Unprofessional Conduct in Nursing Documentation: A Case Study

This case study examines unprofessional conduct in nursing, specifically focusing on documentation errors and their consequences. It details five examples of unprofessional conduct, including failure to document vital signs, pain assessments, pre-operative checklists, blood glucose levels, and patient admission history. The report further analyzes the impact of these actions on various healthcare professionals and departments, such as medical assistants, doctors, supervisors, the management department, and the care-taker department. The analysis highlights how these failures can lead to adverse patient outcomes, increased stress for doctors, and operational inefficiencies within the healthcare system. The case study underscores the importance of accurate and complete documentation in maintaining patient safety, promoting effective communication, and upholding professional standards within the healthcare environment. The study concludes by emphasizing the need for adherence to ethical guidelines and proper training to mitigate the negative effects of unprofessional conduct.

Case study

Table of Contents
INTRODUCTION...........................................................................................................................1
MAIN BODY...................................................................................................................................1
Describing 5 example of unprofessional conduct in relation to documentation committed by
nurse............................................................................................................................................1
Describing 5 professionals/ department which who could be impacted by these acts of
unprofessional conduct................................................................................................................3
CONCLUSION................................................................................................................................5
REFERENCES................................................................................................................................6

INTRODUCTION
The health care professionals have the scope of practice in which they are operate in.
while on the other side, there are many areas where these health care professionals follow
unprofessional conduct. In the same way, current report is also based upon the case study of
CARNA Member where the nurse perform different unethical work. That is why, the report
describe five different example of unprofessional conduct in relation to documentation
committed by nurse. Further, it also explain 5 professionals/ department which who could be
impacted by these acts of unprofessional conduct as per the case study.
MAIN BODY
Describing 5 example of unprofessional conduct in relation to documentation committed by
nurse
As per the case study, there are different unprofessional conduct done by the nurse with
relation to documentation. The first is, she failed to document vital signs q4h as she was already
instructed by the doctor to perform the same. Therefore, it is quite essential for the nurse to have
critical care of the patient even it was a day or a night, especially it is required to take proper
documentation of vital signs q4h because ill patients may have a life- threatening changes and
that is why, it is necessary to jote down the pulse rate, temperature of the body, respiratory rate
and blood pressure of the body (Komolaf and Porterfield 2018). It is so because having a proper
documentation of these vital signs q4h will help to provide proper medication for the same. As
every patient have different pulse rate, BP and respiratory rate and for that doctor also prescribe
different medicine after monitoring the whole.
Second unprofessional conduct is that nurse failed to document pain assessments such
that it Is regraded as a fifth vital sign of the healthcare because it is accepted in the healthcare
sector that the pain is like the other vital sign. That is why, it is quite necessary for the nurse to
done proper pain assessment so that it will help to determine the actual condition of the patient
(Escolar and Magpantay, 2019). As per the case study, the nurse missed to have a proper
documentation of the pain assessment and as a result, the doctor did not prescribe proper
medicines to the patients and as a result, the chances of error increases. Therefore, pain
assessment is mainly involves the clinical judgment which is based upon the observation of the
type and in the context of a patient's pain experience.
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Third is nurse failed to document on the pre-operative checklist, though it is quite
essential and consider one of the important list that must be followed by the nurse. Thus,
comprehensive pre- operative assessment is that tool which is used by the nurses in order to
identify, document and also communicate the patient risk factors as well a vulnerabilities. This
check-list includes the time of last food, time to last drink, time of surgery, showered and voided
so that it will help the doctor to provide medication after that (Kunyk and Deschenes, 2019).
Moreover, this checklist is consider as a patient safety tool which further allow the surgical team
in order to conduct the patient assessment by asking variety of questions related to procedure.
Thus, it is clear that by applying pre- operative check-list the patient critical situation may easily
analyzed. In addition to this, it is also analyzed that if nurses did not perform the pre- operative
check-list in which nurse did not determine the patient's vulnerabilities then the nurses did not
manage the critical environment of the patient and as a result, patient health may also suffer as
well.
