Critical incident analysis in organizational practice

¶ … managed care situation, such as the one described in the case study. The individual's attention must on only be focused on the task they are performing, but also be able to refocus quickly in the event of an emergency, such as the code blue that occurred in this example. There must also be protocols in place to assure that when one duty is paused, that the individual has retained control and locked down their particular function so that any security risk can be minimized. This was not the case for the staff person who was in charge of the medication chart in this experience. This led to another critical incident that could have been avoided if the proper precautions were in place. There are also other considerations when evaluating this report. The individual must be assessed on many levels of competency such as education, training as well as physical status and health. The supervisors on the floor must also e analyzed to see if they are giving correct leadership and instructions to the staff, and the staff must function as a team.

This is time flow of the case and the critical missteps taken during that period:

Patient a was admitted after having a motor vehicle accident. She suffered minor injuries but was held for observation. At that time it was discovered she had a history of depression but she and the admitting medical officer confirmed it was under control and cured by the use of the herbal remedy St. John's Wort.

This was taken on face value and no further inquiries were made, hence the first misstep. There is no substantiated medical proof that St. John's Wort cures depression. This should have sent up a red flag for a more thorough background check into her condition. Perhaps something would have triggered a higher security precaution regarding this patient sooner.

The next morning during medication rounds there was a code blue. The Staff person, a recently graduated nurse, was performing medication distribution. At the code blue she rushed to assist and left the cart unlocked. Patient a was able to grab a handful of paracetamol, a pain reliever, from the cart. Later at 10 p.m. she complained of dizziness and confessed to stealing over 100 tablets and taking them. So, not only was the nurse remiss in locking and removing the medication cart from the patients room, she did not notice the difference in count of the meds after rounds were over. So fourteen hours were allowed to pass that if the missing medication were detected the incident could also have been avoided. These are critical oversights in patient care and hospital procedure. The patient was properly treated for the overdose and moved to a more appropriate unit for further observation.

Another mitigating factor in this is that the composition of the staff is as follows: one second year RN, two recently graduated nurses and two undergraduate nurses. Outshoorn also points out that "There is already a shortage of paid care workers. Turnover is very high because of work pressure and 'not always favorable work conditions,' and the work requires expertise and responsibility" (2002, p. 186). This aspect is also agreed upon by other in the field such as Goodin H. Janiszewski an Assistant Professor at the School of Nursing, Capital University, Columbus, Ohio. She states that there are even more contributory factors to this problem, "Four main areas were identified as the major contributors to the nursing shortage: the aging RN workforce; declining enrolment; the changing work climate; and the poor image of nursing" (2003, p. 335). Janiszewski also sees that job satisfaction is one of the primary issues affecting the workforce now and will probably becomes even worse in the future, "Based on reports from 43,000 nurses in more than 700 hospitals, similar and confirming data were revealed. Reports of low morale, job dissatisfaction, burnout and intent to leave their current employers were common across the sample' (2003, p. 337).

Staff nurses across the nation are reporting a dramatic increase in the use of mandatory overtime as a staffing tool. This dangerous staffing practice is having a negative impact on patient care, fostering medical errors, and driving nurses away from the bedside. (Staff Nurses, 2007)

Most staff will never say to overtime and this practice often eliminates the need for additional staff that may or may not be as qualified and that surely will need to be trained. The trade off is certainly a possibility in the decline of patient care and safety for both staff and patient.

Despite progress in increasing nursing program enrollments and graduations, significant numbers of interested and qualified applicants to nursing school have been turned away each of the past five years. "In 2006, the National League of Nursing reported 88,000 qualified applications to all (community college and university) nursing programs were turned away due to insufficient capacity." (Joynt & Kimball, 2008, p. 5)

The National Competency Standards for the Registered Nurse points out several ways that theses circumstance could have been mitigated. In one of the first section is found the following standard

1.2 Fulfils the duty of care performs nursing interventions in accordance with recognised standards of practice clarifies responsibility for aspects of care with other members of the health team recognises the responsibility to prevent harm performs nursing interventions following comprehensive and accurate assessments (National Competency Standards, 2008, p. 2)

The standard of care here implies a much higher vigilance than what we have observed in this case. Nursing supervision must take into account not only the response to the emergency situation that began the incident, but also the surrounding team and its responsibilities to the other patients on the floor. As previously mentioned the makeup of the staff is less than optimal, very new and unseasoned nurse on the floor. This should have triggered a higher level of supervision from the charge nurse. Leadership skills and supervision are the first line of defense in any situation and need to be in place so such occurrences can be avoided.

Leadership skills, such as visioning, strategic planning, embracing diversity, fostering interprofessional relationships, and networking, take on critical significance for the rural nurse, physician, or public health professional. These professionals are often alone or part of a small team of experts available within a geographic region. To succeed in improving health, professionals must be able to work together effectively and collaborate with community members in a meaningful way. The community-based (Feldman & Greenberg, 2005, p. 192)

The team as a whole must then be looked at to see how it behaves and functions, where it strengths and weaknesses lie.. This is a term that Lewin referred to as "Group Dynamics," and breaks this down into the following six categories:

1) Group productivity: why was it that groups are so ineffective in getting things done? (2) Communication: how influence is spread throughout a group. (3) Social perception: how a person's group affected the way they perceived social events. (4) Intergroup relations. (5) Group membership: how individuals adjust to these conditions. (6) Training leaders: improving the functioning of groups (T-groups). (Greathouse, 1997)

One characteristic of effective leaders is the attainment of formal training and educational credentials in addition on-the-job training and life experience. The requirements for a professional nurse are operationally defined as "one who has been prepared with a minimum of a baccalaureate or higher degree in nursing." (Feldman & Greenberg, 2005, p. 219) the nurse must also have some degree of people management skills as personality conflicts and issues are also another consideration that the charge nurse has to keep I mind when assigning duties. There are many variable to consider, which is why the credentialing of nurses has taken a dramatic turn in recent years. In the United States the position of clinical nurse leader has come into wide use:

The AACN [American Association of Colleges of Nurses] proposed the development of a new nursing role, that is, the clinical nurse leader (CNL), in 2003. A CNL will require a master's degree in nursing and will have to design, implement and evaluate client care by coordinating, delegating and supervising the care provided by the health care team, including licensed nurses, technicians and other health professionals. Some nursing leaders and organizations have embraced it, but others have questioned its validity and usefulness. (Nelson, 2005, 24)

These would be nurse that have had at least attained a master degree or higher and have had more years of career experience and on-the-job training. In fact there may be an evolution taking place. A development that is bringing the pendulum of masters-level nursing back to the center. "National movements are calling for the development of a generalist masters-prepared nurse, the Clinical Nurse Leader degree. Discussions of a nursing practice doctorate are increasingly gaining favor." (Mccabe, 2005, p. 88)

In light of the expanding role of professional nurses in health care settings today, it is imperative that they acquire the leadership skills necessary to influence positively this dynamic and uncertain environment. These skills are vital for them to make an impact, considering the powerful relationship between leadership strength and influence. (...)

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)