Standards For Practice: Enrolled Nurses And Duty Of Care In Nursing – Case Study

Enrolled nurses and the Standards for Practice

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ASSESSMENT:  Practical – Case Study

S/NS result given.  All criteria must be answered correctly to attain a satisfactory result.

This case study is based upon one (1) scenario and fifteen (15) associated questions. Please read the scenario carefully and answer ALL of the questions.  Word counts are provided as a guide only.

Case Study

15 Questions All must be answered correctly to attain a satisfactory result

Scenario

On 15th April 2015, EN Rose Baxter is working on the day surgical ward alongside RN Simone Jones. EN Baxter has been allocated the following two clients, both of whom are booked for surgery today. Client 1. Mr John Smith  DOB 6/9/1945 Mr Smith is a diabetic – type 1, fasting from midnight for surgery at 0800 for removal of skin lesions. As Mr Smith is diabetic, his treating doctor has ordered an antibiotic (intra venous Cephalexin 500mg), to be delivered during his surgery as a prophylactic. (He has an increased risk of wound infection associated with his diabetes).  Client 2. Mr John Smythe  DOB 6/9/1945 Mr Smythe has been fasting from 0200 for surgery to remove polyps from his bowel. Culturally, Mr Smythe is a practicing Buddhist and has requested no narcotic analgesia, preferring to meditate to relieve any pain. Mr Smythe is partially deaf and with poor hearing, unless he has his hearing aids in place. He has a medication alert on his chart as he has an allergy to Cephalexin. When EN Baxter admits him, she notes this in his chart and she places an allergy alert band on Mr Smythe’s wrist. Actions Neither of the clients has been flagged during the admission process as having similar names and identical dates of birth. EN Baxter reports this to RN Jones and places an alert band on each client and an alert notation in their medical record, to notify all staff. At 0800 Mr Smith is called for theatre and EN Baxter checks his blood glucose level (BGL) before his transfer to theatre. As she approaches him with the BGL kit Mr Smith holds out his hand ready for the finger prick test for his BGL. EN Baxter hands over his diabetic status and BGL to theatre staff. At 0810, the theatre staff called for Mr Smythe to come down to theatre. The doctor handed EN Baxter a pathology slip for skin lesions, and a medication order to start an IV antibiotic, Cephalexin. When EN Baxter looks at the documentation she was given, she notices it has Mr Smith’s details on the pathology request and on the Medication order, and that it is incorrect for Mr Smythe to have this order.

1. As an enrolled nurse, your practice is guided by legislation. The Standards for Practice: Enrolled nurses, are an element of the legislation. Identify what these standards are used for, generally. (50 words or less)

• The enrolled nurse standards are core practices guides which provide effective framework for assessing the practice of enrolled nurse. Enrolled nurse woks in line with registered nurse as part of health care team in order to demonstrate competence, which offers direct and indirect supervision of the registered nurse, , (Durham et al, 2016).                                                                                   

Explain the duty of care the enrolled nurse had in caring for Mr Smith and Mr Smythe, taking into account if there was a breach or a potential breach of duty of care during this scenario. Use any actions or evidence from the scenario to discuss the answer. (100 words or less)                                                       

Enrolled nurse has the responsibility of ongoing self-responsibility and to maintain knowledge base through lifelong learning. Although none of the clients having similar name and similar date of birth was not flagged and the there was a high chance of medical error, but it was correct in part of EN Baxter to place an alert band on their wrist and an alert notation on their records for notifying all the staffs. It was also the duty of the nurse to flag the two patients also in the medication room or the pharmacy to prevent medication error. The EN was also successful in identifying the medical error that occurred in the OPD. EN Baxter has also been mindful in providing an alert band on Mr. Smythe’s wrist for his allergy to a particular medication, which complies with the professional codes of nursing; to be accountable to all the actions, but it is also evident that Mr. Smythe is a practicing Buddhist and does not want any narcotic analgesia and hence this should have been notified in the medical chart.

Duty of care in nursing

In regard to Mr Smith having his BGL taken before transfer to theatre, briefly explain how he consented to the BGL procedure and what typeof consent does this represent.

• It is evident from the given case study that Mr Smith holds out his hand on his own for the blood sugar testing which indicates a non-verbal consent to the health care examination. This type of consent falls under the category of implied consent, where the consent of a person can be guessed from the voluntary action of the patient.

1. Conduct Statement 1, from the Code of Professional Conduct for Nursesstates;

“Nurses practice in a safe and competent manner.”  

 Identify how the enrolled nurse applied Conduct statement 1 in the scenario. 

