November 6, 2000
Volume XXXIII, No. 37

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Nursing faculty use ‘critical incident’ teaching strategy

Hank, a surgery patient, buzzes the desk to ask for his pain medication. He received a dose 15 minutes ago. The physician declines to order more pain medication or change the prescription. What should the nurse do?

Alison is a strong-willed 15-year-old asthma patient who is recovering from a serious bronchial infection. She insists on leaving the ward without the aid of a wheelchair. What is the nurse’s responsibility?

Ben, a patient with advanced cancer, falls in his hospital room during the night. He breaks a bone. What preventive measures should have been taken?


A University Hospital intensive care nurse adjusts an airway tube in a patient.

The medical-surgical nurse faces situations such as these on a daily basis. Nursing students also experience such incidents with concerns about patient advocacy and professional competence. Several faculty members in the School of Nursing have begun teaching their baccalaureate students a strategy for critical thinking utilizing "critical incident" situations.

"Understaffing and multiple-patient loads are common today, and half of all critical incidents involve medications," says Dr. Mary Heye, a registered nurse and associate professor in the Department of Acute Nursing Care. "We are teaching students to talk about patient and health care professional encounters that are a source of dilemma, in an effort to increase their problem-solving ability and reflection on steps to take in such situations. The questions are, ‘What happened here?’ ‘Who was responsible?’ and ‘What could have been done?’"

Students have discussed 150 scenarios of incidents with profound implications. The learning strategy, developed by S. Kay Thornhill and Melissa Wafer of the School of Nursing at Southeastern Louisiana University, involves six steps:

  • Identify the critical incident,

  • Note personal experience,

  • Identify and challenge assumptions,

  • Challenge the importance of context,

  • Explore alternatives, and

  • Identify issues impacting professional practice.

Dr. Heye and faculty colleagues Dr. Margaret Bell, Laura Campion, Barbara Owens, Pauline Hendricks and Janemarie Schoonover, all registered nurses, began their work with first-semester nursing students. "Studying actual critical incidents helps us highlight current issues and the role of the professional nurse as provider of care," Dr. Heye says. "Using this strategy provided a model that is easily described and discussed by both students and faculty."

Faculty analyzed three sets of data using content analysis. The first set involved critical incident scenarios submitted by the students, the second addressed students’ written responses to four personal experience questions and the third consisted of faculty recordings of each clinical group’s discussion of a selected critical incident.

Dr. Heye and her colleagues presented the preliminary findings at two national nursing meetings.

"Students’ descriptions of these critical incidents more often portrayed negative than positive situations, and caring and uncaring emerged as common themes," the authors wrote in a project summary.

"Individual responses to the selected critical incidents demonstrate the professional socialization conflicts that challenge beginning nursing students," the authors continued.

Investigation of this learning strategy will be continued in future clinical groups and will be extended to include senior students to provide data for comparative analysis, Dr. Heye says.