Quality & Safety

1.    Discussion Forum: Read Overcoming Barriers Impeding Nurse Activation of Rapid Response Teams.  https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-24-2019/No3-Sept-2019/Articles-Previous-Topics/Barriers-of-Rapid-Response-Teams.html  – due Friday by 2359.

Instructions
: Discuss what are some of the factors that may contribute to a lack of rapid response by nursing staff and others during an emergent situation and what are some of the implications noted in the article for future nursing practice?

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

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

Instructions: Read

HISTORICAL CASE STUDY #1: Restraints Gone Awry

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

a.      What could Nurse Jones have done differently in this situation?

b.      In your opinion, did the inmate die of positional asphyxia as noted in the case study or do you think it was a result of a self-inflicted injury by the patient trying to commit suicide by hanging himself?

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.

HISTORICAL CASE STUDY #1: Restraints Gone Awry

PRACTICE BREAKDOWN, INTERVENING

HISTORY

The following nursing activities and behaviors outlined in this case scenario provide an example of events that demonstrate a nurse’s failure to intervene on behalf of her patient.

THE COMPLAINT

Ms. Maggie Jones was a registered nurse who worked in a prison setting. She was reported to the board of nursing through a complaint received as follow-up to the findings of a peer review committee. The committee determined that Nurse Jones exposed an inmate to risk of harm because of failure to adequately care for him.

In summary, the specific allegations indicated that Nurse Jones failed to conduct a thorough assessment of the inmate, continually evaluate and observe him, recognize early signs of his symptoms of respiratory compromise, and initiate life-saving measures. The committee concluded that Nurse Jones exhibited an inability to supervise and lead subordinates in cardiopulmonary resuscitation, which resulted in the inmate’s death.

INVESTIGATION

An autopsy of the inmate showed mild hemorrhage in the soft tissues anterior to the larynx, severe congestion of the conjunctival and scleral vessels, severe congestion of the lungs, and petechiae on the epicardial surface of the heart. The pathologist determined that the inmate’s death was caused by positional asphyxia. These conclusions were based on the autopsy findings and the events that were documented in a recorded video.

This incident involved a state prison inmate, Mr. Jimmy X, who had a history of attempted suicide through hanging. Mr. X had succeeded in hanging himself from the ceiling on the night of the reported incident but was quickly taken down and transported by gurney to the prison emergency room.

Once in the emergency room, Mr. X began to struggle. The staff decided to restrain him and place him prone with his legs brought up and secured close to his buttocks. Mr. X continued to struggle and started moaning after which he quickly became unresponsive to the staff. Security staff became concerned about Mr. X’s lack of movement and summoned medical assistance. A code was initiated, but Mr. X did not respond and died from positional asphyxia.

Nurse Jones had been assigned as charge nurse for the prison night shift. On the night of the incident, she was expected to orient Mr. Paul Phillips, a newly hired registered nurse who had been licensed for only 3 months. He was in his second month of practice at the facility. When the restrained inmate appeared to be in distress, Nurse Jones told Nurse Phillips to stay with the patient while she left the area to make “necessary calls.”

Facility policy indicated that the charge nurse’s duties included orientation of new staff, which was a role Nurse Jones had engaged in many times. A position description provided by the prison indicated that a nurse is the first health care provider to see an inmate and assess his/her health status to determine whether he/she is sick or malingering. Interviews with several staff members revealed that the culture of the prison led nurses to believe that they must always be cognizant of security needs and could not stop security personnel from using force.

Nurse Phillips stated that he had been licensed for only 3 months and had worked for the prison for only 2 months prior to the incident. Nurse Jones was assigned to be his preceptor that night. He had briefly been involved with an assessment of the inmate when he was first brought to the emergency room. The incident was his first code. He had never initiated CPR, but he did so because no one else was aiding Mr. X. He said he had called Nurse Jones but said that she left him shortly after arriving in the emergency room. Mr. Phillips reported that he felt that Nurse Jones did not take charge or provide him with any guidance during the episode. He continued CPR until he was relieved by paramedics.

Nurse Jones’s statement was that she had excellent evaluations, good nursing assessment skills, and had never been counseled for job performance issues. She considered the code to be an unusual situation. The “hogtie” restraint that was used on Mr. X was routinely used by security as a means of restraint. She stated that, in her opinion, a reasonably prudent correctional nurse would not have foreseen that Mr. X would suffer positional asphyxia. When it was apparent that the patient was in trouble, she made the necessary calls to obtain assistance.

Nurse Jones indicated that she did not have Advanced Cardiac Life Support (ACLS) certification and did not have a current CPR certificate. Initiating CPR was not second nature to her. However, she considered herself an advocate for the patient. In fact, she had been moved from second shift to the night shift because she was characterized by her supervisors as being “weak,” as evidenced by her “seeing the patients more times than was warranted.” Nurse Jones’ statement that her record was “unblemished” seems incongruent with her additional comment that she was moved from second shift because she was “weak and seeing inmates too many times.”

