In the case study examined, the patient was vomiting intermittently in postoperative care while receiving Morphine intravenously. The patient’s nurse Pamela is not responsible or trained for prescribing medication, so she decides to seek advice from a senior nurse. The senior nurse Jane orders Pamela to cease the Morphine administration and changes the protocol to 10mgs of Metoclopramide. While Pamela stops the Morphine administration, she refuses to administer Metoclopramide without a prescription. Despite the warnings against administering regulated medication, Jane proceeds to act on her decision and administers the Metoclopramide intravenously, which causes the patient to respond with an allergic reaction.
It is evident that Jane’s actions violate both legal regulations and ethical codes for nurses. From a legal perspective, Jane is liable for criminal charges because of patient safety violations and lack of adherence to professional standards in healthcare delivery. This paper discusses how adherence to expected standards protect the nurse and organisation from legal liability in case of adverse events and why Jane and her hospital are responsible and liable for any legal action in this scenario. From an ethical perspective, she also shows lack of consideration for both her colleague and the patient, and this paper discusses why positive relationship in the workplace are important for care quality and patient safety. Finally, she violates several national competency standards, including actions outside of her scope of action, skipping proper assessment requirements, and failing to implement evidence-based practice (EBP) in her care delivery.
According to Dunn, Cashin, Buckley, and Newman (2010), the prescriptive authority for nurse practitioners in Australia was established in 2001, even though a systematic review of literature by Bhanbhro, Drennan, Grant, and Harris (2011) reveals that there is not enough evidence to support the effectiveness and efficiency of nursing prescriptive authority in clinical practice. However, it is important to consider that the prescriptive authority in Australia pertains only to registered nurse practitioners because they have the education and skill requirements to perform such tasks. That means other nurses do not have the authorization to prescribe medicine. Because Jane does not have prescriptive authority, her failure to provide quality care and ensure the patient’s safety is a breach of duty that affects both Jane and her employer.
The hospital is liable whenever any employee performs a breach of duty, so Jane’s independent actions that result in an adverse event can be a legal liability for the hospital if the patient dies, suffers additional medical damages, or experiences a physical or psychological injury from inadequate treatments (Huang & McLean, 2010). While the Australian law of negligence acknowledges the possibility of mistakes in making diagnoses, the law does require medical practitioners to provide evidence of adherence to professional standards while performing treatments (Huang & McLean, 2010).
Without inspecting the patient’s medical record and medical history, Jane does not adhere to the professional standards of care that account for patient safety, which means she is responsible for patient negligence. From a legal perspective, both Jane and her employer are liable for criminal charges, and Jane may face additional penalties from her employer, such as job dismissal or other disciplinary actions (Anderson & Townsend, 2010).
While Jane’s actions violate the Australian law of negligence, the organization is also responsible for developing policies and guidelines for ensuring treatment quality and patient safety. For example, a qualitative study in an Australian hospital by Nichols, Copeland, Craib, Hopkins, and Bruce (2008) reveals that drug administration protocols can be non-existent or inadequate.
According to the Australian Commission on Safety and Quality in Health Care (2013), small hospitals are responsible for implementing a medication safety system for supplying, administering, and storing prescription medicine. For example, bar coding can be implemented in automated dispensing systems to prevent misuse of prescription medicine (Semple & Roughead, 2009). If Jane can obtain prescription medication without a written statement from a prescriptive authority, the organisation is also at fault for any adverse events because they do not demonstrate appropriate safety standards.
There is strong evidence that suggests the organisational system significantly determines medication error with staff and patient factors being only contributory (Roughead & Semple, 2009). Therefore, the hospital is required to introduce measures that adhere to contemporary EBP standards. For example, the introduction of a standard national inpatient medical chart in Australian hospitals can reduce medication errors significantly (Coombes et al., 2011).
Another useful EBP for organisations is the Australian national drug usage evaluation methodology because it provides nurses with better guidelines for managing postoperative pain, nausea, and vomiting (Pulver, Wai, Maxwell, Robertson, & Riddell, 2011). Introducing inter-professional structured briefings in the preoperative phase can also improve patient safety and teamwork in postoperative and follow-up care (Lingard et al., 2008). Without these types of systems in place, the organization is also liable if the patient or the patient’s family take legal actions.
It is also important to consider that nurses mainly obtain technical skills in their formal education while their employer is responsible for developing clear expectations and enhancing their communication skills (Propp et al., 2010). If the institution fails to consider additional training for its employees to improve care delivery and patient safety, they can also be liable and face criminal charges in case an employee performs a breach of duty.
Although the organisation apparently holds some responsibility in this scenario, that does not justify Jane’s actions. The organisation can only be partially responsible if adequate systems are not in place, but the “Code of Professional Conduct for Nurses” clearly determines the nurse’s responsibility in the workplace. For example, Conduct Statement 3 states that nurses must be familiar with laws relevant to their practice (ANMC, 2008a). Nurses also must not engage in or delegate practices that are prohibited by those laws, such as ordering or administering prescription medication without prescriptive authority. Therefore, even if there are any fallacies in the organisational system, Jane is still personally responsible for any adverse outcome that occurs.
However, it is also important to consider the implications of this outcome for Pamela. While Pamela refuses to act outside of her scope of practice, she also fails to inform a relevant practitioner or prevent Jane from administering the prescription drug without a written statement. According to ANMC (2008b, 2011) nurses must consult relevant members, avoid extending their scope of practice determined by their position in the team, and report questionable practices by colleagues.