Fourth unprofessional conduct of nurse is such that she failed to appropriately document
the patient’s blood glucose level, which is quite essential for the nurse because it may affect the
overall body of the patient. Without proper documentation of the patient's body, doctor will not
prescribe the medicines and as a result, it would leads to delay in the operations as well (Cusack
and et.al., 2019). Moreover, if the nurse did not document the patient’s blood glucose level then
it is fore sure that she also failed to check the patient’s medication orders as well as further
assessment too. This is a part of careless and as a result, it will definitely affect the patient and
their family in adverse way. In addition to this, due to improper assessment, it will affect the
quality of care and treatment provided to the patient and as a result, it will definitely affect the
overall working environment in opposite way as well. That is why, it is necessary to make sure
that there is a need to have proper assessment and care so that it will not affect the patients in
opposite way. Hence, proper documentation is the legal record which is used as an evidence
which helps to provide proper treatment to the patient.
As per the case study, Fifth unprofessional conduct is she failed to document the
adequate patient admission and history, this also helps the nurse or a profession to identify the
people with higher than usual chance of having the common disorder like heart disease. Further,
the purpose of obtaining the health history is to collect subjective data from the patient or from
their family so that the health care team or professional create a best plan in order to promote
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health and to minimize the chronic health conditions as well (Johnstone and Facn, 2019). While
on the other side, nurse did not document adequate patient admission and history, as a result,
prior disease will not identified and as a result, the medication will not be provided to the patient.
That is why, it is necessary for the nurse to take proper care of the patient and also done proper
documentation of the patient so that it will not affect the overall health and even the
professionals also take proper care of their patient by providing timely medicines and also
develop better care plan in order to minimize chronic illness as well.
Describing 5 professionals/ department which who could be impacted by these acts of
unprofessional conduct
As it is cleared that by following unprofessional conduct in a hospital creates negative
impact upon the business and as a result, it will also affect the overall brand image of the hospital
as well. Therefore, there are 3 professionals and 2 departments are mention below which also
creates direct impact due to unprofessional conduct. These are as mention below:
Medical Assistant: they are the professionals in health care sector whose main duty is
verifies the patient information by interviewing the patients, also record the medical history and
then confirm the purpose of visit (Devine and Chin, 2018). Therefore, when nurse failed to
document the basic documentation such that assessment of medical history, then it will creates
negative impact upon the medical assistant. While on the other side, it is also analyzed that when
there is no proper documentation of the patient then the doctor will not provide proper
medication to the patient and even not also promote to better health as well. As medical assistant
main duty is to filing patient's medical records but when the nurse did not have proper
documentation related to patient then the entire process will be delayed and it affect the overall
system too. As per the case study, it is analyzed that nurse failed to perform the documentation
related to blood pressure, weight and temperature, then it will create barrier for Medical assistant
to judge the performance of any patient without having proper documentation.
Doctor: Due to unprofessional conduct, doctor are also affected in adverse way such that
the doctor are remain under stress because they did not provide proper care to their patient and
ultimately it impact upon the workplace retention as well (Fischer, 2017). Such that as per the
case study, it is observe that nurse failed to document the ital signs q4h and as a result, doctor
did not have proper information about the current status of the patient. Therefore, the doctor will
not provide proper medication and as a result, it affect the patient mental level as well as
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increases doctor's mental stress. Therefore, it clearly shows that without proper documentation,
doctors are not able to provide medical facilities to their patient and overall, the patient has to
suffer. Moreover, it is clearly reflected that due to unprofessional conduct, most of the
professionals creates negative impact and as a result, it creates adverse impact upon the business
brand reputation as well.
Supervisor: They are another professional who monitor the entire work of the nurse and
other people who are working in the healthcare sector, it may also includes home health aide
who also provide home services to the patient because they are unable to come and enjoy the
services offered by the hospitals and doctors directly (MacLean, Coombs and Breda, 2016).
