INTRODUCTION

This assignment is an analysis of a critical incident on gastric lavage of a neonate that took place during a clinical placement at the Central Regional Hospital of Cape Coast on a Pediatric ward. A brief description of the incident will be given. Theoretical models and selfcare principles will be incorporated in the analysis. I will apply Gibbs (1988) reflective model to identify my own strengths and weaknesses noted in the analysis and how they may be enhanced to create further strength. In conclusion, I will state how much I have gained from the actual experience and the structured reflection. Pseudonyms shall be used to maintain confidentiality. Experiential learning and its associated teaching methods have become popular in nursing and midwifery education in recent years. It is suggested that experiential learning strategies provide opportunities for students to develop interpersonal skills, self-awareness, reflection, insight, ability to express emotion and problem solving skills, all of which are desirable for professional growth (Burnard 1989; Iwasiw & Sleihgtholm 1990). Burnard (1988) defines knowledge as propositional, practical and experiential. Experiential knowledge is knowledge gained through direct encounter with a person, object or place. Experimental learning is a process in which a particular experience on reflection translated into concepts which in turn become guidelines of new experiences. Experiential learning always begins with the experience and is followed by reflection, analysis and evaluation of the experience. For this reasons there is a growing interest in the role of writing in learning, where by students use writing as a tool to foster reflection on specific experiences (Walker 1985). Critical incident analysis involves both writing about and reflecting on, an experience/incident which occurred in the practice setting. It is therefore suggested that critical incident analysis can be used effectively as an educational tool

to assist nursing and midwifery students to learn from their experiences, thus providing the opportunity to develop new skills, knowledge and attitudes. Flanagans original (1954) definition of a critical incident is an observable human activity that is sufficiently complete in itself to permit inferences and predictions to be made about the person performing the act. Critical incident analysis requires the student to recall the experience, identify feelings and then to learn through the process of writings and/or role playing the critical incident for analysis. As a result the student may demonstrate outcomes of the experience within any of the educational domains as identified by Watson (1991): affective (emotions or attitudes), cognitive (knowledge), or psychomotor (skills). In the analysis, the experience or incident is translated into concepts which in turn illuminate future experiences. BODY Self-assessment of this clinical self-care procedure was done through the use of Gibbs (1988) reflective model to question what could have been done to such incident should it occur in the future. Gibbs described six steps of reflection: description, feelings, evaluation, analysis, and conclusion and action plan. Description of the event The account occurred on the Pediatric ward. The client in question is a preterm neonate who had been delivered only some several hours ago through caesarian section. The neonate was brought to NICU of the Pediatric ward while the mother was being taken care off at the Obstetric and Gaenacology ward. The client was admitted into the ward at 2pm that day. In the night, I was on duty with two rotation nurses and one enrolled nurse as the in charge. The ward was handed over to us by the afternoon shift staff after all activities and documentation had been

ensured to have been done. Immediately, we took over the ward and carried on with nursing activities and documentation. At about 11pm medications, vital signs, feeding, changing of diapers and all activities had been performed. As a result all the neonates were fast asleep except for this preterm neonate who was under a radiating heater in his cradle to provide warmth. The client continually kept crying with little intermediate sleep. His diapers were changed since soiled diaper is a major reason why neonate cry, we fed extra to rule out hunger. Eventually we found thick bloody mucous in his mouth and so we took turns to suction. This was done with a suction enema, a gallipot to receive the mucous and gauze to protect the mouth. The client became temporarily relieved and slept any time we suctioned but the secretions continually flowed into his mouth and made him to cry any time it happened. After about an hour of continual suctioning we realized the neonate was having shortness of breath and was cyanotic at the extremities. This prompted us to seek for medical attention but all efforts proved futile. This was because the only medical officer on duty in the hospital was also very busy attending to other emergency cases at the Accident and Emergency Unit and was on call for other emergencies like cervical tear in other wards as such he was not immediately available to attend to this client. This was documented and after about another hour of still suctioning the nurses were so tired they retired to sleep in order to wake up later and perform their routine activities before day break. But the situation will not put me to rest and so I stayed on to continually suction and reposition this baby just to afford him some sleep. At 2:30am I realized the baby was in respiratory distress but anything I had done did not make the situation any better. I then decided to carry on with a gastric lavage, an idea I had suggested shortly before they all retired to sleep. This was a procedure that was not very common but was done on the unit. The in-charge felt reluctant to do it when I had first suggested it earlier and did not do it. I also could not do it

