Nursing Assignment: Analyzing SNB Code through Case Studies

This report presents an analysis of two nursing case studies, focusing on violations of the Singapore Nursing Board (SNB) code and ethical principles. The first case examines an enrolled nurse's breach of practice by independently administering intravenous (IV) medications without proper authorization and outside of a hospital setting, leading to potential patient harm. The analysis highlights violations of the SNB code related to accountability, clinical guidelines, and scope of practice, discussing the consequences of medication errors and the importance of adhering to nursing competencies. The second case study explores a nurse's display of violent behavior towards a patient, violating principles of public trust, self-regulation, and professional conduct. The report considers factors contributing to such behavior, including long working hours and lack of support, while emphasizing the importance of ethical practice and patient rights. The report provides a comprehensive overview of ethical considerations in nursing practice, supported by relevant literature and regulations.

Running head: NURSING ASSIGNMENT
Nursing assignment
Name of the student
University name
Author’s note

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Table of Contents
Case study 1:..............................................................................................................................2
Case study 2:..............................................................................................................................6
References................................................................................................................................11

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Case study 1:
1. As per regulation 52 of the Singapore Nursing Board (SNB) code for nurses and midwives
no registered or enrolled nurse can practice nursing in their own accountability or in
partnership without taking consent and approval from the nursing board. Therefore, any
professional who violates such regulation is to be taken guilty and fined an amount of $5000
(Wu, Enskär, Pua, Heng & Wang, 2016). In severe cases the violating midwives, registered
or enrolled could be further convicted.
2. In the current study the enrolled nurse has violated the principle 5 of the SNB code for
nurses and midwives. As per the principle 5, the nurses should act in an accountable and
responsible manner. Additionally, the nurse also breaches principle 6 of the SNB code for
nurses and midwives, which states that the nurses should act in accordance with the clinical
guidelines.
As stated in principle 5 of the SNB code for nurses and midwives, the nurses need to
act within the limits of their competence and scope of practice (Efendi, Nursalam, Kurniati &
Gunawan, 2018). They should escalate concerns whenever they are asked to perform beyond
their scope of practice. As commented by Johnstone (2015), the decision should be supported
by the ethical guidelines. It has been clearly mentioned that the nurses need to alert the
respective authorities when immediate decision making has to be done. This is because a
single wrong decision may endanger the life of a patient. The practice should be strictly
guided by the nursing skills and competencies. This is because breach of the same could lead
to a number of complications within an acute healthcare setup. The consequences are often
lethal endangering the life of the patient.

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In the present context, the nurse had independently administered IV medications to
the patient within the premises of the patient’s home. This was a breach of the principle 6 of
the standards of practice for nurses and midwives. Though the intravenous (IV) method
diluted or undiluted medications are directly administered into the vein using syringe through
a needleless port or an existing IV channel. IV medications are only provided in emergency
situations. Since, the medication is directly absorbed through the blood channel it results in
immediate elevation of serum levels and has high concentration in some of vital organs such
as heart, brain and kidneys. Since the IV medications are only provided in emergency
situations they need to be provided under a parenteral drug therapy manual. As reported by
Efendi, Nursalam, Kurniati & Gunawan (2018), incorrect administration of type IV
medications can illicit harmful immune reactions. Extraversion of certain medications in
surrounding tissues can cause nerve damage and scarring. Some of the additional risks over
here are central line associated blood stream infection (CLAB) and hypersensitivity.
Additionally, the enrolled nurse had performed the activities within the home of the patient
and in the absence of any medical instructor. Therefore, severe consequences could have
happened including the development of hypersensitivity reactions in the patient. The
hypersensitivity reactions may have resulted in death of the patient due to asthmatic choking.
In order to understand the ground of violation of the nursing code of ethics and
standards we need to understand the basis of administration of the IV medications. Some of
the emergency situations based upon type IV medications could be administered to the
patient are heart attack, poisoning and stroke etc. As the medicines are directly absorbed into
the bloodstream they are quick in their mode of action. The standard IV medications may be
used for controlling pain in the patients. In this a needle is inserted in the vein of the wrist,
elbow or back of the hand. The catherer is pushed over the needle, which remains in the vein
even after the needle is removed. However, as per the nursing standards and code of ethics

