Enrolled Nurse’s Breach Of Professional Conduct And Core Competencies

Importance of Adhering to SNB’s Legislative Framework

Dsicuss about the Laws And Ethics In Health Care and Nursing.

1. The regulation 52 of the Nurses and Midwives Regulations 2012 (Cap. 209, S 119/2012) signifies that consent is required from the board before practicing on own account. There are three provisions for the regulation 52.
2. A registered nurse cannot practice nursing on his/ her own account without written consent from the board.
3. A registered midwife will not practice nursing on his / her own or with partnership with another without any written consent from the board.
4. Any person who will contravene the regulation will be penalized with a fine not exceeding $5,000.

Such provisions are made for the public interest and to deliver a safe care to the public. This is because SNB offers approval or accreditation only to those nurses and midwives who are skilled and competent in their own scope practice. It is evident that an incompetent nurse or a midwife can not only deteriorate a patient’s condition and can also bring about mortality. The case can turn out to be more dangerous in case of the midwives as lack of skills and competence may bring about fatal condition to both the child and the mother (Gachoud et al. 2012). Penalties are imposed upon those contravening the regulations as penalties would help to retain the fear among the lawbreakers.

According to the SNB Code for Nurses and Midwives (2018), the enrolled nurse has breached the Principle 5, which states that a nurse should practice in a responsible and accountable manner (SNB, 2018). According to this principle, enrolled nurses should understand and abide by the legislative framework of the SNB. The SNB codes of ethics provide guidelines for the nurses that a nurse should uphold in his/her professional career to provide a safe care to the patients. The SNB codes of conduct help the enrolled nurses with the knowledge of responsibility and accountability for the patient care (SNB, 2018).

Nurses and midwives hold positions of responsibility and are therefore accountable to the care that they provide to the patients (Chadwick and Gallagher 2016). Responsibility can be defined as the obligation to perform duties using the professional judgment and being justifiable for his/ her decisions (Scrivener & Hooper, 2011). Accountability refers to the capability to give proper justifications against any nursing action. It is all about maintenance of the competency and safeguarding the patient and preserves the standards of the nursing profession (Gachoud et al., 2012). In general, all the enrolled nurses are legally accountable or answerable to any kind of decisions they are taking while providing care to the patients (Lachman, 2012).

It is true that accountability cannot be achieved unless the enrolled nurses has got the autonomy to practice the right to autonomy is actually provided by the written format (Krautscheid, 2014). Nurses are accountable to the accreditation body, the patient and their family. Lack of any legal consent form the board does not provide the nurse with any legal accountability (Scrivener & Hooper, 2011). In order practice nursing, a nurse should ensure that she/he has suitable professional indemnity insurance, as each patient has the right to hold the insurance in case, any violation of the tort of negligence comes in to play (Lachman, 2012). The SNB also thrives to safe guard the nurses with their legal shields. In this case the enrolled nurses practice nursing without any legal consent from the board. In such a case the concerned nurse is not accountable if any adverse situation comes up. Hence it is clearly evident that the nurse has breached the standards, as she has practiced nursing without any consent from the regulatory body and she has also applied intravenous medications independently at patient’s home. Normally it is the duty of an enrolled nurse to refrain from practices where he/ she has not developed competence or has not received appropriate training (Krautscheid, 2014). It should be remembered that as per the law no EN can apply IV medications without notations and they can only do so in the supervision of the RNs and if they have completed intravenous medication administration training (Krautscheid, 2014).

Responsibility and Accountability in Nursing Practice

The nurse have also breached principle 6 that states that nurses should advocate patient safety and should be aware of the current clinical practical guidelines (SNB, 2018).

An enrolled nurse should be aware of his/ her limitations in the scope of practice and should understand the differences in the responsibility of an RN and an EN as long as the situation demands. It has to be remembered that administration of IV medications needs proper training as there are several factors that has to be taken care of such as the drug dose, drug timing, and the intactness of the IV line (Cerit & Dinç 2013). IV drugs might not be compatible with certain drugs and may interfere with their mode of action. The role of the nurses is expanding with time, but these shifting boundaries are actually leading some nurses anxious about their legal accountability and responsibilities (Krautscheid 2014). Apart from specific situations that law does not allow the nurses to take up the responsibilities that are not suitable for a particular designation (DeBourgh & Prion 2012).

Responsibility is equal to the duty of care in law and the duty of care applies from simplest to the most complex type of care such as bathing a patient to a complex surgery (Scrivener & Hooper, 2011).

It is the legal liability of each and every health care professional, to their patients. Whenever a task is assigned to an enrolled nurse, it is the RNs that assure that the delegation has been appropriate (Cerit & Dinç 2013). In this case it can be seen that the EN have practiced independent nursing and have also administered IV medications without any supervision by an RN. She should have thought that a small mistake on her part could have not only caused adverse outcomes like mortality, but could have also jeopardized her professional career.

