Learning from other nurses' mistakes: there are some hard lessons to be learned for nurses who take on unrealistic workloads and then face disciplinary proceedings arising from those untenable workloads.

The New Zealand Health Practitioners' Disciplinary Tribunal was established following enactment of the Health Practitioners' Competence Assurance Act 2003 (HPCA). Thirteen cases related to nurses have been referred to the Tribunal. Five have been heard and eight are not yet completed.

In four cases, the nurses were found guilty of professional misconduct and in one the nurse was referred to the Tribunal following a conviction in the District Court. Under section 67(a) of the HPCA, the Registrar of the Court is required to notify the relevant Authority when a health practitioner has been convicted of an offence "punishable by imprisonment for a term of three months or more" (1) This case did not relate to patient care but did reflect adversely on the nurse's fitness to practise and was judged as likely to bring discredit on the profession. In this case the nurse's registration was cancelled. (2) In the cases of professional misconduct, nurses have been judged as falling short of recognised professional standards.

On call 24/7

Two cases have come to the attention of NZNO's professional nursing advisers. In one, a resthome nurse manager was the only registered nurse (RN) employed, hence she did all clinical assessments, policies, supply and food ordering and preparation for accreditation. (3) She was expected to be on call 24 hours a day, seven days a week, an unrealistic workload. Such nurses often think they will be backed by their employer when problems arise. Rather, employers often say if the nurse had told them it was an unreasonable workload, they would have employed someone else as well. They tend to place the responsibility for the decision to take on an unreasonable workload firmly on the nurse's shoulders (and firmly off their own).

The complaint related to the management of an insulin-dependent diabetic patient. The caregivers phoned the RN for advice. The RN apparently failed to assess, monitor and evaluate the patient's changing blood glucose levels and the patient did not get appropriate care. The Tribunal, in its report, acknowledged mitigating circumstances. Firstly, the nurse was constantly on call outside her normal working hours, and secondly, she also had distressing family circumstances at the time. Thirdly, she was distracted when she was called at home to make clinical decisions. Her stress was compounded by the fact the rest-home was rapidly losing residents to a newly-opened facility.

Even when all these stressors were taken into account, the Tribunal still had a primary responsibility to protect the health and safety of members of the public. The Tribunal did not remove this nurse from the register but imposed a condition that she must practise under the supervision of an RN approved by the Nursing Council. The Tribunal's decision took into account the fact the nurse earned only $15 an hour and therefore was unlikely to be well off. Nevertheless, the nurse was fined $10,000.

The Tribunal noted the nurse had not responded to the charge brought by the Health and Disability Commissioner's Director of Proceedings, who then took the complaint to the Nursing Council. The case was then referred to the Tribunal, which called ten witnesses. Nurses must understand that if they ignore any correspondence from the Nursing Council or the Health and Disability Commissioner's Office they will be seen as irresponsible. If they answer promptly and seek to have the situation resolved quickly they will be seen as responsible and professional. In another case an RN who owned an agency undertook most of the care planning for an elderly woman. The Tribunal found there were deficiencies in the care provided but there were also mitigating circumstances. (4) The nurse facing the charges was no longer practising. The Tribunal noted this and placed conditions on the nurse should she return to practice. In neither of these cases did the nurse have a legal advocate. These two cases highlight the difficulties for nurses in the aged-care sector. When RNs work with caregivers they are responsible for ensuring caregivers have sufficient knowledge and understanding to carry out the care delegated to them. For example, it is nurses' responsibility to ensure there are policies in place and education provided so caregivers understand what a normal blood level is, and the expected response if the blood sugar is higher or tower than the desired level.

Nurses' professional accountabilities

A nursing expert adviser to the Health and Disability Commissioner on aged-care issues, Jan Featherston, said there were an increasing number of cases where nurses have undertaken unrealistic workloads. "Nurses need to be aware and be able to clearly articulate to managers and owners their professional accountabilities and undertake to do only what they can manage safely," she told me.

Many nurses now work as the sole RN in an institution. They feel isolated, overworked and unsupported. In this environment they can lose sight of the extent and limits of their professional responsibilities. Being paid $15 an hour and receiving a $10,000 fine is a hard lesson. In one case, the Tribunat's conclusion (4) was relevant to all heath professionals: "Understand and apply relevant Codes (Patient Rights, Professional Code of Conduct), Standards of Nursing Care, and the HPCA.... Seek mentoring and supervision opportunities; ensure indemnity insurance is in place; and take care of yourself so you remain capable of delivering quality nursing care. " (4) Nurses, managers and caregivers who work with older people deserve our support. If we work together for education and support systems for all staff, older people will have a greater chance of being cared for in a way that always protects their dignity..

References

1) The Health Practitioners' Competence Assurance Act (2003) Wellington: Published under the authority of the New Zealand Government--2003.

(2) www.hpdt.org.nzDecision23/Nur05/13P. Retrieved 28/4/06.

(3) www.hpdt.org.nzDecision20/Nur05/09DI. Retrieved 28/4/06.

(4) www.hpdt.org.nzDecsion28/Nur05/12P. Retrieved 28/4/06.