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Narrative Reflection Assignment – Safety
Darah Daskalakis
Adelphi University College of Nursing and Public Health
NUR 476-350: Integration Seminar III
Professor Kimberly Defatta
November 9, 2021
During my time in the clinical setting this semester, I had encountered many situations that influenced the way I view the nursing profession. One situation that sticks out in my mind the most, however, had to be the time where I witnessed a nurse on the floor distribute multiple pills to a patient (all at the same time) and the patient ended up choking. I had just finished taking this patient’s vital signs and documenting them in my patient profile worksheet when the nurse came in for her medication rounds. This patient was an elderly woman (86 years old) and was taking several different medications, due to the fact that she has cardiovascular issues. My professor asked if it would be alright that I take notes and experience watching how this patient is administered their medications, and in return, the nurse said it would be alright that I stayed and watched. In fundamentals, I was taught that when administering more than one medication at a time, you have to give the medications one by one to the patient for a couple reasons. Two reasons that I remember most prominently were: 1) to ensure that the patient doesn’t have a reaction to 1 medication (so giving them one by one would make it easier to decipher which medication caused a reaction in the patient) and 2) to ensure that the patient doesn’t choke. While observing the nurse getting her medications ready to be given to the patient, I noticed that this nurse did not ask for the patient’s name and date of birth or scan the wrist band of the patient. She attempted to scan the wristband, but it did not go through the first time, so I asked her if she had to re-scan and she replied to me saying, “it’s fine, I know my patient, I’ve had this one for the last two days.” I understood, but at the same time, realized she should’ve scanned the wristband until it went through. Next, the nurse scanned each pill individually and put them all in the same paper cup for the patient. I recognized this as correct, knowing that it makes delivery easier. However, the nurse did not instruct the patient to take these pills one at a time (there were 6 in the cup), so when the nurse turned her back to throw away the pill packaging, the patient threw the cup back and attempted to swallow all 6 pills at once. I informed the nurse of what just happened and she started laughing it off, exclaiming to the patient, “how did you manage to take them all at once? I know I couldn’t have done that!” Well, it wasn’t so funny when the patient started choking on the pills. Again, the nurse had her back turned and was heading out of the room, so I had to call for her to inform her that the patient is choking. She came back in the room to instruct the patient to cough, to give the patient a sip of water once the pills came back up, and then left.
My response to this situation was to make sure that the patient was okay. Informing the nurse of what I was observing was obviously another key part of my response, but it was all based on what I witnessed when trying to make sure the patient was safe and comfortable. Seeing the patient choking on pills made me nervous, to be completely honest. I recognize that she is an elderly woman to begin with, but especially being in the hospital for cardiac issues, I know that she is not in the best shape. So, to see her choking on pills and coming into a potentially fatal situation that could have been prevented if the nurse at hand was not negligent, made me angry as well. I am aware that this was something that could have very easily been prevented if the nurse instructed the patient to take the pills one at a time. Instead, she just handed the patient the cup of pills and walked away before the administration was complete (the nurse is supposed to watch the patient swallow the pills and make sure instances like this do NOT occur). I feel that my response of speaking up and informing the nurse of the patient’s obstructed airway greatly impacted the situation. If I had not spoken up, the nurse would not have even known the patient was choking because she was already halfway out of the room when I informed her of the situation, and the patient could have had many potential complications.
If I were in the patient’s place during this situation, I would have been scared. Nobody wants to choke, so being that this patient has been through so much already to have been admitted into the telemetry unit of a hospital, she was probably very nervous going through this situation on top of everything else. If she was given instruction and was being observed throughout the medication administration by the nurse, this instance wouldn’t have happened, and I’m sure the patient could have figured that. Yes, she is elderly and is used to taking many medications on her own, however, being in a hospital should ensure that accidents like this do not happen. The patient told the nurse she was fine after she took a sip of water, but up until this point for a short period of time, she was uncomfortable and unable to breathe.
