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Question:

Describe about the Advanced Decision Making and Practice of  nursing incident?
 
 

Answer:

The second scenario has been selected to critically analyze a nursing incident. This piece of work will include incident description, concerning points, role of inter-professional communication, and role of the registered nurse and concluding lesson for future practice.

Section 1

Aspects of the critical incident

Being in the third week of a first year in her career, the registered nurse in this case study is taking part in the emergency department and has been assigned to take care for four critical patients. All the three patients are comfortable with stable vital indications and all are waiting for their diagnostic test results. But the fourth patient, who is a 26years old female suffering from constant headaches which is intense and she could not even able to sleep for last two days. This condition can be identified as a critical factor in this case. This is because nursing care focuses on the reduction of pain to enhance the quality of life of the patient. In this case, the patient has been referred to a medical officer who has recommended for an MRI scan. But in this case, as the patient is immensely suffering from head ache, the nurse could have intervene and treat this particular condition as the first treatment option. Then she could have asked for MRI scan. Undoubtedly MRI scan is a good option to recommend for this patient but as priority wise, reduction of pain should have come to the first place (Calloway and Young, 2014). This patient is on complete neurological observations hourly. The time has come when the registered nurse need to undertake the net set of hourly neurological observation. To perform this the registered nurse have entered into a darken cubicle and before the nurse say anything the mother of this patient asked the registered nurse not to disturb her daughter as she has gone to sleep after almost two days.  Here comes another issue. The registered nurse should perform what she is supposed to. She should not encourage the instructions given by the patient family member (Daniels, 2004). But in this case study, it is seen that the registered nurse consulted the prior observation charts and come to an decision point that prior two sets of observations were within normal range, so this time the result would also be the same. Hence, the registered nurse did not wake the patient up (Thompson and Dowding, 2009). The registered nurse also did not note on the emergency chart that she was requested not to wake the patient by her mother (Loke et al., 2014). So, here another issue arrived. It is an offense that instead of taking the actual neurological reading the registered nurse just supposed her neurological condition and left noting any observational signs, which was also influenced by the patient’s family member (Braddock, 2010). After that, the registered nurse had also ignored to note on the emergency chart that she was requested no to awake the patient by the patient’s m other. During the lunch break she has handed over the patient to the coordinator, who assured that she will take care of the patients. Finally, the patient’s condition got deteriorated and the registered nurse was enquired why she ignored taking note on her neurological observations for the third time (Washer, 2009). This could be another issue (Secord, 2005). The registered nurse knew the condition of the patient (Lai, 2012). Yet, she left for her lunch, handing over the patient to a coordinator. She could have inform the medical officer regarding the issue, that is her mother was unwilling to wake up her daughter and she did not note any neurological condition of the patient for the third time (Standing, 2011). The nurse should have been little more conscious and focused on her responsibility while she is working in an emergency department (Jasper, 2012). She could have followed proper process, so that her patient did not undergo an unconscious state.

To avoid this situation the registered nurse need to be more careful while making decisions and working in the emergency department (Johansen and O'Brien, 2015). At the very beginning she needs to focus on pain control and then go for the proper intervention of her immense headache. She should only focus on the correct medical process. If it is mandatory to check for her neurological data at particular intervals, nurse should perform so, instead of skipping any step to obey the patient parties. Here comes the situation of decision making. In this type of critical condition she should have directly speak to the medical officer regarding this matter and solve clarify the confusion immediately with proper intervention (Walker and Breitsameter, 2014). She has also got ready to go for lunch after handing over her patients to the coordinator. The registered nurse could have consult this situation immediately with the medical officer and then proceed further as the medical officer recommends. Instead, the registered nurse assumed about the patient’s stable neurological condition freely went for her lunch. The registered nurse should write the entire details she has been performing with each and individual patient. In this case study it is seen that she ignored taking note on the emergency chart that she was requested not to wake up the patient by her mother. The registered nurses did not even bother to take a note of it, which is again against the nursing guidelines (Holland and Roberts, 2013).  The registered nurse should understand that she is a fresher nurse and should always follow the rules set by the nursing board or regulation agency.