The nurse in statement acted in a manner that ensured there was practice and competent manner of ensuring patient safety. In can be seen that EN Baxter made it sure to report the unflagging of the two similar name patients and having similar birth dates. She had been mindful in notifying it to RN Jones in order to prevent any confusion regarding patient identification. Furthermore the EN also ensures to avoid any medication or adverse drug reaction and hence places an alert nad on Mr. Smythe’s wrist. The EN could even recognise the medication error that occurred with Mr. Smith and Mr. Smythe that proves that that the nurse has abided by the codes of professional conduct of the nurses (NMBA, 2018).

1. Explain what EN Baxter should do when she realises the pathology slip and medication order is for the wrong client, including who must be notified of this error.

Medical issue

• There is an incidence of mistaken identity of two patients bearing similar names and same bio data but different diagnosis. The near error was noticed by Enrolled Nurse Mrs Baxter, whom received the patients into the ward. The incident occurred while the wrong patient was being taken in for theatre procedure.

Cause of the issue

• The near error misdiagnosis occurred due to lack of careful attention on patient file by the health care staff. There was no confirmation undertaken on the pathology slip and the medication order of the patient.

• The right actions to be undertaken by the enrolled nurse is to ensure that the right patient be prepared to the theatre while the wrong patient being taken back to await his scheduled time for lab. The enrolled needs to notify the health care staff working for the patient on the need for consideration of assessing carefully patient file.

1. Identify if the enrolled nurse was working within her scope of practice during this scenario. Explain how you came to this conclusion, based on the enrolled nurse’s actions.              (100 words or less)

• Nursing within the scope of practice and being accountable and responsible to the patients are one of the core competency skills of the nurses. It is evident from the case study that the nurse made it sure to notify RN Jones about the improper documentation and failure of the staffs to flag the similar names of the patients having same date of birth. The EN knew that it was beyond her scope of practice to take legal steps of warn them as it falls under the scope of an RN or a medical manager. The case study reveals that the nurse had abided by all the practice guidelines of the nursing by cross checking the medications or obtaining the vital signs.    

1. The Standards for Practice: Enrolled nurses, Standard 1, states;

           “Functions in accordance with the law, policies and procedure affecting EN practice”

The enrolled nurse in the scenario demonstrated knowledge and understanding of patient safety and care. She ensured that proper labelling of the patient was done with clear instructions on the care for the patient. The procedure for patient having similar traits allows for tagging and notifications to be labelled on the patient, (NMBA, 2018).

1. From the Code of Ethics for Nurses in Australia,Value Statement 6 states;        

           “Nurses value a culture of safety in nursing and health care” (100 words or less)                                                                                     

• In promoting the culture and safety of the patients, enrolled nurse undertook the responsibility of ensuring that patient receive care which is in line with their beliefs and culture, (NMBA, 2018;Masters, 2015 ). As an enrolled nurse ensuring proper documentation of non administration of analgesic s to the patient is key. In documenting this in the patient file and the notification on her wrists is crucial in promoting respect to patient Buddhism faith.

1. Within the scope of practice of the enrolled nurse, outline an example of the actions and strategies that would be implemented when handing over Mr Smythe to the theatre staff. These actions should advocate for his needs and rights to be upheld when in theatre, in order to address any ethical issues. (100 words or less)    

• In addressing the needs of the patient in the care process, enrolled nurse needs to ensure that proper handling procedures for the patient are adhered. Proper handing over of the patients files and patient identification process need to be prioritized.
• Enrolled nurse needs to incorporate and handover the patient file with clear instructions labelled and written with regard to his wishes of non analgesics use. Further, there is need to handover the patient carefully with the wrist notification which notifies the theatre staff on the allergies which the patient can be susceptible to and his wishes, (Anderson et al, 2015).                         

1. As the error/s of pathology and medication were intercepted before the clients were in theatre, discuss the benefits orharm of practicing open disclosure in this instance, taking into account if Mr Smythe would benefit from knowing the near-miss mistake and if discussing the near-miss error with Mr Smythe falls within your scope of practice.                                                     (150 words or less)                                                                                  

• As an enrolled nurse, the scope of work undertaken usually follows the direction registarted nurses. As an enrolled nurse, my actions are geared towards my nursing actions and practices. Thus the duty of informing the patient or engaging in open disclosure with the patient involves the registered nurses, thus my scope don’t allow me engage in open disclosure, (NMC, 2008)
• The ethical benefits of error reporting to the patient are geared to hoping the care nursing for the patient, and it proposes that there is good rapport build on the patient. Information sharing for Mr Smyth regardless of positive or negative builds good relationship for the patient and the health care team.
• As the patient is aware of the potential error that should have been received, they will require quality improvement efforts through shared learning thus building critical nurse-patient relationship.

