Case Study

Case Study for assignment #1Historical Case Study

#1: When Nursing Care and More Complex and Adequate Training and Supervision Are Absent

ENVIRONMENT AND HISTORY

This case took place in a small rural community of 8000 people. Mr. Kenny Salamino was a developmentally and physically disabled 32-year-old man. He had lived most of his life in a group home with seven other residents and was cared for by a staff of two unlicensed assistive personnel (UAP) 24 hours a day.

Ms. Marsha Mitchell, a licensed practical nurse whose title was “Medical Director,” had worked at the group home Monday through Friday, 8 AM to 5 PM, for 7 years. Ms. Rose Sinclair, a registered nurse, served as “Consultant.” Nurse Sinclair was employed to “be a resource” and provide a course entitled “Assistance With Medications Course for Unlicensed Assistive Personnel.” The owner of the facility, Mr. Brian Adams, did not live at or maintain an office at the facility. He hired the staff and expected the registered nurse and the licensed practical nurse to manage the resident care.

The state board of nursing in which the facility was located received a complaint from the Department of Health and Welfare. Mr. Salamino had died after admission to the hospital, and the state's surveyors from the Bureau of Facility Standards had investigated the circumstances of his death. Over a period of 6 months, Mr. Salamino had lost 40 pounds during which time the nurses had not assessed his health care needs or provided for adequate medical or nursing interventions. The bureau's investigation determined that the events that led to Mr. Salamino's death were due to lack of fiduciary responsibility of Practical Nurse Mitchell and Nurse Sinclair who, the report asserted, should be held accountable for Mr. Salamino's death.

THE NURSES' STORY

I have been a registered nurse for 10 years. I worked full time in a small hospital in a nearby town for 9 years as the supervising registered nurse. When I decided to work part-time, I chose to drop back and work in a less restricted environment than the hospital. The administrator of the group home hired me as the “Registered Nurse Consultant,” and my responsibilities included teaching to new unlicensed assistive personnel a course entitled “Assistance With Medications Course” and providing to the licensed practical nurse 24/7 support face to face or by cellular phone.

My contract specified that I was to be paid for 24 hours of work every 3 months. I did not receive an orientation to residential care/group home, federal, and/or state regulations.

The first indication I had that Mr. Salamino was having a problem was when Practical Nurse Mitchell called me and said that Mr. Salamino had just returned from the hospital with a new jejunostomy tube (J-tube). She said that she thought Mr. Salamino should have been discharged to a skilled nursing facility, but his physician, Dr. Fred Stark, sent him back to the group home because he thought Mr. Salamino would receive better care there. Dr. Stark worked with Practical Nurse Mitchell and the patients in the group home. They knew and loved Mr. Salamino.

I asked Practical Nurse Mitchell if she could handle the J-tube. She said she could, and thus I did not go to the group home to assess Mr. Salamino or to confirm Practical Nurse Mitchell's competency. I did not believe this was part of my job.

THE LICENSED PRACTICAL NURSE'S PERSPECTIVE

I could tell Mr. Salamino was losing weight over several months. I didn't become concerned at first because he continued to feed himself and didn't appear to be hungry. After several months, I called his doctor and he told me to bring Mr. Salamino in for a checkup. Dr. Stark was concerned about Mr. Salamino's weight loss and ran some tests. He had something wrong with his digestive tract and wasn't absorbing his food.

Dr. Stark arranged for a consult with a surgeon and that's when they decided to insert a stomach tube. Mr. Salamino was in the hospital for 2 days and was then transferred back to the group home. He was able to swallow and drink liquids. He didn't have a pump for his feedings when he arrived, so I called and ordered the pump and the liquid feeding solution that Dr. Stark had ordered. I didn't worry too much about the fact it took 4 days to start the feedings because Mr. Salamino continued to drink liquids.

When the pump and feeding solution arrived, I hooked it up but couldn't get the pump to run. I called Dr. Stark who arranged for me to take Mr. Salamino to the emergency room and meet the surgeon, Dr. Hari Harimoto. Dr. Harimoto discovered that something was wrong at the insertion site on his stomach. He repaired the insertion site and sent Mr. Salamino back to the group home. The aides and I gave Mr. Salamino his feedings as Dr. Harimoto ordered, but he developed a fever, was readmitted to the hospital about 2 weeks later, and died the same day.