Section 2

Analysis of this situation

Different situations might have caused this incident to occur. First of all in this case study the registered nurse is just a fresher who is participating in the emergency management and only within the third week of her career, she has been assigned four critical patients under her. This might present a huge pressure on a fresher. Also, there is no senior or experienced registered nurse within the emergency ward, who can assist her while the fresher nurse performing her tasks. Assistance from senior member is always important and effective for a fresher nurse to enhance his/her practical experience (Husted and Husted, 2008). In this case study her lesser experience also thought to be one of the most important factor in deteriorating the patient’s condition. It is not a good decision to assign four critical patients under a fresher registered nurse (Pines and Everett, 2008). The factors which are associated with this condition might include her lack of experience, inability to properly make a strong decision, nervousness, lack of awareness and lack of responsibility.

The main players who are responsible for this situation might include patient’s mother, the registered nurse, the coordinator and to some extent the medical practitioner also. From the mother’s maternal instinct it is obvious for her to mention not to give her daughter a wakeup call, as she has slept after two long days. But it is the nurse’s responsibility to make her understand that the wakeup call would be for her daughter’s own good (Guido, 2010). The mother should also have the understanding that the healthcare professionals know their actual responsibility and should not interfere in their interferences.  The coordinator has been assigned for some work but the professional failed to properly keep a track on the patient. If this staff would have concentrate more on his/her function for that particular time, this patient might not have undergone to her unconscious state (Penrod, 2011).  During the deteriorating condition of the patient, the coordinator should have given a call to the medical officer or the other experienced nursing staff. The medical officer when checked the patient and recommended for her MRI scan, the medical officer have understood the critical condition of this young female patient, yet the officer left the emergency department without arranging any special facility for this patient. For example: recruiting an experienced nurse instead of the fresher registered nurse. It is a true fact that practical experiences immensely support individuals to learn more in their life and help in their long professional career. It also supports the fresher nurses to obtain more professional knowledge (Ulrich, 2012). Hence, it would be good if the medical officer took the responsibility to pace an experienced nurse in the first place regarding this young patient’s care and the registered fresher nurse should follow how the experienced nurse is performing the tasks as per the priority (Elliott, Aitken and Chaboyer, 2012). Another analysis which can be included in this discussion is the communicative nature of this registered nurse. If the nurse is facing any kind of confusion or difficulty she could have asked any of the experienced staff present within the department or she could have directly call the medical officer when the mother of the patient asked her not to give her a wakeup call for further neurological observations. Two factors can be discussed here in this context (Kerschner and Cohen, 2002). One is her sense of fear where she might have felt that if she calls the medical officer or a senior nursing staff, they might not assist her properly as she is a fresher or they might have scold her. Another factor can be her ego issues or out of shame she might not consult this condition with any other staff to clarify her confusion (Foreman, Milisen and Fulmer, 2010). The nurse has demonstrated her irresponsibility completely by skipping the documentation of the patient’s neurological observations. It is also mentioned in this case study that the registered nurse did not even documented that she skipped taking note on neurological observations of this patient (Sollins, 2007). This represents her negligence towards her role as a registered nurse. From the starting point of the nursing education it is taught that the nurses are responsible for each and every step of nursing care and intervention (Meacher, 2006). They should follow certain rules and regulations and should always focus on patient wellbeing to improve their quality of life. But in this case study the registered nurse have failed to properly focus and maintain her nursing responsibilities within the emergency department.

