Identify a case from the NSW Nurses and Midwives’ Board or AHPRA website which involved a registered nurse(s) who had their registration cancelled or suspended for greater than 6 months due to their involvement in an adverse event for a patient in their care..
NB: provide the reference and link to the case
- Provide a brief synopsis/overview (1-2 sentences) to summarise the case. NB: Tell us who the patient was – describe the clinical setting the patient was admitted in and what ultimately happened to them?
- What actions/omissions on the part of the Registered Nurse(s) contributed to the adverse outcome for the patient.
- Were there any other factors (e.g. systems-based) that contributed to the adverse outcome for this patient?
- With reference to the evidence based literature (including relevant NSW policies) outline the actions that should have been taken by the Registered Nurse(s) to prevent adverse outcome for this patient.
A tribunal has suspended a nurse’s registration for professional misconduct for unwarranted physical contact with a patient and falsifying a report of the incident.
The Nursing and Midwifery Board of Australia (NMBA) referred Ms Silvia to the South Australian Health Practitioners Tribunal (the tribunal), alleging that the following behaviour amounted to professional misconduct:
1. She placed her hand on, over or otherwise in contact with the face of a 98-year-old patient, who was then receiving treatment at the Royal Adelaide Hospital and who had presented with, among other things, a mild cognitive impairment, causing a bruise to the patient's left lateral jaw.
2. She generated a false, inaccurate or misleading electronic report on the SA Health Safety Learning System database (the SLS Report) which attributed the patient's injury to inadvertent contact with her bed railing.
3. She later implored another enrolled nurse to corroborate the false, inaccurate or misleading SLS Report that she had generated.
Ms Silvia admitted the factual basis of the allegations as outlined by the NMBA which asked the tribunal to send a clear message to the public and the profession that unwarranted physical contact with patients will not be tolerated.
This behaviour was aggravated by the falsification of the SLS Report and Ms Silvia attempts to enlist the cooperation of a colleague who observed the behaviour to corroborate her false version of events.
The tribunal agreed that Ms Silvia behaviour amounted to professional misconduct and imposed the following disciplinary sanctions :reprimand, suspension of registration with the NMBA for one year, three months and six days, expiring on 9 June 2017, and conditions on her registration requiring that she practise under supervision and carry out further education in the areas of managing challenging behaviours, managing cognitive impairment and ethical behaviour of nurses.
One of the fundamental aspects of nursing is the duty of care which most of the nurses view it as a vital part of their professional duties. The legal underpinnings of duty care have however been overlooked hence nurses tend to get stranded on what to do in cases of emergency, especially when off duty (Dowie 2017). Some of the ethical obligations involve confidentiality, accuracy, safety, and workplace relationships (Williams n.d.). Additionally, ensuring patients’ safety is another fundamental role of nurses (Registered Nursing n.d.). Failure to adhere to the set ethical and professional guidelines while on duty has its repercussions as was the case below.
Ms Silvia Csepregi’s registration with the NMBA (Nursing and Midwifery Board of Australia) was suspended for professional misconduct by the South Australian Health Practitioners Tribunal in 2016 (Nursing and Midwifery Board of Australia 2016). The tribunal’s decision followed proven allegations that Ms Csepregi had behaved in a manner that amounted to professional misconduct in three ways. Firstly, the registered nurse engaged in unwarranted physical contact by placing her hand on, over, or in contact with the left lateral jaw of a patient. As a consequence, a bruise of about 5cm in diameter developed on the face of the patient (Health Practitioner Tribunal of South Australia 2016). The patient was 98 years old and had been admitted at the Royal Adelaide Hospital for treatment. The hospital is located in Adelaide, South Australia. According to the Health Practitioner Tribunal of South Australia (2016), the patient, whose name was not disclosed, had been admitted to the hospital with several health complaints including a mild cognitive impairment. More precisely, the client was in a vulnerable position while lacking basic skills of communication.
In addition to causing injury to the patient, another form of professional misconduct resulted when Ms Csepregi falsified a report in the Safety Learning System database claiming that the patient’s injury had resulted from accidental contact with her bed railing (Nursing and Midwifery Board of Australia 2016). What is more, the registered nurse beseeched a colleague to substantiate the falsified report that she had come up with (Nursing and Midwifery Board of Australia 2016). After Ms Csepregi owned up the mentioned allegations, the South Australian Health Practitioners Tribunal established that the nurse’s behavior had resulted to professional misconduct and that her conduct amounted to a significant departure from appropriate standards (Health Practitioner Tribunal of South Australia 2016). As a consequence, Ms Csepregi was reprimanded, her registration was suspended for approximately one year, and certain conditions were imposed on her registration (Health Practitioner Tribunal of South Australia). These conditions required the nurse to practice under supervision of a registered nurse and enroll for further education in the management of cognitive impairment and challenging behaviors, and nurses’ ethical behavior (Nursing and Midwifery Board of Australia 2016).
