Assessment 1: NUR3201 Written Assignment Task Overview
|Brief task description
|Students are to read a coronial case and then conduct a critical analysis.
Comprehensive details of the required task can be found in the ‘Task Information’ section of this document and the assignment marking rubric provided on your course study desk under ‘Assessments’.
Students are to use current and relevant supplementary literature to support the analysis and are to specifically link supporting literature to the case. The analysis should relate to patient assessment, detection and escalation of clinical deterioration and communication provided from the Registered Nurse’s within their scope of practice whilst caring for Michael James Calder.
|Word limit is 1800 words ( +/- 10%) (word length includes in-text referencing and excludes your reference list and appendices)
|Marks out of: Weighting:
|Maximum Grade 70
|Course Objectives measured
|LO-1, 2, 3, 4, 6 & 7
|In order to successfully complete this assignment you will need to complete all of the following;
Introduction (approximately 300 words)
The introduction should set the scene for the critical analysis of the case of Michael James Calder in the context of detection of deteriorating patients with consideration to the accountability of a Registered Nurse.
Body & Analysis of the Case (approximately 1200 words)
Students are to conduct a critical analysis of the case referencing key pieces of information specifically from the case, and using contemporary literature to support the analysis. The analysis should specifically relate to the detection and escalation of clinical deterioration provided from the Registered Nurse within their scope of practice whilst caring for Michael James Calder.
|This assessment piece will be written in the form of an academic essay providing references to relevant peer reviewed articles and legislative policies and guidelines. Students need to demonstrate synthesis of published material with the student’s own analysis to demonstrate appropriate understanding.
THE INQUEST INTO THE DEATH OF MICHAEL JAMES CALDER
Mr Michael caldera, a 33-year-old male, was admitted to Holy Spirit Northside Private Hospital on 8 July 2014 with an intense occipital headache. He had a past medical history of viral meningitis and sleep apnoea. After being diagnosed with viral meningitis he was prescribed an analgesic regime consisting of Opioid. After four days of his admission, he has unexpected, sudden death. The autopsy report suggested lethal opioid levels as the cause of the death. The essay conducts a critical analysis of the case concerning essential information and available literature to support the analysis. The analysis aims to detect and escalate clinical deterioration provided by the Registered Nurse within their scope of practice while caring for Michael James Calder.
Registered Nurses Role and Responsibility in Detection and Escalation of Clinical Deterioration
As per the Ministry of health, policy directive named Recognition and management of deteriorating patient, a nurse should establish the clinical deterioration and respond through management of the physiological and mental state deterioration of patients through appropriate escalation care process ("National Safety and Quality Health Service Standards Second edition", 2017). The nurse should provide timely and appropriate care to the patient whose current condition deteriorates and communicates with the patients and cares. In their clinical practice, the nurse is responsible for highly engaging in the process of recognizing and responding to the clinical deterioration of patients in acute healthcare settings (Anstey et al., 2019). As stated by the Australian Commission on Safety and Quality in Healthcare, nurses should anticipate the deterioration of the patient's condition and manage the organisational framework for escalation and the rapids response system criteria (NSQHS, 2017). The collective team approach, keen observation of the risk assessment tools, and accurate communication across the patient's journey can help recognise and respond to clinical deterioration (Anstey et al., 2019). As per standard nine, nurses are accountable for recognising clinical deterioration in acute health conditions for all patients whose conditions are deteriorating to receive appropriate care (NSQHS, 2017).
For detection and escalation of clinical deterioration in a patient, the nursing competencies include assessing the deterioration and establishment of the signs of deterioration. This includes comprehensive systemic and mental state assessment of the patient's condition, documenting the history or any medical history. It is essential to engage patient carers, family members, case manager, or the clinician in the assessment process (Anstey et al., 2019).
Missed Opportunities from the Perspective of a Registered Nurse
When Mr Calder was admitted, his history form was not filled correctly; hence there was limited information in the form of query related to his condition of sleep Apnoe. He has taken surgical interventions for sleep apnoea from the same hospital; hence, the nurse should have checked the hospital records. R.N Greecezel Goudswaard involved in the caring for two days failed to communicate the condition to the treating physician Dr Brockett, although the pain was higher on the scale with no relief. The enrolled nurse Meadowfair on 9 July failed to register any notes on the perceived notion of Michael being brighter. R.N. Roach cosigned the administration of Ordine by her buddy nurse R.N Xie Juan although they both were not sure of the frequency or the maximum dose provided. As per the hospital policy, the orders must be communicated to two nurses, which was not done. R.N Juan says she kept the dose of opioid lower intentionally from the ordered range as there was no pain assessment, and she noted that he was given Oxycontin slow-release recently. Even not being aware of the pain response, she administered a 20mg dose of Ordine. She administered another dose of 40mg of Ordine on the patient's complaint of headache as bad as before without any assessment on the pain scale or discussion with Dr Brockett. R.N. Goudswaard noted in progress notes that his headache remained 3+; however, on the observation chart's pain score was recorded '0'. The following RNs providing the care failed to monitor the oxygen saturation, report the changes in the vital to the treating physician and continued to administer analgesic treatment without thorough examining of narcotisation.
Early Warning Tools, Pain assessment, Documentation, Communication and Medical history
Standard clinical tools support the nurses to assess the patients and recognise the patient deterioration and need for appropriate escalation care. The standards clinical tools designed by the Ministry of health are designed using the guiding principle's human factors. As advocated by the Australian Commission of safety and quality in national healthcare standards, several actions are laid down that enables the nurse to perform actions desired about the situation. For example, the MEWS chart advocates nurses to apply oxygen if the saturation level below 88% ("National Safety and Quality Health Service Standards Second edition", 2017). The pain assessment is an ongoing process that indicated the underlying pathological process; hence comprehensive and focused pain assessment allows data collection for evidence-based practices (Kovacs et al., 2016). Precise nursing assessment through appropriate tool ensures critical care rather than trial by error approach. Regular document of pain in charts improves pain management goals, patient satisfaction, prevention of opioid crisis and oversedation risk(Bucknall et al., 2017).
