Jessica Kingsley Publishers.
Collins, S. (2009b) Reflecting on and developing your practice: A workbook for social care workers, London: Jessica Kingsley Publishers.
Department of Health (2008) Our Health, our care, our say: A new direction for community services, London: Department of Health.
Fan, C. (2011) ‘Factors associated with care burden and quality of life among caregivers of the mentally ill in Chinese society’, International Journal of Social Psychiatry, 57(2), pp. 195-206.
Glasby, J., Dickinson, H. & Community Care (2008) Partnership working in health and social care, London: Policy Press.
Gordon, C., Wilks, R. & McCaw-Binns, A. (2013) ‘Effect of aerobic exercise (walking) training on functional status and health-related quality of life in chronic stroke survivors: a randomised controlled trial’, Stroke, 44(4), pp. 1179-1181.
Harris, D. & Haboubi, N. (2005) ‘Malnutrition screening in the elderly population’, Journal of the Royal Society of Medicine, 98(9), pp. 411-414.
Jasper, M. (2006) Professional development, reflection and decision-making, Oxford: Oxford University Press.
Jones, L. (2010) Reflective practice in nursing, Exeter: Learning Matters Ltd.
Langhorne, P., Bernhardt, J., & Kwakkel, G. (2011) ‘Stroke rehabilitation’, The Lancet, 377(9778), pp. 1693-1702.
Maclaughlin, E., Raehl, C., Treadway, A., Sterling, T., Zoller, D. & Bond, C. (2005) ‘Assessing medication adherence in the elderly: which tools to use in clinical practice?’, Drugs & Aging, 22(3), pp. 231-2455.
McCullagh, E., Brigstocke, G., Donaldson, N. & Kaira, L. (2005) ‘Determinants of caregiving burden and quality of life in caregivers of stroke patients’, Stroke, 36, pp. 2181-2186.
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Rimmer, J. & Wang, E. (2005) ‘Aerobic exercise training in stroke survivors’, Topics in Stroke Rehabilitation, 12(1), pp. 17-30.
Runciman, B. & Merry, A. (2012) Safety and ethics in healthcare: A guide to getting it right, London: Ashgate Publishing, Ltd.
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