When I looked back on the events that took place, I felt I was left to do everything myself. I wished Nurse Sinclair would have been more involved in what was going on, but she said she was not hired to see the residents. I know we gave Mr. Salamino better care than he would have gotten at the nursing home. They have too many patients and not enough nurses.

THE ADMINISTRATOR'S PERSPECTIVE

I have owned this facility for 15 years and never had a problem until this happened. Practical Nurse Mitchell is a good licensed practical nurse and handles things perfectly fine. I don't see any reason to have to pay a registered nurse to do what Practical Nurse Mitchell, a licensed practical nurse, can do on her own. I didn't see any reason to orient the registered nurse or licensed practical nurse to residential care/group home regulations. They are supposed to take care of the residents.

CASE ANALYSIS

This case demonstrates the classic example of the common expectation that residential/group home care does not require the level of nursing skill and attentiveness that is required in a hospital or skilled nursing facility. This expectation persists despite the fact that residents change in their care needs, and the home may not be able to keep up with the technical care demands of these changes. This owner-established care supervision plan was inadequate given the nature of the changes in the care the patient required. Several actions were inadequate in this series of events regarding the decisions that affected the patient's well-being. The practice breakdown elements included the following:

· 1The administrator of the group home did not provide orientation for the registered nurse immediately after her arrival. Consequently she was unaware that the State Regulations for Residential Care Facilities required that a registered nurse assesses patients on a regular basis to identify any health care needs that may be developing and to refer the patient for medical care as needed. It was only when the patient died that the state surveyed the facility and discovered the lack of supervision of a registered nurse.

· 2The administrator failed to provide adequate resources for the registered nurse and licensed practical nurse in their respective roles. The registered nurse was only paid for 24 hours of work in a 3-month period. She understood that her role was to provide the course “Assistance With Medications Course” for newly hired unlicensed assistive personnel, but this responsibility alone took more than the 24 hours for which she was paid. She did not understand that she was in a role that required her participation and direction for the care of the patients in the facility. She did not recognize her role as a “registered nurse consultant” to be “anything more than a registered nurse available on the cellular phone 24 hours per day.” She was not expected by administration to assume responsibility for assessment of the patients and/or to collaborate with the licensed practical nurse and physician.

· 3Practical Nurse Mitchell had the title “Medical Director,” which led her to believe that she was to make all decisions related to patient care. The licensed practical nurse was reluctant to call the registered nurse when she had concerns. She did contact the physician, but she did not identify the patient's health issues until the patient required hospitalization. The health care system in which the licensed practical nurse and registered nurse practiced did not design, mandate, or pay for the support and guidance that a registered nurse should have provided.

· 4After the first hospitalization, the patient's physician discharged his patient to the group home. The physician believed that the patient would receive better care in his “home,” where the staff was familiar with him, rather than refer him to a skilled nursing facility that could provide the skilled care he required. However, this group home was not adequately prepared to provide the skilled nursing care he needed.

The licensed practical nurse did not doubt her ability to administer medications by common routes and to provide care to two or more patients. But the evidence in this case did not address the competencies required for tube feeding and recognizing malnutrition. Further, the licensed practical nurse was slow to contact the physician regarding the patient's emerging physical changes, which could have been due to either a reluctance to call the physician and/or her lack of assessment or awareness of the dangerous level of weight loss and malnourishment.

Both nurses in this case were not aware that their individual levels of nursing education applied in this setting. The descriptions of their positions defined the relationship between the registered nurse and the licensed practical nurse. The licensed practical nurse was “in charge,” and the registered nurse was hired as a figurehead to meet the administrator's interpretation of the requirements for licensure of a group facility. These institutional policies established the scenario that eventually resulted in a patient's death. The licensed practical nurse assumed responsibility for all patient care but did not have the skills or support from the registered nurse to identify the patient's initial life-threatening weight loss, and later the need for timely initiation of his tube feedings. She continued to deal with the situation alone rather than contact and consult with the registered nurse and physician to determine the actions needed. Because the registered nurse had never worked in residential care before and was unaware of the federal and state requirements for residential care, she assumed that the duties as written in her position description were appropriate. Based on these duties, she did not assume a supervisory or active collaborative role to support the licensed practical nurse. The registered nurse and the licensed practical nurse did not question the scope of the duties in descriptions of their respective positions, nor did they look to the Nurse Practice Act and Administrative Rules to identify the roles their state board required for each respective nursing license or question their “positions” at the time they were hired. The registered nurse was content to have minimal collaborative responsibility and limited hours. The licensed practical nurse did not recognize that she lacked sufficient knowledge and training to provide the more skilled nursing care involved in tube feeding a patient through a jejunostomy. Further, the licensed practical nurse was flattered by her title and did not question the fact that she was not appropriately educated and competent to manage and provide adequate nursing care without support.

