Analysis of Nursing Care Challenges in Managing a Complex Patient

Introduction

The delivery of effective nursing care is important (van Belle et al., 2020) because as it helps in providing enhanced treatment to the patient for overcoming their physical and mental health ailments which are needed to support their good health. In case study 3, the patient named Sam is 70-years-old who is suffering from diabetes and Chronic Obstructive Pulmonary Disorder (COPD) and has medication history of Emphysema. He is active smoker and his current family includes his daughter and son who supports him in care. Sam is currently admitted to the hospital due to increased confusion and high blood sugar level. After initial admission, Sam is transferred to Ward 3 of the diabetic unit for treatment of Diabetic Ketoacidosis (DKA) which is busy and has high staff turnover due to which it is managed regularly by bank and agency staff. Sam was treated in the ward for DKA, but he has developed breathlessness. He was initially treated with inhaler and later with oxygen therapy, but his breathlessness was not improved. He was transferred to the respiratory ward for Non-Invasive treatment (NIV) as he was identified to be over-oxygenated, but he remained poorly stable. The case study of Sam is to be analysed by using 5Why’s as the RCA framework to determine the cause of the hindered health of Sam. In such complex cases, nursing dissertation help can be valuable in thoroughly assessing and addressing the issues. Thereafter, three contributory factors leading to hindered health management of Sam is to be analysed and recommendations to resolve them are to be discussed.

Nursing Framework

Sluggett et al., (2020) mentions RCA Framework is referred as Root cause analysis tool which helps healthcare professionals as well as organisations retrospectively examine root cause of any hindered care events of the patients. According to (Martin-Delgado et al., 2020), the purpose of undertaking root cause analysis (RCA) in healthcare delivery is that it helps the health professionals and staff to understand which factors are to be improved in existing care so that harm can be prevented, and better patient safety is to be established. The different RCA used in identifying root cause of problem are 5 Why’s, fishbone diagram and London Protocol. The similarity among all the RCA methods is that they help to analyse the problem in identifying the key causes leading towards its development (Gunawan et al., 2018). The 5why’s and fishbone diagram are similar compared to the London Protocol for RCA. This is evident as 5 why’s and fishbone diagram presents cause-effect relationship of factors leading to create the problem from different modes without investigating into each systematic step in the scenario that gradually led to the problem (Latha and Merlin, 2019). However, in London Protocol, steps-wise clinical investigation is developed to identify the cause that led to the problem raised from each step of actions in the journey towards the problem (Pulgarín et al., 2020).

In explaining Sam’s case, the 5 Why’s model as RCA framework is to be used. Cai et al., (2021) mentions 5Why’s model is to be used because it helps in identifying the root cause of the problem and determining the relationship between different causes of the problem. Moreover, it is the easiest tool for root cause analysis and does not require specialised statistical analysis in determining the cause of the raised problem. Apart from 5 Why’s, the fishbone diagram is also to be used for root cause analysis of the identified problem in case of Sam. This is because it is informed by Latha and Merlin (2019) that fishbone diagram helps in analysing the problem from various modes to determine the possible triggers that caused the issue. In comparison, the London Protocol Investigation is not to be used because Pulgarín et al. (2020) it is time consuming and requires expert skill to perform the investigation along with increased staff which is currently not available. (refer to Appendix 1 and 2)

The major problem identified in case of Sam is his respiratory failure that has led to his poor stable health condition. According to the 5Why’s model, root cause analysis of the problem is developed with examination of his entire care procedure. One of the causes identified for his respiration failure is over oxygenation during oxygen therapy. Mirastschijski et al., (2020) informs over oxygenation for prolonged time is harmful because it causes oxidative damage to the respiratory cell member leading to collapse of the alveoli responsible for oxygen transfer in the lungs. Sam has suffered over-oxygenation which is evident as he was administered oxygen at 35% oxygen via venturi mask (Ford and Robertson, 2021) which is required to be 24-28% oxygen via venturi mask for COPD patients.

The cause of over oxygenation is found to be related to violation of prescribed oxygen saturation range by the nurse irrespective of the medical register specifying through prescription the oxygen saturation to be followed for the patient. It is evident from the case study as Sam’s oxygen saturation remained 94-96% for 24 hours irrespective of medical register prescribing the oxygen saturation to be maintained between 88-92% for the patient. Further, the fishbone diagram informs that the violation is caused due to careless health monitoring because his vitals were available the entire day but was ignored to be focussed by nurses in making any care showing carelessness in health monitoring and delivering support. In addition, careless delivery of support to Sam as identified from the fishbone diagram mentions care is been caused due to lack of presence of permanent and well-qualified staff in the care environment. It is evident as bank and agency staffs are used to cover sick leave and annual leave of nurses instead of regular registered nurses in delivering care within the busy care environment where Sam was admitted. It is also caused due to high turnoff of registered nurses in the ward leading to lack of adequately skilled nurses to be present in delivering unhindered care to the patients.