Details of the Case
As evidenced in the above case, Ms Csepregi’s actions directly contributed to the injury or bruise on the face of the patient. More precisely, on 3 April 2014, she engaged in unwarranted physical contact with the patient. She placed her hand on or over the mouth of the patient causing a bruise around that area. According to Ms Csepregi, her actions were not meant to hurt the patient. On the contrary, the conduct that led to bruising was aimed at preventing the patient from screaming and yelling at her ear as she carried out her duty of hygiene care to the patient. It was later revealed that the patient was agitated and aggressive, whirled hands and body, and spitted at nurses as they tried to discharge their care duties towards them. Despite these revelations, Ms Csepregi committed a professional misconduct when she had unwarranted physical contact with the patient which led to bruising. Additionally, the nurse failed to give considerations to the old age and health condition of the client, and thus their vulnerability while handling them. As already mentioned the patient was 98 years old and had various health issues, and was in a frail condition.
In an attempt to cover up her misconduct, Ms Csepregi also engaged in other actions that were deemed as professional misconduct. During the time of the mentioned incident the hygiene needs of the patient were being attended by Ms Csepregi in collaboration with another nurse. The other nurse had briefly stepped out of the room and when she returned she noticed that Ms Csepregi’s hand was on the chin and mouth of the patient. After Ms Csepregi noticed the nurse re-entering the room she removed her hand and they both continued with their professional duties towards the patient. After some time, a bruise which was noticed by the two nurses appeared on the same location where the nurse had placed her hand. Ms Csepregi acknowledged to the colleague that her earlier action may have contributed to the bruising. However, Ms Csepregi did not own up to her actions when documenting the events of day. Instead, she prepared a Safety Learning System (SLS) report where she associated the incident that caused bruising as one which involved inadvertent contact between the bed rail and the patient’s face. The report was reviewed by a Clinical services coordinator and made enquiries on patient’s wellbeing. The coordinator’s conclusion was that nothing additional was supposed to be done, considering the nature of the described incident in the SLS report. Evidently, Ms Csepregi masked her actions by generating a misleading, inaccurate, and false electronic report which alleged that the injury of the patient resulted from inadvertent contact with the bed railing.
Legal and Ethical Obligations of Nurses
In addition to falsifying the records, Ms Csepregi also tried to mask her wrongdoing by engaging in another misconduct after an internal investigation to the issue commenced three months later following an anonymous letter being sent to the hospital. Here, it was alleged that the patient had been assaulted, and that Ms Csepregi and the other nurse were aware of the incident. Upon learning of the ongoing investigation, Ms Csepregi contacted the other nurse in numerous occasions attempting to get her to stick to the version of events as recorded in the SLS report. What is more, Ms Csepregi first denied that she had engaged in any form of misconduct in the two initial interviews during the investigation. Later, she made admissions to all the three complaints subjected against her.
Proactive Identification of Threatening Behaviors
There are certain ways through which the injury to the patient would have been prevented, and thus avoiding all the other associated outcomes. Firstly, the nurses should have recognized the threatening behavior of the patient. As it was revealed in the case, during routine care the patient displayed reactions and physical behaviors such as agitation, yelling, spitting to the nurses, and moving the arms and body. These are potential factors that indicate that the patient was in a position to trigger violence, a condition that necessitated interventions. According to Terry (2018), physical reactions and cognitive experience are among the three ways in which impending violence and anger presents. In the current case, the nurses ought to have sought to recognize the underlying cause of yelling and agitation. As such, proactive identification of such behaviors may have helped to prevent the nurse’s action that led to bruising.
Following the identification of the threatening behaviors, the nurses should have implemented interventions as early as possible to minimize violence by the patient. For instance, instead of placing her hand on the patient’s mouth to prevent the patient from yelling in her ears, Ms Csepregi should have first spoke to the agitated patient before commencing the activities of hygiene care and help them to stay in a more comfortable position. Additionally, the nurses should have reassured the patient that they understand their situation and that it is important that they carry out their duties towards the patient. Also, approaching a patient in a friendly manner can also help reduce violent behaviors. For instance, the nurses should have given the patient a reassuring smile as well as greeting as a way to show their positivity towards the client.
Consequences of Non-compliance
By nature, nursing entails close physical association between nurses and patients. Considering that patients can easily be agitated, a collaborative effort among the staff is a potential way through which safety can be ensured as suggested by Terry (2018). As such, both nurses should have worked together to care for the patient.