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the type IV catherers are to be given within the hospital premises under medical supervision
(Wu et al., 2016). Therefore, the enrolled nurse had clearly breached the terms of contract
over here. Some of the drugs which are most commonly administered via channel IV are –
chemotherapy drugs such as vincristine, paclitaxel ; pain medications such as
hydromorpohine and morphine; drugs for low blood pressure such as dopamine, epinephrine,
norepinephrine . As per the current case study, the enrollment of the nurse was suspended for
a period of 5 months. In this context, the enrolled nurse may have breached the code of ethics
and nursing standards owing to a number of reasons, which had been hypothesized over here.
Here, the patient that the nurse was catering to might have experienced a sudden stroke. Thus,
the nurse thought it was appropriate to administer IV medications before shifting the patient
in an actual ambulatory setup. Therefore, instead of administering the type IV medications
the nurse should have escalated concerns to the respective authorities. As commented by
Johnstone (2015), wrong infusion and wrong dose were some of the most common
medication errors. The intravenous medications which were commonly subjected to error in
the present case were heparin, furosemide, Nitroglycerin, Insulin, streptokinase, dopamine
etc. As asserted by Tan et al. (2016), medication errors occurred more frequently for
intravenous medication than for oral medicine.
3. There are a number of core competencies and skills as highlighted by the Singapore
nursing board. The nursing competencies and skills further govern the quality of practice and
care. The core competency consists of a standard set of performance domains and
corresponding behavioral standards which a nurse is expected to depict within their actual
practice sessions. Based upon the competency areas the enrolled nurse is further expected to
depict professional skills. The nursing competencies as per the Singapore health board could
be further divided into a number of sub-domains which are- professional, legal and ethical
nursing practice; management of care; professional development; leadership and nursing

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management. Some of these could be further related with the present case study where there
was a clear breach of the professional, legal ethical nursing practice. Here, the nurse was
expected to depict accountability for care within the scope of practice. The enrolled nurse
was supposed to act in accordance with the national legislation policies and procedural
guidelines. The nurse here failed to follow the directives as specified in the five rights of
medication mentioned within the specific skill sets provided by the SNB code of ethics and
nursing practices. As commented by Zhang et al. (2018), some of the recommendations to
reduce harm doe to medication are administrating the right patient, the right drug, in the right
dose, through the right route and the right time. As supported by Ver Donck et al. (2014),
under no circumstances a nurse is expected to practice beyond her scope of practice.
Therefore, the nurse had breached the competency domain 1, where she failed to abide by the
professional practice standards.
In this context, an overdose of the type IV medication may have developed a number
of secondary immunological reactions within the patient. In this respect, the Type IV
medications are injected in the form of bolus.The dosage should be controlled or tightly
regulated for which the nurse needs to perform drug calculation. As commented by Tan et al.
(2016), an overdose or under dose of the medication in result in the development of severe
consequence. As reported by Ver Donck et al. (2014), 0.8% of the fatalities could be
accounted to the administration of wrong medications via intravenous channels. Therefore,
instead of administering the type IV medication, the nurse should have approached the
respective physician. However as argued by Efendi et al. (2018), the occurrence of an utter
medical emergency may act as compulsion sometimes forcing the healthcare professional to
undertake an unspecified route. As supported by Wu et al. (2016), though a medically hasty
decision is sometimes guided by good conscience they may prove to be lethal endangering
the life of a patient. As per the competency domain 2, the nursing professional needs to abide

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by the risk management strategies. However, the enrolled nurse had taken a huge risk over
here by administering type IV medication to the patient without a prior approval from the
concerned medical board. As commented by Liaw et al. (2017), display of an irresponsible
behavior by the nurse could have put the both the patient as well as the nursing professional
at risk.
Case study 2:
1. Based upon the SNB code for nurses and midwives the nurse here failed to follow some of
the relevant principles and guidelines. Some of these have been discussed over here which
are principle 8 and 9 of nursing professional standards. As per the principle 8 of the nursing
code of conduct and practices a nurse should strive to achieve public trust and confidence and
in no manner should jeopardize the reputation of the profession. As mentioned by Yoo &
Park (2015), the nurse is accountable for the kind of behavior they depict towards their fellow
patients. As per principle 9 of the nursing code of conduct and practices a nurse needs to
practice self regulation. A nurse should uphold personal integrity and emotional fitness when
dealing with a patient. However, here the nurse has depicted violent and unacceptable
behavior towards the patient which made the condition of the patient worse.
2. In the current study the nurse had projected a violent behavior towards the patient by
inflicting harm upon the patient. This had gone against the nursing code of practice as well as
damaging the reputation of the nursing profession. As commented by Chong et al. (2016), a
nursing professional is expected to perform in manner which will uphold the public interest
and rights. However, projecting a jeopardizing behavior towards the patient can result in legal
breaches alongside affecting the overall well being of the patient.
In this respect, a number of factors had caused the display of such unacceptable
behavior in the nurse. Some of the factors which had could be taken into consideration over

