A critical incident that occurred in practice

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The aim of this report is look at a critical incident that occurred in practice and relate this to the theory and knowledge regarding communication and interpersonal skills, that is to say, what skills were and were not used at the time of the incident. Carl Roger’s necessary conditions for effective counseling, Heron’s six category intervention and methods of non-verbal communication will all be examined. The incident that was chosen was so for the reasons that the situation made the student aware of inadequacies on her own part and those of the staff on the ward, which made her reflect upon the situation and how this could be learned from, so as not to make the same mistake again. Due to confidentiality, the patient concerned in this incident will be referred to under the pseudonym of “Mrs. Khan”. The incident took place on an adult rehabilitation ward.


Communication is essential for effective nursing practice (Kacperek, 1997; Rowe, 1999). Communication occurs all of the time between people, not just verbally, but non-verbally too, by way of gestures, facial expressions, tone of voice and so on. Clear, effective and thoughtful communication is vital for health care professionals, who work with and care for other people (Burnard, 1992).

Fielding (1995) argues that communication is the transmission of messages from one person to another. These messages contain information and the senders of these messages intend particular meanings to reach the receiver of the message, who will then attach a meaning to the message. The intended meaning may differ from the meaning attached to the message by the receiver. This is not only due to the words used but also by the non-verbal messages that are also sent (Fielding, 1995).

Heath (1997) argues that communication occurs in various ways and at diverse levels of awareness. Barber (1993, cited in Heath, 1997) states that communication is concerned with sharing understandings and involves openness to enquiring of another person, with the bearing of attention, perception, receptivity and empathy towards that person.

Peplau (1988, cited by Betts, 2002, in Kenworthy et al, 2002) views nursing as an interpersonal process. Betts (2002, cited in Kenworthy et al 2002) argues that effective communication is intricate and obscure. Both the nurse and the patient are distinctive individuals, and they both bring with them their own perceptions, values, interpretations and experiences to the interpersonal process. Davies et al (1997) argue that nursing is moving away from the medical model, towards an individualized, holistic approach whereby the patient is taking a more active part in their care. In order to achieve this, the nurse must use effective communication skills.

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Before the critical incident is examined it is important to look at what a critical incident is and why it is important to nursing practice. Girot (1997, in Maslin-Prothero, 1997) states that critical incidents are a means of exploring a certain situation in practice and recognizing what has been learned from the situation. Benner (1984, cited by Kacperek, 1997) argues that nurses cannot increase or develop their knowledge to its full potential unless they examine their own practice.

Description:Critical Incident.

Mrs. Khan was admitted to the Adult Rehabilitation Ward. The ward concerned was divided into three bays and three side rooms and Mrs. Khan was initially admitted into the bay the student worked in. Mrs. Khan was an elderly lady from India who spoke no English. Mrs. Khan could not read her native language. Her native language was Punjabi. Her family assisted with her admission details, however after admission her family rarely visited.

Despite the language barrier, Mrs. Khan and the student developed a good rapport. The hospital link worker came to visit her and translated what Mrs. Khan wished to say to the student and vice versa. During this time the student learned that Mrs. Khan had pain in her legs and that she had only recently lost her husband, which explained why Mrs. Khan was tearful at times. At the times when Mrs. Khan was tearful and the student did not know why, the student could only stroke her hand and her my arm around Mrs. Khan. The student asked the link worker to explain how inadequate she felt that she did not know what Mrs. Khan was trying to tell her and to apologize for this, and that she wanted to help Mrs. Khan. The link worker informed the student that Mrs. Khan was grateful and Mrs. Khan hoped that the student’s family and the student would be blessed.

