Vulnerable.

1. Discussion Question:

 

How Cultural Diversity Influences Community and Public Health Nursing?

·Must address the topic.

 Rationale must be provided. ·         

Illustrate an interdisciplinary approach to improvement of the healthcare outcomes of the vulnerable populations.

150-word minimum/250-word maximum without the references.

Minimum of two references (the course textbook must be one of the references) in APA, the format must have been published within the last 3-5 years.

Safety.

1. Discussion Forum: Read the Article Billions spent to fix VA didn’t solve problems, made some issues worse. http://www.cnn.com/2016/07/05/politics/veterans-administration-va/index.html – due Friday by 2359.

Instructions
: The article states that money is not the issue. With a minimum of 200 words, discuss what you think is the problem? 

Minimum of 
1 reference
 to support your point of view related to Improving quality & safety in healthcare.

2. Assignment: Read Case Study and submit APA Paper due by Sunday at 2359.

Instructions: Read CASE STUDY: BEWARE: One Emergency May Hide Another

!
 and submit APA Paper due by Sunday at 2359, write a paper addressing the following:

a.      Which nursing standards were violated in this case study?

b.      What could have been done to avoid the problem?

 

Paper must be at least 1 page, excluding title page and reference page. (at least 1 reference no more than 5 years old), make sure to reference the article.

3. Discussion Forum: Read Practices to Improve Handwashing Compliance. 

https://archive.ahrq.gov/clinic/ptsafety/chap12.htm

 – due Friday by 2359.

 

Instructions
: Discuss what are some of the factors influencing poor handwashing compliance and their implications on harm to patients.

 

Provide 
1 reference
 to support your point of view related to Improving quality & safety in healthcare.

4. Assignment: Read Case Study and submit APA Paper due by Sunday at 2359.

Instructions: Read HISTORICAL CASE STUDY #1: An Ounce of Prevention and submit APA Paper due by Sunday at 2359, write a paper addressing the following:

a.      What actions or inactions by the nurse significant to the propagation of infection?

b.      In your opinion, was the lack of adherence to prevention measures due to lack of knowledge or just carelessness?

 
Paper must be at least 1 page, excluding title page and reference page. (at least 1 reference no more than 5 years old), make sure to reference the article.

1. Capstone.

1. Discussion Topic:    What kind of image does the phrase “a powerful nurse” conjure in your mind? How have the roles and the status of women in American culture shaped the exercise of power among nurses? What kinds of behaviors do you observe in people that tell you whether they are powerful? Which of these behaviors do you consider socially desirable? Which are undesirable?

 

The Discussion:

· Must address the topic.

· Rationale must be provided.

· May list examples from your own nursing practice.

· 150-word minimum/250-word maximum without the references.

· Minimum of two references (the course textbook must be one of the references) in APA format, must have been published within last 3-5 years.

2. Discussion Topic Week Five:  What organizational characteristics are most applicable to today’s healthcare delivery organizations?  Why did you select each characteristic?

The Discussion:
· Must address the topic.
· Rationale must be provided.
· May list examples from your own nursing practice.
· 150-word minimum/250-word maximum without the references.
· Minimum of two references (the course textbook must be one of the references) in APA format, must have been published within last 3-5 years.

1. CASE STUDY—BEWARE: One Emergency May Hide Another!

A hospital submitted a report to the State Board of Nursing reporting that an RN had been terminated after the death of a patient following surgery for a tubal pregnancy.

THE NURSE’S STORY

—SALLY SIMMS, RN

I had worked the medical-surgical units at the General Hospital ever since graduating from my nursing program 4 years before. This was the worst night, the worst shift, of my nursing career.

I was assigned to care for eight patients that night, which is not an unusual number of patients, but they all were either fresh post-ops or so very sick. Four patients had just had surgery that day. One patient was on a dopamine drip to maintain his blood pressure, so he needed frequent monitoring. One patient was suspected to have meningitis, one patient had pneumonia, and a patient with suspected histoplasmosis completed my assignment.

One of my post-op patients was Betty Smith, a young woman in her early thirties who had laparoscopic surgery late in the day. She had been transferred from the recovery room late in the evening shift and was very uncomfortable when I first made my rounds. At 12:05 AM, I called Betty’s physician because she was vomiting and thrashing in bed. Per his order, I medicated the patient with Phenergan.

The next time I checked on Betty, she seemed to be more comfortable, but I realized that her IV had infiltrated. I was really overwhelmed with meeting the needs of all my patients, so I asked Joan Jones, the charge nurse, to restart Betty’s IV. It was about 2:00 AM when Nurse Joan restarted the IV.

I had been able to pretty much stay on top of everything at that point in the shift, and by 2:30 AM I had assessed all my patients, given pain medications, and called four physicians to update them regarding their patients and for various orders. I thought things were settling down. I thought wrong.

Mrs. Holmes, the patient with histoplasmosis, seemed a bit off from when I had cared for her the previous two nights. Mrs. Holmes’ vital signs were unstable and her O2 saturation was only 80%. I notified her physician and he ordered stat arterial blood gases. The lab called with the results, and they were alarming. Mrs. Homes was losing ground, and her physician ordered us to transfer her to the ICU. I was preoccupied with accomplishing the transfer and accompanied Mrs. Holmes to the unit. I returned from the ICU at about 3:50 AM.

On my return, I first checked the patient who was on dopamine, medicated another patient for pain, and did visual checks on the rest of the patients who all seemed to be sleeping. I began my charting.

At 6:05 AM, I went to start IV antibiotics on Betty’s roommate, and to my horror discovered Betty was not breathing. I called the code. The first time I discovered that Betty had had a low blood pressure and elevated pulse was when I checked the vital signs sheet when the ER physician (who responded to the code) asked how Betty’s vital signs had been during the shift. The nurse’s aide who was assigned to monitor Betty had not informed me, and I had not checked the vital signs sheet.

It was such a terrible night; I was so busy with the transfer and caring for the other patients. Betty just had an outpatient procedure; if she had been earlier on the surgical schedule, they would have sent her home. I did not physically check her vital signs, and the aide did not report the elevated pulse and low blood pressure. I depended on the aide—my mistake. I know I was responsible.

I was terminated from employment and reported to the board of nursing. I have taken myself out of nursing; something died in me when I found my patient.

EMPLOYMENT EVALUATIONS

An evaluation conducted a few weeks before the incident showed mostly good ratings (11) with three excellent ratings. The hospital would consider reemployment if Ms. Simms improved her critical thinking skills.

PATIENT MEDICAL RECORD

Surgery Notes—Laparoscopy to remove unruptured ectopic pregnancy from distal portion of the fimbriae with estimated blood loss of 150 cc, three references to homeostasis, two references to cautery, patient “… to recovery room in excellent condition.”

Recovery Room Nurse’s Notes—In recovery 2110 to 2300, initial post-op flow sheet noted at 2210 BP 124/74, pulse 94; at 2225 BP 123/65; at 2240 BP 107/85, pulse 123. Assessment signed at 2220 “abdomen distended with few faint bowel sounds … patient shivering, c/o [complained of] abdominal pain, medicated ×3 [three times] with IVP Demerol, total of 50 mg. Patient awake, three dressings dry. No c/o N/V/D.” [No complaints of nausea, vomiting or diarrhea.]

Medication Record—Patient received Demerol 50 mg. with 25 mg Phenergan IM at 2215 and 0200.

Cardiopulmonary Resuscitation Record—Compressions noted at 6:08 AM. [RN had initiated code at 5:55 AM], MD arrived at 6:15 AM, patient intubated at 6:20 AM, patient administered atropine ×3, Eppy [epinephrine] ×5 [five times], bicarbonate [of sodium] ×2 [two times]. Pacemaker never captured. Patient never had return of spontaneous pulses and pronounced dead at 6:38 AM.

Death Certificate—Immediate cause of death was hemoperitoneum due to postoperative hemorrhage of placental tissues after salpingotomy for a right tubal ectopic pregnancy.

BOARD ACTION

Ms. Simms entered into a consent agreement with the board of nursing, admitting that her conduct constituted a failure to practice in accordance with acceptable and prevailing standards of safe nursing care. Nursing standards cited were failure to assess and document the health status of the patient, failure to provide ongoing patient monitoring, and failure to communicate appropriately with members of the health care team.

Ms. Simms’ license was probated with stayed suspension for 2 years, with requirements for successful completion of ordered education including an advanced assessment course at an educational/collegiate institution, continuing education hours in risk management/legal issues in nursing (in addition to continuing education hours required for license renewal). Order noted RN’s voluntary evaluation by a mental health care professional and her compliance with all aspects of the treatment plan. Other terms included quarterly reports from nursing employer and self-reports. Ms. Simms was required to appear in person (as requested) for an interview with the Board or a board-designated representative.

