Nursing Misconduct: A Case Study of Mr. Dixon

This report discusses nursing misconduct and its impact on patient's life, focusing on the case study of Mr. Dixon. It analyzes the allegations faced by him and suggests strategies to avoid such events in the future.

HIN2110 Assessment

Nursing misconduct is one of the most common but dangerous thing for health care
worker, performing any kind of misconduct in the health care process might lead to serious
problem and accuser even have to face lawsuit (Senior, 2018). Every health care worker know
their jobs are highly ductile, a small amount of mistake impact patient and risk their lives.
Worker who act as nurse or care provider should follow ethical as well as legal guidelines
provided by the management, misconduct take away all legal rights and licence of health care
professional. It is very clear nursing misconduct risk life of patient who depend on care provider,
misusing drugs, misguiding patient and wrongful treatment bring patient life in danger.
This report is based on Mr. Dixon's case study, this nurse was registered with Rozelle
Holm care home. Mr. Dixon performed certain misconduct in the process of his employment
which almost risked life of patient, due to his carelessness, he was charged with several
allegations which was often proved right and some were proved wrong by the court. Every court
hearing open new doors of misconduct performed by Mr. Dixon, he was accused with certain
misconduct case done by him in his nursing practice. This report will use reflection model to
understand what happened and what are allegation faced by Mr. Dixon, report will find out if
allegation or charges was right or proven wrong by the court in the process.
What:
Registered nurse John Laurence Dixon was suspended from his duty because he
performed misconduct in the employment process, Mr. Dixon was accused of misleading
medicinal process. He fails to keep record of drugs and medicine and fail to perform nursing
according to requirement, Mr. Dixon was charged with certain allegation that was proven right as
well as wrong, some charges rightly raised by the court and somewhere wrong. There is timeline
to understand what exactly happened and what are allegation charged on Mr. Dixon, these are:
TIMELINE
S.no. Date Case Decision
S. No 1 04/09/14 Dixon was charged
with allegation that he
did not call GP
(General practitioner)
after demand raised by
This charge was
proven.

resident family which
lead to serious
problem to the patient
and lead to misconduct
performed by Mr.
Dixon.
S. No 2 27/12/15 Mr. Dixon was
charged with
allegation that he
dispensed the wrong
dose to patient leading
to serious health issue,
wrong dose of
Warfarin was given to
patient with critical
health condition lead
to serious problem and
misconduct performed
by Mr. Dixon.
This charge was
proven.
S. No 3 18/07/16 Mr. Dixon was
charged with
allegation that he
misused weak system
of the care unit to
perform misconduct,
he wrongfully filled
MAR Chart with
wrong information. He
signed that dose was
given to patient but it
This charge was not
proven.

was found that no dose
was given to patient
and information is
completely wrong.
S. No 4 13/01/17 Mr. Dixon left
medication unattended
in resident rooms
leading to major issue
in the health of patient,
this carelessness was
performed by Mr.
Dixon when he notices
he was not monitored
by authority in the
process. This act of
carelessness may lead
to serious problem to
patient and may
impact care provider.
This charge was not
proven.
18/03/17 Administered
Furosemide or
Omeprazole or
Ramipril to a resident
when it was already
been given, this is
matter of
misinformation
provided to the
authority leading to
nursing misconduct.
This charge was
proven.

Mr. Dixon was
charged with
allegation that he
misused his power, he
made mistake in MAR
Chart and misleading
medication error in the
medicine process.
10/03/18 Mr. Dixon fail to
check blood sugar of
patient and failed to
record this report in
the sheet allowing him
to disobey policy and
procedure of the clinic,
he failed to check
blood sugar of resident
K which means he
might face serious
health problem
because of this
carelessness in the
process.
This charge was
proven.
So what:
Fish bone diagram:
Lack of policy Lack of leadership Lack of management

Lack of accountability Lack of risk management Lack of team working
Factor:
Fish bone diagram highlight factor that cause accident in the workplace, in the case of Mr.
Dixon, lack of policy, lack of leadership, lack of management, lack of accountability, lack of risk
management and lack of team working can be seen (Coccia, 2018). Which lead to misconduct in
the workplace, it is very clear that these element highlight cause of misconduct where due to lack
of management and leadership, Mr. Dixon was able to perform misconduct and risked life of
patient in the process.
Lack of leadership: Lack of leadership lead to this misconduct where Mr. Dixon was free to
perform nursing according to him for example: there was no senior authority available that can
keep eye on him which means lack of leadership which can lead him.
Lack of proper management: lack of proper management is one of the major reason why Mr.
Dixon conducted this misconduct, this simply means even authority remain in problem as they
were not looking at these activities.
Swiss cheese model:
Swiss cheese model is one of the most effective model used to understand accident or
risk that take place due to lack of proper management and lack of system (Larouzee and Le
Coze, 2020). In the case of Mr. Dixon, there are certain latent factors that give birth to accident
or case, by analysing Swiss cheese model, we can understand what are reason for misconduct in
the care home setting, there are certain layers and holes of Swiss cheese model, these are:

