Decision-Making at the Memorial Hospital

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Table of Contents

Summary of case
Problem Identification
Objectives
The LVN’s Duties
Identification of the Alternatives
Analysis and Choice
IDEAL Grid
References

Summary of case

The case under study concerns practices carried out by a nurse that could lead her to trouble through a lawsuit. Maggie works as a Licensed Vocational Nurse (LVN) at the Memorial Hospital. Her current duty is to attend the Emergency Room, ER, where one other LVN and four RNs, or Registered Nurses are also present to perform their duties. I am the evening charge nurse in the ER for the last two years.

Maggie has been working as a nurse for the past ten years and also has some experience with dealing in medicine in the first Gulf War. She is taking advantage of this plus point in her career by performing tasks in the ER which she is not licensed to. I noticed her assisting physicians in their tasks numerous times before, and have seen their preference for her as their helping hand while carrying out their procedures.

I have currently seen Maggie suture a laceration with the physician standing beside her. She was taking care of the whole procedure by herself, though this is not allowed. She, being a nurse, can only assist the physicians with what they are doing, and not carry out entire procedures on her own. Anyhow, when they saw me look at them, the physician took over the procedure, and the nurse discontinued the suturing, as they both knew they were doing an objectionable deed, for which they could be questioned. They must have felt they were wrong, on which the doctor came to me later on and assured me that nothing would go wrong, and he would take full responsibility for whatever she was doing, in case anything went wrong.

The problem now is that I am not sure of what action to take against Maggie’s recent doings. I must undertake some serious action to stop her from continuing work that she is not entitled to, or even allowed to do, according to the law. She may be performing other actions which she is not legally permitted to, though there is no proof of any such case yet.

Problem Identification

Rumor has it that the LVN may be encouraged to do things that she is disallowed to, despite no evidence being present in this regard. The LVN is being allowed and supported by physicians to break her scope of practice. She is exceeding her scope. An LVN is supposed to provide health services to the people according to certain laws set by the state he or she is residing in. The physician has indicated prior experience with the LVN exceeding the scope she is entitled to.

I, being the charge nurse, have been aware of the rumors about Maggie being indulged in extra work that she is not licensed to do, but I have not paid attention to those rumors. No investigation has taken place in regard to those rumors. One problem existing here is that if I take this matter to higher authorities, an unpleasant atmosphere will be created in the hospital, and the unity with which we all work together will be affected. Besides that, the LVN will continue to perform such acts, which is risky in the medical field. On being the charge nurse, I feel it is essential to let the LVN and physicians know that what they are doing is wrong, and may prove life-threatening.

Objectives

The main goal that has been set is to inform the physicians and LVN about their illegal doings. They know they are not following the rules when they encourage Maggie to help them to such an extent in their endeavors. They need to be reminded about the consequences of this misconduct, on the part of the nurse, as well as the physicians. Undoubtedly Maggie has vast experience in the medical field, but it in no way makes her eligible to perform those tasks that only a qualified doctor is licensed to.

The LVN’s Duties

The duties of an LVN include patient bedside care. This involves constant monitoring of the patients, taking their vital signs, including pulse, respiration, blood pressure, temperature, administering injections, looking after catheters, and applying dressings to wounds. Sometimes they are required to look after the patient’s dietary intake, as well as assist and monitor the essential laboratory tests that need to be undertaken. Nurses have a low-level jobs, but with higher compensations, studies show (Kash, et.al. 2007).

We can see from the duties of the LVN, directed by the law of the state that she or he is not required to perform actions that the doctor is to, like suturing wounds. As far as wounds are concerned, Maggie is allowed to dress them only, and not perform a whole suture. It is apparent that the action carried out by nurse Maggie is against the law of the state, and she can be strictly penalized for this feat.

Work experience is a motivating factor for nurses (Smith, 2004). This may be the reason Maggie has been so deeply involved in the physician’s workings, i.e. to gain experience. But this will not win her the position of a junior physician.

For the case at hand, we will have to make use of a decision to make Maggie refrain from further acts that she is disallowed to perform, from a legal perspective. The decision-making model that I am going to use for Maggie’s case is the I.D.E.A.L model. The first letters of each of the steps involved make up the initials of this model.

Identification of the Alternatives

For a decision to be reached, the problem at hand has to be first identified. The problem here is that Maggie, an LVN, has carried out tasks which she is not allowed to, as a nurse. For her to undertake some of the duties of the physicians she has to be a qualified doctor, otherwise carrying out such deeds may lead her to a court trial. I have seen and heard rumors about Maggie getting deeply involved in patient care, to the extent to which only the doctor is legally allowed to handle patients, like the suture of a laceration, which she was caught doing.