COMMENTARY

This case example illustrates a cascade of clinical events that caused errors in clinical judgment, all of which are related to work overload and consequent lack of surveillance and monitoring of the patient. Nurse Simms made faulty assumptions that the young patient with a tubal pregnancy was her least acute patient. Of course the patient is the primary victim, but Nurse Simms also suffered greatly from this tragic incident, which was precipitated by a collection of untoward events and work overload. The following TERCAP® categories under “Inadequate Clinical Judgment” are appropriate:

Clinical implications of signs, symptoms, and/or interventions not recognized: The abdominal pain was extreme for the procedure and was most likely related to internal hemorrhage.

Clinical implications of signs, symptoms, and/or interventions misinterpreted: The nurse assumed that the primary problem was nausea and vomiting. Other vital signs and symptoms were ignored.

Lack of appropriate priorities: In this case there were at least three competing high-priority situations occurring at once.

Poor judgment in delegation and the supervision of other staff members: Delegation and supervision were problems on several levels. The charge nurse and supervisor failed to provide appropriate support for the RN with a patient in a full-blown crisis. The nurse gave the nurse’s aide faulty supervision in not requesting full vital signs at 5:00 AM.

Inappropriate acceptance of assignment or delegation beyond the nurse’s knowledge, skills, and abilities (given the critical and unstable condition of the eight patients): Eight patients were too many patients to care for given the critical acuity of these particular eight patients. Backup support should have been requested and/or just sent when one patient went into crisis. The nursing supervisor is mistaken in waiting for reports only as a means of knowing what is needed, especially when a patient crisis arises.

CLARIFYING CONCEPTS

During the initial examination of many of the study cases, poor clinical judgment was identified as the cause of the practice breakdown. Often, however, the cause for the practice breakdown was lack of attentiveness. Nurses were not able to begin to engage in a clinical situation and begin to use their clinical judgment because of staffing shortages and competing high priorities among patients. Recommendations to remediate nurse clinical judgment skills in such situations would be nonproductive. Also, a unit can have a very hectic day with more patients admitted than usual, or more patient crises than usual, causing many disruptions to many nurses’ work on the unit. Nurses are called to watch over patients for other nurses and may not have a good grasp of the patient’s ongoing clinical condition and needs. Thus, as discussed in 

Chapter 4

, the issue of attentiveness needs to be addressed in ways that allow the nurse adequate time for attentiveness or awareness of the clinical situation to prevent practice breakdown. If the unit is unusually pressed, short staffed, or the nurse is interrupted frequently because of a heavy workload, a patient in crisis, or new patient admissions, the root cause of the problem may not be clinical reasoning but a system-induced lack of adequate patient monitoring.

All nursing actions contain within them some form of judgment. For the purposes of TERCAP classification of nursing practice breakdown, we are using a restricted definition of clinical reasoning (as described above) because we want to identify situations where knowledge and skill related to clinical judgment are absent or obsolete. In these instances the nurse misinterprets or makes a mistake in judgment about a patient’s needs or concerns, even though he/she has had the opportunity to observe the patient. Common, routine interventions that are required for all patients should not be considered an issue or a problem of clinical judgment, since the primary problem is an omission of routine, standardized practice that requires knowledge. For example, although it is always poor judgment to omit preventive interventions, it is really not an issue of clinical reasoning about a particular patient to omit standard nursing procedures to avoid the hazards of mobility. Likewise, standard infection preventive measures require little latitude or room for judgment and should not be classified as clinical judgment.

Poor clinical judgment will impact the ability of the nurse to advocate for the patient, but if the nurse makes an appropriate clinical judgment but does not follow through with adequate advocacy for the patient, (e.g., calling the physician for an appropriate intervention), then the primary area of practice breakdown is Professional Responsibility and Patient Advocacy. Clinical judgment is always situated. Good clinical judgment requires the possibility of attentiveness. In the one clinical situation above, a nurse had an extremely heavy assignment with the same-day postsurgical patients, one of whom required a vasopressor to maintain his blood pressure. To complicate the situation further, another patient with histoplasmosis developed poor oxygen saturation and required an immediate transfer to the ICU. The transfer of the patient with poor oxygen saturation took the nurse away from the unit at a critical time for the patient after she had had a tubal pregnancy removed; she was now showing all the signs of a postoperative hemorrhage. As a result of information overload and poor backup support, the nurse did not receive or could not attend to the 30-year-old patient who was experiencing a postoperative hemorrhage and extreme pain.

There are human limits to the span of control and the ability to attend to multiple urgent and cognitively complex demands. Many system and practice breakdowns came together at the same time to create this tragic outcome of patient death. The nurse’s aide was not appropriately respectful and attentive to the patient’s requests to call her husband and her physician. The patient was labeled “whiny” and her complaints, as well as the patient’s authority, were devalued and dismissed. The charge nurse did not adequately assess the nurse’s workload. The supervisory practice in the hospital was substandard in that clinical supervisors did not proactively observe and supervise the unit’s workload, changing conditions, and the nursing needs of the patients. Rather, supervisory staff waited until they received an explicit request for help from very busy nurses. There was no Fast Response Team to come to the unit. It may seem obvious that busy, overloaded nurses would automatically call for help, but there is little support for this assumption, because the nurse who is busy phoning physicians and carrying out emergency interventions may be so occupied with urgent, multiple demands that making one more phone call in the moment does not occur to him or her. If help is seldom provided when requested, it may also seem futile to take the time to call.

An intervention at the system level would be a predetermined “SOS” number that requires no explanation or rationale and that receives immediate supervisory attention. Such a signal would require an immediate, mandatory response from nursing supervisory staff, including the immediate nursing staff on the unit. Patients should be routinely given a supervisory number to call 24 hours a day, whenever they feel that their needs are not being adequately attended to on any nursing unit. In this situation, such a routine “fail-safe” backup strategy for patients could have possibly prevented this patient’s death. The patient tried to call her husband for help, and she tried to call her physician. The patient did not imagine that there was any available help in the hospital because her requests were being ignored by the nurse’s aide, and the busy registered nurse had little first-hand contact with the patient.

No doubt the nurse’s information and task overload caused her to deviate from the professional standard of care of closely monitoring the patient’s vital signs postoperatively, checking for potential hemorrhage, and assessing the patient’s pain. In the context of two competing patients’ urgent care needs, the nurse did not make a direct assessment of the postoperative patient’s condition on receiving information from the nurse’s aide about the patient’s changing vital signs. The period of decreased surveillance and monitoring prevented adequate clinical observation, assessment, and thus detection of postoperative hemorrhage that, if recognized, would have saved this patient’s life. In this instance, a critical lack of surveillance occurred during which time the nurse instructed the nurse’s aide not to awaken the patient and check her vital signs at 5:00 AM. It is unknown whether the patient was indeed sleeping, unconscious, or dead at 5:00 AM. when the nurse’s aide reported that the patient was sleeping quietly.

Good clinical reasoning requires knowledge about the patient’s particular condition and therapies being used. Clinical reasoning also requires the ability to perceive and recognize changes in patients’ clinical conditions and responses to ongoing therapy. Unlike scientific reasoning that can be established using formal criteria and decision points at prescribed points in time, clinical reasoning is ongoing about the particular in relation to the general. Clinical reasoning is reasoning across time, about the particular, through changes in the patient’s condition and/or changes in the clinician’s understanding of the patient’s condition over time (

Benner, Hooper-Kyriakidis, & Stannard, 1999

).

Benner, Hooper-Kyriakidis, & Stannard (1999)

 state:

· Critical care nursing practice is intellectually and emotionally challenging because it requires quick judgments and responses to life-threatening conditions where there are narrow margins for error. Developing expertise in this practice requires experiential learning under pressure and “thinking-in-action” (thinking linked with action in ongoing situations) (p. 

2

).

The nurse’s overload and focused concern for the patient whom she considered to be at greatest risk, clouded her thinking-in-action about her other patient’s potential for hemorrhage, and therefore caused her to ignore warning signs of changes in the patient’s condition.

Clinical judgment requires clinical reasoning across time about the particular. Clinical reasoning is very different from scientific reasoning in conducting clinical or bench research. Research uses formal criteria to develop “yes” and “no” judgments. Research is closer to a static, snapshot reasoning than clinical reasoning which, as noted, is reasoning across time about the particular through changes in the clinician’s understanding or changes in the patient’s condition.

· Nursing, like medicine, involves a rich, socially embedded, clinical know-how that encompasses perceptual skills, transitional understandings across time, and understanding of the particular in relation to the general. Clinical knowledge is a form of engaged reasoning that follows modus operandi thinking in relation to patients’ and clinical populations’ particular manifestations of disease, dysfunction, response to treatment, and recovery trajectories. Clinical knowledge is necessarily configurational, historical (by historical, we mean the immediate and long-term histories of particular patients and clinical populations), contextual, perceptual, and based upon knowledge gained in transitions…[Through articulation], clinical understanding becomes increasingly articulate and translatable at least by clinical examples, narratives, and puzzles encountered in practice (

Benner, 1994, p. 139)

.