HISTORICAL CASE STUDY #2: When Short Staffing Hinders Good Clinical Reasoning

ENVIRONMENT AND HISTORY

This case took place in a local hospital of a community of 50,000 people. Mr. Jim Luke, a registered nurse assigned to the ICU/CCU during the night shift, had been working part-time in this unit for about 2 years and had been licensed for 8 years. His previous experience included medical-surgical nursing and working in a cardiac catheterization lab. Nurse Luke said he had not received any orientation or additional training when he was transferred to the ICU/CCU.

The board of nursing received a complaint from the hospital after a patient, Mr. John Clark, had died. The allegations were that Nurse Luke had oversedated Mr. Clark, had used chemical restraints to control Mr. Clark's behavior, and that Nurse Luke's actions had contributed to Mr. Clark's death.

THE NURSE'S STORY

I was the registered nurse who admitted the patient, Mr. John Clark, to the ICU/CCU from the medical-surgical floor the previous night. Mr. Clark was a 73-year-old man with multiple diagnoses including acute pancreatitis, acute respiratory failure, pneumonia, chronic airway obstruction, atrial fibrillation, congestive heart failure, and hypertension. Mr. Clark was confused and complained of pain. He was quite restless and frequently tried to get out of bed. He was started on BiPAP when admitted to the ICU/CCU. His wife had been sitting with him during the nights he was in the medical-surgical unit, and she also sat with him during the night he was admitted to the ICU/CCU.

When I arrived the next night for my shift I was given the report and told there were five patients in the ICU/CCU, including Mr. Clark and four patients who had been transferred from the medical-surgical unit just prior to the shift change. The additional patients included an 85-year-old female with neutropenia who required isolation, a 41-year-old female with a kidney stone, a 22-month-old female with respiratory syncytial virus who required isolation, and an 86-year-old female with congestive heart failure.

According to our infection control policy, the patient with neutropenia and the patient with a virus could not be assigned to the same nurse. One other registered nurse was also assigned to the unit. We did not have a unit clerk or an aide assigned to the unit. I objected and said we would need additional help. The nursing supervisor told me that the patients were not as acutely ill as the usual ICU/CCU patients and, therefore, we did not need additional staffing. I pointed out that two of the patients required isolation procedures and this not only took extra time for the nurses to gown and mask but also no one was available to watch the other patients when the nurses were in the rooms with the door closed with the isolation patients. I was told that this was not an issue and that the staffing was adequate. I asked if there was another registered nurse on call but was told by the nurse supervisor that I did not have authorization to call her in for assistance. I again requested additional help because the admissions for the additional patients were not completed. This would take additional time. Again, the request was denied.

When I began the shift, Ms. Clark was sitting with her husband who was restless and agitated. Mr. Clark said he wanted to go to another hospital and was trying to get out of bed. His wife was able to calm him, but she had been sitting with him every night for over a week and was very tired. I completed my assessments for the shift, and a short time later another patient was transferred to the ICU/CCU from the emergency room, a 17-year-old patient who had overdosed.

I checked on Mr. Clark, who was still agitated, and his wife told me she needed some rest. I arranged for her to sleep in the lounge. Mr. Clark had physician orders in his chart for morphine sulfate IV 2 mg prn q2h, Benadryl 50 mg IV prn sleep HS, Inapsine 2.5 mg IV prn nausea/vomiting q6h, Ativan 1-2 mg IV prn q4h severe agitation, and Phenergan 12.5 mg IV prn nausea/vomiting q1h.

Mr. Clark was complaining of back pain, and I administered morphine sulfate IM 2 mg at 11:00 PM. Mr. Clark calmed down and appeared to be sleeping 15 minutes later.

Again, I requested an additional registered nurse, but this was refused again. The shift continued to be very busy, and at 1:30 AM I checked on Mr. Clark and found him standing beside the bed and talking about leaving the hospital. I assisted him to bed and gave him the IV Benadryl and Inapsine. Thirty minutes later, Mr. Clark was still agitated. I administered Ativan and morphine, and Mr. Clark settled down and fell asleep.