Two ethical principles that I believe would suit this experience would be nonmaleficence and beneficence. Nursingworld.Org describes nonmaleficence as being “directly tied to the nurse's duty to protect the patient's safety. Born out of the Hippocratic Oath, this principle dictates that we do not cause injury to our patients.” I believe that this ethical principle relates to my experience because before the nurse handed the cup of pills to the patient, I was already thinking of the safety of the patient. The fact that the nurse did not try to rescan the patient’s barcode/ask name and date of birth when administering the pills was the first red flag for me. What if this was not the correct patient and they were receiving the wrong medications? Taking the wrong medications is definitely a safety issue, so making sure that this is the correct patient to be receiving these medications is crucial for their safety. As far as taking the pills, I was concerned for the patient’s safety here as well. A patient should not take more than one pill/medication at a time (again, for safety reasons), so when the patient started choking on the medications after taking them all in one shot, I was concerned for her safety. Although putting all of the medications in the same cup made it easier to deliver all of the medications to the patient, the nurse at hand did not have the safety of the patient in mind. The nurse did not anticipate the patient’s actions of attempting to swallow them all at once, so I was glad that I was there to watch over the patient and ensure their safety. The second ethical principle that I believe relates to this experience is beneficence, which Nursingworld.Org describes as, “The second principle, beneficence, is at the heart of everyday nursing practice. Beauchamp and Childress (1994) state that "Each of ...[the following] three forms of beneficence requires taking action by helping--preventing harm, removing harm and promoting good...." (p. 192). I feel that this ethical principle relates to my experience for reasons similar to those stated previously. Since the safety of the patient is the priority task of a nurse, preventing harm and removing good would come from the actions of giving the medications to the patient one by one instead of all at once and staying with the patient until they take all medications (to avoid instances of choking, in this case). Both preventing and removing harm would be done by removing the excess medications from the cup and having the patient take the medications one at a time, whereas promoting good would come from the action of staying with the patient throughout the entire medication administration process.
When considering my future as a nurse, I will take aspects of this experience with me. The aspects that I will remember will be those that are enforced on me on a daily basis in school: keeping the patient safe and making sure to take the correct measures to ensure patient safety. Seeing the nurse in the hospital neglect to make sure her patient was safe during medication administration was a red flag and I will always remember it. Because of this nurse’s actions, there could have been a life threatening issue. This situation could have been avoided if the nurse had the patient’s safety in mind (staying by the patient to ensure the medications were taking in the correct manner) instead of walking away from the scene prematurely. If I hadn’t been there to inform her that the patient was in danger from choking on her medications, this experience could have played out very differently and the patient would be at serious risk. I will always remember to carry out proper medication administration as well as provide the optimal level of comfort and safety for my patients at all times.
References
Silva, Mary Cipriano and Ludwick, Ruth (July 2, 1999). Interstate Nursing Practice and Regulation: Ethical Issues for the 21st Century. Online Journal of Issues in Nursing Vol. 4 No. 2. Available: www.nursingworld.org//MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume41999/No2Sep1999/InterstateNursingPracticeandRegulation.aspx
Think Like a Nurse: Delegation
Darah Daskalakis
College of Nursing and Public Health, Adelphi University
NUR 484-600 Integration Seminar IV
Annie George PhD, RN, NEA-BC, NPD-BC, CCRN-K, FNYAM
April 7, 2022
Throughout my clinical experience, I’ve learned many things regarding a registered nurse’s shift. One of the most apparent things that I’ve learned so far is that time is of the essence and learning how to delegate tasks to ensure proper care throughout the shift is essential. Delegation is defined by the National Council of State Boards of Nursing as “transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains the accountability for the delegation” (National Council of State Boards of Nursing, 2016). On the floor, there are registered nurses, licensed practical nurses, and unlicensed assistive personnel who all work coherently. Registered nurses can delegate tasks to other RNs, as well as delegate tasks to LPNs, who then can delegate tasks to UAP. During a typical shift for a registered nurse, it certainly feels like there are a million things to do, so delegating helps them to get everything done that needs to be completed during a shift, using time as efficiently as possible.
While on the floor, I was able to witness delegation and prioritization firsthand and see just how important it really is to stay on track throughout the shift. In the specific situation that occurred, my nurse was running behind schedule. The unit was short staffed, she had seven patients, and she had to give an abundance of medications in a short time span. According to the nurse practice act, administering medication is the sole responsibility of the registered nurse, so she needed to prioritize her time and actions to administering medications to her patients. Currently, it was also breakfast, so several her patient’s needed assistances with feeding as well. Realizing that she needed to stay on track and prioritize her medication administration, the registered nurse asked for assistance from a UAP on the floor to help feed her patients and do morning care (change the linens, toilet the patients, and give bed baths). The nurse was very clear on what needed to be done, as she had given the room numbers, patient’s names, and assigned tasks to the UAP, so in return, the UAP agreed to help. While all of this was going on, I had the opportunity to go along with the nurse to complete assessments of each patient, administer medications, and learn the proper communication and steps necessary for the delegation to take place.