Clinical reasoning also requires engaged reasoning across time about the particular through changes in the patient’s condition and changes in the clinician’s understanding of the patient’s situation (

Benner, 1984, 2001

). Aristotle called attention to practice or praxis that requires phronesis, something qualitatively distinct from techne (the know-how and skill of producing things). This was in addition to the narrower “rational calculation” or snapshot account of rationality handed down in the Cartesian tradition and captured in early Greek thought by Plato as techne or technique. A practice is a socially embedded form of knowledge that has notions of the good internal to the practice (
Benner, 1984, 2001
). Aristotle’s example was that of a statesman who had to develop character, skilled know-how, practical reasoning, and comportment that included appropriate emotional responses and relationships. This contrast form of rationality and skill-based character called phronesis is similar to clinical judgment. A rational-technical mode, techne (sometimes called “rational technicality”), separates means and ends and focuses on achieving prespecified outcomes.

Rational technical thought is a powerful strategy for those areas of science and technology that can be standardized and made routine. But where clinical reasoning, relationship, perception (or noticing), timing, and skilled know-how are involved, more than techne or rational calculation is required. 
Guignon (1983)
 points out that separating means and outcomes often devalues or does violence to the means, especially where means and ends are closely interwoven. For example, it is not sensible to separate means and ends in birth, comfort, health promotion, or end-of-life care. In each of these caring practices, means and ends are in many ways not separable, since most often there are multiple means and ends at stake in any clinical encounter.

Caregiving relationships may open up possibilities or close them down. But even with the best intentions and comportment, the one cared for may not be able to respond to care. “Outcomes” in caregiving relationships are necessarily interdependent and mutual. Some types of influence are morally unacceptable. Manipulation, coercion, or misuse of professional influence in persuading a patient to accept a treatment is unethical. When things go well and the patient/family is able to respond to caring practices, the practitioner cannot attribute the good outcome solely to the efficacy of some technique they may have used.

In the recent past, nursing practice on “prespecified outcomes” identified and evaluated nursing outcomes in case management based on the premise that only technique is involved in health care, that one knows the outcomes to expect, and that all things can be “fixed.” The problem is further complicated by institutional constraints to effective caregiving. Meeting and responding to the other may clash with the bureaucratic goals of care for the many in the most cost-efficient manner. For all these reasons, developing moral agency and the skills of involvement present ongoing demands for experiential learning and character development. Viewing nursing as a basic human encounter and as a practice that requires phronesis has major implications for nursing education and the moral development of practitioners.

Technical cure and restorative care must not become mutually exclusive for the nurse. One way to create more equal dialogical partners between technical health care and everyday social existence or lifeworlds (defined as a person’s everyday way of being in a particular culture, subculture, and nexus of interpersonal relationships and social roles) is to understand medicine, nursing, and other health care practices as practices that encompass more than the science and technologies they use to effect cures.

Developing expert practice in local, specific settings requires experiential learning as well as communicating that experiential learning to others so that clinical knowledge is continually developed and evaluated. This experientially gained clinical knowledge is held collectively by a local group of practitioners who extend local knowledge through dialogue with larger practice communities. Communities of practitioners must find ways to make their experiential learning collective and cumulative in order for nursing practices in local settings to grow and improve. It is wasteful and harmful when experiential learning is not shared with other clinicians. Experiential learning is expensive to acquire for patients and for nurses. Improving systems and enhancing individual performance and responsibility requires a community of local practitioners who collectively work to improve their clinical practice.

The two dominant approaches to reducing errors in health care, a systems approach and individual practitioner learning and responsibility, both depend on local practice communities and on the larger tradition of good practice. Improving practice systems and performance of individual clinicians both depend on the socially embedded knowledge and teamwork of practitioners in local practice settings. This is another contrast between theory and practice.

Theory derives its power from the ability to be abstract and applicable over a range of particular situations. Practice is local and particular. Excellent practice is lodged in a tradition of fostering good practice and ongoing experiential learning in local settings. The book Clinical Wisdom and Interventions in Critical Care: A Thinking-in Action Approach (
Benner, Hooper-Kyriakidis, & Stannard, 1999
) describes two major habits of thought and action involved in clinical reasoning: clinical grasp and clinical forethought. Parts of the book illustrate the ways in which these pervasive habits of thought and action “work” in relation to major goals of critical care nursing practice. However, these same habits of thought, clinical grasp, and clinical forethought can be found in all domains of nursing practice. 

Table 5.1

 draws heavily on the original research reported in the book on clinical wisdom.

TABLE 5.1 Habits, Clinical Grasp, Inquiry, and Forethought Habits of Thought and Action

· 1 Clinical grasp and clinical inquiry: Problem identification and clinical problem-solving · 2 Clinical forethought: Anticipating and preventing potential problems

From  Benner, P., Hooper-Kyriakidis, P., & Stannard, D. (1999) . Clinical wisdom and interventions in critical care nursing: A thinking-in-action approach. Philadelphia: WB Saunders.

Experiential learning is risky and expensive in underdetermined, fast-paced, clinical circumstances. The clinician’s goal is to be as accurate and certain as possible before acting. Habits of thought and action that foster experiential learning are not automatic. They must be cultivated through practice and reflection on practice by individuals and groups of clinicians. Attentiveness, openness to disconfirming evidence, choosing strategies for confirming hypotheses, and narrative reasoning that considers the clinician’s own transitions in understanding all foster experiential learning. Careless mistakes, lack of attentiveness, and neglect are to be avoided but when they occur, the responsible clinician corrects them and refocuses on the improving practice and the system. Nurse educators in all sectors of nursing education are concerned with ways to teach ethical and clinical reasoning.

Perception or seeing the most salient ethical and clinical issues is the first step in responding to clinical issues. Perceptual grasp comes before defining the problem. Knowing ethical principles and the relevant science are of no avail if learners cannot recognize when the principles and science are at stake in actual clinical situations. Teaching and learning clinical and ethical judgment are made more complex by the rapid time demand and the necessity of moving assessments to interventions or immediate action in crisis situations.

DISTINCTIONS BETWEEN CLINICAL AND SCIENTIFIC REASONING

Clinical reasoning is distinct from scientific reasoning, even though scientific knowledge is central to good clinical reasoning. As noted earlier, clinical judgment entails reasoning about the particular across time, through transitions in the clinical condition of the patient, and through transitions in clinicians’ understandings of the patient’s clinical condition. In contrast, scientific problem solving entails establishing experimental conditions where the scientist can compare experimental results at single points in time, in clearly specified contexts, in the form of absolute judgments. While scientific reasoning can be frozen in time through formal scientific study of appropriate samples, clinical reasoning cannot. Clinical reasoning relies on keeping track of narrative clinical understanding across time. Narrative reasoning across time about the particular must guide the use of critical pathways, prognostic scores, and evidence-based guidelines. Thus clinical reasoning requires an understanding of basic scientific explanations, evidence from aggregate patient populations and the ways in which these might be accurately interpreted in relation to particular patients. As a consequence, even expert clinicians may feel that their practice never measures up to their idealized models of scientific reasoning or making particular decisions based on aggregate data. Yet actual expert clinical reasoning is always linked with notions of good practice (ethical reasoning) and takes into account what has been learned from clinical changes in the particular patient’s condition and the patient’s patterns of responses to interventions over time.

In order to use good clinical reasoning, the nurse must be skillful in moral and clinical perception (

Benner & Wrubel, 1982

; 

Blum, 1994

). Although conceptual knowledge is essential, it is not sufficient to ensure that the nurse will form relationships with patients that lead to salient disclosures, or that the nurse will notice and correctly identify an instance of pulmonary edema, despair, or pain when he or she sees it, even though the nurse may know conceptually what the formal characteristics of these patient conditions are in principle.

In the practice of medicine and nursing, science and technology are used to increase certainty about measurement of signs and symptoms. The practice of these objective measurements reduces errors and improves clinical reasoning. No one would recommend going back to guessing body temperatures by palpation alone. However, even the most formal measurements cannot replace the perceptual skill of the clinician in recognizing when a measurement is relevant or the meaning of a particular measurement. Also, following the course of the patient’s development of signs and symptoms (the trajectory or evolution of signs and symptoms) informs the clinician’s understanding of the meaning of those signs and symptoms. This may seem patently obvious to any practicing clinician, yet current strategies for applying algorithms or making particular clinical judgments based on aggregate outcomes data alone ignore the clinical know-how, relational skills, and need for clinical judgment as reasoning across time (

Halpern, 2001

).

Technique is defined here as prespecified outcomes that can be reduced to routine, predictable, standardized care. A more robust understanding of practice needs to be developed in an era when science and technology have become the dominant, public, legitimized discourses for modern practices.