Following this the student always offered Mrs. Khan a smile and a wave (to say hello) and sometimes sat with her to give her some form of company. Mrs. Khan was admitted to the ward following a trip to India, with a cough. It was suspected on her admission that this cough was due to tuberculosis, however she was still admitted in the bay. Four days following admission, after settling into the bay, it was decided to take the suspected tuberculosis more seriously and to move her into the side room, into isolation, and take swabs to test for tuberculosis. The staff nurse tried to contact the link worker to come and explain to Mrs. Khan why she needed to be moved, however the link worker was not there and a message was left to contact the ward. However, it was decided to move Mrs. Khan immediately rather than wait for the link worker to contact the ward. Two auxiliary nurses went to Mrs. Khan’s bed and began taking her belongings into the side room, and Mrs. Khan was left to wonder what was happening. The student felt totally helpless because she could not communicate to Mrs. Khan what was happening and reassure her.

By the time Mrs. Khan had been moved in to the room she was heartbroken, and all that the student could do was stroke her hand until the link worker finally arrived. Once the link worker arrived and the situation was explained to Mrs. Khan, she calmed down somewhat. However, the patient had been very upset because of the lack of communication and interpersonal skills that the staff and the student had displayed.

Discussion. (1500 – 1800)

The literature regarding communication and interpersonal skills is vast and extensive. Upon reading a small amount of the vast literature available, the student was able to analyze the incident, and look at how badly this situation was handled. However, although the student felt at the time that she did not communicate effectively (due to the language barrier), it was found on reflection and reading the literature that she did do something positive.

One method of non-verbal communication the student used to communicate with Mrs. Khan was touch. Tutton (1991, cited by Kacperek, 1997) asserts that touch is an essential part of nursing care and can have many possible benefits for patients. Watson (1975, cited in Heath, 1997) identified two types of touch used in nursing practice: instrumental (a purposeful touch used to perform an action, such as washing a patient) and expressive (a spontaneous touch to convey feeling). Expressive touch was the intended use in the incident with Mrs. Khan. The student used this to try to convey her own feelings to Mrs. Khan. The student wanted to give Mrs. Khan some degree of comfort and communicate to Mrs. Khan that she cared.

The student also used touch to convey support, genuineness and empathy, which is essential for the helping relationship (Betts, 2002, cited in Kenworthy et al, 2002). Carl Rogers (1967, cited by Betts, 2002, in Kenworthy et al, 2002) recommended three principal conditions necessary for effective counseling: empathic understanding, congruence or genuineness and unconditional positive regard.

Kalisch (1971, cited by Betts, 2002, in Kenworthy et al, 2002) describes empathy as: “the ability to sense the client’s world as if it were your own, but without losing the as if quality”. Empathy involves understanding the patient’s world whilst staying in touch with your own world. Empathy is frequently perceived as the most significant element of the helping relationship (Betts, 2002, cited in Kenworthy et al, 2002).

The terms genuineness and congruence are used interchangeably and used to describe the helper always being real in the helping relationship (Betts, 2002, cited in Kenworthy et al, 2002). Genuineness is important to the patient. When nurse’s offer support it must be genuine, nurses cannot pretend to be interested, supportive and sympathetic (Burnard, 1992).

The third condition vital for effective counseling according to Rogers (1967, cited by Betts, 2002, in Kenworthy et al, 2002) was unconditional positive regard. This can be defined as accepting and caring for the patient without any conditions in place, that is to say accepting the patient for what they are, as a whole, no matter what (Betts, 2002 in Kenworthy et al, 2002).

As the student could not communicate verbally with Mrs. Khan, the student attempted to use non-verbal communication (that is to say touch) to convey empathy, genuineness and unconditional positive regard. The student also attempted to use other methods of non-verbal communication in order to implement these vital components to her relationship with Mrs. Khan.

During the times that the student sat with Mrs. Khan, the student attempted to show she was listening to Mrs. Khan, even though the student did not understand Mrs. Khan’s language. The behaviour of the person listening to the person who is talking is important during the interpersonal process (Unknown, 1990; Burnard, 1992). In order to use appropriate behaviour whilst Mrs. Khan was talking the student attempted to use Egan’s SOLER (Egan, 1990, cited in Unknown, 1990 and Burnard, 1992).

