Response to each peer in 2 paragraphs
Peer 1
Part 1:
While working as a floor nurse in bedside care, one of the main issues I ran into was improper assignments. There are many times that when a nurse is hired she is told a certain nurse-to-patient ratio. A lot of times that number can be lowered as the level of acuity of patients rises. In an ideal situation, a nurse would not have multiple patients who are not in stable condition. The units would also be staffed with adequate medical assistants or nursing assistants.
In my experience, there is never a time that I can remember that my patient load actually fell within the load that I was told. Our nurses would have 6-8 patients in varying levels of acuity. Very rarely did our unit of 25-30 patients have more than one MA or CNA. This meant that the nurses wore both hats during that shift. This is a recipe for disaster. There are many issues that arise in this situation. A situation that is not fair to the nurse, the MA or CNA, and most importantly- the patient.
When you begin to over-assign patients to a nurse you are most certainly compromising patient care. The patients aren’t rounded on as frequently, medications are not given at appropriate intervals, call bells ring more often and longer, the nurse is less intuitive on the patient’s status, patients aren’t changed appropriately, hygiene care is overlooked, and most importantly, signs and symptoms of declining health or an event are missed.
Medication errors have been reduced substantially due to systems such as the PYXIS. The systems tell nurses the exact doses. They sort pills and meds, and they take into account weight-based issues. When nurses are overstaffed, I have seen that they do not pull medications individually. They pull multiple patients at once just to get the medications to the patient and to make it through the shift. When things like this occur, the potential for a medication error increases exponentially. To further compound this, it is likely these errors will be missed due to the improper rounding and patient care one is receiving.
As nurses, we must advocate for ourselves. In this situation, it is also advocating for our patients. If you feel a load is too heavy and patient care will be compromised you must express this to your charge nurse. If it continues to happen, you must report it to the floor nurse. Do not be afraid the use the MA or CNA, regardless of howshort-staffedd you may be. If you need help you must ask for it. If that does not work, demand it. We holdpatients’s lives in our hands. That is nothing the be taken lightly.
Part 2:
- Since Lewis was a minor, his parents held decision making authority. How was the principle of respect for autonomy violated in this case?
The parents in this case were representing the patient who was a minor. The parents repeatedly asked for changes in his plan of care due to his declining health status. The patient’s autonomy was violated because the concerns and requests of his parents were denied or ignored. Although medical professionals know a lot, there is a lot to be said for a parent’s view on their child’s health status. The attending physician was not called as they requested either.
- Identify problematic issues of beneficence and nonmaleficence in the case of Lewis Blackman. How might the nurses have better demonstrated these principles as they cared for Lewis?
In this case, beneficence is the staff’s inability and refusal to see the substantial and fatal change in the patient’s condition and their inability to provide ethical and humane care for the patient and his family. No one on the medical staff advocated for the patient. The major concern seemed to be their egos. The nonmaleficence was not making changes in real-time to the patient’s IV fluids and other medications to better suit his needs as his condition continued to decline. The nurses could have put the patient first and contacted the attending or the doctor on call. As nurses, when you see a situation continuously unfold and evolve and the plan of care is not adequate, we must adapt immediately for the benefit for the patient.
- Aside from lack of knowledge, why do you imagine the nurses failed to act on Lewis’s behalf?
We have expected outcomes when a patient is in the facility for whatever reason. A normally healthy adolescent who had a procedure is not expected to tank and certainly not to die. These nurses were not responding to the signs of decline the patient was showing. They were not attentive or aware of his urine output, his blood pressure, or the family’s repeated requests for help for their son. I think in this case the nurses did not have checks and balances in place to make sure that the patient was recuperating in a positive trend.
- How might a nurse have effectively advocated for Lewis and his mother?
The nurses first should have truly assessed the patient from head to toe. This includes appropriate rounding, assessing input and output, vital signs, patient status, and most obviously the parents who tirelessly advocated for their son. The nurse should have called the attending physician when the parents first requested them to. If he hadn’t responded then the surgeon could have been contacted, an on-call physician, anyone with the knowledge and wherewithal to treat this patient and save his life.
- Justice is the ethical principle that relates to fair, equitable, and appropriate treatment in light of what is due or owed to persons. How does the nurse’s refusal to contact an attending physician constitute a distributive justice issue?
The nurse’s refusal to contact the attending was not justified. Patient centered care extends to the family, especially in the case of minors or those who are incapacitated. The nurse was unjust in refusing to contact the physician or lying to the patient to just “shut them up” for lack of a better phrase. The patient was rapidly declining and there was little to no action being taken on his behalf.