Good nursing practice requires the development of ongoing, clinical knowledge through experiential learning. Experiential learning is not automatic. It requires openness, attentiveness, and responsible, engaged learning on the part of the practitioner. Reflection on practice and active engaged thinking are required. Here a distinction is being made between detached, disengaged reflection and engaged thinking-in-action (
Benner, Hooper-Kyriakidis, & Stannard, 1999
). Standing outside the situation and reflecting back on it is a powerful critical thinking strategy for improving practice, especially in situations of breakdown and error (

Schon, 1987

). However, being emotionally attuned to the patient/family and the demands of the situation in the immediate moment is required for well-timed expert performance.

The Dreyfus Model of Skill Acquisition (
Benner, 1984, 2001
; 

Dreyfus & Dreyfus, 1986

) is based on determining the level of practice evident in particular situations. It elucidates strengths as well as problems. Situated practice capacities are described rather than traits or talents of the practitioners. At each stage of experiential learning (novice, advanced beginner, competent, proficient, expert), clinicians can perform at their best. For example, one can be the best advanced beginner possible, typically the first year of practice. However, no practitioner can be beyond experience, regardless of the level of skill acquisition in most clinical situations and despite the necessary attempts to make practice as clear and explicit as possible. If the nurse has never encountered a particular clinical situation, experiential learning is required. For example, referring to critical pathways is not the same as recognizing when and how these pathways are relevant or must be adapted to particular patients. Experiential learning that leads to individualization and clinical discernment is required to render critical pathways sensible and safe. Such individualization requires clinical discernment based on experience with past whole concrete clinical situations. This ability to make clinical comparisons between whole, concrete, clinical cases without decomposing the whole situation into its analytical components is a hallmark of expert clinical nursing practice. A renewing, coherent, recognizable identity requires that practitioners develop notions of good that are constantly being worked out and extended through experiential learning in local and larger practice communities. Practice is a way of knowing, as well as a way of being in the world (
Benner, Hooper-Kyriakidis, & Stannard, 1999
). A self-renewing practice directs the development, implementation, and evaluation of science and technology. Clinical judgment requires moral agency (defined as the ability to affect and influence situations), relationship, perceptual acuity, skilled know-how, and narrative reasoning across time about particular patient transitions (
Benner, Hooper-Kyriakidis, & Stannard, 1999
).

CLINICAL GRASP

Clinical grasp describes clinical inquiry in action. Clinical grasp includes problem identification and clinical judgment across time about the particular transitions of particular patients/families. Four aspects of clinical grasp include (1) making qualitative distinctions, (2) engaging in detective work, (3) recognizing changing relevance, and (4) developing clinical knowledge in specific patient populations.

MAKING QUALITATIVE DISTINCTIONS

Qualitative distinctions refers to those distinctions that can only be made in particular, contextual, or historical situations. In the clinical example above, the nurse was listening for qualitative changes in the breath sounds, and changes in the patient’s color and also changes in the patient’s mental alertness. Context and sequence of events are essential for making qualitative distinctions; therefore they require paying attention to transitions and judgment (

Benner, 1994

; 
Benner, Hooper-Kyriakidis, & Stannard, 1999
). Many qualitative distinctions can only be made by observing differences through touch, sound, or sight, as in skin turgor, color, and capillary refill (

Hooper, 1995

).

ENGAGING IN DETECTIVE WORK, MODUS OPERANDI THINKING, AND CLINICAL REASONING

SOLVING PUZZLES

Nurse educators and regulators alike have conflated critical thinking, scientific thinking, and clinical reasoning. Clinical reasoning is always about reasoning across time about the particular through changes in the patient’s concerns of condition and/or changes in the clinician’s understanding of the nature of the patient’s condition (
Benner, Hooper-Kyriakidis, & Stannard, 1999
). Nurses use scientific evidence in their clinical thinking and reasoning, but they do not “use the scientific problem-solving process,” since that process is both static and linear and designed to yield convincing evidence for confirmation or disconfirmation of hypotheses according to formal criteria or operational definitions. Critical thinking is essential for examining outmoded practices, and for when there is confusion and complete puzzlement about the patient’s clinical condition and the meaning of signs and symptoms. Critical thinking is a form of deconstruction and critical reflection. It critiques and judges what is wrong or puzzling, and evaluates the soundness of assumptions. But reasoning through transitions over time is required for clinical reasoning and discernment. This is a form of practical reasoning and puzzle solving that is analogous to “modus operandi” thinking (

Benner, Tanner, Chesla, 2009

).

Clinical situations are open ended and underdetermined. Modus operandi thinking keeps track of the particular patient, the way the illness unfolds, and the meaning of the patient’s responses as they have occurred in the particular time sequence. Modus operandi thinking requires keeping track of what has been tried and what has or has not worked with the patient. In this kind of reasoning-in-transition, gains and losses in understanding that are error reducing are evaluated for their significance (

Benner, Hughes, & Sutphen, 2008

; 
Benner, 1994
; 

Taylor, 1989

, 

1993

). For example, an advanced practice nurse clinician reviewing a patient’s x-ray considers her condition and considers the possibility of pneumothorax. He determines that a second comparative chest x-ray is needed. Later in an interview he states:

· I guess it could have been a pulmonary embolus. But I was really sort of focused on the differences and the fact that it was fairly similar in appearance, which can happen with pulmonary emboli. The heart rhythm pattern had not changed, although it was elevated. There was some tachycardia. Uhm, but, it sort of was leading me to believe that this was more sort of a pulmonary problem as opposed to a pulmonary circulation problem, you know (
Benner, Hooper-Kyriakidis, & Stannard, 1999
).

The clinician is guessing that this is a problem of physical phenomenon of air moving in and out rather than obstructions to pulmonary circulation. The evidence is subtle, so the clinician stays open to disconfirmation but proceeds with attempts to obtain the chest x-ray and is prepared to recognize the sudden change in the patient’s respiratory status when that occurs. Another qualitative distinction was the judgment of whether the patient’s change in mental status and agitation was primarily the result of anxiety or hypoxia.

RECOGNIZING CHANGING CLINICAL RELEVANCE

Recognizing changes in clinical relevance is an experientially learned skill that enables clinicians to distinguish what is relevant in situations. The meanings of signs and symptoms are changed by sequencing and history. In the above example, the patient’s mental status and color continued to deteriorate, as did the diminishment of his breath sounds. Once chest tubes were in place, a dramatic change occurred in the patient’s color. Each of these changes in the patient’s signs and symptoms is made by examining the transitions as they occur.

DEVELOPING CLINICAL KNOWLEDGE IN SPECIFIC PATIENT POPULATIONS

Because this clinician has had the opportunity to observe both pulmonary circulation problems and mechanical breathing problems, he is able to recognize a kind of “family resemblance” with other mechanical breathing problems (as opposed to pulmonary circulation problems) that he has noticed with other patients.

Refinement of clinical reasoning is possible when nurses have the opportunity to work with specific patient populations. The comparisons between many specific patients create a matrix of comparisons for clinicians, as well as a tacit background set of expectations that create active detective work if a patient does not meet the usual predictable transitions in recovery. What is in the background and foreground of the clinician’s attention needs to shift with changes in the patient’s condition. Understanding a particular patient population well can assist with recognizing these shifts.

CLINICAL FORETHOUGHT

Clinical forethought is another pervasive habit of thought and action in nursing practice evident in this narrative example (
Benner, Hooper-Kyriakidis, & Stannard, 1999
). Clinical forethought plays a role in clinical grasp because it structures the practical logic of clinicians. Clinical forethought refers to at least four habits of thought and action: (1) future think, (2) clinical forethought about specific patient populations, (3) anticipation of risks for particular patients, and, (4) seeing the unexpected.

FUTURE THINK

Future think is the broadest category of this logic of practice. In the example, the advanced practice nurse stated: “So I stayed in with the nurse, and we were talking and going over what the plan was and things we might be looking for in the evening.” Anticipating likely immediate futures helps with making good clinical judgments and with preparing the environment so that the nurse can respond to the patient’s immediate needs in a timely fashion. Essential clinical judgments and timely interventions would be impossible in rapidly changing clinical situations without lead time or anticipation, a well developed sense of salience for noticing what is most urgent in the situation, and an environment prepared for anticipated patient needs. Future think governs the style and content of the nurse’s attentiveness to the patient. Whether in a fast-paced, acute care, or slower paced rehabilitation setting, thinking and acting with anticipated futures guide clinical thinking and judgment. Future think captures the way judgment is suspended in a predictive net of thoughtful planning-ahead and preparing the environment for likely eventualities.

CLINICAL FORETHOUGHT ABOUT SPECIFIC PATIENT POPULATIONS

This habit of thought and action is so second nature to the experienced nurse that he or she may neglect to tell the newcomer, the “obvious.” Clinical forethought involves much local, specific knowledge, such as who is a good resource and how to marshal support services and equipment for particular patients. The staff nurse used good judgment in calling the advanced practice nurse to assist in solving the puzzle when she was unable to convince the less clinically experienced junior resident. The advanced practice nurse made use of all available physicians in the area. Part of what made a timely response possible was the actual planning of a situation that might change rapidly.

