The case study (HCCC v Jarrett, NSWNMPSC, 2013) explains the enquiry made into the role and activities of registered nurse [RN] Janelle Jarrett in respect to the care of a patient during a night shift from 30th September 2011 to 1st October 2011. RN Jarrett was rostered as the Hospital in Charge [HIC] and Nurse in Charge [NIC] of a general ward. The patient first presented to Ballina District Hospital emergency department [ED] at 1428 hours on 30th September 2011 with increasing shortness of breath [SOB], muscular aches and pains and a history of chronic obstructive pulmonary disease [COPD].
The patient was triaged as category three and investigations into medical records detailed documentation that described the patient’s SOB as being secondary to heart failure and advanced COPD. At 2000 hours the patient was admitted to the general ward with an incomplete nursing checklist and a moist cough. Throughout the night shift the patient appeared confused, with a decreasing level of consciousness [LOC] and abnormal vital signs.
From 2300 to 0200 the patient was observed to be combative and restless with increased work of breath, however these observations were not reported to Dr McKenzie the General Practitioner Visiting Medical Officer, nor were thorough nursing assessments performed. At 0200 RN Jarrett phoned Dr McKenzie requesting a sedative for the patient, failing to convey an adequate account of their physical and mental condition. At 0225 hours the patient experienced an unwitnessed fall following the administration of 5mg Valium.
Subsequently, neurological observations were commenced and repeated at 0340 with a Glasgow Coma Scale [GCS] of 6/15. Dr McKenzie arrived at the hospital between 0630 and 0700 hours, and was then informed of the patient’s unwitnessed fall, GCS score and ondition. The patient was then transferred to Lismore Base Hospital [LBH] at 0930, presenting with confusion, increased SOB, decreased LOC, abnormal vital signs and a GCS of 3/15. The patient continued to deteriorate and was palliated, passing away at approximately 1900 hours on 1st October, 2011. 318 words 1.
Episode of Care and Relevant Factors (300) The first episode of care worth examining in relation to the RN’s responsibility in providing quality and safe care is the administration of 5mg Valium at approximately 0200 hours as per phone order from Dr McKenzie (HCCC V Jarret, 2013, 14). Key issues within this episode of care include the nurse’s failure to demonstrate leadership in delegating responsibilities and empowering staff, recognising and communicate a deteriorating patient and adhering to policies and protocols to ensure safe and effective patient care (ASCQHC, 2012, p. 2). RN Jarrett did not delegate responsibilities in that she failed to request or empower RN Elliot, a relatively junior nurse, to complete the prerequisite Patient Care Plan, conduct and document regular and thorough nursing assessments including vital signs during the patient’s admission and complete the falls risk assessment s was normal practise at the beginning of the shift (HCCC V Jarret, 2013, 14, 42).
This demonstrates the nurses lack of knowledge of clinical risk management as adhering to standardised processes, protocol, checklists and frameworks all contribute to clinical risk management (Felton, 2012, p. 23) and the adequate documentation of patient records and regular monitoring enable any health worker to recognise the deteriorating patient (Tower & Chaboyer, 2013, p. 1406. ).
If RN Jarrett was aware of signs and symptoms of the deteriorating patient and had then escalated care and expressed clinical oncerns to the doctor, the prescription of a sedating medication such as Valium would not have occurred (Smeulers et al. 2014). Additionally, RN Jarrett did not request that Dr McKenzie attend the hospital and review the patient’s deteriorating condition demonstrating poor communication skills and a failure to advocate for the patients quality and safe care through appropriate communication (HCCC V Jarret, 2013, 64; Beaumont et al. 2008, p. 45). 2.
Episode of Care and Relevant Factors The nursing assessment and lack of appropriate nursing interventions following the patients unobserved fall that ccurred approximately 20 minutes after the administration of Valium further highlight the ward nurses lack of knowledge of clinical risk management, identification of the deteriorating patient, communication and leadership skills (HCCC V Jarret, 2013, 46-48, 65). Patient documentation such as the checklist, care plan and falls risk assessment were incomplete although completion of these is standard practise and the commencement of a shift (HCCC V Jarret, 2013, 42).
The failure to complete and document these assessments significantly contributed to the patient’s level of risk and eventual adverse utcome as the failure to identify signs and symptoms of the deteriorating patient reduces the window of opportunity to treat the deteriorating condition (Twigg, Duffield & Evan, 2013, p. 542). Again, poor communication skills are evident in RN Jarrett failing to notify Dr McKenzie of the patients unwitnessed fall in a timely manner, instead waiting until he arrived at the hospital between 0630 and 0700 hours (HCCC V Jarret, 2013, 62-68).
RN Jarrett’s leadership deficiency is notable in her lack of presence on the general ward, despite her awareness of the patient’s deteriorating condition and that responsibility of care ad fallen to a relatively junior nurse (HCCC v Jarret, 2013, 37, 66-67). Being in a leadership role of HIC and NIC, RN Jarrett should be an accountable leader and delegator who is able to satisfactorily recognise and respond to the deteriorating patient (HCCC v Jarret, 2013, 3; ASCQHC, 2012; O’Malley, 2013).
However, RN Jarrett’s was not available to support RN Elliot and advise her on how to detect and implement interventions for a deteriorating patient as she was absent from the ward for a large part of the shift, resulting in poor outcomes for the patient. This is supported by Twigg, Duffield and Evans (2013, p. 43) who highlight impaired leadership results in a reduced level of care being delivered. 3. Episode of Care and Relevant Factors After the patient experienced an unobserved fall and possible head injury, neurological observations were taken, revealing a decreasing LOC and GCS score (HCCC v Jarret, 2013, 49, 50).
The subsequent lack of communication between ward nurses, RN Jarrett and Dr McKenzie and the patient’s eventual outcomes reflect a failure to escalate the deteriorating patient, a failure to communicate both verbally and written, poor inter-professional communication skills and negative leadership traits. All nurses are leaders, displaying accountability, motivating and empowering other colleagues to achieve quality and safe care (O? Malley, 2013, p. 28; Giltinane, 2013, p. 35).
RN Jarrett was heavily relied on by the nursing team who failed to deliver a high standard of care without her presence, demonstrating a Transactional style of leadership where a combination of autocratic and Laisse-faire were evidenced in the inadequate guidance provided to RN Elliot (Giltinane, 2013, p. 36). RN Elliot failed to assess the patient at the level satisfactory to her knowledge and experience between 0225 and 0340 hours when he nurse was not present on the ward, and failed to seek clarification on the frequency of observations or assistance from RN Jarrett (HCCC v Jarret, 2013, 49-50).
Liaw et al. (2014, p. 259) Explains that poor communication and handover contribute to adverse outcomes for the patient. This is epitomised in the poor inter-professional communication skills of RN Jarrett, where her failure to speak up and clearly deliver an accurate handover of the patient’s deteriorating condition in order to promptly escalate care (Garon, 2011, p. 361) and failure to notify the doctor of the subsequent fall and GCS of 6 until he arrived in the orning (HCCC v Jarret, 2013, 49-50, 68) could have contributed to the patients adverse outcomes.
Furthermore, RN Jarrett and the other nurses did not demonstrate adequate written communication skills, shown by the lack of documentation and records of tasks, events, observations, vital signs and GCS scores obtained during the shift. Inadequate records make it extremely difficult for health care professionals to recognise the deteriorating patient, and poor communication contributes to a failure in the application of adequate skills and knowledge to care for the deteriorating patient (Tower & Chaboyer, 2013, p. 1406; HCCC v Jarret, 2013, 14).