FLA B

Example of FLA Assignment B

Critical Reflection of an Increased Arousal Incident at Work

The Incident

As an intensive care nurse in a large, tertiary hospital, I am responsible for the planning, management and evaluation of complex care for patients who are critically unwell. A large component of this role is patient and family advocacy, which is especially important when caring for patients, who due to their illness, may be unable to express their own wishes regarding treatment and support. This was particularly relevant for a young international patient I was caring for one night, who was brought in by a close friend (Max) with acute septicaemia. Max had known the patient for several months, and said that due to his religious beliefs, the patient would not want to receive blood products. His mother, cited as next-of-kin, was located in Germany, and was unable to be contacted to confirm treatment options.

Along with myself, other people caring for the patient that night were the ICU registrar (Dr X) and the Clinical Nurse Specialist (CNS). As the shift progressed, the patient became increasingly unwell. Despite the significant protestations of Max, and my attempts to advocate for the patient, a decision was made by Dr X and the CNS to deliver blood products to stabilise the patient’s condition. Whilst this treatment ultimately proved successful, the patient, his mother and Max were distressed that treatment had been given which contradicted the patient’s expressed wishes and beliefs.

Self-reflection

Reflecting on this incident, I can identify that my arousal increased as the patient became increasingly unwell. I experienced a building negative valence due to stress regarding the patient’s worsening condition, which was compounded by the anxiety and distress emanating from Max. My negative valence was further amplified by the decisions made by Dr X and the CNS, and the ensuing conflict. Whilst I recall feeling angry and frustrated at the time, upon reflection, this heightened state of arousal was as a result of the helplessness I felt in being unable to successfully advocate for the patient. Furthermore, this incident contradicted my own values and beliefs, which Sulmasy (2019) suggests is a powerful motivator for healthcare induced stress. Whilst the patient’s condition did stabilise, I was left feeling guilty and self-critical, repeatedly re-examining my decisions, and ruminating whether I could have done more to advocate for the patient.

2

Structured Reflection

Table 1:

A reflective exercise on the effect of our emotions on behaviour

Emotion	Behaviour	How did emotion influence behaviour?
· As the patient was being admitted, I felt nervous. I could feel my heart rate increasing, and had the sensation of ‘butterflies’ in my stomach.	· I worked quickly to prepare for the patient, working mostly in silence and concentrating on immediate tasks. · By nodding and asking follow-up questions, I tried to actively listen to critical information about the patient, and wrote multiple notes.	· My nervousness, accelerated heart rate and ‘butterflies’, were due to the release of adrenaline as part of the fight-or-fight response, which Young (2012) argues is initiated to maintain focus in periods of acute stress. This enabled me to maintain full concentration on the patient’s needs, which was appropriate behaviour in this context. · My active listening skills enabled me to elicit critical information about the patient. My behaviour in drawing out further information was appropriate, although this could have been expanded by paraphrasing, which would have confirmed the accuracy of understanding (Eunson, 2012).
· As the patient’s condition deteriorated, I could feel my stress, anxiety and focus increase.	· I continued to work quickly, but due to the volume and complexity of work, I delegated some tasks to my colleagues. · My communication was direct and assertive.	· I was self-aware of my increasing stress, and recognised the need to seek support from my colleagues. Faguy (2012) argues that self-awareness is critical in dealing with stress and managing sensitive healthcare issues. · With the patient’s condition deteriorating, the use of assertive communication was suitable, as clear and direct communication has been shown to reduce the likelihood of errors (Eunson, 2012).
· During the conflict with Dr X and the CNS, I felt angry, frustrated and helpless. · I was shaking, my face was flushed, and I could hear my heart pounding. · Although I felt hyper-alert, I found it difficult to process decisions.	· Although I attempted to be direct and assertive, my voice was raised above normal volume. · I was shaking my head, saying “no”, and gesturing to my notes where I had written the patient’s treatment wishes.	· The angry and distracted behaviours I demonstrated were a result of the intense emotions I was feeling. Whilst these behaviours may be considered a typical anger response, Faguy (2012) suggests that it may signal emotional immaturity. On reflection, more appropriate behaviour may have been to take some calming breaths, take a short break, or try an alternative approach to express my viewpoints (Faguy, 2012).
· Following the incident, I was exhausted and felt a sense of injustice and guilt. · I was self-critical and saddened by my decisions and performance.	· I said goodbye in a quiet, shaky tone, with my eyes and head lowered. · I moved slowly and quietly, taking longer to achieve tasks than earlier in the shift. · For several weeks I was flat and subdued at work, avoiding social interactions.	· The behaviors I demonstrated are consistent with prolonged stress. De Hert (2020) suggests that whilst stress can heighten awareness, extended exposure can lead to diminished mental functioning and fatigue. Furthermore, Faguy (2012) argues that failing to appropriately manage emotions can result in feelings of being overwhelmed, which may have been reflected in my flat affect and feelings of ongoing guilt and sadness. · The negative thoughts and behaviours I demonstrated may be attributed to excessive rumination, which Coffey et al. (2010) suggest can be improved by practicing mindfulness.

