Leadership and Clinical Governance in Nursing - Essay Example

Leadership and Clinical Governance in Nursing Leadership and Clinical Governance in Nursing A. Introduction I. The Case The case to be analyzed here is that of HCCC v. Jarrette Janelle, NSWNMPSC 2012. The case resulted from unsatisfactory conduct by Janelle Jarrette, RN leading to the demise of Mrs. Webb, the patient. II. Chosen Standard The selected standard is the Standard 9-Recognising and Responding to clinical deterioration in acute health care. III. Outline The analysis primarily seeks to showcase how quality improvement, nursing leadership, and nursing management are the building blocks towards a quality and safety patient care delivery. Therefore, the paper primarily draws a number of concepts and premises from the NSQHS Standards (Standard 9) as well as the national clinical guidelines (NSW Health Rural Adult Emergency Clinical Guidelines Third Edition GL) to inform the analysis of the case presented. Further, the researcher peruses a number of clinical assessment tools (AVPU/GCS, and Delirium Assessment tools) as well as methods (Confusion Assessment Method, CAM) in the discussion to reflect how the inception of Standard Nine has improved the quality of health care delivery (Gastmans, 2013). Moreover, the paper applies such policies as the NSW Policy Directive Falls- Prevention and Harm from Falls amongst Older People 2011-2015 as in the discussion. B. Summary of the Case The practitioner was the Nurse in Charge (NIC) of the General Ward in the Balliina District Hospital. The nurse was to oversee such obligations as transitional care, emergency care, general ward and rehabilitation. The nurse conducted significantly below the reasonable standard as outlined in Standard 9 culminating to demise of a patient (Mrs. Webb). Subsequently, HCCC consulted with the Nursing and Midwifery Council of New South Wales. The HCCC applied section 39(2) and 90(B) of the Health Care Complaints Act 1993 and section 145A of the National Laws to file the case to the Committee anchored on section 150D(4) of the National Law (Wong, Yee and Turner 2008). The Nurse was found to have unsatisfactory conduct that was not commensurate to the equivalent knowledge and training she had. The Committee thus reprimanded the Nurse and ordered a number of conditions on the practitioner registration. For example, she had 24 months to successfully complete a post graduate certificate in acute care nursing incorporating leadership module. The Nurse was further prohibited from engaging in any role and functions of a Nurse in Charge of a ward or Hospital (Hatten-Masterton & Griffiths 2009). The Nurse was found to have violated the Standard 9 and many other guidelines including NSW Health Rural Adult Emergency Clinical Guidelines Third Edition GL. In addition, the Committee noted that Practitioner did not showcase the expected levels of assessment required to have saved the practitioner. Further, the practitioner failed to contact the doctor about the unseen patient fall and deterioration conditions (Wong, Yee, Turner 2008). C. Key Issues The Nurse showed a lack of proficiency in her work as she took it herself by manual diagnose that the patient was perceived to be withdrawing. Further, she never documented the patient unwitnessed fall and did not even inform the doctor of such unwitnessed fall. Therefore, the unwitnessed fall risk assessment was incomplete as affirmed by Nurse Eliot and even allowed nurse Eliot to administer valium to the patient without recording and telling the doctor. Further, the Nurse being a HIC never performed as provided in the guidelines and Standard 9 as she allowed the patient to put in a hardback chair without documenting the unwitnessed fall risk assessment (Fischer & Ferlie, 2013). Further, she allowed Nurse Eliot to perform neurological observation without specifying the frequency of the observation. In essence, there was an inadequate nursing assessment of Mrs. Webb’s condition with respect to response to the clinical deterioration of the patient. Lack of communication in the facility is also key issues noted from the case. Communication with the patient and carers is an integral part of the Standard 9. There should be a satisfactory and inclusive communication that incorporates families, carers and patients are fully aware of and supported to enhance their full participation in the recognition and response system available in the facility and respective process involved. The set of information should be synthesized to facilitate the clear understanding and meaning of the systems and process circumventing recognition and response for the patients with the deteriorating conditions (Aldrich at al. 2009). Once, all the stakeholders are informed about the concerns and signs and symptoms of deteriorating conditions, the quality and safety of care delivery will improve as the stakeholders are even presented with the procedures and protocols for communicating their concerns with