The core competencies for the enrolled nurses consist of 3 competence domains. In a nursing career, a nurse should be abiding by all the competencies. Breaching of any of the competency skills would hamper the both the professional development of the nurse and his/her commitment towards the nurses (CORE COMPETENCIES OF ENROLLED NURSE, 2018). The case study reveals that the nurses have breached the domain 1 which states regulation regarding the professional, ethical and legal nursing practice. It is known that a nurse would understand the legislative framework at first, the role of the regulatory organizations and its effect on nursing practice. The primary purpose of any regulating body is the protection of the public and giving structure and function to the nursing bodies (Dossey et al., 2012). The stringent laws and the regulations are enables no compromise with the sills and competencies (Gastmans, 2013). The legislative framework set up the professional standards for the nurses as it is the professional standards that actually describe the level of care in each level of nursing (DeBourgh & Prion, 2012). The competency domains help to reflect a desired and standard level of conduct with which the nursing performances can be compared with. It should be remembered the health care litigation is developing and patients are preparing themselves to assert their own legal rights (CORE COMPETENCIES OF ENROLLED NURSE, 2018). A critical appreciation of the legal, professional and ethical framework is necessary to generate professional awareness among the enrolled nurses (Dossey et al., 2012). The legal standards of the nurses are actually the embodiment of the collective knowledge of nursing required by an enrolled nurse to maintain the proficiency. In the previous decades before the growth of professional nursing practice, nurses were judged by the same standard of care like an ordinary man or woman (DeBourgh & Prion ,2012). With time the duty of the nurses has increased along with the responsibilities and the accountabilities Complex health care and the growing population has made the duty of nurses more critical (Chadwick & Gallagher, 2016). With more complex health care medical errors have also increased causing morbidity and mortality. The competency indicator under the competency domain 1 states that EN should support, cooperate and collaborate with the team members while caring for a patient. In this case also the EN could have seeked help from her per senior nurse or RN while applying the sensitive medications.   Another important competency indicator related to this case study is the maintenance of a legible and clear records and documentation, as those can be used to confront any legal cases related to patient’s life. They are the only medical evidences against any allegations. It is evident that the nurse had been practicing nursing, probably for increasing her personal income. The nursing codes of ethics enable a nurse to keep the patient’s interest above all to ensure a safe care. It is clearly seen that the nurse had taken part in an activity that conflicts healing and caring.  Another domain of the core competency skill is the management of care. Enrolled nurses should participate in the implementation, development, evaluation and documentation of a planned nursing care (Lachman, 2012). In this case study the patient had not worked under the supervision of any RN and has administered the IV education.  The management of care ensures to provide a safe environment for the clients, that is maleficience.  Another domain of the core competency skill is the management of care. Enrolled nurses should participate in the implementation, development, evaluation and documentation of a planned nursing care to the patient. In this case study the patient had not worked under the supervision of any RN and has administered the IV education.  The management of care ensures to provide a safe environment for the clients. That could be done by doing the procedures under the controlled clinical settings, under the surveillance of the nurses and the doctors, participating in the continuous quality improvement and the activities that would assure the qualities. It is necessary to practice its own level of competence, but that does not mean that the clients should be practicing nursing without any accountability to the regulating board (Affara & Al-Jabri, 2016).

Legal Liability and Patient Safety

1. The principles of the codes of conduct help the nurses to take ethical and justifiable decisions in case of complex care. It acts as a guideline in order to avoid any professional misconduct and to preserve the public interests. As per the case study, the registered nurse APT have been found to be breaching Principle 6, which states that a nurses should be able to practice a competent care in the people, Principle 8, that promotes professionalism and uphold trust of the public. Principle 9, which states practicing self regulation among the nurses (SNB, 2018).

