Reflective Essay: Case Study Analysis of Patient Care Incident in MHS

This reflective essay analyzes a critical patient care incident within a mental healthcare setting, where a patient with Schizoaffective disorder attempted self-harm. The essay uses Gibb's reflective cycle to evaluate the incident, focusing on the lack of psychiatric treatment, communication breakdowns between staff, and the patient's overall care. The author, in the role of a shift coordinator, describes the incident, analyzes stakeholder perspectives, identifies challenges related to implementation, and suggests tools for improvement, including better communication, staff training, and policy changes. The essay highlights the need for improved patient safety, ethical considerations, and a more supportive environment to prevent future incidents. The author also provides an action plan with steps to improve patient care and reduce the risk of similar events. The essay concludes with a reflection on the positive and negative aspects of the situation and the importance of a comprehensive approach to patient care.

REFLECTIVE ESSAY
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Table of Contents
Introduction......................................................................................................................................3
Outline of the problems...................................................................................................................3
Stakeholder analysis........................................................................................................................5
Challenges of implementation.........................................................................................................6
Tools to tackle challenges................................................................................................................8
Conclusion.......................................................................................................................................9
Action plan.....................................................................................................................................10
Reference list.................................................................................................................................12
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Introduction
Patient care is a multi-centric approach that supposes to be provided to the entire patient based
upon their physiological as well as psychological condition. In the mentioned case study, it has
been identified that a patient was suffering from a psychological issue because of which he has
consumed foreign bodies like shaves blade and nails. This condition can be referred to as Schizo-
affective disorder. Here, have found that in the medical care there was a significant gap as the
patient was not provided any kinds of psychiatric treatment in the hospital on his first visit to the
hospital with similar kinds of problem. The physical issue has been resolved and the
psychological issue has been left as such that makes him injured by himself again.
The mentioned scenario has become even worst when it has been found that the patient had
stabbed himself in the bathroom of the hospital. Depending upon this condition Gibb’s reflective
cycle, I am going to use for attempting a critical evaluation on the overall medical emergency
through self-reflection. I am going to attempt a descriptive discussion depending upon the
feelings about the incident that leads to making an evaluation on it. This condition would bring a
conclusion of the overall aspect that could help me to decide effective action for the
improvement of the condition (Sekarwinahyu et al. 2019, p.22).
Outline of the problems
At this stage, the situation is explained in a coherent way without presenting a specific
conclusion in this context. I was assigned the role of shift coordinator in the mental healthcare
hospital. I was informed about the incident take place in the bathroom of the hospital where a
patient found to stabs himself with the knife. The other patient who was also there who came out
screaming after witnessing such a horrifying scene. After running out of the bathroom, he went
directly to the patient attendant to inform him about the incident taken place. The patient
attendant rushed quickly to the spot where he found the patient lying on the floor with the knife
in his chest. He removed the knife out of his chest and summon for the nurse (The Kings Fund,
2017). The summoned nurse quickly started to pressurize the area of the wound to stop further
bleeding. In between that, the ambulance was called along with police and physician. The
physician inserted an IV line into the body of the patient for blood transfusions to prevent
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excessive loss of blood due to bleeding. I have also reached the incident spot after the screaming
to know and understand the scenario and situation of such an incident. Besides, I was also taking
notes of the actions followed by the staffs there and analyzing their ability to cope with such a
dreadful situation. In addition to that, I was also paying attention to the measures that were
undertaken by the staff member in such a difficult scenario.
To my surprise, I witnessed something quite different and unusual. The staffs at the hospital
should be well trained and prepared to face and understand such a situation. However, the scene
was quite different from my expected reality. The staffs of the hospital found to look scared and
nervous after witnessing such a dreadful incident (Mansfield-Devine, 2017). Rather solving and
attending the situation, they were panicking and putting blame on each other. I observed that the
unit manager, who was also present at the scene, found to be shouting at the staff members for
carelessness and unprofessional approach. The unit manager was getting infuriated and was
warning them regarding their careless attitudes and approach. In between, when the environment
becomes cool, I approach the unit manager and told him to come and meet me outside of the
unit. I also was greeting angry and want to know the answers for such irresponsible behaviors of
the staffs. I suggested and explained that mere shooting at the staffs is neither going to resolve
the issue nor help you out this context.