respect to deterioration. Further, the Standard 9 is core in fostering the communication with all stakeholders by providing that they have to be informed of the possibility of undertaking advance care plans as well the intervention-constraining orders. This is achieved by ensuring effective patient clinical record about the patient is availed. As provided by the Committee findings and the statements from the nurse, there was a leadership laxity in the Hospital. For example, the history of the inability of the doctor to attend to critical conditions once noted by the nurse showcases the communication breakdown and poor management and leadership of the Hospital. Some of the uncalled for decisions made by the nurse was due to her initial failed dealings with the doctor who always gives defends his actions on the basis of being forgetful. The nurse could therefore not appreciate that at times she ought to have accepted the existence of actions that were above her capacity hence leading top wrong clinical decision that led to the demise of the patient (National Health and Medical Research Council 2010). D. Critique The primary role of nurses in acute care is to provide a quality and safe patient care. Nurse Jarrette did not uphold the provisions of NSW Health Rural Adult Emergency Clinical Guidelines Third Edition GL. The guideline advocates that shortness of breath with a history of chronic obstructive pulmonary disease degree of consciousness must be monitored from time to time based on AVPU/GCS Assessment Tools (Calzvacca et al. 2010). Further, the nurse failed the test of the guideline as she never undertook the precaution that provides that the mental status indicates the worsening hypoxia, as well as hypercapnia. She, therefore, failed by not being aware of signs of hypercapnia based on the deterioration level of consciousness as evident by the patient. The Nurse further failed below the standards of the guideline by failing to apply such assessment tools as AVPU/GCS and Delirium Assessment tool based on confusion assessment method that were available in the Hospital. The finding from these assessments was critical to informing the subsequent medical assessment that could have saved Mrs. Web immediately (Roussel & Thomas, 2014). Thus, the core intention of the Standard 9 of ensuring that the deterioration of the patient is promptly recognized and immediate appropriate response taken were violated. Indeed, nurse Jarrette performed unsatisfactorily as she failed to uphold the response component of the Standard 9 (Armstrong, 2011). For instance, she failed to deliver timely and appropriately care to deteriorate Mrs. Webb’s condition. Further, the Nurse failed to comply with the provision of Standard 9 that provides for effective communication of all clinical issues during the handover situation as was seen when Nurse Eliot handed over an incomplete assessment to Nurse Janelle. Further, the Nurse failed to manage Mrs. Webb’s deteriorating conditions despite the Hospital having effective formal systems for response such as the use of delirium assessment tools through CAM method (Storch, 2009). Further, as provided by the ACSGHC, the Nurse failed to apply the guideline that provides the essential elements for recognizing and subsequently responding to the clinical deterioration as founded on the National Consensus Statement. The Standard 9 has also established a framework that if sufficiently followed in acute care will culminate in the efficient and on time recognition and response to deteriorating patients. Thus, the Nurse ought to remain consistent with the National Consensus Statement and employ the organization-wide system and deliver effective recognition of as well as a response to Mrs. Webb’s deteriorating condition to prevent the demise (Clark, Squire, Heyme, Mickle & Petrie 2009). Despite the existence of developed policies, procedures and protocols, the Nurse failed to comply with the Hospital protocols to assess or inform Nurse Eliot to assess the Mrs. Webb and constantly monitor her deteriorating based on the GCS. E. Recommendations From this case study, it was evidenced that the death of the patient was caused by the poor quality services rendered by the NIC. For this reason, this paper suggests that a wide range of measures should be taken to avert the occurrence of such a problem in future. Therefore, it gives recommendations on the clinical leadership, management and governance as outlined below: First, it recommended that leadership should be fostered in a healthcare facility. With proper leadership, everyone would be given their own roles and adequately supervised to ensure that all activities are done as expected. If this was done, the NIC would not have demonstrated such a poor performance. Under strict leadership, the whole medical staff should perform their roles without any loop hole. Secondly, there should be a proper management at the facility. Under this, the nurses, physicians and pharmacists should be encouraged