- What is your reaction to Helen Haskell’s view that nurses need policy-level help to be empowered with respect to communications with physicians?
The nurses do need help in this regard. Although physicians are considered “more educated” we as nurses cannot refuse to contact a physician based on their request to be “left alone” or not “awakened in the middle of the night”. As a nurse on a busy bedside unit, I often endured verbal abuse from certain physicians who didn’t want issues that arose to be their problem. We still have to do what is in the best interest of the patient and discuss the HR violations with the appropriate channels later. As nurses we require open and honest communication with the physicians, and the patient’s lives depend on it.
- How does the culture in hospitals in which you’ve worked compare to the culture described in Helen Haskell’s story?
Unfortunately, in my experience the culture is similar. I can say on the night shift it is probably worse because you only have one or two physicians you can reach out to. This culture has got to change. We have to advocate for our patients regardless of the negative or unpleasant communication we may have to endure to do so.
- Which of the errors you described were “system” errors? Which were errors that individuals committed? What distinguishes these categories in your view?
I would consider the system errors to be the medications being incorrect for an adult patient and for a lower-weighted pediatric patient. The individual errors are the lack or proper rounding, proper assessment of input and output, proper taking and reporting of abnormal vital signs, and listening to the patient and his family. The system errors are errors in the medication and computer systems. Although nurses with experience would usually catch these errors. Individual errors are judgement calls or processes performed by individuals and decisions they made.
- What are your ideas about patient empowerment and nurse empowerment in terms of the overall safety of our health care systems? When are the interests of patients and nurses in alignment? When are they not?
Patients and nurses aren’t always going to be in alignment. There are times that we as nurses make judgment calls that patients do not agree with or understand. Based on our experience and training, we make these calls. There are also times when the patient and nurse agree on a path forward, such as calling a physician. The empowerment for a patient is to always advocate for yourself. You know your body better than anyone else and you have to trust your instincts and what your body is telling you. As far as nurse empowerment, I think it is ok with being not liked. Know your unit, know the processes, know that you are a confident and ethical nurse, decide that patient care comes first, and don’t be afraid to report attendings or residents who are not acting in the patient’s best interest or misrepresenting themselves.
Peer 2
There are many legal issues that arise in healthcare and nursing. In a perfect world malpractice wouldn’t exist and we would have the capacity to perform our jobs with only positive outcomes. Malpractice cases are constantly being brought forth against nurses and doctors. With these new cases being brought we are allowed to work together to come up with solutions to avoid malpractice issues.
Negligence is a big legal nursing issue that we are taught about from the beginning of our education. Negligence is the failure to act and respond in a way a prudent, reasonable person would (Burkhardt & Nathaniel, 2020). This could be something minor like not wiping up spilt water from the floor to prevent falls, or it could be more major, like administering the wrong medication to the wrong patient.
Nurses are held to standards that are monitored by our employers and the law. Nurses are held accountable to a duty to the patient, and when there is a breach of duty, or injury to the patient occurs we are found to be negligent in our practice. Negligence can take place in many forms. Some of the most common causes of negligence are failure to assess and monitor, failure to administer medications properly, failure to communicate, failure to act, failure to plan and execute care, and failure to avoid emotional harm (Burkhardt & Nathaniel, 2020). Many facilities have policies in place to prevent negligence and are aimed at assisting in nurses providing care.
We have many duties as nurses and all want to have the best outcomes for our patients, and certainly not many of us wish to be negligent on purpose. We know that there are many factors that influence our care. In recent news sources we know that we are very short staffed profession at the moment. We may have up to eight or more patients at a time and with a heavy assignment, monitoring and continuing to provide basic care needs in a timely manner can be difficult, and while we are administering medications in one room, we may be missing a critical vital sign in the next room.
I think the solution to many negligent situations in at the bedside begin with teamwork. We need to able to lean on our coworkers and the healthcare team and trust that they have the same positive goals for our patients. Communication is a huge step in combating negligence as well. We need to able to communicate with the physicians without fear of retribution, and we need to able to communicate with our care staff to keep the patient safe. The most important communication needs to happen with the patient as well. Many patients feel neglected when they are unaware of what is happening and what their plan of care is. Having a simple conservation with the patient about how their day is going to look may keep them safe from harm and feel like are involved in their own care. Just culture has greatly improved the working environment for nurses and allowed us to speak up to better improve systems that may cause negligent situations.