After the incident, I call upon the staffs of the other unit and request them to look over this unit
for the time being till the staffs here calm down and relax. I attempted to provide them comfort
so that I could the opportunity to indulge them into communication (World Health Organization,
2007). My aim was to know the exact reason behind the cause of failure as well as risk factors
which had been total neglect leading to such an incident.
Several issues identified in the case study such as communication, human errors, policy,
healthcare practitioners, system or process errors. I found that there is a significant lack of
communication between the nurse and physician. Furthermore, I witnessed that there is no
effective medium of communication established between the administration and nurse to
determine or address the challenges faced by the staffs during the inspection (Gopee, N. and
Galloway, 2017). Communication styles and approaches of the physician, treating team and
staffs were also not at all effective as the patients did not respond to their approaches. This
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reflects the lack of establishing a friendly and positive environment which could help the patients
to verbalize and communicate his thoughts and feelings to others.
Moreover, some ethical concerns need to be considered by the medical practitioners in order to
provide better quality of healthcare service. It has been stated that the ethical practices can help
the medical practitioners to influence the psychological factors of patients (Manzi et al. 2017).
Stakeholder analysis
The case study gives an opportunity to deal with a critical situation related to health care that
helps in enhancing my professional and interpersonal skills. Through critical analysis of nursing
attendant, the patient has suffered from depression and a potential sign of suicide that increase
the vulnerability of health care in the hospital. Through my personal experience, it is essential for
the nursing attendant to change the approach for handling patient to make sure the need and
expectation of service users can be positively met. In order to explore issues and problems within
a patient treatment, I have used a fishbone diagram that implies that there is some limitation in
health care service and treatment facilities (De Hahn, 2005). I have analyzed that the current
policy is not reliable and effective to create an n effective corporate strategy to make sure each
staff and practitioner can perform their responsibilities vigilantly through applying my personal
skills, supporting staffs or nursing supervisors are needed monitor activities of a patient for a
positive change approach. It has been observed that the patient tried to stab himself in the
bathroom which is a clear sign of suicide, which is clear evidence of negligence from supervisors
(Gopee & Galloway, 2017). This incident has occurred at 1 PM that directly triggered negligence
of departments such as physicians, nursing unit and security department. Most of the time, a
patient has been found a sign of low mood and depression that are required to consider by the
senior supervisor and General Practioner (GP) in order to take strict action.
Strategies used to create the change OR innovation
In case I would get a chance to lead then a proper documentation process of each a functional
activities associate within health care has been implemented, which is missing in case scenario.
The assessed of medical staffs' pantry is also a cause of incident where the patient gets the knife.
By using my problem-solving skill, I would implement a security system within organization to
ensure that activities of person can be positively achieved successfully. I have analysed that there
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are some areas that need improvement or changes to make sure potential risks or challenges can
be mitigated effectively (Hess & Bacigalupo, 2011). In arguing with this, environmental error is
one of the important causes of incident that does not resist illicit behaviour of person that
eventually help in creating effective workplace environment. In regard to the incident, I have
realized that the patient has not referred to a psychologist to improve the coping mechanism that
prevents sustainable behaviour positively. In order to change the current operation of health care,
it is essential to provide training and problem-solving techniques to ensure that they can
successfully tackle potential risks and challenges positively.
In addition, human error is also considered as one of the important reasons for this unfortunate
incident to make sure maximum benefit can be achieved positively. I have realized that patient
does not refer to psychologist in order to give problem-related to depression and low mood that
made person to take illicit activities. As per my personal experience, I can clearly assert that a
consultancy process is required to provide that enable patient to share a feeling for a positive
change. Similarly, communication between nurse and physician was not adequate and
experienced to tackle the critical situation to make sure maximum benefit can be extracted
(Manzi et al. 2017). Therefore, I can clerkly assert that a positive and effective action plan need
to formulate to ensure that maximum benefit can be gathered or extracted for reliable growth.