earlier because I had never passed a naso-gastric tube before and I lacked the necessary confidence to go on ahead and carry it out. But after staying with this baby all this while and seeing the baby in respiratory distress, I gathered the courage to perform the procedure. I quickly collected the needed equipment i.e. naso-gastric tube (neonatal size), lavage solution (normal saline), syringe (10cc), bath towels to absorb any drainage and gallipots. I still felt I needed to be supervised and so with a sense of urgency I woke up the in-charge to supervise me while I do the procedure. In her sleepy state she stood by me while I tried to pass the naso-gastric tube on two occasions but was met with obstructions in all attempts. At this point she took the NG tube from me and with some effort passed the tube. Immediately the tube got into the stomach, the lumen of the tube filled with fluid. With the 10cc syringe she then aspirated the gastric content and to our disbelief, thick bloody coffee brown gastric content was aspirated and immediately you could see the relief on the babys facial expression. After drawing 30cc of the content, the baby began to sleep. We drew 20cc more of this content and lavage until the stomach contents returned clear with 20cc of normal saline. The procedure was recorded. My feelings having experienced the incident I believe that I achieved the second phase of the reflective cycle, as I felt unsure about being able to perform this procedure. The incident left me with the feeling that due to my lack of confidence the baby could have died. Nevertheless, I also felt a sense of fulfillment when I was credited by the in-charge and my other colleagues on duty for the way I dealt with the client. Actors views (evaluation) of the situation Using the third phase of the cycle, although the nurses felt I had catered for the client in the correct way they advised me to be more assertive in the future any time I have a conviction

about something. This is because patient care is team work which involves inputs and ideas from members of the team in order to deliver care to patients. Analysis of the incident Gastric lavage is the washing out of the stomach via a nasogastric tube or stomach tube. Lavage is ordered to wash out the stomach (after ingestion of poison or an overdose of medication, for example) or to control gastrointestinal bleeding. In this babys case, he had swallowed amniotic fluid during the caesarian section which had eluded the theatre team because they thought they had aspirated all the meconium. And that made him a candidate for the procedure. Conclusion and action plan Using the fifth and sixth phase of the cycle, Gibbs (1988) asks the question, what else could you have done? in the conclusion phase of his reflective cycle. I felt I could have passed the naso-gastric tube if I had been more calm and relaxed. In future I will be more assertive about my opinions until proven wrong or better alternatives are provided as part of my action plan if the situation arose again. CONCLUSION In conclusion, there is much to be gained from the experience and the structure of reflection. This critical incidence on gastric lavage has made me appreciate the role of the nurse as a care giver and has enabled me to acquire skills in the clinical area. The bold decision helped me provide care and helped save the life of the baby.

REFERENCES Burnard, P., 1988, Building on experience. Senior Nurse 8(5): 12-13. Burnard, P., 1989. Experiential learning and andragogy-negotiated learning in nurse education: a critical appraisal. Nurse Education Today 9:300-306. Flanagan, J., 1954, The critical incident technique, Psychological Bulletin 51(4): 327-358. Gibbs (1988) in: RCN Realizing Clinical effectiveness and Clinical Governance through Clinical Supervision Practitioner book 1, RCN Institute, Radcliffe Medical Press, Oxford. Iwasiw, C.L., Sleightholm-Caims, B.J., 1990. Clinical conferences- the key to successful experiential learning. Nurse Education Today 10:260-265. Palmer, A. et al (ed.), 1991, Reflection practice in nursing: The growth of the professional practitioner: Blackwell Scientific, Oxford. Walker, D., 1985, Writing and reflection. In : Boud, D., Keogh, R., Walker, D.,(eds) Reflection: turning experience into writing. Kogan Page, London. Watson, S.J., 1991. An analysis of the concept of experience. Journal of Advanced Nursing. 14(16): 1117-1121.