Discussion of Care

In the care environment, the lack of adequate permanent qualified nurse impact to create deliberate violation of care principles and health monitoring of Sam. This is evident as the care environment which was also mentioned to be busy was seen to include bank and agency staff on regular basis to cover the sickness and annual leave of the nurses. According to Runge et al. (2017), the temporary staff from the NHS staff bank and agency staff shows hindered focus in delivering enhanced care leading to deliberate medical error. This is because (health.org.uk, 2019) temporary care staff do not have effective background information, knowledge of entire medical history of the patients, prescribed care to be followed for regulating routine and well-focused care for the patients. It leads them to feel lack of engagement in care and deliver nursing care in hindered manner out of lack of care information (health.org.uk, 2019) leading to cause increased rate of in-hospital care error and safety concern for the patient.

The care environment in the hospital in which Sam was provided support could be identified from the existing case study information that it was not entirely unstructured to influence hindered focus and delivery of care from the temporary bank and agency staff or registered nurses. This is because medical registrar was found to be present who provided prescription of the changed oxygen and inhaler for Sam to be followed in care along with the oxygen saturation to be ensured for the patient. It is evident as the delivery of oxygen therapy was immediately arranged for Sam based on the prescription. However, the registered nurse and other temporary staff in the agency caring for Sam were either not adequately qualified or careless in delivering support to the patient. This is because (Roy et al., 2020) the administration of 24-28% oxygen through venturi mask is common action to be performed for patients with COPD by the nurses so that they can reach determined 88-92% oxygen saturation (Branson, 2018) and are not over oxygenated. However, the existing nurses or others caring for Sam ignored the value and support administration of 35% oxygen via venturi mask.

The study by Bourassa et al. (2020) mentioned that 24-35% oxygen administration by venturi mask is to be initiated to achieve oxygen saturation of 92%. This is because reaching the percentage limit oxygen-induced rise in Paco2 which has adverse impact on the body to cause increased breathlessness. However, the goal was not followed by the registered nurse agency in delivering oxygen therapy to Sam. It is evident as Sam’s observation in the vital pack expressed that his oxygen saturation remained 94-96% for 24 hours. This proves that the nurses or agency staffs caring for Sam showed carelessness by not adequately monitoring the vital patient data in regular time interval to ensure the oxygen saturation as prescribed by the medical registrar is maintained. However, it is not clear from the case study whether the information of percentage of oxygen saturation management was written in clear format to be understood by the nurses. This is because (Dobler et al., 2020) hindered written information is found in some cases leads to medical error from the carer or nurses as they do not understand the information and deliver care through anticipation to the patient which raises the error.

The case study does not inform any presence of effective multi-disciplinary healthcare team in the agency where nurses worked together in delivering care to Sam. As asserted by Freeman et al. (2019), the effective presence of multi-disciplinary team in the care environment helps the patients to access enhanced quality care that holistically fulfil all their needs and demands. This is because the multi-disciplinary team involves wide number of experts with specialisation in different treatment to be delivered as per needs of the patient. Thus, the lack of presence of multi-disciplinary healthcare team in the care environment of Sam created lack of presence of expert care providers in the agency who can effectively identify the cause of extended respiratory failure of Sam even after the oxygen therapy. They would have also affected to create better control of oxygen saturation in case of Sam during the therapy so that his health could be improved rather than deteriorated. As argued by Leeftink et al. (2020), the lack of multi-disciplinary team in the care environment creates hindered service coordination and increased chances of error as well as barrier in care. This is because without multi-disciplinary team no sharing of expertise and enhanced ideas is established needed for well-coordinated smooth care delivery to the patient. Thus, in case of Sam, no care coordination with respiratory nurses was mentioned to be implemented in the care environment leading towards his hindered care management.

Taylor and Aldridge, (2017) mentions lack of presence of multi-disciplinary team creates hindered referral of patients for specific treatment which makes the patients do not have direct access towards the people they are required to contact for receiving the special treatment. In case of Sam, it is seen that for his special treatment regarding respiratory issues while in the agency, he had no direct access to respiratory consultant due to lack of presence of multi-disciplinary team in the agency. It was seen that after handover to the substantiate nurse from the agency nurse he was able to get direct access to respiratory consultant needed to provide him special support to improve his continued respiratory failure. As asserted by J. Morrice et al. (2020), multi-disciplinary team presence allows them to make the patient set specific care goals for themselves and make family involvement to reduce inpatients stays. However, the lack of presence of multi-disciplinary team in the care environment created lack of development of any care goal or family involvement for Sam. This led to his distracted care and increased tension among the family members regarding his health and ability of the agency to support his well-being.