The following step is to identify all the possible solutions to the problem. The possible solutions to Maggie’s case are as follows:

We could write a note addressing Maggie and the physician repeating the case about what had happened, and the consequences they could face on account of such behavior. I can include my view as an eye-witness and try to word the write-up in a way that could convince them that they may face serious trouble if they do not discontinue giving Maggie so much liberty, especially because she is not designated to do things she does.
A second option could be that I could talk to my supervisor about what I witnessed currently, the suturing of the laceration by Maggie instead of the physician, and see what he has to say about it. I could leave the decision to him, but on the other hand, convince him to discourage such practices in the hospital.
Thirdly, I could talk to both the LVN and the physician. If I speak to Maggie about her objectionable deed, she could feel more pressurized and may feel she has been scolded and embarrassed, and keep away from such efficient actions in the future. On speaking to the physician, he will also feel embarrassed on breaking the rules of the state regarding patient treatment and care. This is a downright violation of the law.
The entire episode could be reported by me to the Board of Vocational Nursing and the Medical Board. This could affect the employment of both the physician and Maggie, for violating state laws, which they were well aware of.
Another option could be to talk to the supervisor and request a meeting between the nurse, doctor supervisor, the chief of medicine, and myself.

Analysis and Choice

If a write-up is presented to Maggie and the physician, they may not take it too seriously and think that once the paper is folded back, it has no significance any longer. Plus it will be a personal message to them, which they might not feel embarrassed of, and may even continue to do the same in the future.

The second option of telling the supervisor may seem a little risky too, as he may not properly attend to the situation, and ignore the whole situation on his part. On reporting it to the Board of Medicine, the same may happen. They may not take the case seriously, and such malpractices will continue in the hospital.

The best solution to me seems the last option, of holding a meeting with the LVN, supervisor, and chief of medicine. This could prove beneficial because a face-to-face talk with the higher authorities would produce more constructive results as compared to a discussion with me as a charge nurse.

From the elements of the case study, we have learned that if someone is given undue liberty, and goes against the law for performing actions, strict measures should be taken against them, before they get out of hand.

IDEAL Grid


I	Identify the problem	1 LVN, Maggie has exceeded her job description as an LVN in the hospital, although she has done nothing illegal of which you are aware. You have given her satisfactory performance evaluations in the past, even though everyone is aware that she sometimes pretends to be a “junior physician.” You also suspect that the physicians sometimes allow her to perform duties outside her licensure, but you have not investigated this or actually seen it yourself.
D	Describe all possible solutions to the problem	1- Write a note addressing Maggie and the physician repeating the case about what had happened, and the consequences they could face on account of such behavior. 2-A second option could be that I could talk to my supervisor about what I witnessed currently and decision to him. 3 – Talk to both the LVN and the physician. 4-Another option could be to talk to the supervisor and request a meeting between the nurse, doctor supervisor, the chief of medicine, and myself.
E	Evaluate each solution (pros and cons of each solution)	Writing to Maggie and physician and also personally talking to them about the responsibilities of each one. Bring to their awareness the risks and threats involved if each one exceed their practice scope limit and not perform their duty well.
A	Act on the best solution (Choose the best solution and try it; Assessing the options)	The best solution is to hold a meeting with the LVN, supervisor, and chief of medicine.
L	Launching a plan into action	LVNs and physicians must be provided with guidelines to remind them of their duties and limitaitons

References

Kash BA, Castle NG, Phillips CD. Nursing home spending, staffing, and turnover. Health Care Manage Rev. 2007;32(3):253-62. PMID: 17666996 [PubMed – indexed for MEDLINE]
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Ringerman E, Flint LL, Hughes DE. An innovative education program: the peer competency validator model. J Nurses Staff Dev. 2006;22(3):114-21; quiz 122-3. PMID: 16760770 [PubMed – indexed for MEDLINE]
SGNA Practice Committee. Role delineation of the Licensed Practical/Vocational Nurse in gastroenterology. Gastroenterol Nurs. 2006;29(1):60-1. No abstract available. PMID: 16552303 [PubMed – indexed for MEDLINE]
Poster E, Adams P, Clay C, Garcia BR, Hallman A, Jackson B, Klotz L, Lumpkins R, Reid H, Sanford PG, Slatton K, Yuill N. The Texas model of differentiated entry-level competencies of graduates of nursing programs. Nurs Educ Perspect. 2005;26(1):18-23. PMID: 15816255 [PubMed – indexed for MEDLINE]
Smith JE. Exploring the efficacy of continuing education mandates. JONAS Healthc Law Ethics Regul. 2004;6(1):22-31. PMID: 15206173 [PubMed – indexed for MEDLINE]
Davidhizar R, Shearer R. Self-talk for the licensed practical/vocational nurse. J Pract Nurs. 2000;50(1):16-8; quiz 19-21. PMID: 11951235 [PubMed – indexed for MEDLINE]

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