While Pamela does not act outside of her scope of practice, she also does not consult a relevant team member to ensure patient safety. She demonstrates an understanding of legal requirements for medication by refusing to administer prescription medication without a written statement (ANMC, 2011). However, it is not clear why she does not delegate the patient’s case to a pharmacist or doctor instead if she believes the medication needs to be changed.
When nurses in postoperative settings need to administer new drugs for which they require written orders, they must contact the doctor on the ward (Manias, Bucknall & Botti, 2005). According to a study in Melbourne by Manias, Bucknall, and Botti (2005), changes in the drug administration protocols often require multidisciplinary team efforts to produce safe and effective alternatives to existing medication protocols. Therefore, Pamela’s decision to ask a senior nurse for assistance is not consistent with the competency standards. By understanding relevant laws for nurses, Pamela should be able to know that only doctors can change the patient’s medication.
However, it is possible to consider Jane, rather than Pamela, accountable for the adverse event in this case. While Pamela does not consult a relevant practitioner for advice, Jane also fails to comply with the same competency standards and code of conduct. Furthermore, Jane fails to adhere to several other provisions, such as provision 3.2 of the national competency standards. According to provision 3.2, the nurse must understand and implement EBPs to ensure the quality of care and patient safety (ANMC, 2011).
Between 20 and 30 percent of postoperative patients experience nausea and vomiting, and there are no clear guidelines for best practices nurses can use for reducing vomiting (Gan et al., 2007). While various antiemetic medications are established as effective in managing postoperative vomiting, Apfel et al. (2004) mention that prophylaxis is a better approach. That means using Metoclopramide during the intra-operative phase is a safer alternative than administering it in postoperative settings (Wallenborn et al., 2006).
Even though developing prophylaxis guidelines is the organisation’s responsibility, Jane’s behaviour cannot be excused because she obviously lacks knowledge of EBPs relevant to the scenario. There is no evidence that postoperative administration of Metoclopramide is effective in decreasing instances and severity of postoperative vomiting. In fact, Metoclopramide is considered inefficient in preventing postoperative vomiting when used in standard doses of 10 mgs (Gan et al., 2007), and the slow infusion of Metoclopramide, which Jane decides to use in this case, is also not an effective solution to nausea and vomiting (Tura et al., 2012).
The use of Metoclopramide is clearly not a suitable option in this scenario, especially because it is associated with extrapyramidal acute dystonic reactions and tardive dyskinesia (Therapeutic Goods Administration, 2009). Therefore, Jane’s intervention neglects the codes of professional conduct and competency standards that require nurses to adhere to and promote EBPs.
Furthermore, according to provision 5.2, the nurse is responsible for making detailed assessments to obtain information that can be used for diagnosis or treatment prescription (ANMC, 2011). Jane made her decision without conducting any assessment technique, such as observation, interview, and obtaining the patient’s medical history. Consequently, she failed to identify potential health problems and adverse outcomes related to her decision for administering Metoclopramide.
Without performing an assessment, Jane shows patient neglect and fails to build a relationship with the patient. According to Halldorsdottir (2008), a positive nurse-patient relationship can encourage patients and provide the psychosocial support they need to remain hopeful and optimistic. On the other hand, a negative relationship with patients can increase their vulnerability and reduce their hope in recovery. Jane’s failure to communicate with the patient and perform the required assessments before deciding which therapy to use is clearly a sign of neglect in the nurse-patient relationship that eventually damaged the patient’s physical well-being.
Also, her communication with colleagues is not consistent with the expected national standards. While Pamela followed the code of conduct and requested assistance from a more experienced colleague, Jane failed to respect her colleague and her advice. That is a violation of the nursing code of ethics because it is clearly stated that nurses need to respect their colleague’s knowledge, take in account their preferences, and follow collaborative approaches in caring for patients (ANMC, 2008b).
However, it is also important to mention that organisational settings and conditions in critical care may significantly affect the nurses’ ability to establish and maintain their positive relationships with the patients (Bridges et al., 2013). For example, some nurses may reduce their emotional engagement with patients if they feel the organization does not support their efforts in care delivery. It is possible to notice that organisations also have significant impact on workplace relationships and can be considered responsible when instances of negative relationships occur.
While Jane appears to be the most responsible practitioner for the adverse outcome in this case, Jane, Pamela, and the hospital all share the responsibility for the outcome to a certain degree. All evidence regarding postoperative vomiting suggests that the best strategies include preoperative risk-assessment for each patient and intra-operative interventions. Furthermore, organisations are responsible for developing systems that can be used to enhance team collaboration, team communication, ensure medication safety, and promote EBPs.
However, organisational factors alone are not responsible for individual actions. While it is true that multitasking, unclear roles, inadequate workplace standards, fatigue, and interruptions in the workplace can affect personal decision-making, those factors are not excuses for violating legislations and codes of professional conduct. As a nurse, Pamela is required to understand relevant laws, which means she should know that only a doctor or pharmacist can issue new orders for changing the medication protocol. With her decision to change the protocol without consulting a doctor or a multidisciplinary team, Jane clearly violates the Australian law of negligence and several provisions from the competency standards, code of ethics, and code of professional conduct for nurses
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