Examples of preparing for specific patient populations abound in all settings. Examples including anticipating the need for a pacemaker during surgery and having the equipment assembled ready for use saves essential time, or forecasting an accident victim’s potential injuries when intubation might be needed for the accident victim.

ANTICIPATION OF RISKS FOR PARTICULAR PATIENTS

This narrative example is shaped by the foreboding sense of an impending crisis for this particular patient. A staff nurse uses her sense of nervousness or uneasiness about the changes in a patient’s breathing to initiate her problem search. This aspect of clinical forethought is central to knowing the particular patient, family, or community. Nurses situate the patient’s problems almost like a topography of possibilities. This vital clinical knowledge needs to be communicated to other caregivers and across care borders.

Clinical teaching could be improved by enriching curricula with narratives from actual practice and by helping students recognize commonly occurring clinical situations. For example, if a patient is hemodynamically unstable, then managing life-sustaining physiologic functions will be a main orienting goal. If a patient is agitated and uncomfortable, then attending to comfort needs in relation to hemodynamics will be a priority (
Benner, Hooper-Kyriakidis, & Stannard, 1999
). Providing comfort measures emerges as a central background practice for making clinical judgments, and contains within it much judgment and experiential learning. When clinical teaching is too removed from typical contingencies and strong clinical situations in practice, students will lack practice in active thinking-in-action in ambiguous clinical situations. With the rapid advance of knowledge and technology, students need to be good clinical learners and clinical knowledge developers. One way nurse educators can enhance clinical inquiry is by increasing experiential learning in the curriculum.

Experiential learning requires open learning climates where students can discuss and examine transitions in understanding including their false starts or their misconceptions in actual clinical situations. Focusing only on performance and on “being correct” and not on learning from breakdown or error dampens students’ curiosity and courage to learn experientially.

One’s sense of moral agency, as well as actual moral agency, in particular situations changes with level of skill acquisition (

Benner, Hooper-Kyriakidis, & Stannard 1999

; Benner, 2005). Furthermore, experiential learning is facilitated or hampered by learning skills of involvement with patients/families and engagement with clinical problems at hand. Those nurses who do not go on to become expert clinicians have some learning difficulty associated with skills of involvement, and consequently with making clinical judgments, particularly making qualitative distinctions (
Benner, Hooper-Kyriakidis, & Stannard, 1999
; Benner, Tanner, & Chesla, 1996). Experienced, nonexpert nurses see clinical problem solving as a simple weighing of facts or rational calculation. They do not experience their own agency in making clinical judgments. They fail to see qualitative distinctions linked to the patient’s well being.

SEEING THE UNEXPECTED

One of the keys to becoming an expert practitioner lies in the ways in which the practitioner holds past experiential learning and background habitual skills and practices. If nothing is considered routine, as a habitual response pattern, then practitioners cannot function in emergencies attending to the unexpected. However, if expectations are held rigidly, then subtle changes from the usual will be missed and habitual and rote responses will rule. The clinician must be flexible in shifting between what is in the background and the foreground. This is accomplished by staying curious and open. The clinical “certainty” associated with perceptual grasp is distinct from the kind of “certainty” achievable in scientific experiments and through measurements. It is similar to “face recognition” or recognition of “family resemblances.” It is subject to faulty memory, false associative memories, and mistaken identities; therefore such perceptual grasp is the beginning of curiosity and inquiry and not the end (
Benner, Hooper-Kyriakidis, & Stannard, 1999
; 

Benner, Chesla, & Tanner, 2009

).

In rapidly moving clinical situations, perceptual grasp is the starting point for clarification, confirmation, and action. The relationship between the foreground and the background of attention needs to be fluid so that missed expectations allow the nurse to see the unexpected. For example, when the background rhythm of a cardiac monitor changes, the nurse notices, and what had been background tacit awareness becomes the foreground of attention. A hallmark of expertise is the ability to notice the unexpected (
Benner, Hooper-Kyriakidis, & Stannard, 1999
). Background expectations of usual patient trajectories form with experience. These background experiences form tacit expectations that enable the nurse to notice subtle failed expectations and pay attention to early signs of unexpected changes in the patient’s condition. Clinical expectations gained from caring for similar patient populations form a tacit clinical forethought that enables the experienced clinician to notice missed expectations. Alterations from implicit or explicit expectations set the stage for experiential learning depending on the openness of the learner.

DIAGNOSTIC DISCERNMENT, MORAL AGENCY, AND ADVOCACY

Moral agency relies on more than will and intent (

Sherman, 1997

). The Kantian tradition is insufficient for practice disciplines in that it focuses primarily on will and intent, and overlooks moral agency as the ability to respond emotionally and act in relation to notions of “good” (

Kant, 1785

). Aristotle, in 322 B.C., noted that carrying out and acting on moral principles requires the development of character and skill in a social context. For example, given the same moral intentions, the experienced expert nurse will be able to exercise moral agency in a complex situation because of perceptual acuity, skilled know-how, and social competence gained in a particular social setting. However, the beginning nurse may be too caught up with the tasks at hand, lack adequate perceptual acuity to recognize the moral infraction, or lack the social understanding and influence to make the appropriate corrective response to the situation.

Intelligent and timely advocacy requires critical thinking that enables the nurse to evaluate the level and adequacy of medical treatment and nursing care for the patient. As noted, this requires sufficient time for the nurse to meet and attend to the patient. For example, if a patient misunderstands the implications of a medical treatment or nursing intervention, then the nurse must assist the patient in clarifying the implications, consequences, and potential side effects. Advocacy may be involved in helping a patient understand the need for an unpleasant medical procedure, such as the insertion of a nasogastric tube and subsequent suctioning, when the patient is suffering from vomiting and distention due to a gastrointestinal blockage.

Advocacy is more than ensuring the “consumer’s preferences.” It requires understanding the patient’s plight, understanding the concerns in relation to the potential benefits of medical treatments and nursing interventions, and working with the patient to confront difficult decisions. Advocacy must place the patient’s autonomy and choices first. But the expectation goes further to help patients better understand and assess the implications of their decision.

DIAGNOSTIC DISCERNMENT AND THE ENVIRONMENT OF CARE

Many environmental factors exist in health care systems that influence the decisions that nurses make while providing nursing care. In the ideal workplace, the nurse is able to make sound, professional, and humane nursing decisions based on extensive knowledge, clinical skills, competency, and time to make decisions. A culture of safety informs the work environment so that a context exists without serious organizational structure or process impediments and in which a nurse can exercise sound clinical judgment and implement decision-making skills. Sound practice requires a work environment that reinforces and sustains the notions of good practice internal to the practice.

Unfortunately, many impediments within a health care setting do exist. These may hinder a nurse’s ability to make the best clinical decision and will often force a choice between implementing the best course of action for the patient or modifying best care standards based on poor policies or inadequate resources within the workplace.

DIAGNOSTIC DISCERNMENT AND THE MARKETPLACE

Assuring adequate nurse staffing has been affected by significant cost-cutting initiatives throughout the health care system. Unfortunately, the evidence or lack of evidence for such decisions has often resulted in negative patient outcomes, nurse frustration, and increased long-term costs. Examples of several of the factors impacting nurse staffing include:

· 1The worsening nursing shortage coupled with the aging of the nurse workforce.

· 2An aging population that is associated with increased demand for health care.

· 3Increased expectations for health care organizations to operate within a business model framework (

Aiken, Sochalski, & Anderson, 1996

).

· 4Decreased reimbursement for health care services.

· 5Increased competition for staff.

· 6A health care system increasingly driven by free market competition coupled with escalating costs of health care services.

· 7Use of efficiency-driven institutional policies often at odds with effective, safe health care delivery practices.

· 8Expectations for safe staffing ratios, job descriptions, philosophy of care, and allocation of resources to support profit making at the expense of patient care outcomes.

· 9Expectations for the licensed nurse to “delegate” and/or assume additional roles in a climate that does not reflect the standard of nursing practice that may be optimal for the patient for which unlicensed personnel have been inadequately prepared (

Aiken et al., 2001

).

· 10Efforts to reduce costs by decreasing the number of registered nurses and increasing the number of unlicensed nursing assistants and support caregivers.

· 11An acute shortage of nursing faculty so that it is impossible to increase the capacities of nursing schools to accommodate the number of new entrants into the profession required (
Buerhaus, Staiger, & Auerbach, 2000
).

· 12Consumer awareness and demand driving changes in the way health care is delivered. An increasing number of patients and families are requesting home care rather than traditional hospitalization and/or long-term care and are demanding to play an active role in the care they receive.

· 13The proliferation of clinical monitoring technology available for health care services. The use of technology requires increasingly greater registered nurse time and attention to individual patients, many of whom are now placed in ICUs and step-down units for intensive, highly technical care. Clinical monitoring technology has also influenced the way health care is delivered. A larger percentage of critically ill patients survive and have shorter inpatient stays in the acute care hospital setting but still require skilled nursing care outside of acute care hospitals. This has resulted in an upward shift in the acuity of patients in nursing homes, assisted living/residential care facilities, and home care. Many times these facilities are licensed by the state and certified through Medicare. These regulations often do not reflect the acuity of their current patient population.

