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other patients on the unit who needed looking after; just get on with it. I
don‘t remember seeing the registrar again. I came to realise opportunities
to talk like this were unusual - not part of normal ward life; the emphasis
was on doing nursing not talking about it. Talking could be saved for the
pub later but it was the funny stories that tended to be recalled and shared
not the emotionally difficult ones.
As a consequence of my error, the unit decided to change its policy about
clamping chest drains before moving patients. Eventually about six months
later it was deemed an unsuitable place for newly qualified staff nurses to
work because it was felt that junior staff needed more experience to work
more independently in the single rooms. Supervising inexperienced staff
placed a large burden on the senior staff. Certainly, I remember feeling
alone and isolated in the single room unable to ask questions of the more
senior staff and I worried that I knew enough about the patients‘
complicated conditions to nurse them effectively. I continued to work on
the unit but this incident inspired me to apply for an intensive care course
to develop my theoretical knowledge underpinning my practice.
In the course of this PhD inquiry I have realised this was my only
experience of a debriefing session (informal as it was) after a clinical
event. When I became a ward sister I had the autonomy and power to
instigate them for my own staff. I have also come to realise that I
successfully blocked out this experience from my memory until I was
pressurised during my progression exam, again during this inquiry, to
show how a personal story could have an impact on an organisational
system to influence change.
I felt destroyed by telling this story publicly and even here I still hesitate to
present it. This is not because I am unwilling to own up to making mistakes
because even at the time I remember doing this. It is because the
emotions stirred by it are still painful and powerful; much easier to keep
them buried in my subconscious! Nevertheless at the time, I was lucky to
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