Through a proper action plan, it is easy to change the behaviour and initiative within an
organization to make sure a legitimate process and program can be effectively amend that
support health care organization to monitor change in behaviour and activities positively.
Challenges of implementation
Positive aspect of the situation
This segment is the continuous discussion of the case study analysis, where I am going to
discussion about the evaluation as per the reflective cycle. Through a critical evaluation, I am
able to determine, a few positive signs about the patient's condition. According to my feelings,
the patient was responding to the treatment of the psychiatric team of the hospital and revealed
the reason for his low mood and dissatisfaction along with the tendency of having a suicidal
attempt. However, it has been analyzed that the patient has not felt comfortable at home in the
presence of his father and escaped to the hospital again. From this condition, I would like to add
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significant evidence that says the service care provider in MHS is effective enough that the
patient becomes comfortable to stay in the hospital (Leslie et al. 2016). It has also been
evaluated that the support of the mother of the patient has led him to be comfortable to be an
active part of society by overcoming his upset look and low self-esteem (Maru et al. 2012).
However, my final line in this segment would be it has been clearly evaluated from the condition
that the patient requires the support of the psychotic team for effective treatment.
Negative aspect of the situation
There are numerous documents that reflect due lack of environmental, human and social policy
related error the patient has suffered, which is not at all signifying the quality care by the care
providers. The patient used to share a resident with a VIP patient who may have influence as per
my instinct. Nevertheless, the VIP patient rejects to be a part of investigation. From this
evaluation, I strongly feel that the environment for the patient to cope up with his medical
condition is not comfortable enough for receiving the treatment. Apart from the mentioned I also
feel that there are other challenges in the environmental rounds and the ratio of staff and patient
was not significant (Mills et al. 2004). Most importantly, it was not identified whether the patient
had got the knife from home or hospital's pantry where he had accessibility. The policies and
standards of the hospital from that point of view is not much effective I feel as the incident prove
that there is no clear corporate strategy that could resist the violent behavior of the patient.
Moreover, I found a lack of surveillance from the administration team as well. This is because
the patient was on monitoring of the nurses on a 24-hour basis, although the nurse left to the
bathroom without handover the responsibility of the patient on some other persons. Policies play
an important role to control the overall condition in a systematic manner (Edvardsson et al. 2017,
p.218).
Decision making approach
From the discussed approach mentioned above has led to making me draw a summative
statement about some area of mitigation that can be undertaken for improving the quality of life.
Person-centered care can help patients to take care of themselves through an effective care
approach (Coventry et al. 2015, p.2716). It is the duty of the medical personals to ensure the
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person-centered approach among the patient and their family members or caregivers so that their
physical and psychological health can be improved (Leslie et al. 2016, p.116). The below-
mentioned figure is going to depict the causative factors along with the area of mitigation that
can be undertaken for improving the quality of life among the residents of the hospital.
Figure 1: Area of improvement
(Source: Developed by the Researcher)
Tools to tackle challenges
The main reason for fear in the patients and staffs was the thought, if he has the guts to kill
himself then, he could be a danger for them as well and may pose a threat to their own very well
being. The most embarrassing moment, I felt when I saw the staffs of the hospital blaming each
other for the occurrence of such dreadful incidents in the presence of all other patients. The
attitude and behaviour of the nursing staffs can influence and create a major impact on the
perceptions and beliefs of the service users in the health and social care setting (Mitchell, 2013).
However, the approach of the staffs and game of blaming may have affected the perspectives of
the patient's others and gave way to many unusual beliefs regarding the services, treatments, and
care offered to them. I found myself in a situation where I felt helpless and miserable because I
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Errors in the situation
Human error
system error
Environmental error
Area of mitigation
1:1 ratio between the
nurses and the
patients
Improvement of
company policy and
standard
Lack of suvillence by
the administration
Use of metal detector
to check the patient

was not able to provide any kind of help either to patients and staffs who have got depressed
from such an incident. In this case, some analytical tools might help in understanding a broader
concept of challenges (Edvardsson et al. 2017). With the help of analytical tools, healthcare
service providers can be able to use some strategies to mitigate the identified challenges.