Part 2
Autonomy is defined as a person’s freedom to make their own choices about issues that affect themselves without coercion (Burkhardt & Nathaniel, 2020). The Lewis Blackman case is an extremely heartbreaking case that had many injustices that influenced his care. Lewis Blackman was a teenage boy under the supervision of his parents, his legal guardians, and one of the ways that his autonomy was violated was the staff’s refusal to listen to his parent’s request to speak with the attending physician, or the lack of information that they were provided about Lewis’s care. Without being able to speak with the physician and gather the information needed to make an informed decision about his own healthcare. The staff ignored the parents’ requests for further evaluation of their son and took away Lewis’s autonomy to make an informed choice about his carefree from coercion, lies and restraint. Beneficence is the ethical principle to do good (Burkhardt & Nathaniel, 2020). Nonmaleficence is the ethical principle that is to do no harm, accidental or deliberate (Burkhardt & Nathanial, 2020). By ignoring the family’s pleas for further evaluation from the attending physician, not taking vital signs appropriately and dismissing key symptoms the healthcare team broke beneficence and did not do good in preventing harm towards Lewis. Furthermore, the inability to obtain timely vital signs and ignore fluid and medication orders, or give medications incorrectly, nonmaleficence was violated by resulting in serious harm to Lewis and his family.
Aside from the lack of knowledge on the nurses’ part, I believe that they dismissed claims from the parents by assuming that because the patient was previously healthy and had no comorbidities that Lewis would be fine. I think that a lot of trust in Lewis’s physical health and his young age made it easier in the nurses’ minds to ignore the parents’ request for further evaluation. I think that this belief made it harder for the nurse to see the outward signs and symptoms of a decline, I also think that maybe the environment to speak up and escalate the parent’s concerns might have been toxic and the nurse was fearful to intervene. The nurses should’ve gotten the providers involved sooner. The fluid order should’ve been corrected sooner than it was and the Toradol administration should’ve questioned and clarified instead of blindly carried out. In addition to this the nurses should’ve communicated more effectively with the family about their son’s plan of care. If the attending or senior providers in Lewis’s case were not responding to their pages, then the nurses should’ve escalated the parent’s concerns up the proper channels to reach a resolution. Everyone, especially patients who are vulnerable, has the right to justice. Justice for Lewis was not delivered when the nurses and residents ignored the family. The family mentions the lack of information they were given and describes the confusion on who was who, meaning they didn’t know who their nurses were, and they were under the impression that the resident speaking with them was the attending they had been requesting. This confusion played a part in the injustice that was committed by multiple parties in Lewis’s care. Nothing that transpired with the medication errors and lack of communication was justice.
Helen Haskell mentioned that nurses need policy-level help to be empowered when communicating with providers. I think this is a sad fact that is unfortunately true for nurses. Many nurses report instances when providers refused to listen to concerns when brought forth to them. I have seen providers ignore pages to prevent harm to patients and then those preventable concerns result in rapid responses being activated. Having the Lewis Blackman Act in place does empower us as nurses to reach out to the providers at the requests of patients and gives us enough back up to be able to dodge backlash from the provider, no matter how small the communication may be viewed by the healthcare team. While there were many errors and wrongs that were committed in this case, it wasn’t just one person at fault. I would define system errors as errors that were committed by multiple people with the use of technology. The system errors that occurred were the standard fluid orders that were not appropriate in this case. This order set was developed to prevent mistakes, but in the system allowing the provider to blindly order took away a checks and balances system. The among of NSAID’s that were administered to Lewis also points to a system failure within the pharmacy system. Nothing in these order sets alerted the team to a potential error, if it did, the error was easily ignored. Individual errors that were committed were the nurses failing to take vital signs and recognize the downward trends, the attending physician was never contacted, and the resident misrepresented themselves as the attending provider.
Patients should feel empowered to speak up and ask questions. Nurses should be empowered and feel confident in decision making and have the resources and support from physicians to speak up on behalf of the patient. Healthcare can be an intimidating field and patients, nurses and physicians need to able to voice their concerns and ideas to achieve positive outcomes. Sometimes patients may have different goals that may not be achievable in the hospital setting and that can misconstrue the patient to nurse relationship. The biggest legal concern in Lewis’s case is the amount of malpractice that occurred in the form of neglect. The staff neglected to rescue, to respond to the family’s concerns, and failed to keep Lewis safe from harm.
- What is the biggest legal concern that you see with what happened?
There are a couple of legal issues I see here. First are the medication errors. I also see an issue with assessments and patient care. There were also false misrepresentations that a resident was an attending and staff saying the attending had been contacted when he had not been. The failed response when the patient was coding is an issue as well as a lack of proper functioning equipment. Every ball, in this case, was dropped, except for where the parents are concerned.