At 3:00 AM I assessed Mr. Clark, and he was sleeping with minimal respiratory effort and breath sounds were diminished with upper quadrant wheezes. This was not a change from previous assessments. Mr. Clark continued to rest quietly throughout the shift. Nurses notes indicated: “minimal respiratory effort, shallow respirations, moves little air.” I reported off to the day shift nurse and included the medication I had administered to Mr. Clark in my report.

When the day shift nurse entered Mr. Clark's room to do her assessment, she found him in sinus tachycardia with diminished breath sounds and having brief periods of apnea. He was lethargic and only withdrew from pain. The physician was called in, and Mr. Clark was placed on a ventilator. Mr. Clark's condition continued to decline and he died one week later due to complications of pancreatitis, systemic inflammatory response syndrome, respiratory failure, progressive renal insufficiency, and sepsis.

CASE ANALYSIS

Hamric, in Reflections on Being in the Middle (2001) , states that “nurses are expected to be trustworthy team members in hierarchical top-down systems while at the same time working from the base up so as to meet patient and family needs” (p. 254). In this case, the registered nurse was caught between a nonresponsive hospital hierarchy and the dilemma of choosing the most appropriate means to protect the patient from harm.

The registered nurse recognized immediately the potential issues that could possibly arise from the staffing that was scheduled for his shift. He requested additional nursing and support staff, and the supervising/managerial personnel refused to listen to his concerns and did not accept his logic for making the request. He was forced to acquiesce to his superiors' decisions and felt he should not continue to pursue his request for additional staff.

At the beginning of the shift, the patient's wife was with him and able to calm and protect him from his confused and agitated mental state. However, she was unable to continue to be by her husband's side throughout the shift. When she left to sleep in another room, the patient was left alone without her support. The registered nurse recognized that the patient would need additional surveillance and assessed him to determine his needs. Because the patient exhibited signs of pain, the registered nurse medicated him for pain and it did calm the patient for a period of time. The admission of a new patient to the floor diverted more attention from the case study patient. Finally, in a misguided but understandable decision, the registered nurse chose to give the patient additional medication to calm him. When this did not work, he made the same decision again and administered additional medication before the effects of the previous medications were apparent. This resulted in oversedation of the patient.

Both the patient and the registered nurse paid the price for a system that did not allow for flexible decision making in order to best protect the patient from harm. Nurse Luke did not adequately recognize the significance of the patient's decreased respiratory efforts that resulted from overmedication. An additional nurse may have prevented this scenario from ending as it did. It is probable that an unlicensed individual assigned to be with Mr. Clark could have prevented this outcome had nonchemical means been provided to comfort and reassure the patient.

Nurse Luke was reported to the board of nursing for being grossly negligent and reckless in performing nursing functions and for endangering a patient. The hospital employee who reported the nurse to the board was responsible for protecting the hospital's State Licensure and Medicare Certification status in the shadow of an allegation that one of their nurse employees had used chemical restraints to subdue a patient. An experienced nurse, committed to his practice and attempting to protect a patient, made a quick, inappropriate clinical judgment in the context of work overload and a poor staffing mix that could have been prevented had the system provided additional resources.

References

L.H. Aiken, S.P. Clarke, D.M. Sloane, J.A. Sochalski, R. Busse, H. Clarke, et al.: Nurses' reports on hospital care in five countries. Health Affairs. 20(3), 2001, 43–53.

L.H. Aiken, J. Sochalski, G.F. Anderson: Downsizing the hospital nursing workforce. Health Affairs. 15(4), 1996, 88–92.

Aristotle: T. Irwin, Trans. In Nicomachean ethics. 1985, Hackett Publishing Co, Indianapolis, (Original work published 322 B.C.).

P. Benner, R.G. Hughes, M. Sutphen: Clinical reasoning, decision making, and action: thinking critically and clinically. In R.G. Hughes (Ed.): Patient safety and quality: An evidence-based handbook for nurses. 2008, AHRQ, Rockville, MD, Available online at  http://www.ahrq.gov/qual/nurseshdbk/ , Accessed October 2, 2008.

P. Benner: In From novice to expert: Excellence and power in clinical nursing practice. 1984, 2001, Prentice-Hall, Upper Saddle River, NJ, First edition and Commemorative Edition.