The SOLER acronym is an aid to identifying and remembering the behaviours that should be implemented in order to promote effective listening (Burnard, 1992). The student Sat facing Mrs. Khan; she assumed an Open posture; Leaned towards Mrs. Khan slightly (in order to express interest); maintained Eye contact and attempted to appear Relaxed, as advised by Egan (1990, in Unknown, 1990 and Burnard, 1992). The student believes that this interaction was beneficial to Mrs. Khan as it was one of the few times Mrs. Khan was in a position to talk to another person and Mrs. Khan’s non-verbal communication conveyed this. Mrs. Khan appeared to also adopt the SOLER approach; she sat facing the student, openly and leaned slightly towards the student, maintained eye contact with the student and appeared to be relaxed. Mrs. Khan’s eyes conveyed warmth and Mrs. Khan also smiled whilst she was talking to the student.

Bush (2001) asserts that non-verbal communication is just as important as verbal, and that interpreting non-verbal cues can become easier if nurse’s remain aware of patient’s eye contact, expressions, gestures and so on. Bush (2001) also maintains that non-verbal communication is a part of the communication process and cannot be separated from the verbal part.

The nurse-patient relationship according to Bradley and Edinberg (1986, cited in Rowe, 1999) can be an equal partnership or unequal. However, patients are placed in a position of vulnerability and dependence, as they are reliant on the nurse for safe and effective nursing care. This gives the nurse a degree of power over the patient (Rowe, 1999). The nurses on the Adult Rehabilitation Ward had a degree of power over Mrs. Khan. The nurses had a choice of whether to wait for the link worker to effectively communicate to Mrs. Khan the reason why she was to be moved to a side room, or move her anyway and tell her why after the task had been completed. The nurse’s chose to implement the latter option because of the issue of time. Bush (2001) argues that regrettably, the lack of time available to nurses stops them from offering effective communication.

The issue of the power that the nurse’s had over Mrs. Khan reflects Berne’s theory of Transactional Analysis. Transactional analysis is a method of observing, analyzing and understanding all form of verbal and non-verbal interactions and behaviours (Freedman, 1980, cited by Bailey, 1996). The central theme of transactional analysis is that the personality is divided into three ego states: parent, adult and child (Rowe, 1999). The parent ego is where behaviours are copied from our parents; the adult ego state is where behaviours, thoughts and feelings are balanced and reasonable and the child ego state refers to behaviour repeated from childhood (Bailey 1996; Rowe, 1999).

Transactional analysis examines communication between people and identifies the ego states in play. Transactions can be either complementary (a suitable and steady flow of communication) or crossed (where the ego state differs in the communication). This is the transaction that occurred in the incident with Mrs. Khan. The nurses adopted a parent ego state and placed Mrs. Khan in the child ego state, resulting in Mrs. Khan feeling hurt and vulnerable. This parent-child transaction is inappropriate when caring for patients; a complementary adult-adult transaction should be used instead (Rowe, 1999). In other words the nurses on the ward should have waited for the link worker before moving Mrs. Khan.

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Along similar lines is Heron’s Six Category Intervention. The theory behind six category intervention is the classification of effective communication between the nurse and the patient. Six category intervention examines nursing interventions and identifies them as either authoritative or facilitative (Rowe, 1999). The term authoritative is further categorized into prescriptive (attempting to direct behaviour), informative (informing and/or instructing the patient with new knowledge) and confronting (directly challenging the attitudes, beliefs and behaviours of the patient). Heron categorizes facilitative as cathartic (releasing tension by encouraging the release of emotions), catalytic (drawing out information in order to reflect and enable the patient to learn and develop self-discovery) and supportive (assert the value and worth of the patient (Rowe, 1999).

The six category intervention relates to the nurse-patient relationship and the notion of the nurse having controlling power over the patient. The nurses on the ward took the authoritative role over Mrs. Khan rather than the facilitative. The importance of six category intervention is that it aids the nurse in identifying the intention of clinical interventions. Nurses reflecting on which categories they are skilled in and which they are not, aids identification in practice of what skills that the nurse needs to improve upon (Rowe, 1999).

