Teaching and Learning Forum 97 [ Contents ]
Using critical incidents in professional education to
develop skills of reflection and critical thinking
School of Nursing
Curtin University of Technology
Critical incidents can help senior students extend to skills of reflection and critical analysis. Curtin midwifery students use a process developed by Tripp (1993) to work through events which occur in every day clinical practice. This process requires the students to describe and incident together with the social context in which it occurred. It might be an interaction between a colleague and client which made the student feel uncomfortable, upset or even very positive. Next, the student must explain the meaning of the incident within that social context, then provide a more general meaning. This forces the student to go beyond their personal response and consider the "bigger picture". Through reflecting on and analysing the components of the incident, the student increases their ability to withhold judgement until all aspects of a situation have been considered. This presentation will show you how to use critical incidents. In addition it identifies benefits and common pitfalls when using them in professional education programs.
Increasingly university programs, with clinical or field components that require paid supervisors, are being asked to find ways to reduce expensive practicum time. This means that students can expect to receive much less exposure to real world situations during their program of study. How can we help students make the most of their experiences - and move beyond the egocentric focus of task completion and manual skills to develop the skill of professional judgement?
Critical incident work is one way we can assist the student to extend to cognitive skills of reflection and critical analysis. It is not always an easy process. In fact you can probably expect that the most needy students will be those who experience the greatest difficulty in making this conceptual leap!
What is a critical incident?
My use of critical incidents stemmed from reading about Tripp's (1993:42) contention that any event could be analysed to create a critical incident. This was important for me because; within the discipline I teach, much of what the student must learn involves working effectively and cooperatively as part of a team, comprising not only health professionals but a birthing family. I reasoned that if students could be taught to apply a simple technique to analyse events in clinical experience, it might facilitate their appreciation of the multiple variables to consider, the interaction between those variables and how this can affect the resulting outcomes.
The idea that any event in professional practice can be treated as a critical incident cannot be overemphasised. Tripp (1993:24-25) wrote that:
The vast majority of critical incidents...are not at all dramatic or obvious: they are mostly straight forward accounts of very commonplace events that occur in routine professional practice which are critical in the rather different sense that they are indicative of underlying trends, motives and structures. These incidents appear to be 'typical' rather than 'critical' at first sight, but are rendered critical through analysis.
Teaching critical incident analysis
Midwifery students report that critical incidents have helped them in a variety of ways. These include: 'becoming more analytical'; helping me identify my position in ethical dilemmas', and 'helping me think about all the things that go on in clinical and where I fit in'. One of the methods advocated by Tripp (1993:26) involves the steps of a) describing an incident b) providing a contextual explanation of the incident c) finding a more general meaning, and d) articulating a position . These steps are outlined as follows together with some of the printed instructions I usually provide for the students.
As part of the assessment requirements for the midwifery program, students are invited (it is an optional item) to compile a critical incident file. Over a period of 14 weeks the students are required to create at least 12 critical incidents by analysing events which occur during their clinical experience. These events may involve an interaction between a colleague and client which made the student feel uncomfortable, upset or even very positive. By analysing the event to produce a critical incident the student is forced to go beyond their personal response and consider the "bigger picture". Through reflecting on and analysing the components of the incident, the student increases their ability to withhold judgement until all aspects of a situation have been considered.
- Describe an incident and the social context in which it occurred:
At 0930 I went down to room 18 to do Tracey's antenatal 'obs'. She was on strict bed rest with bathroom privileges due to worsening blood pressure problems at 35 weeks gestation. I had spent nearly two hours talking with Tracey yesterday about her pregnancy and how she could help to carry the pregnancy to term. Tracey is a single mother aged 24 with two children aged 4 and 6. She lives with her mother and younger brother. Anyway, when I arrived at her room, the lady in the next bed said Tracey had 'gone down for a smoke'. I was...!
- Explain the meaning of the incident within that social context:
By deciding not to comply with her plan of care in this way, Tracey was demonstrating her...
- Provide a more general meaning. Ask yourself:
- Identify your position
A student's perspective
Initially I found working through an incident critically both difficult and time consuming. It was difficult because I had to consider and rationalise, in addition to my own, the actions and outcomes of the other participants involved in the incident. This was something that I had not previously commonly practiced. I also found searching for a 'critical incident' within my professional practice difficult. If was after several weeks of examining one's own practice, in addition to conversing with my lecturer, I became confident in addressing incidents. The focus of my assessment on an incident has changed from "I" to one of "us". I now question what is actually going on within the incident; what processes are at work within the incidents (for example what or what is influencing the participants actions or involvement within the incident; and whom is most affected by the incident. It has also enabled me to examine my role within the incident and develop strategies to prepare and equip myself to deal with future incidents. Reflecting on the 10 months of critical incidences, I have progressed from identifying what I would or should have done, to actually implementing what I believe to be appropriate at the moment.