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here are long working hours, less pay, violent and aggressive behavior by the nurse. In this
respect, aggressive behavior depicted by the patient owing to a number of diseases such as
dementia may result in additional challenges for the nursing professional (Geoffrion, Morselli
& Guay, 2016). As commented by Tan, Lopez & Cleary (2015), the lack of support from the
patient may affect the success rate of the care and support process. In this respect, a person
affected with dementia often has less cognitive abilities. This makes understanding as well as
decision making difficult for the patients. In such scenarios often intensive conflicts develop
between the patients and the support carer. As commented by McCarthy et al.(2018), the
patients affected with dementia are vulnerable and prone to the adversities, which are often
inflicted upon them by the nursing professionals in charge of their care. It is often difficult
for them to resist the atrocities inflicted upon them owing to the physical and mental
vulnerability. Additionally, the lack of awareness and family support often makes them easy
targets. In this respect, the depiction of a violent behavior by the nursing professional can
towards the patient can stem due to the lack of effective knowledge and training skill of the
nurse (Liaw et al., 2017).
It could be further explained on the basis of the Mental health capacity act, 2005. As
per this act, any individual with less or reduced mental capabilities have the rights to
participate in decision making pertaining to their care. Additionally, the legislation also
states that any person who infected with similar disability has equal rights in living life on his
own terms. Therefore, the nurse employed in the care of the patient over here needs to abide
by the ethical rules and regulations. Additionally, the support staff depicting violent behavior
could also stem from personal grudges and rivalry against the patient.
As mentioned by Yoo & Park (2015), the nurses employed within the care and
support services of the patients with limited abilities often have to suffer under the huge
burden of responsibilities. Therefore, the long working hours often results in compassionate

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fatigue in the nursing professional. As mentioned by McCarthy et al. (2018), 2 % abusive
patient-carer records have been found din the Singapore based healthcare. Under such
circumstances both the patient and the support carer needs help in terms of health support and
counseling. Additionally, lack of effective guidelines also resulted in gaps and breaches in the
implementation of healthcare policy. In the presence of an effective nursing policy the
chances of ethical and legal breaches gets reduced. As supported by Clarke (2015),
compliance monitoring is another factor which needs to be taken into consideration over here.
The lack of knowledge and training within the nursing professionals also results in the
hampering the safety standards and the quality of nursing care (Schober, 2013). In this
respect, a background check must be done before employing a nursing professional in the
care of a patient.
3. As per the new definition of professional misconduct stated in the SNB code 2018 the
nurse cannot abuse the professional relationship with the client (Newell, Nelson-Gardell &
MacNeil, 2016). Additionally, the nurse cannot bring the profession into disrepute. In the
current scenario, the nurse had depicted violent behavior towards the patient where he had
inflicted multiple wounds over the patient which resulted in the fracture of the ribs, left
chest wall bruise etc. therefore, the nursing professional in this case has brought sufficient
dispute to the nurse patient relationship.
As per the core competencies and management skills as mentioned in the Singapore
board of nursing, the enrolled nurse need to provide a safe and positive environment for the
healing of the patients (Griffith & Tengnah, 2013). However, here the nurse had been
personally inflicting aggressive and violent behavior against the patient. This has brought
disrepute to the nursing profession apart from endangering the overall well being of the
patient. Additionally, there are a number of nursing and professional values which had been
challenged over the present context. Some of these are advocating care in the best interest of

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the clients. Therefore, upholding the interest of the client is of utmost importance (Liu &
Haseltine, 2016). The practice environment should comply with the effective nursing practice
and guidelines.
4. In the current scenario, the nursing practices related to ethics management had been taken
into consideration. In this respect, the nurse should acts in accordance within the ethical
standards and practices (O’Neill, 2014). The present scenario describes an acute healthcare
setting where the nursing professional had depicted violent behavior towards the patient. This
has resulted in a number of issues such as causing damage and disrepute to the nursing
profession as a whole. In this respect, reference has been made to a number of codes of ethics
and nursing practices. Some of these have been described further such as the principle 8 and
9 of the SNB code. As per the codes the nurse needs to uphold personal integrity and
maintain emotional fitness. However, the action depicted by the nursing professional over
here has been clear violation of the ethical principles and guidelines. Some of the effective
precautions which could have been taken over here are compliance monitoring. The
compliance monitoring would help in ensuring that the patient safety standards are taken care
of. This could have been implemented in the form of regular home visits of the patient.
Additionally, working in partnerships with a large number of healthcare channels would have
also helped in providing of additional support to the support carer in dealing with the patient
depicting an aggressive behavior. Some of the practices which could be implemented over
here are provision of training to the healthcare professionals as an acute care setup a nurse is
often prone to develop conditions such as compression fatigue (Mather et al., 2017). As
commented by Bennett (2015), lack of appreciation of performance appraisals can further
affect the prospective growth of a nurse in his career. Therefore, the nursing committees
should occasionally review the performance of the healthcare staffs and provide them with
performances appraisals (Adrian & Chiarella, 2015). Additionally, involvement of the family

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member of the patient in the decision making can also help in the prevention of ethical
conflicts between the patient and the care service provider.
The implementation of effective legal framework along with provision of sufficient
training to the healthcare professional regarding the same can prevent the ill treatment of
patients within the clinical setup. The nurse in this step was convicted in this case for
purposely inflicting injury to the patient. However, the analysis of the case scenario shows a
clear gap and loopholes in the implementation of the legal guidelines.

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