Communication is vital for all patients, but communication with the elderly brings with it its own uniqueness. Lubinski (1981, cited by Gravell, 1988, in Squires, 1988) states that

The ability to communicate, either verbally or non-verbally is the single most important skill older people need to remain valued and contributing members of their surroundings.

Nurse-patient relationships with older people have tended to implement the parent-child ego state of Berne’s transactional analysis (Koch et al, 1995, cited in Heath, 1997). Older people are presently the chief client group in the majority of areas health care and communication has been identified as a crucial part of nursing practice that needs improving in this client group. Older people have had longer to participate in and adapt to communication than any other group of people and have a vast amount skills for people to learn (Heath, 1997).

The concept of self-awareness is also vital for effective communication skills (Fielding, 1995). The nurse needs to be aware of aspects of themselves that can considerably affect interactions with patients (Betts, 2002, in Kenworthy et al, 2002). Self-awareness is not just asking ‘who am I?’ but asking ‘what is the effect of me on this moment and other people?’ especially for nurses (Rawlinson, 1990, cited in Rowe, 1999). Reflective practice and self-assessment, which is the aim of this report, is one way of becoming self-aware, with the ultimate aim of learning from the reflection and improving communication skills. Heron’s six category intervention and Berne’s transactional analysis are both effective ways of increasing self-awareness (Rowe, 1999).


The UKCC Code of Professional Conduct states that the nurse should “…act at all times in such a manner as to safeguard and promote the interests of individual patients and clients” (UKCC, 1992). The nurses on the ward did not show their awareness of this clause whilst caring for Mrs. Khan. The nurses used their power over Mrs. Khan and placed in a position that caused her to feel hurt and vulnerable, therefore their approach did not promote the best interests of Mrs. Khan. They opted for the parent-child ego state of Berne’s transactional analysis and the authoritative approach of Heron’s six category intervention (Rowe, 1999).

At the time of the incident student felt very inadequate. She felt that she was not a good advocate for Mrs. Khan, nor did she fulfill the clause of the UKCC’s Code of Professional Conduct and act in her best interests (UKCC, 1992). The hardest part for the student was not being able to communicate verbally with Mrs. Khan. However, upon examining the literature regarding communication and interpersonal skills, she felt that she did help Mrs. Khan, if only in a small way. The invaluable use of non-verbal communication has now become clearer to the student. The student believes she has become more self-aware regarding her own non-verbal communication and hopes that in the future she will use her communication skills to become a better advocate for the patient in her care.


Bailey, J. (1996) Transactional analysis: how to improve communication skills. Nursing Standard. Vol. 10, No. 5, pp. 39-42.

Burnard, P. (1992) Communicate! A communication skills guide for health care workers. London: Edward Arnold.

Bush, K. (2001) Do you really listen to patients? RN. Vol. 64, No. 3, pp. 35-37.

Fielding, R. (1995) Clinical communication skills. Hong Kong: Hong Kong University Press.

Heath, H. (1997) Communicating with older people. Nursing Standard. Vol. 11, No. 16, pp. 48 – 56.

Kacperek, L. (1997) Non-verbal communication: the importance of listening. British Journal of Nursing. Vol. 6, No. 5, pp. 275 – 279.

Kenworthy, N. et al. Eds. (2002) Common foundation studies in nursing. (3rd edition) London: Churchill Livingstone.

Maslin-Prothero, S. Ed. (1997) Baillière’s study skills for nurses. London: Baillière Tindall.

Rowe, J. (1999) Self-awareness: improving nurse-client interactions. Nursing Standard. Vol. 14, No. 8, pp. 37-40.

Squires, A.J. Ed. (1988) The rehabilitation of the older patient. A handbook for the multi-disciplinary team. London Croom Helm Limited. P. 41.

Unknown. (1990) The student nurse’s guide to counseling. Nursing Times. Vol. 86, No. 12, p. 56.

UKCC. (1992) Code of professional Conduct. London: UKCC.


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