Table 2:

A reflective exercise on interpreting behaviour

Behaviour	Interpretation and emotion	Alternative interpretation and emotion
· Dr X was initially speaking in a relaxed tone with a neutral expression, but became increasingly agitated and abrupt. · As the situation intensified, he started shouting. His lips became pursed, his eyes narrowed, and his nostrils flared. · As the patient’s wishes were not formally recorded, and the next-of kin could not be contacted, Dr X declared that he “knew best” and ordered the CNS to comply with the treatment.	· Initially, I interpreted the behaviour of Dr X as professional and I felt comfortable approaching him. · As the patient deteriorated, I felt increasingly intimidated by Dr X’s aggressive tone and pitch, which along with his facial impressions, I interpreted as anger. · I felt frustrated at Dr X’s decision-making, and interpreted his remarks as arrogant and lacking in empathy.	· Loewenstein (2005) argues that whilst most medical decisions are made by well-meaning healthcare professionals, many have a difference perspective from the person impacted by the decision. This can result in an empathy mismatch, with negative consequences for ongoing decision-making (Loewenstein, 2005). Having a greater understanding of this potential mismatch may have prevented me responding in anger and frustration to Dr X and the CNS. Instead, adopting a more rational and calm approach may have provided greater situational clarity and harmony (Faguy, 2012). · Furthermore, Lowenstein (2005) suggests that in some circumstances, the dispassionate perspective of the healthcare professional may be the most suited for making decisions which meet long-term patient needs. Whilst neither Dr X or the CNS could be considered dispassionate, this alternate interpretation and motive of their behaviour could have elicited greater understanding and support. · The behaviour of Dr X and the CNS may have also been driven by stress, which De Hert (2020) argues can impede decision-making, productivity and work-attitude. Molero Jurado et al. (2019) further explain that in addition to experiencing their own stressors, healthcare professionals are vulnerable to experiencing the stress and concern from patients and families, placing further pressure on their decision-making abilities.
· The CNS was initially helpful and focused on providing support. She was smiled and frequently made eye contact. · However, as the conflict arose, she became increasingly morose and silent, making sounds of disapproval. · Without making eye contact with me, she informed Dr X that he could leave the care of the patient in her hands.	· I considered the early behaviour of the CNS to be friendly, evoking a sense of trust and rapport. · As the shift progressed however, I felt her to be condescending and inpatient, interpreting her behaviour as lacking in empathy and respect.

Emotional Intelligence Model

Whilst several theoretical models of emotional intelligence (EI) have been developed, Goleman’s model (1995) most closely relates to the workplace incident described. This model focuses on the EI components of self-awareness, self-regulation, motivation, empathy and social skill (Goleman, 1995). Of these, the domains of self-awareness and empathy are the most pertinent to this situation, as these reflect EI capabilities focused toward the self and others (Hurley & Linsley, 2012).