· 14Advances in documentation technology that have changed the way nurses communicate. Nurses now often communicate by computer with nursing colleagues, physicians, pharmacists, and those to whom they delegate, resulting in an electronic format and approach to medical records. Currently this change to computerized medical records is promising though uneven in different health care actions. For example, an electronic record may improve the accuracy of documentation of vital signs, decreasing the error rate to 5% (

Gearing et al., 2006

). A study by 

Singh, Servoss, Kalsman, Fox, & Singh (2004)

 demonstrated a decreased sense of threat for patient safety in nurse-physician and physician-chart interactions, but an increased risk in physician-patient assessment and nurse-chart interactions. The authors conclude that through electronic records the visibility and awareness of other problem areas may increase, and indeed electronic records may create new problems that do not show up until the system is in place and tested over time.

When working environments are less than optimal, the infrastructure for safe and effective diagnostic discernment is most likely absent, and negative patient outcomes may result. Work environment design and efficiency models have become major driving factors of patient care outcomes. In this regard, nurses are not able to overcome all the impediments to providing safe levels of monitoring and surveillance. Complaints filed with state boards of nursing frequently reflect the unstable and unsafe working environments in the health care system.

CHALLENGES IN DEVELOPING SKILLS IN DIAGNOSTIC DISCERNMENT

Nurses enter the workforce after they complete their undergraduate work. They believe that they have learned the basic elements of the profession and that they will be able to provide safe and competent nursing care in their chosen health care setting. This belief is supported by the Report of Findings From the Practice and Professional Issues Survey 2002 (

NCSBN, 2003

) in which newly licensed and practicing nurses reported feeling competent to perform basic nursing procedures, such as “administer medications by common routes” and to “provide direct care to two or more clients.” However, the practices these respondents reported about which they did not feel competent included “provide direct care to six or more clients”; communication and management skills required to “supervise care provided by others”; and “know when and how to call a client’s physician.” If the educational institution or the employer does not provide this school-to-work and day-to-day practice transition skills, the care delivered may be compromised during the initial period of learning.

Another factor that impacts acceptable practice is the gap between the regulatory board’s defined scope of practice for the licensed nurse and state and federal regulations that define the minimum licensure and certification requirements of health care agencies. These gaps suggest that coordination and institutional design are not congruent with the newly graduated nurse’s actual capacities to provide safe nursing care throughout the full range of current health care environments. Specifically, these may include the gaps between the licensed nurse’s confidence in his/her ability to practice safely, the errors that occur in heath care environments new to the nurse, and the policies of the various health care agencies in which nurses practice. These gaps call for improved educational programs and better transition from school to work in practice settings. The Carnegie National Nursing Education Study, based on Sullivan’s work, has identified three apprenticeships as essential to professional education (

Benner, Sutphen, Leonard, & Day., in press

; 

Sullivan, 2005

). To capture the full range of crucial dimensions in professional education, the organizations developed the idea of a threefold apprenticeship: (1) intellectual training to learn the academic knowledge base and the capacity to think in ways important to the profession, (2) a skill-based apprenticeship of practice (and clinical judgment), and (3) an apprenticeship to the ethical standards, social roles, and responsibilities of the profession through which the novice is introduced to the meaning of an integrated practice of all dimensions of the profession grounded in the profession’s fundamental purposes. The creators of this initiative noted: “This framework has allowed us to describe tensions and shortfalls as well as strengths of widespread teaching practices, especially at articulation points among these dimensions of professional training” (

Benner et al., in press, p. 7

).

Aristotle linked experiential learning to the development of character and moral sensitivities of a person learning a practice (Dunne, 1997). In the Carnegie studies of professional education, the development of moral character is called “formation” by the clergy. Good teaching practices seek to integrate all three apprenticeships so that students will learn how to intertwine these three essential apprenticeships in their practice. No doubt rational calculations available to techne—population trends and statistics, and algorithms created as decision support structures—can improve accuracy when used as a stance of inquiry in making clinical judgments about particular patients. Ultimately, however, the skills of phronesis will be required for nursing, medicine, or any helping professional (Dunne, 1997). Specifically, these refer to clinical reasoning that reasons across time, taking into account the transitions of the particular patient/family/community and transitions in the clinician’s understanding of the clinical situation. As noted in 
Chapter 4
, good clinical judgment requires adequate institutional design, time, and support, nurse monitoring, and attentiveness to allow for nurses to adequately monitor and spend time with patients. Good clinical reasoning is facilitated when the nurse knows the patient and is able to pay attention to changes in the patient over time. Delegated monitoring and vital sign assessments must be communicated clearly. Good clinical reasoning is also facilitated when the nurse has in-depth knowledge of the particular patient population in question. Understanding usual patient recovery trajectories in a patient population helps nurses recognize deviations from the usual recovery trajectory.

Clinical reasoning is affected by the context of care. If the nurse is not familiar with a patient population, a resource nurse should be made available for consultation and cross-checking of the patient. When a patient crisis drains the staff resources to attend to all patients on the unit, the supervisory staff must have a plan in place to provide additional staff support during these times of high demands. It is crucial to sort out causes of poor clinical judgments, breakdowns in monitoring and attentiveness, inadequate patient history or information, lack of knowledge about the relevant clinical signs, and the symptoms to be observed.

Historical Case Study #1: When Nursing Care and More Complex and Adequate Training and Supervision Are Absent

ENVIRONMENT AND HISTORY

This case took place in a small rural community of 8000 people. Mr. Kenny Salamino was a developmentally and physically disabled 32-year-old man. He had lived most of his life in a group home with seven other residents and was cared for by a staff of two unlicensed assistive personnel (UAP) 24 hours a day.

Ms. Marsha Mitchell, a licensed practical nurse whose title was “Medical Director,” had worked at the group home Monday through Friday, 8 AM to 5 PM, for 7 years. Ms. Rose Sinclair, a registered nurse, served as “Consultant.” Nurse Sinclair was employed to “be a resource” and provide a course entitled “Assistance With Medications Course for Unlicensed Assistive Personnel.” The owner of the facility, Mr. Brian Adams, did not live at or maintain an office at the facility. He hired the staff and expected the registered nurse and the licensed practical nurse to manage the resident care.

The state board of nursing in which the facility was located received a complaint from the Department of Health and Welfare. Mr. Salamino had died after admission to the hospital, and the state’s surveyors from the Bureau of Facility Standards had investigated the circumstances of his death. Over a period of 6 months, Mr. Salamino had lost 40 pounds during which time the nurses had not assessed his health care needs or provided for adequate medical or nursing interventions. The bureau’s investigation determined that the events that led to Mr. Salamino’s death were due to lack of fiduciary responsibility of Practical Nurse Mitchell and Nurse Sinclair who, the report asserted, should be held accountable for Mr. Salamino’s death.

THE NURSES’ STORY

I have been a registered nurse for 10 years. I worked full time in a small hospital in a nearby town for 9 years as the supervising registered nurse. When I decided to work part-time, I chose to drop back and work in a less restricted environment than the hospital. The administrator of the group home hired me as the “Registered Nurse Consultant,” and my responsibilities included teaching to new unlicensed assistive personnel a course entitled “Assistance With Medications Course” and providing to the licensed practical nurse 24/7 support face to face or by cellular phone.

My contract specified that I was to be paid for 24 hours of work every 3 months. I did not receive an orientation to residential care/group home, federal, and/or state regulations.

The first indication I had that Mr. Salamino was having a problem was when Practical Nurse Mitchell called me and said that Mr. Salamino had just returned from the hospital with a new jejunostomy tube (J-tube). She said that she thought Mr. Salamino should have been discharged to a skilled nursing facility, but his physician, Dr. Fred Stark, sent him back to the group home because he thought Mr. Salamino would receive better care there. Dr. Stark worked with Practical Nurse Mitchell and the patients in the group home. They knew and loved Mr. Salamino.

I asked Practical Nurse Mitchell if she could handle the J-tube. She said she could, and thus I did not go to the group home to assess Mr. Salamino or to confirm Practical Nurse Mitchell’s competency. I did not believe this was part of my job.

THE LICENSED PRACTICAL NURSE’S PERSPECTIVE

I could tell Mr. Salamino was losing weight over several months. I didn’t become concerned at first because he continued to feed himself and didn’t appear to be hungry. After several months, I called his doctor and he told me to bring Mr. Salamino in for a checkup. Dr. Stark was concerned about Mr. Salamino’s weight loss and ran some tests. He had something wrong with his digestive tract and wasn’t absorbing his food.

Dr. Stark arranged for a consult with a surgeon and that’s when they decided to insert a stomach tube. Mr. Salamino was in the hospital for 2 days and was then transferred back to the group home. He was able to swallow and drink liquids. He didn’t have a pump for his feedings when he arrived, so I called and ordered the pump and the liquid feeding solution that Dr. Stark had ordered. I didn’t worry too much about the fact it took 4 days to start the feedings because Mr. Salamino continued to drink liquids.