Frat et al., (2019) informs over oxygenation during delivery of oxygen therapy creates prolonged and deteriorated respiratory condition which is currently faced by Sam. This is because prolonged oxygenation damages the alveoli of the lungs leading to hindered oxygen transfer to the blood and causes oxygen toxicity. This has impacted Sam to face hindered health outcome and increased inpatient stay as well as referral to respiratory unit for further care. In the care environment for Sam, the principles of risk management were found not to be applied in any way for delivering care to the patient. This is evident as (hse.gov.uk, 2021)initial principle of risk management is avoiding any risk in the care environment. As commented by Aven et al. (2019), risk in care environment is avoided with effective implementation of protective care for the patients by holistically considering all their needs and demands as per the patient’s health condition. In case of Sam, the lack of adequate and skilled staffs and nursing professional in the agency failed to implement the principle of risk management. This is evident as the inadequate skilled staff with a smaller number of nurses made them have increased care burden to look after many patients at a time. It made them fail to make in-depth health analysis of Sam to determine the health risk to be avoided apart from current health aliments regarding diabetes as he is mentioned to be active smoker with COPD and emphysema.

The other principle of risk assessment (hse.gov.uk, 2021) is identifying the risk which cannot be averted and make assessment to determine the nature of risk and what is involved in instigating the risk. Patients with diabetic ketoacidosis (DKA) often experience breathlessness because (Çekiç et al., 2021) the ketones which are built up in the body and toxic in nature due to inability of the kidney to remove them faster leads the lungs to try to expel the excess ketones. It causes shortness of breath in patients with the condition and similar condition is faced by Sam. In the case study, the actions taken in resolving DKA in Sam is not mentioned and the efficiency with which nurses have delivered care in the aspect is also not mentioned. Moreover, nothing is mentioned regarding risk assessment and identification regarding DKA in case of Sam being followed by nurses while he was admitted to the agency. This may be due to the inefficient skill of the nurses making them act carelessly in identifying the risk for Sam before its occurrence that led him to face the risk of respiratory failure and increased complication.

The principle of risk management in care (Liu, 2019) include analysing the risk to rate its likelihood of occurrence and evaluate the risk to determine way it could be eliminated. In case of Sam, no risk analysis or evaluation was executed by the nurses or carer indicating they were careless or had inadequate skill in understanding the importance of risk analysis for patients before initiating their care. Amelio and Figus (2021) other principle of risk is determining strategies to treat the risk for its timely resolution and monitoring the people responsible for managing the risk. In the care environment for Sam, no coordinated participation of nurses and carer as a team was seen that would ensure monitoring the risk management strategies in care for the patient. This led to over oxygenation of Sam being unreported to be later identified under specialised care environment.

In RCA, Duty of Candour is effectively linked and according to the duty which is set by the NMC, 2018 it is legal responsibility of the nurses to inform the patient or their family about the wrong action being executed in care that hindered the health of the patient. However, in caring for Sam, the agency nurses did not informed Sam or his family about their wrong action of increased oxygenation that has led to his current health deterioration indicating they are violating legal principles set by the Duty of Candour. The Duty of Candour (GMC, 2019) mentions nurses responsible in causing harmful action to apologise to the patient and offer them appropriate remedy for the action to be resolved. However, in case of Sam, the nurses did not apologise for their wrong action and did not arranged care with personal responsibility. They instead handover the patient (Sam) to substantiate nurse who arranged care for helping Sam overcome the action of wrong care. Thus, it is required for the agency nurses to come forward and apologise for their mistake regarding oxygen therapy as well as arrange respiratory support further needed for health improvement of Sam.

The Duty of Candour (GMC, 2019) is to be applied in care as it leads the healthcare and nursing professional to show their openness and honesty towards the patient which is their legal responsibility. Moreover, (NMC, 2021) it is to be applied in care to support explanation of the cause and effect of any unexplained event to the patient or their family members that have harmed their health or caused death. This is to make them clearly understand the action that has contributed towards the health condition of the patients. Thus, the nurses and carer in the agency by following the Duty of Candour are to mention Sam and his family regarding occurrence of over oxygenation followed by the cause and the effect. This is to make them understand the reason behind the current poor but stable respiratory condition of the patient as well as show moral responsibility in accepting their error in care.

