This afternoon, I went with staff nurse Tan to observe how to administer an intramuscular injection. During the procedure, I noticed that staff nurse Tan did not aspirate the needle to check for blood flow and she administered the injection rapidly. I was taught to aspirate and to check for blood flow as, if there is blood flow, I will need to stop immediately and compress at the intramuscular site as the injection might have entered the blood vessel instead of the muscle layer. Later that evening, patient’s daughter asked me why is there a big bruise on the patient’s left arm and that was the site which staff nurse Tan administered the intramuscular injection.As seen in my scenario and as in my opinion, staff nurse Tan did something that was very wrong.
According to the code of ethics and professional conduct under Singapore Nursing Board, every nurse is to provide care for all patients under their nursing care in a responsible and accountable manner but it clearly shows that staff nurse Tan did not comply with the work ethics. And as a student, I feel that I did injustice towards my patient as I did not tell the patient the truth about the nursing negligence that took place. This negligence happened as the duty of care was not met by staff nurse Tan. This led to the breach of duty which somehow has caused the injury to the patient’s left arm tissues.
This scenario leads me to have a dilemma regarding the right ethics and practices.Firstly, I am confused about keeping mum from everyone about the negligence that took place towards the patient. The biggest dilemma is keeping mum or to escalate about the incident to someone. Should I inform and clarify the situation with my clinical facilitator? Or should I inform the ward’s nursing officer? Should I clarify and question the staff nurse Tan about the wrong practice? Or should inform the patient about the negligence that took place with her? Will my grades or the experience in that clinical posting be affected by my actions? These are some of the ethical dilemmas that have put me in a fix to think of what should I do.The pertinent data in this scenario is that staff nurse Tan did not aspirate to check for blood flow, which is done to check the correct route of administration of the drug before administering the intramuscular injection. As a result of this action, it had led to the patient having a big bruise at the site of injection which was administered earlier on. The implication of administering intramuscular injection through the wrong route is that it is a medication error.
I believe some nurses skip the aspiration step prior to injecting the drug, as it is mentioned in the article “Needle Aspiration and Intramuscular Vaccination”, that aspiration before injecting the drug can be time-consuming if done properly, and that the current recommendation to aspirate prior to intramuscular injection may be needed to be reconsidered in the year 2006 (Ipp, Sam, & Parkin, 2006).An article in the year 2002 mentions that once the needle has been injected through the skin and into the muscle layer, nurses are supposed to aspirate by pulling back on the plunger for 5-10 seconds at least. It is necessary to make sure that the needle is not in a low flow blood vessel. A study has shown that the complications that have occurred are usually the result of an intra-arterial or intravenous injection of medication (Nicoll & Hesby, 2002).In Ngee Ann Polytechnic, the students are taught by referring to Nursing Skills Book 2 that says at point 24, to pull back the plunger slightly, after the insertion of the needle in the muscle layer. This is done to observe for any blood withdrawn, as the presence of blood indicates that the needle has entered a blood vessel. Injecting the medication into the bloodstream clearly indicates that it is the wrong route of drug administration and this negligence may cause harm to the patient.
The right practice to be done is to aspirate for the presence of blood after injecting and if there is blood. One is supposed to withdraw and discard the needle with the drug and to prepare a new injection and is supposed to inject the drug at a different site (Chua, Lam, & Shree, 2017).Veracity is, to tell the truth, but the ethical principle has been contradicted, by not telling the patient the truth of the negligence done by the staff nurse.Autonomy is providing the information in decision making and respecting their decision but as a student nurse, I did not give the patient the autonomy to know the truth.Fidelity is keeping the commitment to care, but it has evidently shown that staff nurse Tan has not provided the best nursing care for the patient.
Respect is to respect every individual, including their rights and autonomy regardless of gender and race but staff nurse Tan did not respect the patient’s wish, which is to have a good health. And as humanity, no patients are to be mistreated by any of the healthcare professionals.Justice is to be fair and equal but as a student nurse, I was not fair to the patient as I hidden an essential information about the negligence and did not reveal the truth to the patient and did not clarify it with my clinical facilitator.Beneficence is to do good but the staff nurse Tan’s actions have contradicted the ethical principle of beneficence.The principle of non-maleficence has been contradicted in this scenario, as it is to do good that can sometimes cause unintentional harm but as for this scenario, the patient has already acquired an injury.Based on the actions done on the patient, not only it contradicts the ethical principle of maleficence and nonmaleficence, it is also against the principle of fidelity, justice, respect, veracity, and autonomy.There are many solutions to this scenario.
