Case study critique NURS6900

Name: XXXXXXXX

Essay Title: Case study critique

Word Count: 1500

Actual word count: 1483 (except the title page and reference list)

Introduction

Patient safety remains a significant challenge faced by healthcare settings worldwide (Damen et al., 2017). One in ten hospitalised patients experiences adverse events (AE), defined as unintended injuries, disabilities, or deaths caused by healthcare management (Eriksson et al., 2020; World Health Organization, 2017). Evidence shows that most AEs stem from human and organisational factors such as ineffective teamwork and failures in communication (Aaberg et., 2021; Pelzang & Hutchinson, 2018). The author reviewed a critical care scenario (part one with version one of part two) that portrayed an AE resulting from a medical error involving a junior nurse, a resident doctor, and another nursing staff.

This essay will reflect and discuss three issues identified in the scenario that impact patient safety: the lack of interprofessional collaboration, poor communication, and the failure to raise concerns. Presentation of different recommendations to mitigate patient will follow after.

Reflection, critique and discussion

One of the primary factors that affected the patient's care was poor interprofessional collaboration. Interprofessional collaboration is characterised as collective decision making and shared responsibility and power of health workers from different disciplines (Manias, 2018). Problems with collaboration affect occupational well-being, work environment and hinder effective delivery of patient care. (Aghamohammadi et al., 2019). Additionally, the negative interprofessional dynamics witnessed by patients can affect their trust and confidence in the healthcare team (Henry et al., 2016). In the presentation, the doctor was dismissive towards the novice nurse who sought clarification regarding his medication order. Unfortunately, because the doctor ignored the nurse's concern and insisted on giving the medication as prescribed, the patient deteriorated.

Stressful workloads, insufficient time to discuss treatments, and a hierarchical mindset are issues assumed to possibly explain the doctor's behaviour (Mboineki et al., 2019). Undeniably, some doctors view nurses as subordinates and not partners in health care (Elsous et al., 2017; Zhang et al., 2016). With this culture of medical dominance, nurses can experience hostility and criticisms, which results in workplace conflicts and stress that contribute to suboptimal care and increases incidences of AE (Chua et al., 2020; Jerng et al., 2017).

Drawing from personal experience, being humiliated by a doctor after suggesting an intervention for a patient surfaced feelings of incompetence. It affected focus at work resulting in missing a medication dose for another patient. Fear of embarrassment also deterred communicating with the physician that was especially difficult when there were concerns for patient care. The study of Gleddie et al. (2018) resonates with the same problems resulting from the negative nurse-physician relationship, such as job dissatisfaction, increased turnover, and breakdowns in communication. The power differentials among nurses and physicians resulted in delays in patient care, failure to rescue, and clinical deterioration. The authors concluded that the quality of team relationships have a direct effect on patient outcomes.

Poor communication was another factor recognised that affected patient safety in the presentation. Poor communication is the leading cause of health care errors and continues to be a severe challenge in the patient care setting (Hammoudi et al., 2018; Wilson et al., 2016). In particular, how staff communicate or convey information impact other clinician's well- being and performance, which, in turn, can affect patient outcomes (Hanssen et al., 2020; Klingberg et al., 2018). An Australian research surveying 5,178 staff from seven tertiary hospitals found that impolite communication was the second most frequently experienced unprofessional behaviour which negatively impacted teamwork and the quality of patient care

(Westbrook et al., 2021). Reviewing the scenario, the author thinks that the doctor was not respectful towards the nurses as he communicated by yelling at them. Perhaps, his actions could have interrupted the nurses from checking the medication order against the drug manual. Furthermore, being yelled at could have pressured the nurses to give the medications despite being concerned about the correctness of the order.

Similar to the study of Villafranca et al. (2017), clinicians who faced disrespectful interactions were intimidated into compromising clinical judgment at the expense of patient safety. Despite known risks of harm, some participants admitted to accepting and administering incorrect medication orders so that they could avoid dealing with the instigator. On the other hand, the findings of Farzi et al. (2017) revealed that multiple medications errors resulted from a communication breakdown. In the study, the nurses refused to call the doctors to verify unclear orders and decipher the doctor's prescriptions independently. The nurses reasoned that their refusal was due to the doctors' inappropriate responses towards nursing staff.