 

Section 3

The action

Had I been a registered nurse in her place, I would have definitely spoken to my mentor or the medical officer about my capacity whether I can take the responsibility of four critical patients during my initiation of nursing career within the department. I would have definitely ask for assistance from my senior colleagues and communicate any little issues so that I can easily resolve it in near future (Albini, 2010). I would always prefer to assist my seniors so that I can gain some practical knowledge about critical nursing and also can develop the power of making decisions during critical situations (Jarrett-Williams, 2012). My preliminary focus would be the reduction of her immense headache. Then I would have recommended a family counselor for the patient’s mother. The counselor could have make her understood the importance for each and every nursing steps, so that in near future she will not interfere in her daughter’s critical and necessary treatment (Aston, Wakefield and McGown, 2010). I would have also asked the medical officer for further nursing assistance. Prior handing over my patient to the coordinator I would have definitely check whether that person is capable enough to take such responsibilities. I would have not skipped taking neurological observations for the final time and never assumed about her final neurological indications based on the prior two observations. I would have understand the significance of documenting neurological observations of the critical patient and also briefing of  the same to the medical officer to avoid such accidental situations, like whatever has happened in this case study.

Being in the higher authority post within a healthcare set up, the respective person should take proper action against this registered nurse (Ankner, 2007). Human error is very common and can happen at any point of time during care. But that error should not be life-threatening and in nursing no errors should be present while taking care of a patient (Iszatt-White, 2007). In this situation it is mentioned that the medical officer has enquired about the reason why the last neurological observations has not been documented (Naeem, Ahmed and Rabbani, 2013). To respond this it is pretty clear that the irresponsibility and lack of knowledge of the registered nurse would be prominent in this regard. Hence proper punishment should be given to this registered nurse against such breach (Roberts, 2010). The higher authority of the health care set up should understand the capacity of the registered nurse, prior they assign a critical patient in the emergency department. Allotting a fresher registered nurse for four critically ill patients is really a big blunder. The critical situation of the patient needs to be stabilized as early as possible to reduce internal chaos. Proper planning should be implemented prior starting up a nursing intervention. It is quite obvious that prior giving serious responsibilities the higher ups should evaluate and understand that whether the person has the capacity to perform it in an appropriate manner or else chances of errors are high. In this case study it is apparent that the registered nurse has failed to take proper decisions in several times. To avoid this kind of errors in near future, it is the responsibility of the hospital authority to arrange for a proper training structure for the fresher registered nurses who are participating in critical care and emergency department. The Code of Ethics for nurses has been structured for nursing profession in Australia (Nursingmidwiferyboard.gov.au, 2015). The codes include various factors; these are: nursing staff value quality nursing care for people; they value kindness and respect for self and other members; they value people diversity; they value quality nursing and quality care for all the patients; they value informed decision making and also value cultural safety. So, in this context, the registered nurse of this case study has violated the code of ethics (decision-making). According to this code, nurses should make informed decisions regarding their practice in the limits of their specialized function and compliant with legal and ethical requirements. Nurses should perform the same without unnecessary pressure or any type of compulsion. Nurses should be accountable for making sure their decision is depend upon relevant, contemporary and well-structured information and knowledge. In this case study the nurse’s performance has created a questionable behavior. Hence, the higher authority should decide whether to provide her a second chance or the form of the punishment would be much severe. Whatever the case it is, from previous risk analysis and research studies it can be said that education and prevention are the best methods to diminish the risk for the clients as well as the care providers (Holmes and Perron, 2007). During nursing training or education, boundary theory need to be discussed along with some critical topics, such as: practice standards, ethics, therapeutic touch and personal space.

 

References

Albini, E. (2010). Medical students' penal responsibilities. Emerg Care J, 6(3), p.41.

Ankner, G. (2007). Clinical decision making. Clifton Park, NY: Thomson Delmar Learning.

Aston, L., Wakefield, J. and McGown, R. (2010). The student nurse guide to decision making in practice. Berkshire, England: Open University Press.

Braddock, C. (2010). The Emerging Importance and Relevance of Shared Decision Making to Clinical Practice. Medical Decision Making, 30(5 Suppl), pp.5S-7S.