1. The case study shows that that the registered nurse caused a grievous hurt to a patient with the serious rib injury. According to the principle 6 of the nursing codes of ethics, nurses should constantly polish their skills; self evaluate and indulge them in lifelong learning to improve the quality of care. The registered nurse here has caused grievous hurt to the patient causing him a fracture on the left 6th and 7th ribs, left periorbital hematoma, left mastoid hematoma and left chest wall bruise. As a nurse she should have tried to uphold her professional responsibility. According to Chadwick and Gallagher (2016), critical thinking and the application of evidence based care is extremely important to provide a safe care to the patient. Informed decision making is another aspect of safe nursing practice. Each and every patient has got their right to know about their treatment regimen starting from the tests to complex live saving surgeries. A registered nurse should never practice beyond her scope under any circumstances and should be clear of her professional boundaries. It seems that the enrolled nurse have misused his/her professional status. The concerned nurse was never perturbed about his/ her career while doing the wrongful deed or was not at all concerned with the reputation of the profession as a whole (Chadwick & Gallagher, 2016). Public’s perception about a nurse is generally a compassionate figure, showing high level of consciousness and ethics when it comes to the provision of care (Affara & Al-Jabri, 2016). As per the nursing codes of ethics, nurses should maintain beneficence and maleficence, that is keep the interest and safety of the patient in the forefront. This act has greatly undermined the patient’s trust and interest, hence breaching of the principle 8 (SNB, 2018). If there were presence of any workplace hazard that can endanger the health of the people, then that could have been reported to the higher authority. Nurses should deter themselves from any activity that may endanger a person’s life. A responsible registered nurse should value safe nursing practice and should be able to avoid situations where the treatment would be impaired (Affara & Al-Jabri, 2016). Nurses pose legal and moral rights for practicing in a safe environment, without any fear for their own safety. The concerned registered nurses APT should have realized that the concerned patient is vulnerable to injuries and a nurse should have the power to detect and prevent any avoidable human errors (Gastmans, 2013). Nurses can actually prevent such errors by continuous monitoring, early detection and early management of the conditions. It is evident that the registered nurse did not have the necessary competent training to take care of the patient and ensure that the nurse deliver the care based on the clinical practice guidelines (Gastmans, 2013). Furthermore the nurses are entitled to preserve the reputation of their profession and hence should maintain the standards and the codes set out by the professional bodies. Nurses should always comply with the mandating reporting of any adverse conditions before the further continuation of the treatment, keeping the patients interest on a priority basis (Tingle & Cribb, 2013).  The focus of a registered nurse should be public protection and self regulation assures that the patients are receiving the safe and ethical care from registered and qualified nurses. Self regulation is an important attribute towards the development of the self competence (Affara & Al-Jabri, 2016).  Generally self regulation in the profession of nursing can be regulated by the professional itself or directly by the regulating body. One of the best way to self regulate is to ensure that the nurses bear a proper accreditation, comply with the regulatory policies. On the other hand a professional may self regulate him or herself by increasing self awareness in herself.  In this case the nurse should have practiced the nursing within her own competence level, hence breaching of principle 9.  
2. According to SNB Code (2018), professional misconduct can be defined as the act of omission which constitutes the deviation from a particular code, bringing down the reputation of the nursing profession and abusing the therapeutic and the professional relationship with the patients.

A registered nurse is said to have committed professional misconduct if he/she is found to have been falsifying the records, abusing a client physically, verbally or emotionally, issuing documentation having false or misleading information. It can also be referred as committing any task that is normally regarded as dishonorable task as per the nursing profession (Kangasniemi et al. ,2015). In this case it has been found that APT nurse have physically harmed the patient, (he had caused serious rib injury to the patient), which is against the professional conduct of the respectable profession of nursing (Tingle & Cribb, 2013). A registered nurse should be able to foster a therapeutic or curative relationship with the patient unlike this case study. Care to a patient should not only remain confined to applying medications and other physical care, but also should include the spiritual and the mental support provided to the patient.

1. Professional conduct can be defined as the manner in which a professional behaves while being in the profession. Each and every professional have their specific professional conduct (Kangasniemi et al., 2015). These professional conducts actually guides the professionals to identify the areas of improvement in the clinical practice as well as to deliver a patient centered care and to maintain work place safety (SNB, 2018). It is the stipulated professional conduct of each of the nurses that helps to promote the best possible outcomes and mitigate the exposure to the harm. Reflecting on the establishment of the therapeutic and the relationship of trust between the patients is necessary to provide a comprehensive and holistic care (Dinç & Gastmans, 2013). Nurses should respect the dignity and the integrity of the patient. Verbal or physical abuse breaks that relationship of trust between the patient and the health care professionals and also contributes to declining of the clinical setting (Kitson et al. ,2013). Nurses neither have a responsibility to harm or exploit the patients and intent to provide them with a quality care (Dinç & Gastmans, 2013). Trust is the most vital factor and once it is lost, it becomes very difficult to re-establish the trust once again (Reader & Gillespie, 2013). Patient neglect has long been a concern in a clinical setting. Patient neglect generally have two aspects, first is the procedure neglect, where a health care professional fails to achieve the standards of care (Dinç & Gastmans 2013). Second is the caring neglect, that refers to the acts that leads the patients to believe that the staffs posses an uncaring attitude towards them (Reader & Gillespie 2013). The reason for the patient neglect is mainly due to the negligence of the nurse and often due to some organizational factors such as high work load and the nurses burnouts, although no such evidences have been provided in the case study. Nurses should not indulge themselves in any work that might bring about disrepute in nursing (Kitson et al., 2013).  In this case the APT nurse has failed to achieve both the aspects and have therefore been penalized for the misconduct. Nursing is the most trusted profession and hence they also have to indulge themselves in patient advocacy to decide the type of care provided to the patients (Reader & Gillespie, 2013). Furthermore the registered nurses often have to be the part of multidisciplinary teams where they have to show their professional skills beyond their scope of practice. In order to avoid any kinds of human errors any such practice should be done in front of an expert health care professional. Although the case study did not provide any information about how the professional misconduct have been made, but proper assessment in front of exerts might have avoided the mishap.

