Professional Accountability and Patient Safety

This case study discusses the professional misconduct of a registered nurse and the adverse outcomes that resulted from it. It also explores the actions that could have prevented these outcomes and emphasizes the importance of practicing within professional standards.

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NAME:
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Professional Accountability and Patient
Safety
NURSING AND MIDWIFERY BOARD OF AUSTRALIA Vs. BRIAN ROHA SMITH
File Case Number: VR: 54/2016
Link:http://decisions.justice.wa.gov.au/SAT/SATdcsn.nsf/
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Introduction
The case filed involved a patient being physically altercated by a registered nurse in Mental
Health Unit of Joondalup Health Campus in the Western Australia. The nurse, Brain Roha Smith
was found to have engaged in professional misconduct and had breached Code of Professional
conduct for Nurses in Australia and did not practice in accordance to National Competency
standards for registered nurse. The incidence started by a meeting at the Psychiatrist Intensive
Unit (PICU) nurses’ station where the nurses together with the respondent attended and decided
to administer medication to the patient. The nurses planned that one of the registered nurse (RN)
Matanda to talk to the patient about the medication while others who were left decided on an
extended plan to restrain the patient if they deemed it necessary because the patient had history
of non-compliance with medication. The nurses escorted the patient to the patient’s room where
the patient was restrained for medicine administration and started verbally abusing the nursing
staff that annoyed the respondent. The respondent got involved with the patient physically that
was termed as breach of professional conduct and a disciplinary action taken against the
respondent that he was reprimanded, disqualified from applying registration for 12 months and
applicant’s costs of a fixed sum of $1,700.
Actions and Omissions on Registered Nurse that Caused Adverse Outcome
Registered Nurse (RN) Brain Roha Smith undertook some actions that led to adverse event. RN
Smith became involved in physical altercation with a patient while other nursing staff observed.
First, Mr Smith was involved in a nurse meeting that decided that they restrain the patient if they

deemed it was necessary in order to inject the patient with the medication. RN Smith together
with other nursing staff escorted the patient to the patient room. The respondent was involved in
inappropriate restrain of the patient and administered intramuscular injections (IMI) and the
patient started to shout and verbally abuse the nursing staff. The patient stated that all nurses are
fucked up or words that effect which happened on several occasions. This was the beginning of
RN Smith getting furious and handling issues personally that led to more adverse events. While
other nurses left the patient’s room, the patient continued shouting and abusing the nursing staff
verbally including RN Smith. Secondly, RN Smith got involved physically with the patient and
they both fell on the floor with the patient landing on his back while Mr Smith on top. Thirdly,
RN Smith held the patient with his arm around his neck region in a way that appeared the
patient’s airway was restricted. The patient punched RN Smith several times on his face and
head while the nurse maintained holding the patient neck for approximately 10-15seconds. The
patient tried to tell the RN Smith to get off him while landing on the floor. Fourth, Mr Smith
placed his finger into patient’s eye. The patient responded by pulling RN Smith hair and he
shouted to the patient to stop. At this time the nursing staff instructed RN Smith to let the patient.
The RN agreed to the instruction of the nursing staff to release the patient. He stood up while
placing his hand on patient’s throats with pressure to push him up. The RN Smith left the
incident place and received medical attention in the JHC Emergency department for his injuries.
The RN Smith then resigned from his job and did not renew his registration with Nursing and
Midwifery Board of Australia.
The RN Smith actions were termed as unprofessional as he made several omissions that resulted
to the adverse events landing him into disciplinary. First, the RN Smith failed to respect the
patient’s dignity. Mr Smith got involved with the patient to inappropriately restrain him that
undermined the patient’s dignity as a person. This was inappropriate as nurses are required to
respect the dignity of the patient that is receiving care in accordance to Codes of Professional
Conduct for Nurses in Australia. Secondly, RN Smith failed as a nurse to provide a safe and
competent nursing care. The RN did not uphold safe practice that placed the patient in a situation
that count harms him resulting to negative health outcomes. The RN also compromised
competent practice in nursing care that involved his capacity to deliver quality nursing care. The
RN Smith did not understand the patient and outline the best way to manage the patient’s
condition in the process of provision of nursing care. The RN had a responsibility to provide a

safe and competent nursing care that promotes quality nursing care delivery that is in accordance
to Codes of Professional Conduct for Nurses in Australia. Thirdly, Mr Smith failed as a RN to
uphold the trust and privilege that is inherent in a nurse patient relationship. Nurses are required
to engage in therapeutic and professional relationships that promote nursing care delivery. This
requires a nurse to have professional boundaries with the patient which RN Smith did not have
with the patient. This led to personal encounter resulting to adverse events. RN Smith therefore
failed to preserve and promote the trust and privilege that nurses must have with individuals
receiving care. Lastly, the RN Smith failed to act appropriate and maintain integrity and dignity
of individuals. Mr Smith did not act with professional integrity by exhibiting professional
behaviour in terms of compassion to the person requiring nursing care. Therefore, the RN Smith
omissions as required by National Competency Standards for the Registered Nurse and Codes of
Professional Conduct for Nurses in Australia.
Other Factors that Contributed to Adverse Outcome for the Patient
Another factor that contributed to adverse event was skill based errors. The respondent RN
Smith had 30 years experience of practice in mental health nursing and he found that the incident
was distressing. This shows that the RN Smith had the experience and knowledge as a registered
nurse in a mental health nursing field. The RN considered the incident to have been very sudden,
his adrenaline increasing very quickly, and getting disoriented when he got the encounter with
the patient. Mr Smith admitted that he was disappointed with the situation and was interested to
manage the situation in the future.
There were three skills errors factors that occurred; de-escalation, aggression management and
conflict management. RN Smith failed to apply these skills that would have prevented the
adverse events that led to disciplinary action against him. First, the de-escalation skills by RN
Smith would have ensured the situation was contained. The de-escalation skill is the first skill to
prevent RN Smith from causing harm to the patient (Moylan, and Cullinan, 2011). The
escalations between the patient and RN Smith spiralled out of proportion and it was difficult for
the nurse to control himself. The RN should have used verbal de-escalation and prevent himself
from getting into a potentially threatening argument that would cause adverse outcomes to the
patient. The second skill error that led to adverse outcome was conflict resolution skill. RN
Smith was not able to find a peaceful solution to a disagreement with the patient. The RN in the

