The Council received a notification in relation to a patient who presented at an Emergency Unit with a loss of vision and an unrelenting headache.
The patient first presented at changeover time and was assigned a nurse. The assigned nurse did not provide the patient with a bell and the patient had to request pain relief from another nurse, who then informed the assigned nurse. There was a significant delay in returning with the medication and the assigned nurse injected the drug without seeking consent, or asking about allergies.
The nurse did not provide an explanation or apology about the delay, although the patient was clearly distressed due to his pain and the length of time it had taken. The nurse attended the patient much later with another injection, which the patient subsequently refused and requested another nurse attend him. The patient stated that the nurse rolled her eyes and asked someone else to look after him. The patient then heard rude remarks about him outside the bedside area.
The nurse stated that the patient was mobile and could obtain the call bell if required. There was a delay in providing pain relief as there were several critical patients she was attending to. The nurse reported that she had checked for allergies on the medication chart and the name band and quickly administered the medication so she could return to her more critical patients. When she returned with more medication much later, the patient became loud and used aggressive language and accused the nurse of not giving the correct dose of pain relief in the first injection. Although the patient was in pain, the nurse believed the patient was being unreasonable
In terms of a complaint assessment, such a notification raises a number of issues including;
- Duty of care - the patient was not provided with the information or means to contact the nurse although the nurse assumes otherwise
- The patient perceived there was a delay in care - the nurse did not provide information to manage the patient’s expectations or seek support for assistance in managing the patient’s pain
- The inadequate provision of information and informed consent – the nurse did not provide the patient with sufficient information about the treatment she was providing to enable informed consent
- The attitude and manner of the nurse – the nurse’s manner was not empathetic or respectful, labelling the patient as unreasonable and difficult, using inappropriate body language.
When a patient is dissatisfied with the care it is important to reflect on this and identify how practice could be improved within the context of care in which the event occurred. Such reflection can prevent recurrence. The codes of conduct and standards for practice are essential tools as they identify the standards expected of nurses and midwives
The following elements from the code of conduct may be relevant for the case described above;
Nurses should create and foster conditions that promote shared decision-making and collaborative practice.
- take a person-centred approach to managing a person’s care and concerns, supporting the person in a manner consistent with that person’s values and preferences
- Nurses should create and foster conditions that promote shared decision-making and collaborative practice
- Positive professional patient-centred relationships are built on effective communication that is respectful, kind, compassionate and honest
- Nurses must be non-judgemental and not refer to people in a non-professional manner verbally, including refraining from behaviour that may be negatively interpreted
- Effective communication and the provision of accurate relevant and timely communication is essential to obtaining informed consent
Informed consent is a person’s voluntary agreement to healthcare, which is made with knowledge and understanding of the potential benefits and risks involved.
The nurse must give the person adequate time to ask questions, make decisions and to refuse care, interventions, investigations and treatments, and proceed in accordance with the person’s choice, considering local policy.
Response to a perceived adverse event
- Listen to the person, acknowledge any distress they experienced and provide support. In some cases it may be advisable to refer the person to another nurse or health professional
- Act immediately to rectify the problem if possible
- Apologise if there has been a delay in treatment and provide reasons for this
Culturally safe and respectful care
Avoid expressing personal beliefs to people in ways that exploit the person’s vulnerability or are likely to cause them unnecessary distress.
Actively manage the person’s expectations. For example, be clear about professional limitations and time constraints when this is relevant.
In cases where the professional relationship has become compromised or ineffective and ongoing care is needed, facilitate arrangements for the continuing care of the person to another health practitioner, including passing on relevant clinical information.
Nurses and midwives work in situations that are complex and often challenging. They are caring for vulnerable people who may react to stress in a variety of ways. Communication is the key to person centred, safe and respectful care.
Although the nurse was busy and attending to a number of patients, timely effective communication in this case may have provided greater patient satisfaction and avoided a complaint. The nurse could have apologised for the delay in medication administration and provided reasons for this. It is also important to communicate in a respectful manner. In this case a complaint may have been prevented.