References

Affara, F. A., & Al-Jabri, S. S. (2016). Professional Self-Regulation for Nursing and Midwifery in Oman: Protecting the Public and Enhancing the Quality of Care. Oman Medical Journal, 31(4), 243–244. https://doi.org/10.5001/omj.2016.48

Arnold, E.C. & Boggs, K.U., (2015). Interpersonal Relationships-E-Book: Professional Communication Skills for Nurses. Elsevier Health Sciences.

Battié, R. & Steelman, V.M. (2014). Accountability in nursing practice: why it is important for patient safety. AORN journal, 100(5),537-541.

Cerit, B.& Dinç, L. (2013). Ethical decision-making and professional behaviour among nurses: a correlational study. Nursing ethics, 20(2), 200-212.

Chadwick, R. & Gallagher, A., (2016). Ethics and nursing practice. Palgrave Macmillan.

CORE COMPETENCIES OF ENROLLED NURSE. (2018). [ebook] SINGAPORE NURSING BOARD. Available at: https://www.healthprofessionals.gov.sg/content/dam/hprof/snb/docs/publications/Core%20Competencies%20and%20Generic%20Skills%20of%20EN_SNB_%20Jan%202018.pdf [Accessed 30 Mar. 2018].

DeBourgh, G.A. & Prion, S.K., (2012). Patient safety manifesto: A professional imperative for prelicensure nursing education. Journal of Professional Nursing, 28(2).110-118.

Dinç, L. & Gastmans, C., (2013). Trust in nurse–patient relationships: A literature review. Nursing Ethics, 20(5),501-516.

Dossey, B.M., Certificate, C.D.I.N.C., Keegan, L. & Co-Director International Nurse Coach Association, (2012). Holistic nursing. Jones & Bartlett Publishers.

Gachoud, D., Albert, M., Kuper, A., Stroud, L. & Reeves, S. (2012). Meanings and perceptions of patient-centeredness in social work, nursing and medicine: A comparative study. Journal of Interprofessional Care, 26(6),484-490.

Gastmans, C.(2013). Dignity-enhancing nursing care: a foundational ethical framework. Nursing ethics, 20(2).142-149.

Kangasniemi, M., Pakkanen, P. & Korhonen, A. (2015). Professional ethics in nursing: an integrative review. Journal of advanced nursing, 71(8), pp.1744-1757.

Kitson, A., Marshall, A., Bassett, K. & Zeitz, K. (2013). What are the core elements of patient?centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing. Journal of advanced nursing, 69(1), pp.4-15.

Krautscheid, L.C.(2014). Defining professional nursing accountability: a literature review. Journal of Professional Nursing, 30(1).43-47.

Lachman, V.D., (2012). Applying the ethics of care to your nursing practice. Medsurg Nursing, 21(2).112.

Manuel, J. & Crowe, M.( 2014). Clinical responsibility, accountability, and risk aversion in mental health nursing: A descriptive, qualitative study. International journal of mental health nursing, 23(4).336-343.

Reader, T.W. & Gillespie, A. (2013). Patient neglect in healthcare institutions: a systematic review and conceptual model. BMC health services research, 13(1).156.

S I N G A P O R E N U R S I N G B O A R D (2018). Code for nurses and midwives. [online] Available at: https://www.healthprofessionals.gov.sg/content/dam/hprof/snb/docs/publications/Code%20for%20Nurses%20%20Midwives_2%20April%202018.pdf [Accessed 30 Mar. 2018].

Scrivener, R., & Hooper, R. (2011). Accountability and responsibility: Principle of nursing practice B. Nursing Standard (through 2013), 25(29), 35.

Shahriari, M., Mohammadi, E., Abbaszadeh, A., Bahrami, M. & Fooladi, M.M., (2012). Perceived ethical values by Iranian nurses. Nursing ethics, 19(1).30-44.

Shrestha, S. & Jose, P. (2014). Knowledge & Practice of Nursing Ethics and Laws. Journal of Universal College of Medical Sciences, 2(3).30-33.

Tingle, J. & Cribb, A. eds. (2013). Nursing law and ethics. John Wiley & Sons.