Breach Of Nursing Code Of Ethics: Administration Of IV Medications At Patient’s Home

Risks and complications of administering type IV medications

Discuss about the Nursing qualification and workforce for Association.

1. As per regulation 52 of the Singapore Nursing Board (SNB) code for nurses and midwives no registered or enrolled nurse can practice nursing in their own accountability or in partnership without taking consent and approval from the nursing board. Therefore, any professional who violates such regulation is to be taken guilty and fined an amount of $5000 (Wu, Enskär, Pua, Heng & Wang, 2016). In severe cases the violating midwives, registered or enrolled could be further convicted.
2. In the current study the enrolled nurse has violated the principle 5 of the SNB code for nurses and midwives. As per the principle 5, the nurses should act in an accountable and responsible manner. Additionally, the nurse also breaches principle 6 of the SNB code for nurses and midwives, which states that the nurses should act in accordance with the clinical guidelines.

As stated in principle 5 of the SNB code for nurses and midwives, the nurses need to act within the limits of their competence and scope of practice (Efendi, Nursalam, Kurniati & Gunawan, 2018). They should escalate concerns whenever they are asked to perform beyond their scope of practice. As commented by Johnstone (2015), the decision should be supported by the ethical guidelines. It has been clearly mentioned that the nurses need to alert the respective authorities when immediate decision making has to be done. This is because a single wrong decision may endanger the life of a patient. The practice should be strictly guided by the nursing skills and competencies. This is because breach of the same could lead to a number of complications within an acute healthcare setup. The consequences are often lethal endangering the life of the patient.

In the present context, the nurse had independently administered IV medications to the patient within the premises of the patient’s home. This was a breach of the principle 6 of the standards of practice for nurses and midwives. Though the intravenous (IV) method diluted or undiluted medications are directly administered into the vein using syringe through a needleless port or an existing IV channel. IV medications are only provided in emergency situations. Since, the medication is directly absorbed through the blood channel it results in immediate elevation of serum levels and has high concentration in some of vital organs such as heart, brain and kidneys. Since the IV medications are only provided in emergency situations they need to be provided under a parenteral drug therapy manual. As reported by Efendi, Nursalam, Kurniati & Gunawan (2018), incorrect administration of type IV medications can illicit harmful immune reactions. Extraversion of certain medications in surrounding tissues can cause nerve damage and scarring. Some of the additional risks over here are central line associated blood stream infection (CLAB) and hypersensitivity.  Additionally, the enrolled nurse had performed the activities within the home of the patient and in the absence of any medical instructor. Therefore, severe consequences could have happened including the development of hypersensitivity reactions in the patient. The hypersensitivity reactions may have resulted in death of the patient due to asthmatic choking.

In order to understand the ground of violation of the nursing code of ethics and standards we need to understand the basis of administration of the IV medications. Some of the emergency situations based upon type IV medications could be administered to the patient are heart attack, poisoning and stroke etc.  As the medicines are directly absorbed into the bloodstream they are quick in their mode of action. The standard IV medications may be used for controlling pain in the patients. In this a needle is inserted in the vein of the wrist, elbow or back of the hand. The catherer is pushed over the needle, which remains in the vein even after the needle is removed. However, as per the nursing standards and code of ethics the type IV catherers are to be given within the hospital premises under medical supervision (Wu et al., 2016). Therefore, the enrolled nurse had clearly breached the terms of contract over here. Some of the drugs which are most commonly administered via channel IV are – chemotherapy drugs such as vincristine, paclitaxel ; pain medications such as hydromorpohine and morphine; drugs for low blood pressure such as  dopamine, epinephrine, norepinephrine . As per the current case study, the enrollment of the nurse was suspended for a period of 5 months. In this context, the enrolled nurse may have breached the code of ethics and nursing standards owing to a number of reasons, which had been hypothesized over here. Here, the patient that the nurse was catering to might have experienced a sudden stroke. Thus, the nurse thought it was appropriate to administer IV medications before shifting the patient in an actual ambulatory setup. Therefore, instead of administering the type IV medications the nurse should have escalated concerns to the respective authorities. As commented by Johnstone (2015), wrong infusion and wrong dose were some of the most common medication errors. The intravenous medications which were commonly subjected to error in the present case were heparin, furosemide, Nitroglycerin, Insulin, streptokinase, dopamine etc. As asserted by Tan  et al. (2016), medication errors occurred more frequently for intravenous medication than for oral medicine.

