Examplars
Critical nursing incidents where you made the difference
Helen Calabretto
School of Nursing, University of South Australia, SA
PP: 038 - 040
Article Text
Physical assessment skills - use them
Saras Henderson RN BScNsg MEd
Recently, I was working in a Special Nursing Care Unit with one of my third year nursing students. She was specialling a client who had been admitted to the unit because she had developed some postoperative complications following major abdominal surgery. The client was attached to a cardiac monitor and had intravenous therapy in progress. She also had an in-dwelling catheter and wound drain in situ. The student was allocated to care for the client with a registered nurse as her 'buddy', in case she needed help. As there were five other clients in the unit, the registered nurse had also been kept busy helping nursing staff with them.
Walking into the unit late morning, I noticed that my student was kept busy with the technical aspects of care of her client. I proceeded to talk with the client who immediately began to complain that her leg had been hurting all morning and that no-one had taken any notice of her concerns. On questioning the student, it was reported that the client had complained about her leg and that the student was waiting for the doctor, who was due any minute, to examine the client.
When I asked the student if she had performed a physical assessment of the client's legs, the student stated she had not done so as she was busy with the other care and because the doctor was due soon anyway. I immediately instructed the student to perform the examination which showed that the client had a swollen left calf, tenderness, heat in that area and a positive Homans' sign- a definite deep vein thrombosis. The doctor was notified immediately and intravenous heparin was commenced.
On reflection, the student stated that she should have used the physical assessment skills she had been taught. Had she done so, the intervention could have been carried out sooner and the client may not have suffered pain and discomfort all morning.
As educators, we need to stress to our students that they are being taught physical assessment skills, not for knowledge alone, but for practical application. Physical assessment is an essential part of nursing practice.
Traumatic incidents and debriefing
Judy Taylor RN RPN BNsg(Ed) GradDipHealthCouns
It was 3.00 pm on a quiet Sunday afternoon in the psychiatric community hostel where I worked as a deputy manager. I was standing in the office doing the boring task of filing the latest memorandums. Suddenly, two of the residents walked into the office without knocking and within seconds I was overpowered and handcuffed to a chair. Naturally I was surprised and a little shocked by this unusual interruption, although initially I was not afraid. I knew my captors; John, 22 years and Helen, 24 years (not their real names).
John and Helen were both ex-clients of a local psychiatric hospital. Both had been diagnosed with borderline personality disorder, were also mildly intellectually disabled and had a number of minor criminal convictions for offences such as arson and assault. Since arrival at the hostel for rehabilitation prior to returning to independent community living, they had behaved appropriately, been pleasant and I liked them both.
As John and Helen were mildly intellectually disabled, they were easily influenced by others and I soon discovered that there was a third person involved in this adventure. Mark, a 17-year-old visitor to the hostel had brought along recreational drugs as a gift for John and Helen on this particular Sunday. Apparently after smoking a few 'joints' and popping some pills Mark produced a set of steel handcuffs and suggested that they could all have some fun. 'Let's handcuff Judy'. Between 3.00 and 3.30 pm I was dragged around various parts of the hostel, handcuffed to different objects and tormented by the trio. I attempted to remain calm and tried to talk my way out of this predicament. John and Helen, however, were becoming increasingly excited with Mark encouraging them to try new forms of 'torture'.
At 3.30 pm, I was standing in the courtyard with both hands handcuffed behind my back, against a brick wall. I was feeling particularly vulnerable and was very aware that the medication keys (which were pinned to my belt) were accessible to my 'captors'. John realised I was beginning to lose my patience with them and he suggested that they let me go. Mark, however, sadistically refused and as I looked at him, I sensed that I was in considerable danger and that I would not be able to talk my way out of the situation.
I realised that I had to somehow take control of the situation and assert my authority. I lowered my voice a little, spoke slowly and clearly with what I hoped sounded like someone in control of the situation. I told them that if they came near me again I would start kicking them, at the same time warning them that I was experienced in martial arts and could kick quite powerfully. (I still remember that even as I spoke, my immediate thought was that as a registered nurse I should not hurt them as they were my clients).
John realised that I was now very angry and said that he would undo the handcuffs despite the protests of Mark and Helen. I was thankful that it was John who was in possession of the key since I believed the situation could have become more serious if it had been Mark. Once the handcuffs were removed, I quickly walked to my office, locked the door and rang for assistance.
John and Helen were later prosecuted by the Police Prosecutor and found guilty, each receiving a $10.00 fine and a 12-month good behaviour bond. Since Mark was not yet 18 years of age, he was prosecuted in the Juvenile Court and I do not know the outcome.
That, however, was not the end of the story. I received some support from colleagues, but was not offered any formal debriefing. Admittedly, this situation occurred in 1983 and at that time, the nursing profession was unaccustomed to the idea of debriefing after critical incidents. I believed that I had survived the incident without any significant ill-effects other than bruised wrists. I did not feel anxious (it was part of the job) and I required no time off-duty.
Two years later, when I was working in a rehabilitation unit for alcohol- dependent clients, Mark entered the unit requesting assessment to undertake the six week rehabilitation program. I was in charge of the unit that day and I was the only available nurse to conduct the assessment. Although Mark and I took only a few minutes to recognise each other, I told myself that I had to conduct the assessment in a professional manner and forget the past incident. Fifteen minutes into the interview I 'lost it'! Suddenly I was overwhelmed by intense feelings of anger and I realised that I wanted revenge. I wanted to scar and hurt Mark as he had done to me two years earlier. I stopped the interview, apologised to him that I could not continue and found a colleague to take over the assessment.
At home that night I was very upset and experienced a variety of unpleasant emotions but in particular the awareness that I wanted to hurt Mark-I wanted revenge! I called in sick the next day as I was afraid that if I had to face Mark I might hit him. Later that day, the staff from the unit rang me to say that Mark had not been admitted and it would be 'safe' for me to return to work. That encounter occurred nine years ago and I have not seen Mark since, nor have I received any formal debriefing or counselling about my experience of being handcuffed by three people, being held hostage and tormented for 35 minutes.
Perhaps writing this article is one method of communicating my need to discuss my feelings, however my main aim of sharing this experience with other nurses is to demonstrate the importance of providing professional debriefing/counselling for all people involved in critical or traumatic incidents in the workplace.
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