Guidelines on how to handle/manage violent patients
Measures and guidelines adopted to manage and prevent violence and aggression of patients in acute old age inpatient settings have associations with the general quality of care offered. The association is in terms of patient characteristics, inpatient environment, and interaction of the staff with patients, sensitivity to culture and mixing gender of staff (Terence et al. 2014). These measures can help caregivers deal with violent patients without a breach of the code of ethics as discussed below
The skill to do an assessment of a mental state and cognition should be well known by a physician. Either, liaison psychiatry and other relevant professionals like psychiatrists or mental health nurses should be positioned in every health centre so as to support and help in the acute medical services (Owen 2006). Mental state examination involves observation of alertness, arousal and attention, assessment of understanding and expressive skills of communication, asking about emotions, feelings and mood like anger, fear and anxiety. Delusions and hallucinations can be assessed by insight, risk and mental capacity.
A friendly communication is a major way of creating a good rapport between a practitioner and a patient as it helps to avert or defuse stress (Hardwood 2016). The nurse can begin a conversation by first introducing themselves, being polite, friendly and respectful after which they can say who they are and what they are doing. The nurse should make sure that they afford a smile, show concern and give a running commentary on whatever procedure they are undertaking so as to allay any kind of fear or misunderstanding. Nurses giving intimate care should refrain from confronting, contradicting, embarrassing or humiliating under any circumstances.
In some cases, sedation may be advisable especially in extreme instances. The drug and dosage used depends on the age and size of the patient, other drugs taken and known illness. An oral sedative is offered to disturbed patients in the first instance in a non-threatening collaborative way. Parenteral sedation can also be adopted though it requires several trained staff to convince the patient or restrain the patient while administering the medication. Sedation will help calm the patient down in cases of extreme violence (Fulde and Preisz 2011).
Taking a patient’s cultural background into account is mandatory especially when formulating diagnosis and care plans (Queensland Mind Essentials 2016). This is because one’s cultural background can greatly influence how symptoms of mental illness are understood or expressed.
In case of an escalated patient’s behavior, it is upon the nurse in charge to notify the NUM/In-charge as well as the ICU team. It is then upon the team to order the restraint in accordance with the SESLHD PD so as to prevent the patient from harming herself and others (Sutherland Hospitals and Health Services 2014). The observations of the skin and restraints must be attended and documented at intervals of 15 minutes as per SESLHD PD 111. Besides physical restraints, security should also conduct a thorough search for the presence of weapons and objects that can cause harm to the patient and nurse, confiscate them and then notify the police concerning the same.
In conclusion, the number of nurses associated with malpractice lawsuits has been escalating with time (Croke 2003). Sadly, experts in patient safety at John Hopkins claim that over 250,000 deaths occur annually in the U.S due to medical errors (Sorrell 2017). Most of the patients get harmed in the course of their health care resulting in permanent injury or death (World Health Organization n.d.), like in the case of our patient A. However, the severity of these health care errors can be reduced by sustained and collaborative efforts of the relevant personnel (Zane et al. 2008). Considering the varied characters of people placed in correctional health care, the nursing team and correctional officers should work together closely so as to manage all emergency situations in patients as well as ensure the security of the health professionals (Australian Primary Health Care Nurses Association 2017). Also, nurses should recognize that licensing of registered nurses is a symbol of trust by both the healthcare system and the public for the professionals to practice with integrity as stated by Porter (2013).
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Dowie, I (2017), ‘Legal, ethical and professional aspects of duty of care for nurses', Nursing Standard, vol. 13, no. 32, pp.47-52.
Fulde, G & Preisz , P (2011), ‘Managing aggressive and violent patients’. Australian Prescriber, vol. 11, no. 34, pp. 166-168.
Hardwood, RH (2016), ‘How to deal with violent and aggressive patients in acute medical settings’. Royal College of Physicians of Edinburgh, vol.47, pp. 176-182.
Health Practitioner Tribunal of South Australia (2016), Nursing and midwifery board of Australia v Csepregi  SAHPT. Available from <https://www.healthpractitionerstribunal.sa.gov.au/download.cfm?downloadfile=836EFE80-32CE-11E6-8B78020054554E01&typename=dmFile&fieldname=filename>[20 March 2019].
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Porter, RB (2013), ‘The American nurses association code of ethics: it is more than skin deep', Journal of the Dermatology Nurses’ Association, vol. 5, no.1, pp. 31-34.
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Sutherland Hospitals and Health Services (2014), Aggressive behavior prevention and management in the intensive care unit st George hospital. Available from <https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/306445/stgeorgeAggressive_Behaviour_Prevention_Management_SGSHHS_CLINICU.pdf>[20 March 2019].
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