Registered nurses have a professional duty to perform patient care tasks dependably and reliably. Regarding delegation, there are five rights: The right task, circumstances, person, supervision, and direction/communication (National Council of State Boards of Nursing, 2016). In the scenario that I had witnessed at my clinical site, the nurse had used the five rights to help with her delegation decisions. For instance, to determine the right task to delegate, the nurse had to ask the following questions: which tasks are legally appropriate to delegate and is it within the hospital’s policy to delegate these tasks? Typically, registered nurses are responsible for assessment, planning, and evaluation within the nursing process. These actions should not be delegated to someone who is not a registered nurse, rather, somebody like a UAP should be delegated tasks that are routine and involve little supervision, such as feeding, toileting, and taking vital signs of patients (National Council of State Boards of Nursing, 2016). After determining the right task for delegation, the registered nurse needed to determine if the circumstances were right for delegation. To do this, the nurse and I had both completed assessments on each patient to figure out if they were good candidates for delegation. She had explained to me that to be good candidates, the patients must be stable and have predictable outcomes for the time being. After this had been done, the nurse needed to ensure that the right supervision was available for this delegation. Nurse practice acts require the registered nurse to provide appropriate supervision for all delegated tasks (Barrow & Sharma, 2021). To ensure this, the nurse had to be confident that the UAP would provide feedback after the tasks are completed. Following task completion, the nurse is responsible for evaluating the outcome of the task with the patient, as she is accountable for evaluation and the overall patient outcomes. Finally, the nurse needed to give the right direction and communication to the UAP, as all delegators must communicate performance expectations precisely and directly (Siegel EO and Young HM, 2010). The nurse needed to consider whether the UAP understood the assigned task, directions, patient limitations, and expected outcomes before they can assume responsibility for it, as well as comprehend what, how, and when to report back after the delegated task is complete (LaCharity et al., 2019). To ensure this, the nurse had the UAP recite the tasks, directions, patient limitations, and expected outcomes back to her before she allowed the UAP to carry out what was being asked of them. Using the five rights of delegation, the nurse appropriately took care of her patients’ needs and was able to complete all of her documentation requirements by the end of her shift.
In this scenario, patient outcomes were related to the effectiveness of team prioritization and delegation. Because the nurse was able to prioritize and delegate tasks properly to the UAP, all patients had their needs met in a timely matter. Medications were given on time, nutritional requirements had been met, and patients had been cleaned and were at less of a risk for skin impairments. During this situation, I felt proud to be a current nursing student and a future nurse. Witnessing how diligently and effectively the nurse’s shift went due to her delegation and communication skills, I now feel more confident in myself if I ever encounter such a situation in my future. I am positive that I will be in a similar situation someday, so I am glad that I now have the experience and know how to properly prioritize and delegate tasks to other members of the healthcare team. That’s the main aspect I am taking away from this: we are all a team. Even though we all have different positions and requirements throughout the shift, we all must work together as a team to ensure the best quality of care for our patients.
References
Barrow, J. M., & Sharma, S. (2021). Five Rights of Nursing Delegation. Europe PMC. Retrieved April 7, 2022, from https://europepmc.org/article/med/30137804#article-21797.r2
LA Charity, L.A.& Kumagai, C.K.& Bartz, B.(2011). Prioritization, Delegation & Assignment Practice Exercises for Medical –Surgical Nursing, Mosby: St Louis, MI ISBN: 978-323-06570-2
National Council of State Boards of Nursing. (2016). National Guidelines for Nursing Delegation - NCSBN. NCSBN.Org. Retrieved April 8, 2022, from https://www.ncsbn.org/NCSBN_Delegation_Guidelines.pdf
Siegel EO, Young HM. Communication between nurses and unlicensed assistive personnel in nursing homes: explicit expectations. J Gerontol Nurs. 2010 Dec;36(12):32-7.
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