When the pump and feeding solution arrived, I hooked it up but couldn’t get the pump to run. I called Dr. Stark who arranged for me to take Mr. Salamino to the emergency room and meet the surgeon, Dr. Hari Harimoto. Dr. Harimoto discovered that something was wrong at the insertion site on his stomach. He repaired the insertion site and sent Mr. Salamino back to the group home. The aides and I gave Mr. Salamino his feedings as Dr. Harimoto ordered, but he developed a fever, was readmitted to the hospital about 2 weeks later, and died the same day.

When I looked back on the events that took place, I felt I was left to do everything myself. I wished Nurse Sinclair would have been more involved in what was going on, but she said she was not hired to see the residents. I know we gave Mr. Salamino better care than he would have gotten at the nursing home. They have too many patients and not enough nurses.

THE ADMINISTRATOR’S PERSPECTIVE

I have owned this facility for 15 years and never had a problem until this happened. Practical Nurse Mitchell is a good licensed practical nurse and handles things perfectly fine. I don’t see any reason to have to pay a registered nurse to do what Practical Nurse Mitchell, a licensed practical nurse, can do on her own. I didn’t see any reason to orient the registered nurse or licensed practical nurse to residential care/group home regulations. They are supposed to take care of the residents.

CASE ANALYSIS

This case demonstrates the classic example of the common expectation that residential/group home care does not require the level of nursing skill and attentiveness that is required in a hospital or skilled nursing facility. This expectation persists despite the fact that residents change in their care needs, and the home may not be able to keep up with the technical care demands of these changes. This owner-established care supervision plan was inadequate given the nature of the changes in the care the patient required. Several actions were inadequate in this series of events regarding the decisions that affected the patient’s well-being. The practice breakdown elements included the following:

· 1The administrator of the group home did not provide orientation for the registered nurse immediately after her arrival. Consequently she was unaware that the State Regulations for Residential Care Facilities required that a registered nurse assesses patients on a regular basis to identify any health care needs that may be developing and to refer the patient for medical care as needed. It was only when the patient died that the state surveyed the facility and discovered the lack of supervision of a registered nurse.

· 2The administrator failed to provide adequate resources for the registered nurse and licensed practical nurse in their respective roles. The registered nurse was only paid for 24 hours of work in a 3-month period. She understood that her role was to provide the course “Assistance With Medications Course” for newly hired unlicensed assistive personnel, but this responsibility alone took more than the 24 hours for which she was paid. She did not understand that she was in a role that required her participation and direction for the care of the patients in the facility. She did not recognize her role as a “registered nurse consultant” to be “anything more than a registered nurse available on the cellular phone 24 hours per day.” She was not expected by administration to assume responsibility for assessment of the patients and/or to collaborate with the licensed practical nurse and physician.

· 3Practical Nurse Mitchell had the title “Medical Director,” which led her to believe that she was to make all decisions related to patient care. The licensed practical nurse was reluctant to call the registered nurse when she had concerns. She did contact the physician, but she did not identify the patient’s health issues until the patient required hospitalization. The health care system in which the licensed practical nurse and registered nurse practiced did not design, mandate, or pay for the support and guidance that a registered nurse should have provided.

· 4After the first hospitalization, the patient’s physician discharged his patient to the group home. The physician believed that the patient would receive better care in his “home,” where the staff was familiar with him, rather than refer him to a skilled nursing facility that could provide the skilled care he required. However, this group home was not adequately prepared to provide the skilled nursing care he needed.

The licensed practical nurse did not doubt her ability to administer medications by common routes and to provide care to two or more patients. But the evidence in this case did not address the competencies required for tube feeding and recognizing malnutrition. Further, the licensed practical nurse was slow to contact the physician regarding the patient’s emerging physical changes, which could have been due to either a reluctance to call the physician and/or her lack of assessment or awareness of the dangerous level of weight loss and malnourishment.

Both nurses in this case were not aware that their individual levels of nursing education applied in this setting. The descriptions of their positions defined the relationship between the registered nurse and the licensed practical nurse. The licensed practical nurse was “in charge,” and the registered nurse was hired as a figurehead to meet the administrator’s interpretation of the requirements for licensure of a group facility. These institutional policies established the scenario that eventually resulted in a patient’s death. The licensed practical nurse assumed responsibility for all patient care but did not have the skills or support from the registered nurse to identify the patient’s initial life-threatening weight loss, and later the need for timely initiation of his tube feedings. She continued to deal with the situation alone rather than contact and consult with the registered nurse and physician to determine the actions needed. Because the registered nurse had never worked in residential care before and was unaware of the federal and state requirements for residential care, she assumed that the duties as written in her position description were appropriate. Based on these duties, she did not assume a supervisory or active collaborative role to support the licensed practical nurse. The registered nurse and the licensed practical nurse did not question the scope of the duties in descriptions of their respective positions, nor did they look to the Nurse Practice Act and Administrative Rules to identify the roles their state board required for each respective nursing license or question their “positions” at the time they were hired. The registered nurse was content to have minimal collaborative responsibility and limited hours. The licensed practical nurse did not recognize that she lacked sufficient knowledge and training to provide the more skilled nursing care involved in tube feeding a patient through a jejunostomy. Further, the licensed practical nurse was flattered by her title and did not question the fact that she was not appropriately educated and competent to manage and provide adequate nursing care without support.

2. HISTORICAL CASE STUDY #2: When Short Staffing Hinders Good Clinical Reasoning

ENVIRONMENT AND HISTORY

This case took place in a local hospital of a community of 50,000 people. Mr. Jim Luke, a registered nurse assigned to the ICU/CCU during the night shift, had been working part-time in this unit for about 2 years and had been licensed for 8 years. His previous experience included medical-surgical nursing and working in a cardiac catheterization lab. Nurse Luke said he had not received any orientation or additional training when he was transferred to the ICU/CCU.

The board of nursing received a complaint from the hospital after a patient, Mr. John Clark, had died. The allegations were that Nurse Luke had oversedated Mr. Clark, had used chemical restraints to control Mr. Clark’s behavior, and that Nurse Luke’s actions had contributed to Mr. Clark’s death.

THE NURSE’S STORY

I was the registered nurse who admitted the patient, Mr. John Clark, to the ICU/CCU from the medical-surgical floor the previous night. Mr. Clark was a 73-year-old man with multiple diagnoses including acute pancreatitis, acute respiratory failure, pneumonia, chronic airway obstruction, atrial fibrillation, congestive heart failure, and hypertension. Mr. Clark was confused and complained of pain. He was quite restless and frequently tried to get out of bed. He was started on BiPAP when admitted to the ICU/CCU. His wife had been sitting with him during the nights he was in the medical-surgical unit, and she also sat with him during the night he was admitted to the ICU/CCU.

When I arrived the next night for my shift I was given the report and told there were five patients in the ICU/CCU, including Mr. Clark and four patients who had been transferred from the medical-surgical unit just prior to the shift change. The additional patients included an 85-year-old female with neutropenia who required isolation, a 41-year-old female with a kidney stone, a 22-month-old female with respiratory syncytial virus who required isolation, and an 86-year-old female with congestive heart failure.

According to our infection control policy, the patient with neutropenia and the patient with a virus could not be assigned to the same nurse. One other registered nurse was also assigned to the unit. We did not have a unit clerk or an aide assigned to the unit. I objected and said we would need additional help. The nursing supervisor told me that the patients were not as acutely ill as the usual ICU/CCU patients and, therefore, we did not need additional staffing. I pointed out that two of the patients required isolation procedures and this not only took extra time for the nurses to gown and mask but also no one was available to watch the other patients when the nurses were in the rooms with the door closed with the isolation patients. I was told that this was not an issue and that the staffing was adequate. I asked if there was another registered nurse on call but was told by the nurse supervisor that I did not have authorization to call her in for assistance. I again requested additional help because the admissions for the additional patients were not completed. This would take additional time. Again, the request was denied.

When I began the shift, Ms. Clark was sitting with her husband who was restless and agitated. Mr. Clark said he wanted to go to another hospital and was trying to get out of bed. His wife was able to calm him, but she had been sitting with him every night for over a week and was very tired. I completed my assessments for the shift, and a short time later another patient was transferred to the ICU/CCU from the emergency room, a 17-year-old patient who had overdosed.

I checked on Mr. Clark, who was still agitated, and his wife told me she needed some rest. I arranged for her to sleep in the lounge. Mr. Clark had physician orders in his chart for morphine sulfate IV 2 mg prn q2h, Benadryl 50 mg IV prn sleep HS, Inapsine 2.5 mg IV prn nausea/vomiting q6h, Ativan 1-2 mg IV prn q4h severe agitation, and Phenergan 12.5 mg IV prn nausea/vomiting q1h.