Self-awareness has been described as the cornerstone of EI, acting as a reliable guide in understanding our emotions, motivations and desires, and how these affect others (Faguy, 2012). I demonstrated some self-awareness skills that night, such as self-confidence, which was reflected in my assertive communication and listening behaviours. However, having a deeper understanding of my emotions (such as fear, helplessness and frustration), and their impact on my colleagues, may have helped to defuse the situation. Whilst the outcome for the patient may have remained the same, recognising and managing my emotions in a more controlled and objective manner may have improved the team’s communication and re-focused our attention. Furthermore, as there is a direct relationship between emotional intelligence and effective conflict management (Hopkins & Yonker, 2015), developing a greater self-awareness of my emotions, and how to manage these, will be critical in responding to similar incidents in the future.

Self-awareness also provides a foundation for understanding the emotions of others, or empathy, which Goleman (1995) suggests is critical in building and managing relationships. Empathy involves recognising and interpreting the emotions of others, without judging their value or validity (Faguy, 2012). Upon reflection, whilst I was empathetic to Max’s emotions, had I directed empathy toward Dr X and the CNS, I might have gained an appreciation of their emotions, and a greater understanding of their behaviour. This would have provided me with further insight into their decision-making processes, improving ongoing communication and collaboration (Faguy, 2012). As Issah (2018) suggests, empathetic individuals know when best to communicate with emotion, and when to communicate with reason. Further developing skills in self-awareness and empathy will strengthen my EI, which Faguy (2012) argues is an essential requirement for effective leadership.

References

Coffey, K. A., Hartman, M., & Fredrickson, B. L. (2010). Deconstructing mindfulness and constructing mental health: Understanding mindfulness and its mechanisms of action.  Mindfulness,  1(4), 235-253. https://doi.org/10.1007/s12671-010-0033-2

De Hert, S. (2020). Burnout in healthcare workers: Prevalence, impact and preventative strategies.  Local and Regional Anesthesia, 13, 171-183. http://dx.doi.org/10.2147/LRA.S240564

Eunson, B. (2012). Communicating in the 21st century, 3rd edition. John Wiley and Sons

Faguy, K. (2012). Emotional intelligence in health care.  Radiologic Technology,  83(3), 237-253. http://www.radiologictechnology.org/content/83/3/237.short

Goleman, D. (1995). Emotional Intelligence: Why it can matter more than IQ, l0th edition. Bantam Books

Hopkins, M. M., & Yonker, R. D. (2015). Managing conflict with emotional intelligence: Abilities that make a difference. Journal of Management Development, 34(2), 226-244. DOI 10.1108/JMD-04-2013-0051

Hurley, J., & Linsley, P. (2012).  Emotional intelligence in health and social care: A guide for improving human relationships. Radcliffe Publishing

Issah, M. (2018). Change Leadership: The role of emotional intelligence. Sage Open, 8(3), 1-6. DOI: 10.1177/2158244018800910

Loewenstein, G. (2005). Hot–cold empathy gaps and medical decision making. Health Psychology, 24(4), 49-56. DOI: 10.1037/0278-6133.24.4.S49

Molero Jurado, M. D. M., Pérez-Fuentes, M. D. C., Oropesa Ruiz, N. F., Simón Márquez, M. D. M., & Gázquez Linares, J. J. (2019). Self-efficacy and emotional intelligence as predictors of perceived stress in nursing professionals.  Medicina, 55(6), 237-251. http://dx.doi.org/10.3390/medicina55060237

Sulmasy, D. P. (2019). Conscience, tolerance, and pluralism in health care.  Theoretical Medicine and Bioethics, 40(6), 507-521.https://doi.org/10.1007/s11017-019-09509-5

Young, E. (2012). Alimentary thinking. New Scientist, 216(e2895), 38-42. https://doi.org/10.1016/S0262-4079(12)63204-7