My first solution is to inform the ward’s nursing officer about the incident and let the nursing management handle the situation. My second solution is to inform the patient and her family members about the negligence that has taken place with her and let her sue the hospital. My third solution is to question staff nurse Tan about the incident and why did she make that negligent mistake. My fourth solution is to inform and clarify with my clinical facilitator about the incident that took place and ask for advice on how am I to react to this situation and what am I supposed to do. My fifth solution is to just keep quiet about the incident and pretend like nothing wrong had happened.
The solution that I have chosen is to inform and clarify with my clinical facilitator about the incident that took place and ask for advice on how am I to react on this situation and what am I supposed to do. This is because, as a student, I am responsible for the actions that I am witnessing and also, I am responsible for my patients under my care. And I also know that under Singapore Nursing Board, all nurses are to abide the Nursing Guidelines and Standards (“Nursing Guidelines and Standards | SNB,” n.d.).Staff nurse Tan has clearly breached the Code of Ethics and Professional Conduct under the Singapore Nursing Board’s Nursing Guidelines and Standards. To my understanding, I believe staff nurse Tan has breached value statement 1, 5, and 6.Value statement 1, is for all nurses to respect patient’s individual values and needs.
All nurses are to provide care that is determined by their patient’s values and needs, without any discrimination based on the patient’s gender, ethnicity, religion, age, social or economic status (“Nursing Guidelines and Standards | SNB,” n.d.). The ethical practice points under the value statement 1 clearly state that all nurses are to assist all the patients to express their individual needs and values and take these into consideration when determining the optimal plan of care. All nurses are to actively involve their patients in the planning and delivery of care. All nurses are also to provide care regardless of patient’s gender, ethnicity, religion, age, health and socioeconomic status (“Nursing Guidelines and Standards | SNB,” n.
d.). Value statement 5, is to provide care in a responsible and accountable manner for all patients under their care. Every nurse is to be responsible for ensuring that their patients receive safe, effective and ethical care (“Nursing Guidelines and Standards | SNB,” n.d.
).The ethical practice points under the value statement 5 clearly state that all nurses are to safeguard the health and safety of their patients against incompetent, unethical or illegal practices. All nurses are to ensure that the safety of their patients is not jeopardized by the commission or omission of any nursing care activity. All nurses are to alert the appropriate authority of any situations which may endanger the health or safety of patients or colleagues. All nurses are also to provide accurate and relevant information when speaking on nursing or health-related matters in public (“Nursing Guidelines and Standards | SNB,” n.d.).
Value statement 6, is to maintain competency in the care of all patients. Every nurse is to constantly evaluate their levels of knowledge and skills as well as the effectiveness of nursing care they provide for every patient under their care. All nurses are to maintain their competency in all their skills through continuing education and practicing evidence-based nursing (“Nursing Guidelines and Standards | SNB,” n.d.). The ethical practice points under the value statement 6 clearly state that all nurses are to ensure that their nursing practice is based on the best available evidence in the current scientific literature. All nurses are to keep pace with advances and innovations in medicine by participating in continuing education activities.
All nurses are also to practice critical reflection and self-evaluation to assess their levels of competence and effectiveness of care delivered (“Nursing Guidelines and Standards | SNB,” n.d.). From this incident, I have learned that there is a reason why there are a Nursing Guidelines and Standards. As healthcare providers, we are to render the best care to all the patients under our care. And breaching any of the guidelines will lead the nurse having to face disciplinary action by the Singapore Nursing Board.
This scenario also taught me the importance of education. This is because, learning is a lifelong journey that every nurse has to be equipped with, to know the latest evidence-based practices to render the right care. From all the learnings in this scenario, I will make sure that I would never make such mistake in my nursing career.