Nursing communication and documentation are essential for accurate reflection on eth assessments, the efficacy of interventions, current clinical state and changes and patient information to support the multidisciplinary team care. Kovacs et al., 2016 suggested that use of appropriate tools and communication, there is a high prediction rate with survival to ICU discharge rate increased from 44% to 53% after introducing intervention as per the implementation of the early warning tool and documentation of assessment. The use of risk assessment tools enriched with communication and proper documentation empower nurses, increasing their confidence while reporting the condition of deterioration to the doctors (Jensen et al., 2019).
Limitations of Early Warning Tools
Early warning tools are widely used across the clinical institution for identifying deteriorating patients; however, their ability to predict specific clinical outcomes is still questionable due to the gap in the theoretical literature and the actual implementation (Downey et al., 2017). Despite in use among almost every clinical sphere, the deteriorating patient often failed to be identified, suggesting insufficiency and lack of robustness of these tools. Studies have indicated several limitations of the tools, including the sensitivity, need for constant engagement of the practitioner and variation of the clinical decision and judgement (Jensen et al., 2019). The early warning tools are known to have reasonable repetitive values among the deteriorating patients; however, there are particular challenges it faces compared to specialty and specific target tools due to their better sensitivity and higher chances of reading. The tool is user-dependent nature hence having higher chances of human errors where the clinical judgment is paramount (Kovacs et al., 2016).
Understanding the strength and weakness of the early warning tools is essential for nursing practice as it diversely impacts nurses' professional conduct while caring for the patient. The nurse should be aware of incorporating their professional accountability and competence as per the law and policy while using such tolls in acute care settings. (Downey et al., 2017) A tool is beneficial alone cannot ensure quality, efficiency and safe care (Jensen et al., 2019).
Implications of Human Factors on Effective Decision
Cognitive dissonance is related to the conflicting attitude and beliefs that arise within certain situations. Cognitive biases and dissonance can lead to diagnostic inaccuracies along with medical error resulting in mismanaged care and treatment (Saposnik et al., 2016). These two phenomena can occur due to emotional polarisation, recent experience and teachings while in nursing institutes. The cognitive biases arise when there is a tendency for impaired decision making due to incomplete information and subjective influence rather than practical, evidence-based information. These factors have several implications on the decision making in management, assessment, planning, evaluation and requesting assistance from the seniors or physicians. This interferes with the particular intervention required, deciding whether an assessment test is required or the mode of the assessment and further synthesising the information from the assessment (Saposnik et al., 2016).
The human factors also influence collecting data, combining multiple factors, information processing, and determining previous intervention's effectiveness (Reedy et al., 2017). The absence of rationality and human factors can lead to deviations from the standardised care as observed in the case. The RN were unable to provide complete information, note history, acknowledge the occurrence of hypoxemia in the patient and, most importantly, repeated doses of opioid, subconsciously unaware of the inappropriate process they were following.
This predisposes to the tendency for exaggerated predictions, and few solutions are favored comparatively, for example, nurses can more be focused on the Michaels headache and repeatedly providing medication which was a simple approach as due to cognitive biases, few solutions are more favoured because it unduly inflates the estimation of the same phenomenon being repeated (Reedy et al., 2017).
Suitable Strategies to Risk Management and Missed Opportunities
There is multiple evidence of missed opportunity throughout the case study, which would have caused different patient outcomes if taken care of. There were several failures in communication, provision of care, detection of clinical deterioration, escalation of care, clinical competence and accountability. The nursing staff should have used the scientific tools and evidence-based information for counteracting the negative influence over the judgement and the going process ("National Safety and Quality Health Service Standards Second edition", 2017). As per the NSQH S Standard – Partnering with Consumers safety and quality actions one and action three nurses should encourage family members to participate as an advisor and encourage regular feedback. The registered nurse should mitigate better communication right from the point of admission.
On the other hand, the hospital should develop a framework so that environment, tool, and resources for engaging family members ("Partnering with Consumers Standard", 2018). Various strategies that can be utilised can include education and high fidelity simulation that can help in risk identification, achieved through web base program or face to face simulation of the clinical scenarios. Continuous training for Recognition and escalation protocol developed as per the scientific tools and evidence. Appropriate utilisation of the handover tools can improve the transfer of the information impacting the patient outcome. Other strategies may include effective communication, teamwork and holistic examination (Vincent et al., 2018).
In conclusion, the root cause analysis identified the nursing staff's failure to recognise the early signs of the deterioration, which can be justified through relevant literature. Saposnik et al., 2016 have provided evidence on how cognitive biases and dissonance can impact the registered nurses' decision-making, which can be reflected in the case by prescription of opioids repeatedly failing on the focused assessment of pain management. The escalation process for clinical observation was also not robust in identifying the deterioration conditions. Downey et al., 2017 emphasised the importance of handover tools, protocols and conduct while dealing with critical patients in reviewing current clinical practice, which the duty nurses did not follow. Allibone et al., 2018 has described the impact of the timely administration of oxygen with deteriorating patients' improved survival rate. The nurse fails to administer the oxygen when the saturation was below 92% as per the escalation guidelines. Also, they were unaware of his sleep apnea. There was failure of communication as staff failed to escalate the matter to the leader or senior nurse on account of thinking that patient is fine. The lesson learnt from the critical analysis and evaluation of the case should be equipped in clinical practice for providing safe and quality care to deteriorating patients.