This paper presents an incident report written from the perspective of a nurse manager responding to a Hepatitis C outbreak linked to a staff member who repeatedly reused needles while administering pain medication. The report examines OSHA bloodborne pathogen regulations under 29 CFR 1910.1030, analyzes how an authoritarian management style contributed to the violation, and applies motivational theory and leadership frameworks — including Fiedler's contingency theory and Robert House's path-goal theory — to explain the employee's decision-making. The paper concludes with recommendations for improving staff communication, employee empowerment, and public relations strategy to prevent future incidents and restore patient trust.
Recently, eighty patients at a local medical clinic tested positive for Hepatitis C. A staff employee admitted to reusing needles up to 25 times per day while administering pain medication. At least 38 cases can be positively associated with exposure at the clinic, while another 35 may be associated. As acting Nurse Manager, the author has been assigned the task of developing a strategy for addressing this situation. The following report discusses the issues and policies involved in effectively managing the current situation and developing a plan to prevent similar events from occurring in the future.
This issue is multifaceted, and there are several elements to consider. The first concern is the safety of the infected patients. The second involves possible violations of federal law. The third is to analyze the situation from a management standpoint — assessing the conditions that led to the event and determining how to prevent recurrence. The fourth consideration is how to prevent a media crisis and restore public faith in the hospital.
Regulations regarding the control of exposure to bloodborne pathogens are contained in 29 CFR 1910.1030 (OSHA Directive CPL 2-2.44D, 1999). Under this regulation, each facility must have a plan in place to prevent exposure to bloodborne pathogens, and that plan is required to be updated annually. Under this regulation, all human blood is to be treated as if it is contaminated. Failure to comply with this guideline will result in a citation or other corrective action against the facility. The incident described in this report represents a violation of federal law under the aforementioned statute, and these issues must be addressed in a way that prevents future exposure episodes. The regulations also include protocols to follow when a series of patients are exposed to bloodborne pathogens. In this particular situation, strict adherence to those protocols is mandatory, as there is no acceptable alternative (OSHA, 2001).
The facility had a Bloodborne Pathogen Exposure Plan in place, reviewed annually as mandated by OSHA. In the case of this exposure, it is clear that the methods and procedures contained in the plan were ignored by the employee involved. The plan strictly prohibits the reuse of needles from one patient to another. Until now, the Bloodborne Pathogens Plan had been reviewed by administration and communicated to employees in an authoritarian manner. Many employees feel that some of the procedures in the plan take too much time and that they face increasing pressure from growing patient loads; as a result, steps get skipped.
In an interview with the employee involved, several concerns arose. He had always been an exemplary employee since beginning employment in 1993. When asked the reason for the blatant violation of protocol, he cited growing pressure to work more quickly due to increased patient load. The pressure to perform had become so great that many employees were beginning to develop their own shortcuts in order to keep up. He explained that while he was aware of the risks and regulations associated with bloodborne contaminant exposure, the pressure to work faster outweighed, in his mind, the possibility of consequences.
Staff has historically been managed through an authoritarian approach using concrete rewards and punishments. In this case, the employee felt that the risk of being punished for non-productivity outweighed the relatively small perceived risk of patients becoming ill from his actions. Under the authoritarian leadership model, he knew the punishments and risks of breaking protocol; however, he weighed the law of averages and decided there was very little chance of patients becoming exposed or of his actions being discovered (Leonard, 1995).
Under the current system of hospital leadership, a list of violations exists alongside a written set of punitive measures for each. This system has historically been considered fair in execution. However, as this incident demonstrates, it does not guarantee that a severe safety violation will not occur. The reason for this lies in motivational theory (Deci, 1971). Current theory on motivation holds that individuals make decisions based on a personal set of perceived benefits and perceived costs. In order to promote a desired behavior, the benefits of compliance must outweigh its costs; conversely, to discourage a behavior, the costs must outweigh the benefits (Leonard, 1995). What constitutes a perceived cost or benefit is highly individual and based on each person's past experiences.
The authoritarian system operated under the assumption that listed punishments would exceed the perceived benefits of non-compliance. The example presented here illustrates a circumstance where the employee faced two competing risks: falling behind on work and potentially contaminating a patient. Both carried costs. He knew with certainty that he would be penalized for falling behind, while the probability of contaminating a patient seemed only slight. Even though the punishment for contaminating a patient involved immediate termination and the punishment for falling behind was only a reprimand, he took the action with the least perceived probability of occurring. This was confirmed in the employee interview and is consistent with current motivational theory.
"Critiques punitive management style as contributing factor"
"Proposes group-goal leadership models as alternatives"
"Addresses media fallout and strategies to rebuild confidence"
"Summarizes findings and outlines management reforms needed"
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