‘Untangling the web of critical incidents’: Ethnography in a paediatric setting

Abstract

Critical incidents (CIs) are the elements that bring about an alert or wake up call for clinicians in hospital wards. They are considered critical because the safety of patients, staff or visitors is at risk. Not all CIs result in dire consequences, nor do they require Root Cause Analysis (RCA). Nonetheless, incidents affect patients and involve clinicians’ interactions with each other. This paper describes the complexities embedded in two CIs in a major paediatric hospital in Australia. An anthropological ethnographic research approach enabled the researcher to observe, document, interpret and make sense of the activities of clinicians in two different clinical areas of the hospital, i.e., the Rehabilitation Unit and the Neonatal Unit (NU). Ethnographic research significantly exposes and highlights hospital dramas and shows the effects on clinicians’ everyday lives. We suggest that CIs have two dimensions: a medical and a social. The medical dimension encompasses factors in the treatment and care of the patient. The social dimension encompasses the social relationships and the socio-affectivity (emotional responses and labour) of treating clinicians. Our main argument is that foregrounding of the socio-cultural dimensions of CIs informs and impacts on the medical dimensions. Our conclusions demonstrate that the social dimensions of CIs have important ramifications for clinical interactions in everyday practices and these impact on the positive learning of clinicians after a CI has occurred.

Keywords:

• socio-affectivity
• heedfulness
• positive learning

Acknowledgements

This research is supported by an Australia Research Council Discovery Grant awarded to Professor Rick Iedema of the University of Technology, Sydney, New South Wales. The support of all eight investigators, work colleagues and the invaluable contributions from the staff of the two units involved is greatly appreciated.

Notes

Notes

1. This refers to Hunter; ‘I’ will be used subsequently.

2. All clinicians’ and patients’ names in the paper are pseudonyms.

3. SBR  = serum bilirubin. There is a concern with high levels of bilirubin because in young children this may cause irreversible brain damage. Low birth weight babies are most vulnerable.

4. The nurses in HDU may be more or less experienced depending on the nursing skill mix required for each specific shift and the medical condition of the infants. They are often allocated between two and four infants to care for on each shift. In contrast, NICU requires the most experienced nursing skill mix because NICU contains the most critically ill and there is a higher staff to patient ratio.

5. Performing a venepuncture on a tiny infant can be extremely difficult. Even experienced paediatricians have difficulty locating a vein in tiny infants.

6. In a study of the morning report clinicians expressed the desire to shorten the time taken to perform and complete the conference (Hill, Tyson, and Riley 1997).

7. Children who are very young and have the tendency to wriggle or move around a lot require a general anaesthetic for this procedure. This is scheduled on certain days only.

8. This child was having a specialised seating system made. Nia had overseen this earlier. The child was extremely distressed at the seating episode.

9. Having a general anaesthetic requires the patient to fast for up to four hours before the procedure.