middle of the conflict could not take a best course of action to resolve the conflict. For instance,
the RN could have handled the situation by avoiding, accommodating, or compromising for the
conflict to be resolved. Another skill based error factor that could have avoided adverse outcome
is aggression management. Aggression arises from innate drive as defence mechanism and the
skill has to be learned (Hegney et al., 2015). Aggression is an important skill that can eliminate
violence in the workplace. Aggression management involves the use non-confrontational
approach and setting up of boundaries between a patient and a patient. The aggression skill also
involves avoiding excessive stimulation and aggressive postures. Therefore, the skills base errors
that contributed to RN Smith getting physically involved with a mental patient who need nursing
care.
Actions that could have Prevented Adverse Outcome
The RN Smith case with the patient could have been avoided. There are actions that the nurse
could have taken or omitted that led to adverse outcomes for the patient and disciplinary action
against registered nurse Smith. First, the RN Smith could have avoided inappropriate restraint on
the patient. The RN together with other nursing staff could have not engaged patient restrain and
rather seek other methods that guarantee patient’s safety. According to Chiarella and Adrian,
(2014), restraining patients increase restlessness and anxiety as a result of loss of self control.
Hofmann et al., (2015) stated that restraints should not be used as punishment or cause harm to a
patient and should be the last choice when other methods to control the patient fail. Therefore
patient in the case could not have shouted or verbally insulted the nursing staff if he was not
inappropriately restrained. Secondly, the RN should not have gotten physically involved with the
patient. The nurse should have not placed his figure into the patient’s left eye or restrict patient’s
airway by placing his arm around the patient neck. This caused physical altercation with the
patient. Physical altercation can cause injuries to patient and the nurse requiring medical
attention (Dixon, 2013). According Dickens, Piccirillo, and Alderman, (2013) nurses should
aggression, escalations, and conflicts in the nursing practice to minimize physical altercation
against patient. Mellor and Greenhill, (2014) Stated that nurses need to have aggression
management skills to prevent conflicts and escalations with patients. Thirdly, the RN could have
engaged with the patient in a therapeutic and professional relationship. The nurse should have
established, sustained, and concluded the relationship with the patients in a manner that

differentiates personal and professional boundaries (Doyle, Hungerford, and Cruickshank,
2014.). A nurse needs to have professional boundaries with patients and they define limits as
result of nurse’s power and vulnerability of patients. According to Snelling (2016) nurses should
respect the power imbalance that exist between a nurses and a patient and ensure they have a
patient centred relationship. Also in building therapeutic and professional relationship, the RN
Smith should have communicated effectively and respectfully to the patient’s dignity in
accordance to Registered Nursing Standards (O’Neill, 2011). Lastly, the RN Smith should have
provided safe and appropriate nursing practice that is within the scope of nursing practice and in
accordance with relevant standards, policies, guidelines, and regulations (Tella et al., 2013). RN
are required to fulfil their duty of care and act appropriate in a way that maintains integrity and
dignity of individuals in the course of registered nursing practice in accordance with National
Competency Standards for Registered nurses (Duffield et al., 2011). RNs are also required to
respect dignity of the individual receiving care, provide safe and competent care, and preserve
and promote trust and privileges that exist in relationship between people receiving care and
nurses as stated in the Code of Professional Conduct for Nurses in Australia
(Nursingmidwiferyboard.gov.au, 2016).
Conclusion
The case file for RN Brain Smith shows that indeed he behaved in a manner that constitutes
professional misconduct. The RN was involved in physical altercation with the patient, placed
his finger into the patient’s eye, and held his neck in a way that restricted patient’s airwave. Mr.
Smith omitted provision of safe and competent care, respect for dignity of an individual
receiving care, and promotion and preservation of trust inherent to nurse and people receiving
care relationship. The adverse outcomes were contributed by skills based errors that included de-
escalation, conflict resolution and aggression management. The adverse outcomes from the
incidence would have been avoided by the RN avoiding inappropriate restraint, engaging in
therapeutic and professional boundaries that differentiate professional and personal relationships,
and abiding to professional regulations, standards, legislation, policies, and guidelines in the
scope of nursing practice. Therefore, it can be concluded that registered nurses need to practice
within professional standards and guidelines to avoid adverse outcomes to the patient and
disciplinary action against them by Nursing and Midwifery Board of Australia.

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