The third issue identified in the case was the failure to raise concern. Patient advocacy is one of the core roles of nurses that includes protecting patients against injuries and possible risks originating from unintentional, deliberate, insufficient or inappropriate care (Davoodvand et al., 2016). Failure to take action in preventing and reporting safety issues can jeopardise the patient's health and also place the nurse in breach of the ethical principle of non-maleficence (Ion et al., 2016; Ng et al., 2017). Looking into the latter part of the second video, one may think that the nurses could have done more than keeping silent. However, from a personal standpoint, reporting errors or speaking up can be challenging. A cross- sectional study conducted among 251 nurses in Iran found that 70.9% of nurses did not report errors or AE mainly because of the fear of negative repercussions of reporting (Mansouri et al., 2019). The participants were afraid of being blamed, labelled as incompetent, and losing support from their colleagues after reporting an error. In another study, power imbalances between physician and nurses, lack of managerial support and a team culture that does not encourage assertive communication were barriers to raising concerns about patient safety (Lee al., 2021).

Recommendations

There are four actions proposed to minimise patient harm in the scenario encompassed by collaboration and effective communication. First, the doctor could have shown respect and willingness to listen to the concerns of the novice nurse. By doing so, the order could have been corrected by the doctor earlier, avoiding any clinical incident. The study of Noguchi et al. (2016) showed that 93.5% of medical errors by doctors occurred during the ordering stage, with a third of these errors intercepted by pharmacists, doctors and nurses. Findings of the same study noted that two-thirds of the errors were unidentified, and a large number of these errors that any team members did not intercept resulted in actual patient harm. Collaboration is achieved by placing value in the contribution of others and putting humility and respect above ones qualifications (Ng et al., 2017; Sabone et al., 2020). Through effective collaboration, patient care improves and adverse events are avoided (Sabone et al., 2020).

Second, the nurses could have been persistent in speaking up as the patient's advocate. 'Speaking up' involves healthcare professionals being assertive in communicating patient safety concerns where immediate action is required to avoid patient harm (Schwappach & Niederhauser, 2019). Nurses have a moral obligation and professional accountability to safely accomplish their roles, including detecting and reporting errors (Martyn et al., 2019). The nurses should not have administered the medication, and instead, they could have asserted that the medication order needed to be correct, fulfilling the five rights of medication administration (Blignaut et al., 2017).

Third, the nurses could have adapted communication techniques such as that from the Tools to Enhance Performance and Patient Safety (TeamSTEPPS) to facilitate speaking up about safety concerns and manage conflicts (Cooke, 2016). The TeamSTEPPS approach is proven to empower staff to speak up, improve staff morale, enhance team performance and decrease medical incidents (Clapper, 2018; Parker et al., 2019). The CUS (Concerned, Uncomfortable, and Safety) model is an effective tool that the nurses could have used to direct response in escalating patient concerns and handle uncivil behaviour (Clark & Gorton, 2019). The workplace should not tolerate rude or disruptive behaviours such as yelling as it could have deleterious effects on the well-being of staff and impact patient care (Clark & Kenski, 2017).

Fourth, the issue could have been reported and escalated to senior staff or the manager who can help in speaking with the physician. Studies show that doctors tend to acknowledge and listen to senior staff more than novice nurses because of their experience, credibility, and the time spent working together (Gleddie et al., 2018). Reporting near misses and errors is also crucial to understand the surrounding circumstances of the incident that could help establish preventive measures to avoid similar problems in the future (Kavanagh, 2017).

Conclusion

Adverse events occur as a result of human and organisational factors. From the review of a critical care scenario depicting the interactions of a resident doctor and two nursing staff, poor interprofessional collaboration, poor communication, and the failure to raise concern were the primary factors recognised to affect the patient's safety and delivery of care. Showing respect and listening, using communication techniques, speaking up, reporting errors and escalating to management are actions suggested to minimise the patient harm in the presentation.