P. Benner: The role of articulation in understanding practice and experience as sources of knowledge. In J. Tully, D.M. Weinstock (Eds.): Philosophy in a time of pluralism: Perspectives on the philosophy of Charles Taylor. 1994, Cambridge University Press, Cambridge, 136–155.

P. Benner, P. Hooper-Kyriakidis, D. Stannard: In Clinical wisdom and interventions in critical care: A thinking-in-action approach. 1999, W.B. Saunders, Philadelphia.

Benner P., Sutphen M., Leonard-Kahn V., & Day L. (In press). Educating nurses: A call for radical transformation. Carnegie Foundation for Advancement of Teaching. San Francisco: Jossey-Bass.

P. Benner, C. Tanner, C. Chesla: In Expertise in nursing practice: Caring, clinical judgment and ethics. 2009, Springer, New York.

P. Benner, J. Wrubel: Skilled clinical knowledge: The value of perceptual awareness. Nurse Educator. 7(3), 1982, 11–17.

L. Blum: In Moral perception and particularity. 1994, Cambridge University Press, Cambridge.

P.I. Buerhaus, D.O. Staiger, D.I. Auerbach: Implications of an aging registered nurse workforce. Journal of the American Medical Association. 283(22), 2000, 2948–2954.

H.L. Dreyfus: In What computers still can't do: A critique of artificial reason. 1992, Massachusetts Institute of Technology Press, Cambridge.

H.L. Dreyfus, S.E. Dreyfus: In Mind over machine: The power of human intuition and expertise in the era of the computer. 1986, Free Press, New York.

H.L. Dreyfus, S.E. Dreyfus, P. Benner: Implications of the phenomenology of expertise for teaching and learning everyday skillful ethical comportment. In P. Benner, C.A. Tanner, C.A. Chesla (Eds.): Expertise in nursing practice, caring, clinical judgment and ethics. 1996, Springer, New York, 258–279.

P. Gearing, C.M. Olney, K. Davis, D. Lozano, L.B. Smith, B. Friedman: Enhancing patient safety through electronic medical record documentation of vital signs. Journal of Healthcare Information Management. 20(4), 2006, 40–45.

C.B. Guignon: In Heidegger and the problem of knowledge. 1983, Hackett, Indianapolis.

J. Halpern: In From detached concern to empathy: Humanizing medical care. 2001, Oxford University Press, Oxford.

A.B. Hamric: Reflections on being in the middle. Nursing Outlook. 49(6), 2001, 254–257.

P. Hooper: In Expert titration of multiple vasoactive drugs in post-cardiac surgical patients: An interpretive study of clinical judgment and perceptual acuity. 1995, University of California, San Francisco School of Nursing, San Francisco, Doctoral Dissertation.

I. Kant: In Critique of pure reason. 1785, Macmillan, London, N.K. Smith, Trans., 1929.

National Council of State Boards of Nursing (NCSBN): In Report of Findings from the Practice and Professional Issues Survey, Spring 2002. 2003, NCSBN, Chicago.

J. Rubin: Impediments to the development of clinical knowledge and ethical judgment in critical care nursing. In P. Benner, C.A. Tanner, C.A. Chesla (Eds.): Expertise in nursing practice, caring, clinical judgment and ethics. 1996, Springer, New York, 269–311.

D. Schon: In Educating the reflective practitioner. 1987, Jossey-Bass, San Francisco.

N. Sherman: In Making a necessity of virtue: Aristotle and Kant on virtue. 1997, Cambridge University Press, Cambridge.

R. Singh, T. Servoss, M. Kalsman, C. Fox, G. Singh: Estimating impacts on safety caused by the introduction of electronic medical records in primary care. Informatics in Primary Care. 12(4), 2004, 235–242.

W.M. Sullivan: In Work and integrity: The crisis and promise of professionalism in America. 2005, Jossey-Bass, San Francisco.

C. Taylor: In Sources of the self. 1989, Harvard University Press, Cambridge, MA.

C. Taylor: Explanation and practical reason. In M. Nussbaum, A. Sen (Eds.): The quality of life. 1993, Clarendon Press, Oxford, 208–231.

A.J. Vetleson: In Perception, empathy, and judgment: An inquiry into the preconditions of moral performance. 1994, Pennsylvania State University Press, University Park, PA.