to foster a spirit of team work at all times. Therefore, when attending to such a patient, NIC would have sought the opinion of other colleagues and effectively communicated with the patient and the carers. This would help in promoting the delivery of high quality services to the patient who ended up losing life. At the same time, under proper management, all the nurses need to follow the stipulated guidelines without any failure (Gastmans, 2013). For instance, while serving the patient, the nurse ought to have strictly followed the provision of the Standard 9 by showcasing reasonable equivalent levels of training and experience. Thus, she could have performed an assessment of Mrs. Webb’s physical and mental state and immediately report the findings to the Dr. McKenzie. The doctor could have then undertaken complete reassessment of the patient to make rational clinical decision relevant to the deterioration clinical situation of the patient. Despite, the fact that the patient’s medical condition was pointing towards that of hypoxia and delirium, the nurse could not make out despite her long work history and experience (Aldrich, Duggan, Lane, Nair and Hill 2009). The Nurse failure to uphold the routine obligatory requirement of creating a record of the Mrs. Webb’s attendance was short of Standard 9. The record is a central part of the nursing practices as it aids the effective health services provision to patients by a nurse. The Standard 9 has provided a counteractive roadmap towards the elimination of failures to recognize and respond to deteriorating patient conditions. For example, the Standard 9 outlines the causes of the inability of the nurses to provide quality and safety care to acute conditions. The inadequacy of knowledge of signs and symptoms that depict deterioration by Nurse Janelle caused the demise of the Mrs. Webb (Calzvacca et al. 2010). Lastly, the facility should foster effective clinical governance, Here, there facility must foster and facilitate teamwork and shared leadership in the Hospital to eliminate the difficulty in offering satisfactory service delivery to the patient. For example, Nurse Janelle was over delegated duties as she served both as HIC and NIC. Therefore, she could never give her best to this particular patient, particularly she failed to monitor the patient deterioration conditions at an interval of fifteen minutes as outlined in the guidelines (Australian Commission on Safety and Quality in Health Care 2009) The poor chain of command in the Hospital hindered the reassessment and documentation of relevant core signs before Nurse Elliot administered Valium at 0200 hours that making the Nurse Janelle unable to minimize the risk of a fall of Mrs. Webb. Nurse Eliot and Janelle could have conjointly worked based on a shared leadership style without being faced with problems of a chain of command and open communication based on effective teamwork. The case has clearly demonstrated that there was a lack of a clear understanding of team nursing and leadership on the part of the Nurse. The facility failed the test as outlined in the Standard 9 whereby the workforce can respond sufficiently and timely during the Mrs. Webb’s deterioration condition (Wong at al. 2008). The clinical workforce should be at all-time comprise of trained and proficient workers and support staff to deal with the emergency situations particularly those of the deteriorating patients. Conclusion In conclusion, the Standard 9 has significantly presented a framework that help effectively respond to clinical deterioration. The Standard 9 provide that practitioners should employ systems available for effective on time care provision for deteriorating conditions such as that reflected in the Webb’s case. For example, the Nurse ought to have effectively used the delirium assessment tool through CAM method to determine the hypoxia conditions and immediately undertake appropriate interventions to save Mrs. Webb. Indeed, Standard 9 provides for emergency call triggering criteria effectively integrated with the escalation policies, protocols, and procedures (Institute of Medicine 2001). The Standard 9 focuses purely on the quality improvement, nursing leadership and nursing management as the building blocks to the provision of quality and safety care to the patient with the determination. The Nurse and the Hospital management failed to fosters effective leadership and management leading to the demise of Mrs. Webb. Particularly, the committee findings were genuine and uncovered no compliance with the guidelines and Standard 9 provision based on protocols and policies (Agarwal, 2009). Therefore, going forward, the reprimand of the Nurse should serve as an example to other nurse who may fail to adhere to the provision of Standard and other Guidelines and Policies as reflected in the discussion to ensure effective recognition and response to the clinical deterioration in acute health care. F. 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