Braddock, C. (2010). The Emerging Importance and Relevance of Shared Decision Making to Clinical Practice. Medical Decision Making, 30(5 Suppl), pp.5S-7S.

Daniels, R. (2004). Nursing fundamentals. Australia: Delmar Learning.

Elliott, D., Aitken, L. and Chaboyer, W. (2012). ACCCN's critical care nursing. Chatswood, N.S.W.: Mosby/Elsevier.

Foreman, M., Milisen, K. and Fulmer, T. (2010). Critical care nursing of older adults. New York, NY: Springer Pub. Co.

Guido, G. (2010). Legal & ethical issues in nursing. Boston: Pearson.

Holland, K. and Roberts, D. (2013). Nursing. Oxford: Oxford University Press.

Holmes, D. and Perron, A. (2007). Violating ethics: unlawful combatants, national security and health professionals. Journal of Medical Ethics, 33(3), pp.143-145.

Husted, J. and Husted, G. (2008). Ethical decision making in nursing and health care. New York: Springer Pub. Co.

Iszatt-White, M. (2007). Catching them at it: An ethnography of rule violation. Ethnography, 8(4), pp.445-465.

Jarrett-Williams, T. (2012). Clinical Judgement and Decision Making for Nursing StudentsClinical Judgement and Decision Making for Nursing Students. Nursing Standard, 26(23), pp.30-30.

Jasper, M. (2012). Nurse managers - a professional scope of responsibilities. Journal of Nursing Management, 20(4), pp.431-432.

Johansen, M. and O'Brien, J. (2015). Decision Making in Nursing Practice: A Concept Analysis. Nurs Forum, p.n/a-n/a.

Kerschner, S. and Cohen, J. (2002). Legislative Decision Making and Health Policy: A Phenomenological Study of State Legislators and Individual Decision Making. Policy, Politics, & Nursing Practice, 3(2), pp.118-128.

Lai, P. (2012). Shared decision making. Surgical Practice, 16(4), pp.127-127.

Loke, J., Lee, B., Noor, A. and Loh, S. (2014). High fidelity full sized human patient simulation manikins: Effects on decision making skills of nursing students. Journal of Nursing Education and Practice, 4(7).

Meacher, S. (2006). Managing near drowning of adults within the emergency department. Australasian Emergency Nursing Journal, 9(1), pp.3-9.

Naeem, S., Ahmed, S. and Rabbani, M. (2013). The Impact of Hospital Libraries on Patient Care and Clinical Decision-Making: A Survey of Teaching Hospitals. Journal of Hospital Librarianship, 13(2), pp.120-130.

Nursingmidwiferyboard.gov.au, (2015). Nursing and Midwifery Board of Australia - Codes and Guidelines. [online] Available at: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx [Accessed 26 Feb. 2015].

Penrod, J. (2011). Commentary on Uncertainty and Surrogate Decision Making. Clinical Nursing Research, 20(3), pp.241-244.

Pines, J. and Everett, W. (2008). Evidence-based emergency care. Chichester, UK: Blackwell/BMJ Books.

Roberts, D. (2010). Violation of a Moral Rule. Orthopaedic Nursing, 29(5), pp.338-341.

Secord, M. (2005). How to retain and “magnetize” registered nurses. Nurse Leader, 3(2), pp.42-44.

Sollins, H. (2007). Nursing Roles in Health Care Decision Making. Geriatric Nursing, 28(5), pp.280-282.

Standing, M. (2011). Clinical judgement and decision making for nursing students. Exeter: Learning Matters.

Thompson, C. and Dowding, D. (2009). Essential decision making and clinical judgement for nurses. Edinburgh: Churchill Livingstone.

Ulrich, C. (2012). Nursing ethics in everyday practice. Indianapolis, Ind.: Sigma Theta Tau International.

Walker, A. and Breitsameter, C. (2014). Ethical decision-making in hospice care. Nursing Ethics.

Washer, P. (2009). Clinical communication skills. Oxford: Oxford University Press.

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