1. There are a number of core competencies and skills as highlighted by the Singapore nursing board. The nursing competencies and skills further govern the quality of practice and care. The core competency consists of a standard set of performance domains and corresponding behavioral standards which a nurse is expected to depict within their actual practice sessions. Based upon the competency areas the enrolled nurse is further expected to depict professional skills. The nursing competencies as per the Singapore health board could be further divided into a number of sub-domains which are- professional, legal and ethical nursing practice; management of care; professional development; leadership and nursing management. Some of these could be further related with the present case study where there was a clear breach of the professional, legal ethical nursing practice. Here, the nurse was expected to depict accountability for care within the scope of practice. The enrolled nurse was supposed to act in accordance with the national legislation policies and procedural guidelines. The nurse here failed to follow the directives as specified in the five rights of medication mentioned within the specific skill sets provided by the SNB code of ethics and nursing practices. As commented by Zhang et al. (2018), some of the recommendations to reduce harm doe to medication are administrating the right patient, the right drug, in the right dose, through the right route and the right time. As supported by Ver Donck  et al. (2014), under no circumstances a nurse is expected to practice beyond her scope of practice. Therefore, the nurse had breached the competency domain 1, where she failed to abide by the professional practice standards.

Factors affecting unacceptable behavior among nurses

In this context, an overdose of the type IV medication may have developed a number of secondary immunological reactions within the patient. In this respect, the Type IV medications are injected in the form of bolus.The dosage should be controlled or tightly regulated for which the nurse needs to perform drug calculation. As commented by Tan  et al. (2016), an overdose or under dose of the medication in result in the development of severe consequence. As reported by Ver Donck  et al. (2014), 0.8% of the fatalities could be accounted to the administration of wrong medications via intravenous channels. Therefore, instead of administering the type IV medication, the nurse should have approached the respective physician. However as argued by Efendi  et al. (2018), the occurrence of an utter medical emergency may act as compulsion sometimes forcing the healthcare professional to undertake an unspecified route. As supported by Wu  et al. (2016), though a medically hasty decision is sometimes guided by good conscience they may prove to be lethal endangering the life of a patient. As per the competency domain 2, the nursing professional needs to abide by the risk management strategies. However, the enrolled nurse had taken a huge risk over here by administering type IV medication to the patient without a prior approval from the concerned medical board. As commented by Liaw  et al. (2017), display of an irresponsible behavior by the nurse could have put the both the patient as well as the nursing professional at risk.

1. Based upon the SNB code for nurses and midwives the nurse here failed to follow some of the relevant principles and guidelines. Some of these have been discussed over here which are principle 8 and 9 of nursing professional standards. As per the principle 8 of the nursing code of conduct and practices a nurse should strive to achieve public trust and confidence and in no manner should jeopardize the reputation of the profession. As mentioned by Yoo & Park (2015), the nurse is accountable for the kind of behavior they depict towards their fellow patients. As per principle 9 of the nursing code of conduct and practices a nurse needs to practice self regulation. A nurse should uphold personal integrity and emotional fitness when dealing with a patient. However, here the nurse has depicted violent and unacceptable behavior towards the patient which made the condition of the patient worse.
2. In the current study the nurse had projected a violent behavior towards the patient by inflicting harm upon the patient. This had gone against the nursing code of practice as well as damaging the reputation of the nursing profession. As commented by Chong et al. (2016), a nursing professional is expected to perform in manner which will uphold the public interest and rights. However, projecting a jeopardizing behavior towards the patient can result in legal breaches alongside affecting the overall well being of the patient.

In this respect, a number of factors had caused the display of such unacceptable behavior in the nurse.  Some of the factors which had  could be taken into consideration over here are  long working  hours, less pay,  violent and aggressive behavior by the nurse. In this respect, aggressive behavior depicted by the patient owing to a number of diseases such as dementia may result in additional challenges for the nursing professional (Geoffrion, Morselli & Guay, 2016). As commented by Tan, Lopez & Cleary (2015), the lack of support from the patient may affect the success rate of the care and support process. In this respect, a person affected with dementia often has less cognitive abilities. This makes understanding as well as decision making difficult for the patients. In such scenarios often intensive conflicts develop between the patients and the support carer.  As commented by McCarthy  et al.(2018), the patients affected with dementia are vulnerable and prone to the adversities, which are often inflicted upon them by the nursing professionals in charge of their care.  It is often difficult for them to resist the atrocities inflicted upon them owing to the physical and mental vulnerability. Additionally, the lack of awareness and family support often makes them easy targets.  In this respect, the depiction of a violent behavior by the nursing professional can towards the patient can stem due to the lack of effective knowledge and training skill of the nurse (Liaw et al., 2017). 