An actual incident
I had birthed the baby's head, checked for cord around the baby's neck and was now awaiting the birth of the body. It was following the restitution of the baby's head, I noticed a left sided cleft lip and a skin tag approximately 1 cm in length above it's left eye. I continued assisting the birth and before passing the baby to its mother I said "You have a beautiful baby". The mother became concerned once she saw the cleft lip and skin tag. She asked repeatedly "What is wrong with it". I then quickly asked "What is it - a boy or a girl?". She then looked and replied "A boy. but what is wrong with it"? She became increasingly distressed, closed her eyes and began crying. The father of the baby was also visibly distressed with what he say and his wife's distress. The doctor, who was present at the birth reassured the couple by explaining what it was and that it was common. I continued to say "Congratulations what a beautiful baby boy you have". The paediatrician was called, who later organised for the baby to be transferred to a larger hospital. Approximatley 2 hours later, I found myself alone with the mother who was nursing her newborn, I approached the bed and said "He's just beautiful". The mother said "Yes he is. When you handed him to me saying he was beautiful and then I saw his face I thought it was a sick joke. But now, I can see past the lip and actually see my beautiful baby. It was real shock". I agreed and went on to say hat he was a very special baby and will have been given a very special gift ; a gift to assist him through tough times. Two days later I saw the mother and she came up to me and asked if I remembered telling her about his gift. I replied "Yes" and she went on to tell me that he had a will of steel. She did not know such a small baby could be so determined, but he was. She also said he was very affectionate and alert. She agreed her baby was very special.
Meaning of the incident within the social context
The parent's reactions, when they first saw their newborn with the skin tag and cleft lip were normal and to be expected. It is every parent's wish/need to have a normal healthy baby and such disfiguration can be very disturbing. By reinforcing to them they had a beautiful baby, regardless of its present disfiguration, we, as health professionals are providing reassurance. Acceptance by the health care team, family and friends of the newborn is very important to parents. I believed what I said and supported my actions, showed the parents I regarded their baby to be equal to all the other babies I had birthed, if not more special.
General meaning of the incident
This was a very difficult time for the parents and one for which they could not have been prepared. The cleft lip, in addition to the skin tag, was very visible and quite frightening to the couple who had never seen nor heard of this condition. It had been a difficult labour and seeing the disfigurement of their newborn was more than they could cope with. It was also difficult for the health professional present at the birth. The distress of both parents was upsetting, particularly when the birth of a newborn is such a momentous occasion and usually a time of great joy and jubilation.
Reflecting on the incident, I do not believe I would have changed what I said and did. I believed it was imperative that the parents received maximum support and reassurance and I began providing support when I informed the couple they had a beautiful baby prior to handing them the newborn. I answered their questions honestly and with sensitivity found the mother's feedback about my care a couple of days later invaluable, because, I did wonder whether I had said the right thing prior to placing the newborn on his mother's chest. Several hours after the birth, the midwife who was present at the birth asked if I knew the baby had a cleft lip while I was assisting the birth. I replied "Yes" and she said "Oh " and walked away. After some deliberation I approached her and asked if there was anything she thought I should have done to enhance the parent's experience during the birth. I was searching for the reason behind the "Oh". She replied, "No" and continued on her way. I have since approached other individual and discussed the birth, but still maintain I did the right thing under the circumstances.
Why use critical incidents in professional education?
It is evident from the example provided here that situations may be complex and varied. Furthermore that there is a potential for students to misinterpret the meaning of an event in a particular social context - especially in the initial phases of the educational program. Tripp (1993:43) informs that although we may use critical incidents in an attempt to confirm what we already suspect is correct, as happened in Catherine's example, the analysis can in fact reveal something new entirely. Tripp (1993:125) goes on to say that broadly speaking the aim is to improve professional judgement. He quotes Schon (1983) who emphasised that "members of a profession are valued for their ability to act in situations where a lack of knowledge (there not being a 'the right answer') demands sound judgement". This is because professional judgement is less about memorising facts and correct answers, and more to do with "reflection, interpretation, opinion and wisdom".
Today's demonstration will further explore the process of developing critical incidents and highlight for you some of the benefits and pitfalls of using them in professional education programs. We look forward to you participation in our session.
Tripp, D. (1993). Critical incidents in teaching. Developing professional judgement. London: Routledge.
|Please cite as: Burgum, M. and Bridge, C. (1997). Using critical incidents in professional education to develop skills of reflection and critical thinking. In Pospisil, R. and Willcoxson, L. (Eds), Learning Through Teaching, p58-61. Proceedings of the 6th Annual Teaching Learning Forum, Murdoch University, February 1997. Perth: Murdoch University. http://lsn.curtin.edu.au/tlf/tlf1997/burgum.html|
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