Recommendations

The hindered factors are to be controlled in care for Sam to create a positive change for improving his health and well-being as well as similar patients to be cared in future. The changes determined is to be implemented and instigated by following the PDSA cycle. The PDSA cycle method is to be used because (Christoff, 2018) it assists in improving any process or making change through a structured experimental approach that facilitates team and organisation learning, individuals and others creating essential alteration needed for holistic improvement. The PDSA Cycle stands for plan, do, study and act. In planning stage, (Coury et al., 2017) the problem is identified and alternative positive actions to be performed are mentioned. In case of Sam, the problem identified is overdose of oxygen therapy due to inadequate and careless staff, inadequate monitoring of health vitals and lack of multi-disciplinary team. In this purpose, recommendations plan of change is recruitment of trained permanent nurses in adequate number who would work with the multi-disciplinary team in care environment to effectively manage risk, monitor and deliver care to patients like Sam.

The presence of skilled permanent nurses in care environment (Gorsuch et al., 2020) leads to create better focussed and continuous support for the patients with minimum error in care as they understand the patients’ needs with regular interaction and continuously manage their care. Moreover, (Burke et al., 2018) the presence of adequate number of nurses in busy care environment would avoid requirement of temporary staff those show lesser focussed care and cause unnecessary medical errors in care. This in turn would create better care opportunity for patients like Sam. The coordinated working with multi-disciplinary team by the nurses (Lavelle et al., 2018) helps nurses include expert professionals in guiding them to deliver more efficient care to the patients that improves their health. For instance, nurses caring for Sam by working with respiratory consultant and physicians in multi-disciplinary team would gather better ideas regarding the way oxygen therapy is to be provided seamlessly to ensure good respiratory condition of the patient. The promotion of effective risk assessment in health care help in detecting health risk prior to their occurrence. Moreover, (Rolfe, 2019) monitoring in care help the nurses to survey the care continuously for the patient to ensure no error such as overdose or underdose of medication or therapy are made in the process. It also allows emergency action to be taken in need of sudden health deterioration of the patient without delay. Therefore, the mentioned change would be implemented as it would help in enhancing the care scenario and health of Sam.

In the Do phase, (Crowfoot and Prasad, 2017) the determined planned actions are implemented for making improvement. Thus, in the current condition, the action of change is increasing permanent nursing staff through increased recruitment and inclusion of multi-disciplinary team to work collaboratively with team along with promotion of increased health monitoring and risk management is to be gradually implemented. The study phase (Connelly, 2021) indicates assessing the efficiency of the changed action in resolving the determined problem. Thus, in the care agency where Sam was provided care, after implementation of the change feedback from the patients and their family members are to be taken. This is because (Sasangohar et al., 2018) patient and family member feedback regarding care help to determine the efficiency with which the nursing staff are showing capability in delivering care. Moreover, the care provided to the patient are to be monitored after implementation of the change to study its impact. This is because (Sasangohar et al., 2018) it helps in determining the level of focussed care been provided by the nurses and the satisfaction of care among the patients. The Act stage (Laverentz and Kumm, 2017) mentions to take action in relation to the determined results gathered after analysing the implemented change. In case the improvement shows standardised results, they are to be ensured to be used regularly and in case the improvements show hindered success then different plan is to be developed based on the information to create successful results of change. Thus, based on the study results for the change, actions to regularise them or new planning is to be made for further improvement to avoid future occurrences of the mentioned issues in care.

In the care environment for Sam, the lack of acceptance of change from the agency staff and existing registered nurses would act as barrier in making the change. This is because (Laverentz and Kumm, 2017) the agency staff may fear losing their jobs due to recruitment of more qualified nurses which would make them useless. However, the barrier is to be avoided by making the staffs understand the way it would help in lowering their burden at work and improve organisation’s reputation of care as well as care for patients with the change. The other barrier to be faced is inability of registered nurses in the agency to act as a team with multi-disciplinary team members in caring for the patients. This is evident as (Sasangohar et al., 2018) disputes and conflicts are often raised in team working with multi-disciplinary team by nurses due to clashing of ideals and working principles. However, to resolve the barrier, teamworking training to registered nurses in the agency is required so that they learn regarding the way to trust and act with team in coordinating care without hindrance or conflict.

Conclusion

The above discussion informs that the key problem raised in caring for Sam is his respiratory failure was controlled in hindered manner that led to his poor health condition. The 5 Why’s model used as RCA indicates that presence of hindered nursing staff retention and high turnover in the agency is the root cause of the problem as it led to over oxygenation of Sam leading to his current deteriorated health. In respect to the human factors, it was seen that nurses due to inadequate skill and work pressure caused careless in care that lead to error in care and deterioration of Sam’s health. The risk management of principles are also not followed in caring for Sam that led to his hindered health risk. The recommendation developed is that trained permanent nurses in adequate number are to be recruited who would work with the multi-disciplinary team in care environment to effectively manage risk, monitor and deliver care to patients like Sam. The PDSA cycle is to be used for instigating the change and based on feedback from patients and family members after the change continuous improvement in plan of care is to be made to avoid future occurrence of such incidence as seen in case of Sam.

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