Monica, a registered nurse (RN), has worked in the same acute medicine unit for 25 years. Katelyn has 10 years of experience practising as an RN and began working on this unit three months ago. Based on her conversations with staff members, Katelyn understands that Monica is highly respected on this unit, clients like her, and she has a close relationship with the unit manager.
On her first day back after time off, Katelyn is working with Monica. During Monica’s break, one of her client’s call bell rings. Katelyn, who is covering for Monica, goes to see what is needed. When Katelyn arrives, George is standing in the middle of the room confused about where he is and what he is doing. George is a newly diagnosed insulin dependent diabetic who was admitted with pneumonia requiring intravenous antibiotics. Katelyn notes he is pale, sweating and his hands are shaking. George complains he is dizzy and his vision is blurry. Katelyn checks his blood glucose, then determines based on the result and the other symptoms that he is severely hypoglycemic. She contacts his physician and provides the appropriate nursing intervention. Katelyn reviews the glucose level readings in George’s health record while she is waiting for the physician to arrive. She notes that while there is a physician order for glucose checks prior to each meal, for the past three days there has not been.
Katelyn initiates the physician’s new orders and reminds Monica that the blood glucose results for George are not in his client record. Monica responds, “Yes, I know they aren’t in there, I didn’t do them. Katelyn responds saying “isn’t that a risk to client safety”? Monica says, “Generally when we recorded them for a few days and they are always the same, I stop doing them; it saves the clients some finger pokes.” Katelyn is surprised by what Monica has told her, in particular that this wasn’t an oversight. Katelyn knows a reporting and learning system(RLS)/incident report should be completed because of the situation, however she is also concerned about Monica not following the physician’s order for glucose checks prior to meals.
Katelyn realizes that because of Monica’s practice, client safety was at risk on this shift and potentially could be on other shifts Monica works. Katelyn wonders how she should handle the situation. She understands that according to the CNA Code of Ethics for Registered Nurses:
Nurses question, intervene, report and address unsafe, non-compassionate, unethical or incompetent practice or conditions that interfere with their ability to provide safe, compassionate, competent and ethical care; and they support those who do the same.
Nurses are honest and take all necessary actions to prevent or minimize client safety incidents. They learn from near misses and work with others to reduce the potential for future risks and preventable harms.
Nurses advocate for persons receiving care if they believe the health of those persons is being compromised by factors beyond their control, including the decision-making of others.
She also reflects on the Practice Standards for Regulated Members and realizes that several indicators apply to her particular situation, such as:
1.1 The nurse is accountable at all times for their own actions
1.2 The nurse follows current legislation, standards and policies relevant to their practice setting
1.3 The nurse questions policies and procedures inconsistent with therapeutic client outcomes, best practices and safety standards
5.8 The nurse reports unprofessional conduct to the appropriate person, agency or professional body
Katelyn wonders if her colleagues have reported the lack of adherence to the physician’s order as according to Monica, this is a usual practice for her. In addition to completing a RLS/incident report, Katelyn believes she needs to share her concerns with the unit manager, but she is worried that this may create problems for her on the unit. She wonders how the manager will respond. She is nervous about what her coworkers would say or do if they find out that she reported a colleague to the unit manager and how Monica will react. She is anxious about the potential consequences and has been having difficulty concentrating. She didn’t sleep last night because she was worrying about the situation. Katelyn determines she should discuss her concerns with an independent individual who can help her work through this situation. Since Katelyn is the newest member of this health-care team and the other members of the team are friends outside of work, she contacts a Policy and Practice Consultant at the College and Association of Registered Nurses of Alberta (CARNA).
Katelyn speaks with the Policy and Practice Consultant who reinforces the requirement for nurses to practice according to the CARNA Practice Standards for Regulated Members. In addition, the Policy and Practice Consultant reviews with Katelyn the process for addressing unsafe practice situations contained in the CARNA Practice Standards for Regulated Members and encourages Katelyn to have a conversation with Monica about her concern for client safety and to discuss best practice, nursing assessment, and following orders. The policy and practice consultant also suggests to Katelyn that if she feels she cannot approach Monica by herself she may want to consider involving a third party such as the unit manager. A third party individual can provide her with support in speaking with Monica if Katelyn feels this would be beneficial. The Policy and Practice Consultant reminds Katelyn that questioning practices she believes are unsafe is meeting her professional obligation for those receiving care. As a result of this conversation, Katelyn realizes she needs to speak with her manager to discuss her concerns.
Katelyn meets with her manager to outline the recent incident and her concerns for client safety. The manager informs Katelyn she will follow up on the concern that has been identified.
Several weeks later Katelyn is assigned to another client who has diabetes and while preparing to test the client’s blood glucose level, she reviews the client record. She notes that on the previous three evening shifts, contrary to the physician’s order, the blood glucose level has not been documented and Monica cared for this client during these shifts. Katelyn continues to have concerns for client safety related to the nursing care provided by Monica. Katelyn decides that she must speak with her manager again about this ongoing concern. At this meeting she plans to discuss with the manager what next steps might be taken to address this concern including whether others in the organization, such as human resources or the program manager, should be brought into the discussion.
Disclaimer: Our case studies are fictional educational resources. While we strive to make the scenarios as realistic as possible, any resemblance to actual people or events is coincidental.
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