Conclusion
The overall assignment can be concluded by stating that healthcare signifies not only the
physical health of the patient it also ensures the mental health of the person. The provided case
study is an example where it is clearly observed that the root cause of the ill health of a patient is
due to psychological distress. Furthermore, psychological distress arises due to the long term ill
effect of the social wellbeing of the patient. I would like to conclude that the patient supposes to
receive strong support from the nurses and the medical personnel by involving the caregiver of
the patient at home. According to my perception, if the patient has received a full time physical
and mental health treatment from the hospital then, he would not have escaped from there
without the concern of the caregivers.
I would also like to add that implication of Gibbs reflective cycle into this assignment has helped
me to lead my overall discussion into a systematic manner. Thus, it makes me enable to attempt
my investigation by evaluating the cause of the problem at first and then followed by the
suggestion for a mitigation strategy to improve the condition. The action segment is going to
play an effective role in suggesting the area for improvement to not only the mentioned patient
but also for the other residents staying in the hospital.
Reflection
In this phase, the feelings, experience or thoughts related to a specific event are discussed.
Different types of emotions prevail in different individual in such circumstances. The screaming
of the patient coming out brought about panic in many people in the hospital. I got surprised at
the first moment when a scream came out of nowhere.
All of sudden, the environment of the hospital had transformed into chaos and rush due to the
screaming of the patient who witnessed such a horrifying scene. The patient witnessed such
incident with his no eye found to be trembling in fear (Benneyan et al. 2003, p.45). I was very
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much concerned regarding the patient who had stabbed himself with the knife. The news of
stabbing greatly changes the flow of the environment and created unrest among the other
patients, staffs and other people around there. Blood smeared floor could easily instigate panic
and fear in the mind of anybody. When I reached the spot, a terrifying sensation runs throughout
my whole body in an instant giving a shivering experience. Apart from me, other patients and
staffs also got afraid by the incident. However, I quickly able to control my feelings and
overpowered them as I have to be tough enough as there may be many such situations that I may
have to face in the future.
Action plan
So.
No.
Actions Responsible
Person
Timeline
1 A corporate strategy is required to amend to resolve the
needs and expectation of services based on issues and
problems significantly
CEO Monty
2 A proper training program is required to implement that
help in developing critical thinking
Head nurses Immediately
3 A proper documentation program needs to amend in
order to collect accurate and training program
significantly.
QPS team Monthly
4 The security system within a health organization needs
to enhance so that activities and change in behavior of a
patient can be monitored significantly
AED of
hospital
Monthly
5 All the associate nurse or staffs are required to provide
proper training suicide scenario assessment for a firm
action and tackle situation vigilantly
Medical
director
ASAP
6 Communication between nurse and physician is needed
to improve positively
AED of QPS Immediately
7 the current policy is required to improve to create an AEDON Monthly
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effective corporate strategy
8 A risk criteria assessment can be improved to make sure
maximum benefit be improved positively
QPS team ASAP
9 A firm policy is required to amend such as Workplace
violence for maximum result.
QPS team Monty
10 The accessibility of each patient is needed to fix to make
sure activities and behavior can be monitored
effectively.
AED of QPS Immediately
11 An e-learning program needs to implement positively to
make sure staffs get all information and accessibility can
be improved within an organization
AEDON Monthly
12 supporting staffs or nursing supervisors are needed to
monitor activities of the patient for a positive change
approach
QPS team Monthly
Table 1: Action Plan
(Source: Created by Researcher)
The above action plan has been formulated based on issues and changes that medical staffs are
facing that create an opportunity to make positive change within an organization. Through this
action plan, it is easy to change the behaviour and initiative within organization to make sure a
legitimate process and program can be effectively amend that support health care organization to
monitor change in behaviour and activities positively. It has also been evaluated that the support
from medical staffs of the patient has led him to be comfortable to be an active part of society by
overcoming his upset look and low self-esteem. With the help of this, a firm policy is required to
amend such as Workplace violence for maximum result by improving current policy to an
effective corporate strategy
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