Mr. Clark was complaining of back pain, and I administered morphine sulfate IM 2 mg at 11:00 PM. Mr. Clark calmed down and appeared to be sleeping 15 minutes later.

Again, I requested an additional registered nurse, but this was refused again. The shift continued to be very busy, and at 1:30 AM I checked on Mr. Clark and found him standing beside the bed and talking about leaving the hospital. I assisted him to bed and gave him the IV Benadryl and Inapsine. Thirty minutes later, Mr. Clark was still agitated. I administered Ativan and morphine, and Mr. Clark settled down and fell asleep.

At 3:00 AM I assessed Mr. Clark, and he was sleeping with minimal respiratory effort and breath sounds were diminished with upper quadrant wheezes. This was not a change from previous assessments. Mr. Clark continued to rest quietly throughout the shift. Nurses notes indicated: “minimal respiratory effort, shallow respirations, moves little air.” I reported off to the day shift nurse and included the medication I had administered to Mr. Clark in my report.

When the day shift nurse entered Mr. Clark’s room to do her assessment, she found him in sinus tachycardia with diminished breath sounds and having brief periods of apnea. He was lethargic and only withdrew from pain. The physician was called in, and Mr. Clark was placed on a ventilator. Mr. Clark’s condition continued to decline and he died one week later due to complications of pancreatitis, systemic inflammatory response syndrome, respiratory failure, progressive renal insufficiency, and sepsis.

CASE ANALYSIS

Hamric, in 
Reflections on Being in the Middle
 (2001)

, states that “nurses are expected to be trustworthy team members in hierarchical top-down systems while at the same time working from the base up so as to meet patient and family needs” (p. 254). In this case, the registered nurse was caught between a nonresponsive hospital hierarchy and the dilemma of choosing the most appropriate means to protect the patient from harm.

The registered nurse recognized immediately the potential issues that could possibly arise from the staffing that was scheduled for his shift. He requested additional nursing and support staff, and the supervising/managerial personnel refused to listen to his concerns and did not accept his logic for making the request. He was forced to acquiesce to his superiors’ decisions and felt he should not continue to pursue his request for additional staff.

At the beginning of the shift, the patient’s wife was with him and able to calm and protect him from his confused and agitated mental state. However, she was unable to continue to be by her husband’s side throughout the shift. When she left to sleep in another room, the patient was left alone without her support. The registered nurse recognized that the patient would need additional surveillance and assessed him to determine his needs. Because the patient exhibited signs of pain, the registered nurse medicated him for pain and it did calm the patient for a period of time. The admission of a new patient to the floor diverted more attention from the case study patient. Finally, in a misguided but understandable decision, the registered nurse chose to give the patient additional medication to calm him. When this did not work, he made the same decision again and administered additional medication before the effects of the previous medications were apparent. This resulted in oversedation of the patient.

Both the patient and the registered nurse paid the price for a system that did not allow for flexible decision making in order to best protect the patient from harm. Nurse Luke did not adequately recognize the significance of the patient’s decreased respiratory efforts that resulted from overmedication. An additional nurse may have prevented this scenario from ending as it did. It is probable that an unlicensed individual assigned to be with Mr. Clark could have prevented this outcome had nonchemical means been provided to comfort and reassure the patient.

Nurse Luke was reported to the board of nursing for being grossly negligent and reckless in performing nursing functions and for endangering a patient. The hospital employee who reported the nurse to the board was responsible for protecting the hospital’s State Licensure and Medicare Certification status in the shadow of an allegation that one of their nurse employees had used chemical restraints to subdue a patient. An experienced nurse, committed to his practice and attempting to protect a patient, made a quick, inappropriate clinical judgment in the context of work overload and a poor staffing mix that could have been prevented had the system provided additional resources.

HISTORICAL CASE STUDY #1: An Ounce of Prevention

PRACTICE BREAKDOWN AND PREVENTION

BACKGROUND

An outpatient oncology clinic was located in a small town with a population of approximately 20,000. The clinic had been open for approximately 5 years. Dr. Dave Brown owned the clinic, and the local hospital had provided financial assistance to start the clinic.

Ms. Danielle Davis, RN, had been employed by Dr. Brown prior to the opening of the clinic. The state board of nursing received a complaint that Nurse Davis was engaging in unsafe practices.

THE NURSE’S STORY

Nurse Davis had been licensed as a registered nurse for 20 years during which time she had worked primarily in the hospital setting on the medical-surgical, coronary care, and intensive care units and in the emergency department. She accepted an offer from Dr. Brown to work as a nurse in the oncology clinic.

Nurse Davis informed Dr. Brown that she had no experience in oncology nursing. Dr. Brown assured her that he would provide her with training. He did train Nurse Davis in oncology treatment practices before she began working with patients. Her duties included administering chemotherapy, preparing medications and chemotherapy agents, accessing ports, drawing blood from ports, flushing ports, administering medications through the ports, and following proper infection control practices and procedures. Dr. Brown said that he had observed her frequently during her employment at the clinic.

The clinic had applied to participate in oncology clinical trials. A registered nurse consultant, Ms. Connie Cousins, came to the clinic to conduct an on-site inspection and evaluation. Consultant Cousins observed many substandard practices while at the clinic. She shared her report with Nurse Davis and with Dr. Brown. Dr. Brown asked that Consultant Nurse Cousins refrain from providing a copy of the report to the local hospital, but Consultant Nurse Cousins ignored this request and provided a copy of the report to the hospital.

Some of the observed substandard practices that failed to follow basic infection control requirements when providing treatment included the following:

· 1Reusing single-use disposable syringes from the same patient when accessing a bag of saline that was used for multiple patients.

· 2Injecting patient’s blood back into the patient’s port after drawing blood for lab testing.

· 3Reusing syringes to mix multiple chemotherapeutic agents.

· 4Storing admixed medications in the drug cabinet for future patient use without labeling the medications with the time and date the medication was mixed.

· 5Failing to label IV bags or syringes with the patient’s name and the contents of the bag.

· 6Maintaining food and food supplies in the same cabinet as the chemotherapy medications.

· 7Discarding chemotherapy-contaminated supplies in the regular trash container.

· 8Failing to wear gloves when providing care for patients.

ADDITIONAL INFORMATION

Ms. Joan Deming, a trained dental hygienist, was employed as a receptionist at the oncology clinic. She informed Dr. Brown on at least one occasion that she had observed Nurse Davis and the other registered nurses employed at the clinic engaging in improper infection control practices.

Ms. Brigette Ingersol was a registered nurse who worked as the infection control registered nurse at the local hospital. Several patients from the oncology clinic approached her with concerns about practices at the clinic. These practices included reusing syringes that had been used to draw blood to obtain saline from a large saline bag, then using the saline to flush patients’ ports.

Consultant Nurse Cousins’ report concluded that the nurses were unable to develop a correction plan regarding the observed unsafe practices. She indicated the part-time registered nurses were overwhelmed with information and that Nurse Davis appeared unwilling to discuss options to correct the practices.

Mr. Niles Anderson became a patient of the clinic. Mr. Anderson was positive for the hepatitis C virus (HCV). He received blood draws and chemotherapy at the clinic. Approximately 1 year after he became a patient, Mr. Walter Belin, another patient, was diagnosed with HCV. Two weeks later, Mr. Tony Caruthers, a third patient, was diagnosed with HCV. Both Mr. Belin and Mr. Carruthers were diagnosed with HCV approximately 2 months prior to Consultant Nurse Cousins’ visit to the clinic.

One month after Consultant Nurse Cousins’ visit, Nurse Ingersol met with Dr. Brown to discuss ongoing concerns expressed to her by several clinic patients regarding unsafe practices at the clinic. In the next 2 weeks, Mr. John Dickson and Mr. Dan Edison, both clinic patients, were diagnosed with HCV. Shortly after the diagnosis of Mr. Dickson and Mr. Edison, Nurse Davis resigned. In the next year, 100 clinic patients were diagnosed with HCV. Of that number, three died as a result of the HCV infection.

The board of nursing reviewed Nurse Davis’ case and recommended revocation of her registered nurse license. The license was revoked.

CASE ANALYSIS

Infection control precautions are basic to the health care profession. Safe practices are the foundation of any procedure or task. In this case, many individuals either did not maintain basic infection control procedures or were unaware that the proper precautions were not being followed. Lack of training and certification in chemotherapy medication administration also contributed to the nurses’ lack of knowledge and skill.

Nurse Davis was the full-time registered nurse at the clinic and carried responsibility for care practices of the other staff at the clinic. She did not practice basic infection control and was not aware that others were not following infection control measures.

The physician was aware of and routinely observed unsafe practices in his clinic. The nurse consultant, the registered nurse, and the infection control nurse at the hospital had made both the physician and his employee, the registered nurse, aware of the unsafe practices being conducted at the clinic.

This is a case where the use of simple infection control precautions could have prevented many individuals from becoming infected with HCV and could have prevented the death and suffering of patients in this vulnerable patient population.