Slice: Slice are layers that demonstrates factors contributing in happening of accident, in the case
of Mr. Dixon, slice are home care setting policy and procedure which need to be followed and
which block any risk that may lead to serious problem in the organization. These slice or layer
stop Mr. Dixon to commit misconduct in the workplace but due to lack of proper policy and
procedure, slice or layers were less leading to accident. Mr. Dixon was committing misconduct
because layers was not available within the workplace (Wiegmann and et.al., 2022). Every slice
play major role in the process which means each policy and factors of organization played vital
role in leading to misconduct in the workplace.
Holes: holes are major causes that lead to an accident, these holes are available in the layers. In
the case of Mr. Dixon, holes are lack of leadership, lack of proper management, lack of
communication, lack of better policy and procedure, lack of team working, lack of risk
management, lack of clinical governance and issue related to professionalism, legal, ethical,
quality, measurement and accountability (Olson and Raz, 2021). Holes allow accident to happen,
there was so many holes in Swiss cheese model used in the case of Mr. Dixon which lead to
major issue for Mr. Dixon when accident happened in the workplace.
Now what:
When looking at the case of Mr. Dixon, it is very clear that due to lack of proper
leadership and management worker may perform misconduct lead to major issue in the
workplace. Mr. Dixon have used weak area of workplace to conduct misuse of his position and
power, lack of management lead to occurrence of risk in the workplace. There are strategies
which can be used to bring change in health care environment and to bring improvement in care
providing process in the health care to avoid such event in the future, these are:
Better policy and procedure: Better clinical policy and procedure is essential element or
strategies required in the process, it is very clear that due to lack of effective policy, cases like
Mr. Dixon can be seen. As a future health care leader, I would craft powerful policy with the
help of key stakeholder of the clinic to avoid such event like I will demand every health care
worker to carefully fill MAR Chart and send it to authority for verification which keep proper
record of medicine and dose provided to the patient (Mason and et.al., 2020). Compulsory filling
of MAR Chart (Medication Administration Records) will cover weak point of policy allowing
me to control such event in the workplace and improve health care environment in the process.

Careful management: Bringing change in management or completely change the management,
in health care area management play vital role, due to lack of management cases like Mr. Dixon
take place and impact whole health care system. As future leader in health care area, I would
have chosen the best management practice to bring betterment in the health care (Almansoori
and et.al., 2021). For example; lack of management allowed Mr. Dixon to perform misconduct as
there was no superior or audit to check these worker, change in management will keep eye on
registered nurse and worker to control such event in the workplace and to bring improvement in
the health care system in the process.
Promote team work: Promoting team work is one of the most important element in the process,
it is very clear team work is much required in the health care area (Schot, Tummers and
Noordegraaf, 2020). Every practitioner and worker need to work in a team to manage condition
of client, in the case of Mr. Dixon, there was no team work available which allowed Mr. Dixon
to perform misconduct in the workplace and mislead certain action that may have lead to serious
issue in care process. As a future leader in the health care, health care worker should promote
team work and push worker to work together to gain max. knowledge with each other. They need
to assign task to group allowing them to share their diverse thoughts and bring betterment in the
health care system.
Feedback system: This is one of the most required thing in health care system, feedback allow
worker and practitioner to improve their weak area and push them to become effective in the
workplace. As a future leader of the health care, I will gather information through feedback
system including feedback from parent and subordinate allowing me to gain maximum
knowledge about each worker working under me (Hovland and Moltu, 2019). For example; to
avoid cases like Mr. Dixon, I will gather information about each worker because it is easy to
keep eye on activity of worker when feedback system are installed in the workplace in clinic.
CONCLUSION
This report has discussed nursing misconduct and its impact on life of patient, misconduct is one
of the most disturbing thing in the nursing practice because lack of care may lead to serious
health issue. This report has focused on misconduct performed by Mr. Dixon who was nurse, he
took policy and procedure lightly leading to misconduct in the workplace. He fail to meet the
demand of policy and performed carelessness, there are many charges filed against Mr. Dixon
who was found right. Some charges where found proven but some did not suit with the

requirement. I would have managed this situation by performing as per the requirement,
following code of conduct and with great sense of responsibility, I can manage health care cases.
It is very important to work with multi-professional team allowing practitioner to explore
different area of development and help him to follow code of practice to avoid misconduct in the
nursing practice. This report has discussed timeline that highlight date and case that happened
with Mr. Dixon or performed by Mr. Dixon in the workplace. Later this report has discussed fish
bone diagram demonstrating what are factors that cause misconduct, each element or factor is
described with this diagram. Later this report has discussed Swiss cheese model demonstrating
slice and holes available in the workplace and its role in stopping factor to cause accident or risk
in the process.

REFERENCES
Books and journals
Senior, A., 2018. Why aesthetic practitioners must keep reporting misconduct to the
authorities. Journal of Aesthetic Nursing, 7(6), pp.329-329.
Coccia, M., 2018. The Fishbone diagram to identify, systematize and analyze the sources of
general purpose Technologies. Journal of Social and Administrative Sciences, 4(4),
pp.291-303.
Larouzee, J. and Le Coze, J.C., 2020. Good and bad reasons: The Swiss cheese model and its
critics. Safety science, 126, p.104660.
Wiegmann and et.al., 2022. Understanding the “Swiss cheese model” and its application to
patient safety. Journal of patient safety, 18(2), pp.119-123.
Olson, J.A. and Raz, A., 2021. Applying insights from magic to improve deception in research:
The Swiss cheese model. Journal of Experimental Social Psychology, 92, p.104053.
Mason and et.al., 2020. Policy & Politics in Nursing and Health Care-E-Book. Elsevier Health
Sciences.
Almansoori and et.al., 2021. Critical review of knowledge management in healthcare. Recent
Advances in Intelligent Systems and Smart Applications, pp.99-119.
Schot, E., Tummers, L. and Noordegraaf, M., 2020. Working on working together. A systematic
review on how healthcare professionals contribute to interprofessional
collaboration. Journal of interprofessional care, 34(3), pp.332-342.
Hovland, R.T. and Moltu, C., 2019. Making way for a clinical feedback system in the narrow
space between sessions: Navigating competing demands in complex healthcare
settings. International Journal of Mental Health Systems, 13(1), pp.1-11.