Need for effective legal framework and training for healthcare professionals

 It could be further explained on the basis of the Mental health capacity act, 2005. As per this act, any individual with less or reduced mental capabilities have the rights to participate in decision making pertaining to their care.  Additionally, the legislation also states that any person who infected with similar disability has equal rights in living life on his own terms. Therefore, the nurse employed in the care of the patient over here needs to abide by the ethical rules and regulations. Additionally, the support staff depicting violent behavior could also stem from personal grudges and rivalry against the patient.

As mentioned by Yoo & Park (2015), the nurses employed within the care and support services of the patients with limited abilities often have to suffer under the huge burden of responsibilities. Therefore, the long working hours often results in compassionate fatigue in the nursing professional. As mentioned by McCarthy  et al. (2018), 2 % abusive patient-carer records have been found din the Singapore based healthcare.  Under such circumstances both the patient and the support carer needs help in terms of health support and counseling. Additionally, lack of effective guidelines also resulted in gaps and breaches in the implementation of healthcare policy.  In the presence of an effective nursing policy the chances of ethical and legal breaches gets reduced.  As supported by Clarke (2015), compliance monitoring is another factor which needs to be taken into consideration over here. The lack of knowledge and training within the nursing professionals also results in the hampering the safety standards and the quality of nursing care (Schober, 2013). In this respect, a background check must be done before employing a nursing professional in the care of a patient.

1. As per the new definition of professional misconduct stated in the SNB code 2018 the nurse cannot abuse the professional relationship with the client (Newell, Nelson-Gardell & MacNeil, 2016). Additionally, the nurse cannot bring the profession into disrepute. In the current scenario, the  nurse had depicted violent behavior  towards the  patient where he had inflicted  multiple  wounds over the  patient  which  resulted in the  fracture of the ribs, left chest wall bruise etc. therefore, the nursing  professional in  this case  has  brought sufficient dispute to the nurse patient relationship.

As per the core competencies and management skills as mentioned in the Singapore board of nursing, the enrolled nurse need to  provide a safe and positive environment for the healing of the patients (Griffith & Tengnah, 2013).  However, here the nurse had been personally inflicting aggressive and violent behavior against the patient. This has brought disrepute to the nursing profession apart from endangering the overall well being of the patient. Additionally, there are a number of nursing and professional values which had been challenged over the present context. Some of these are advocating care in the best interest of the clients. Therefore, upholding the interest of the client is of utmost importance (Liu & Haseltine, 2016). The practice environment should comply with the effective nursing practice and guidelines.

1. In the current scenario, the nursing practices related to ethics management had been taken into consideration. In this respect, the nurse should acts in accordance within the ethical standards and practices (O’Neill, 2014). The present scenario describes an acute healthcare setting where the nursing professional had depicted violent behavior towards the patient. This has resulted in a number of issues such as causing damage and disrepute to the nursing profession as a whole. In this respect, reference has been made to a number of codes of ethics and nursing practices. Some of these have been described further such as the principle 8 and 9 of the SNB code. As per the codes the nurse needs to uphold personal integrity and maintain emotional fitness. However, the action depicted by the nursing professional over here has been clear violation of the ethical principles and guidelines. Some of the effective precautions which could have been taken over here are compliance monitoring. The compliance monitoring would help in ensuring that the patient safety standards are taken care of. This could have been implemented in the form of regular home visits of the patient. Additionally, working in partnerships with a large number of healthcare channels would have also helped in providing of additional support to the support carer in dealing with the patient depicting an aggressive behavior. Some of the practices which could be implemented over here are provision of training to the healthcare professionals as an acute care setup a nurse is often prone to develop conditions such as compression fatigue (Mather et al., 2017). As commented by Bennett (2015), lack of appreciation of performance appraisals can further affect the prospective growth of a nurse in his career. Therefore, the nursing committees should occasionally review the performance of the healthcare staffs and provide them with performances appraisals (Adrian & Chiarella, 2015). Additionally, involvement of the family member of the patient in the decision making can also help in the prevention of ethical conflicts between the patient and the care service provider.

The implementation of effective legal framework along with provision of sufficient training to the healthcare professional regarding the same can prevent the ill treatment of patients within the clinical setup. The nurse in this step was convicted in this case for purposely inflicting injury to the patient. However, the analysis of the case scenario shows a clear gap and loopholes in the implementation of the legal guidelines.

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