(...) In Australia the following study has noted a change in skill mix may be necessary:

Rising demand for health services, cost containment and shortages of nurses, midwives and other health workers were cited as the major catalyst for skill mix changes by ICN (2005d in ICN 2006). ICN (2004 in ICN 2006) noted that the evidence base in the area of skill mix was limited, but growing, with examples of studies that reported cost and quality improvements. (Fox-Young, 2007, p.17)

Regarding education, these nurses should have been exposed to training even in the classroom the would make them better prepared for these circumstances by,...using real life case studies in the classroom and clinical set- tings This complex and progressive learning is a continuous process that occurs throughout one's (Feldman & Greenberg, 2005, p. 6)

Perception of workload problems by the staff is also an issue. In this 30 bed unit some may feel they are being overly worked. This is often the case when newer nurses who need more experience, are assigned to more shifts. Newer nurses are also cheaper to utilize than nurses who have been with the hospital for some time, which is the case here where an inexperienced nurse is assigned the medication cart. Seniority and overtime is also an issue. While overtime and patient care is another issue, some limits that need to be set about overtime during a given period by one individual in an attempt to uphold that standard of patient care. (Continuing Competence, 2006)

Not only is call bell response time a concern, it is also trouble that nurses did not notice a change in the patients condition until she brought it toothier attention. While a call bell is required to protect the patient, vigilant staff should not rely on it as the only course of identifying a problem. (Schroder, 2003) in this case, nurses on round the entire day should have been more aware of the patient a's demeanor and possibly signaled an earlier response to her distress. Current research suggests further studies attempt to replicate and improve upon these results. That a more systematic assessments of both patients' and staff's overall satisfaction be made to determine further improvement. Also, that more studies research the influence of other factors that may not be as obvious such as patient, age, gender, race, etc. As wel as other nursing attributes Nursing must constantly adapt to health care changes and better protocols in order to return the utmost in patient care. (Coombs, 2004, p. 5) the Australian Nursing and Midwifery Council (ANMC) which is "...the peak body established to bring a national approach to the regulation of nursing and midwifery in Australia." (a national framework, 2007, p. 3) provides a set of the national principles, one of which is to "Enhance safety and quality when integrated with a comprehensive approach to managing risk." (a national framework, 2007, p. 5)

Finally there are several tools already in place which, if in use in the current situation would have helped to prevent this problem. For instance in section five of the National Competency Standards for the Registered Nurse points out:

5.2 Uses a range of assessment techniques to collect relevant and accurate data uses a range of data gathering techniques, including observation, interview, physical examination and measurement in obtaining a nursing history and assessment collaboratively identifies actual and potential health problems through accurate interpretation of data accurately uses health care technologies in accordance with manufacturer's specification and organisational policy identifies deviations from normal, or improvements in the individual's/group's, health status identifies and incorporates the needs and preferences of individuals/group into a plan of care

There are other tools are provided by the ANMC These are tools such as the Nursing Practice Decision Flowchart presented in Appendix I and the Nursing Practice Decisions Summary Guide Provided in Appendix II. These coupled with the proper training and supervisory techniques may have prevented...

Continuing competence is the ability of nurses and midwives to demonstrate that they have maintained their competence in their current area of practice. (National Competency Standards, 2008
Certainly the nurse in charge of the medication chart appears to be the primary target of the critical incident. However, in reality the team and the supervisor is ultimately to blame for not having better prepared the staff overall. The assessment from the beginning that the patient a's depression was being controlled by St. John's Wort should have signaled more vigilance and the level of care simply did not meet the competency standards right from that point and then onward. There is also the matter that this small staff was in charge of a 30 bed unit, and that the workload may have been to great as well. But in an era of cost cutting, more vigilance and improvements in training for smaller staffs working as a team must come into play,.