1. Nurses work in environments where several events can happen at once. In the scenario, discuss how the enrolled nurse demonstrates that she can complete her usual tasks whilst managing a circumstance which could not have been predicted.                                                    (100 words or less)  

• Activities being undertaken in ward environment by nurses have an impact on specific patient safety outcomes. Nurse’s can have positive environment practice which enhances patient safety. , (Cho et al, 2015). The enrolled nurse demonstrated this by clearly documenting the patient health history and ensuring patient tagging is done, while thereafter, enrolled nurse checked the medication sheet vis-à-vis the patient medical file , which she realised that wrong patient had been brought to the theatre. This actions led to prevention of the near medical error commission. Thus enrolled nurses can perform their duties well while managing adverse medical actions which might occur.                                                                         

Nurses are required to demonstrate ethical practice in all their interactions with clients, and their families. In the above scenario, consider the example of Mr Smythe’s wife arriving at the end of the day to take him home and asking if everything went well.

• Reporting of potential harmful errors which have been intercepted before harm to patients is key in enhancing patient safety and trust. Patient safety measures have been identified as key in ensuring that systems are enabled to identify such errors.
• In the case study voluntary reporting to the care giver is crucial. Disclosing near error to the patient is critical to ensure collaborative trust between the patient, caregivers and the health care team, (Blais, 2015).
• Informing the wife is crucial in that, similar case can happen in different hospital with the same patient; hence ensuring that the wife is aware of the potential threat will be beneficial for future care process. The nurse needs to go beyond the autonomy principle and ensuring that there is open disclosure of truth to the wife. This will be followed by request for forgiveness and promise that such confusion will not take place in future as critical protocol process will be laid down to enhance the present procedures.
• Hence as an enrolled nurse, job specifications and line of duty falls within the scope of registered nurse. My actions don’t call for open disclosure with the patient or their representatives. Thus it is the prerogative of registered nurse to determine whether to disclose to the patient what happen during the treatment phase.

Regarding the recording of incidents as given in the case study, identify at least five (5) aspects of nursing documentation that ensure legislative requirements are met.  

• Care to be documented by staff providing care
• Documentation of patient information in chronological order
• Documenting time of providing care
• Carrying out comprehensive and in depth documentation for the client
• Completing of patient safety event report

Document the incident regarding Mr Smythe on aclinical incident form (provided below). Include all of the issues that have led to the error, and your actions.

CLINICAL INCIDENT REPORT
Client Name:                  Mr John Smythe                                   DOB:  6/9/1945
Incident type (Circle appropriate type)	Actual	Potential
Date
Time	0810
Location	Theatre
Description	Wrong patient file as to pertaining care process. There was documents mix up for information with respect with patient identity similarity. The incident was identified before any medical process had been initiated for the patient. The actions taken include proper documentation and filling of the patient documentation with regard to ensure that such error could be not be experience again. As an enrol nurse, i ensured that the patient documentation is tagged to have reflect the actual patients so as to minimise such error in future.
Reported to:	Registered nurse
Signature and role:	Enrol Nurse Bxter Rose……BR.

Reflect on the legal and ethical concerns discussed in this scenario, taking into account that you are working in a busy health facility as an enrolled nurse. Discuss how you would identify and monitor your own actions and abilities to maintain your compliance with your professional responsibilities.  (50 words or less)         

Adherence to ethical principles of maleficent and beneficence is critical in the case study. Thus ensuring of mandatory reporting and adherence to handover guideline protocols will ensure that such errors are minimised, further adherence on nursing codes of practice is key towards patient care, (Johnstone, 2015).

References

Anderson, J., Malone, L., Shanahan, K., & Manning, J. (2015). Nursing bedside clinical handover–an integrated review of issues and tools. Journal of clinical nursing, 24(5-6), 662-671.

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

Cho, E., Sloane, D. M., Kim, E. Y., Kim, S., Choi, M., Yoo, I. Y., … & Aiken, L. H. (2015). Effects of nurse staffing, work environments, and education on patient mortality: an observational study. International journal of nursing studies, 52(2), 535-542.

Durham, M. L., Suhayda, R., Normand, P., Jankiewicz, A., & Fogg, L. (2016). Reducing medication administration errors in acute and critical care: multifaceted pilot program targeting RN awareness and behaviors. Journal of Nursing Administration, 46(2), 75-81.

Häyrinen, K., Lammintakanen, J., & Saranto, K. (2010). Evaluation of electronic nursing documentation—Nursing process model and standardized terminologies as keys to visible and transparent nursing. International journal of medical informatics, 79(8), 554-564.

Johnstone, M. J. (2015). Bioethics: a nursing perspective. Elsevier Health Sciences.

 Masters, K. (2015). Role development in professional nursing practice. Jones & Bartlett Publishers.

Miller, F. G., Joffe, S., & Kesselheim, A. S. (2014). Evidence, errors, and ethics. Perspectives in biology and medicine, 57(3), 299-307.

Nursing and Midwifery Board of Australia, (2018). Viewed on 19/04/2018 Accessed at https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

Nursing and Midwifery Council. (2018). The Code: Professional standards of practice and behaviour for nurses and midwives.