Nurse Jones’ actions demonstrated that she had no awareness of the possibility of post-trauma swelling and edema that could compromise breathing and that this possibility would not be immediately observable without an appropriate assessment. This lack of awareness constituted a major knowledge deficit. In this instance, the posthanging injury and the hogtie restraint placed the patient at risk for asphyxiation. The cause of death, according to the autopsy, was positional asphyxia, not injury from the attempted hanging. It is important to note that Nurse Jones did not take a leadership role in the code and attributed this to her lack of experience. During the investigation, it was found that Nurse Jones had been a licensed practical nurse for many years. Once in the emergency situation, Nurse Jones did not take the lead during the resuscitation attempt, which is the expected standard for her level and experience. Mr. Phillips, the recent registered nurse graduate and new employee, was left to his own resources without appropriate and necessary assistance.

ANALYSIS USING TERCAP: HEALTH CARE TEAM

Because the circumstances suggest a cavalier attitude by all persons involved, it is troublesome that Nurse Jones was the only individual singled out for discipline. This is an oversight in the investigation as other staff members’ roles in this incident may have been at issue here. For instance, one question that arises is whether a well-defined process for medical emergencies was in place with physician oversight and review. Correctional facilities should have protocols in place to address these types of emergency issues. Additionally, questions arise as to the nurse’s responsibility and authority in relation to security personnel. This case clearly demonstrates that nursing interventions should have been the priority and that the nurse should have had the organizationally mandated authority to direct the safety of the inmate’s handling by the security guards.

Other team factors should have been investigated and additional questions asked including the following: What supervisory feedback had been provided to Nurse Jones? Should she have been put in a preceptor role? What is the culture for incorporating new graduates into autonomous staff positions? One must question the ways in which this incident affected the junior registered nurse as a newly graduated nurse. Clearly, more support and training should have been planned for his orientation on the job. This case also raises an important question related to continued competency, that is, What is the best way to ensure that nurses are both knowledgeable and capable of performing a seldom needed but extremely critical function?

ANALYSIS USING TERCAP: HEALTH CARE SYSTEM

Planning and training were issues in this scenario. Trauma and attempted hangings are anticipated events in a prison environment. Thus it is critical to ensure prior identification of these potential incidents with prepared emergency plans, training, and evaluation. Practicing through mock incidents is one of several approaches to address readiness. In addition, training for ACLS is needed given the requirements for resuscitation in a prison environment. In this regard, leadership should ensure inclusion of these training elements. Recognition of the emergency and intervening with basic airway/CPR techniques would likely have stabilized the inmate until EMS arrived. Given the prevalence of security personnel, they too should have been prepared to provide basic rescue interventions in situations of violence and injury.

The guards’ behavior and training are also in question. Prior to this case, it appears that no one had questioned the procedure of restraining a person by means of a hogtie prone position, which was the direct cause of the inmate’s suffocation in this incident. Such ties have been identified as unsafe and should be eliminated as a restraining measure. All personnel should be trained to adhere to restraint procedures that are safe and updated regularly.

Even though this was a prison setting, potential safety issues such as use of restraints for an injured inmate should have been implemented and directed by appropriate health care personnel. Additionally, there should have been a clear understanding of the hierarchy of authority and an identification of those in charge in this correctional facility.

AGGRESSIVE BEHAVIOR: PROTECTING THE PATIENT AND PROTECTING THE NURSE

The preceding case study reviews issues in caring for patients who demonstrate aggressive behavior. Caring for patients who exhibit aggressive behaviors is not limited to prison settings but rather transcends practice settings and population groups. For example, behavioral manifestations of aggression may range from elderly patients who become confused and disoriented after a surgical procedure to adolescents who are dealing with role identity and anger management issues to patients who experience a psychotic episode. Aggressive behavior can occur in any health care setting, and nurses must be prepared with specific interventions to ensure the safety of patients and staff.

When aggression is a component of patient behavior, the provision of nursing care becomes highly complex and may quickly lead to a dangerous situation. Practice breakdown can be exacerbated by the crisis that may occur with combative patients. Although the nurse should consider his/her own well-being and desire for safety, the urgent needs of the patient must be addressed. The nurse may have to manage the patient’s attempt to harm others as well as protect the patient from self-harm. In addition, the nurse’s duty to the patient may be compounded by other obligations, such as ensuring the safety of other patients or staff. This complex patient care situation can easily contribute to practice breakdown. The need for comprehensive planning and education cannot be overstated.

Some nursing disciplines are more prepared for aggression than others. For example, most psychiatric facilities have extensive training and protocols for preventing and managing aggressive behavior. Other settings may not have specific orientation or protocols to provide nurses with the education needed to address aggressive behaviors in specific workplace environments. Nurses must understand the etiology of and reasons for aggressive behavior in given patient populations and in particular practice settings, and protocols should reflect appropriate methods for recognizing and managing aggressive behavior. Finally, all institutions where resuscitation does not occur often must institute ongoing classes for health care personnel to ensure that nurses are prepared to provide effective and safe immediate rescue efforts for patients.

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