Moreover, unprofessional conduct are also creates negative impact upon the supervisor. Such
that when the nurse failed to filling a pain assessment of the patient and as a result, it shows that
either they receive wrong training from their supervisor or they did not follow the ethics of the
premises. As a result, it creates negative impact upon them as well. Moreover, if the nurse
mistreat with the patient then it is also consider a part of unprofessional conduct because
everyone should be treated in equal manner such that no one is liable to treat anyone with
disrespect. Therefore, it directly creates negative impact upon the supervisor and these
unprofessional conduct should be minimized so that it will not affect the brand image of the
organization.
Management department: It is the department which is affected the most when there is
no proper documentation done by the nurse and as a result, the management department faces
difficulties to manage the entire work (Starr, 2015). In addition to this, it is also analyzed that
when the nurse did not perform pre-operative checklist in which the entire situation of the patient
is describe then at that time, the management suffer problems to manage the things as per the
needs. Moreover, due to these unprofessional conduct done by one nurse and when the shift
changes and another nurse examine the report. At that time, they also faces issue to manage the
work and as a result, the management department suffers. Hence, it is clear that due to
unprofessional conduct, there are various department and professionals who suffer from this.
Care- taker department: it is the department which takes proper care of entire team as
well as patient such that this department perform daily checklist in order to make sure that the
team provide proper care to their patient by complying proper ethics and laws (Komolaf and
Porterfield 2018). But on the other side, from the case study, it is analyzed that there are different
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unprofessional conduct perform by the nurse and that is why, it creates negative impact upon the
care taker department as well. Such that when nurse did not have adequate patient admission
and history then as a result, when the patient shift towards another department, it may creates
confusion what treatment should be provided. That is why, it is necessary for the nurse to have
proper documentation related to patient's medical history so that doctors may take proper
initiatives as per requirement.
CONCLUSION
By summing up above report, it has been concluded that there are different
unprofessional conduct which are followed by the nurses as per the case study such that vital
signs q4h, pain assessments, pre-operative checklist, document the patient’s blood glucose level
and adequate patient admission and history. Therefore, these unprofessional conduct creates
negative impact upon the health care sector and as a result, patient also creates affected in
adverse way. Moreover, report also concluded that by following these unprofessional conduct,
there are different departments and professionals which also got affected, such that Medical
assistant, Doctor, supervisor, management department and care- taker department.
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REFERENCES
Books and Journals
Cusack, L. and et.al., (2019). Re-engaging Concepts of Professionalism to Inform Regulatory
Practices in Nursing. Journal of Nursing Regulation.10(3). pp.21-27.
Devine, C. A. & Chin, E. D., (2018). Integrity in nursing students: A concept analysis. Nurse
education today. 60. pp.133-138.
Escolar, R. C., & Magpantay, J. C. J. (2019). Moral distress of undergraduate nursing students in
community health nursing. Nursing ethics.26(7-8). 2340-2350.
Fischer, S. A., (2017). Transformational leadership in nursing education: Making the
case. Nursing science quarterly. 30(2). pp.124-128.
Johnstone, M. J. & Facn, P. B. R., (2019). Bioethics: a nursing perspective. Elsevier.
Komolafe, G. U., & Porterfield, S. (2018). Unprofessional Conduct In Nursing and its Impact in
Nurse Retention and Job Satisfaction.
Kunyk, D., & Deschenes, S. (2019). Disciplinary Decisions Regarding Professional Nurses:
Exploring Regulatory Decisions in a Western Canadian Province. Journal of Nursing
Regulation.10(3). 28-33.
MacLean, L., Coombs, C. & Breda, K., (2016). Unprofessional workplace conduct... defining
and defusing it. Nursing management.47(9). pp.30-34.
Starr, L., (2015). Is failing to declare a criminal history unprofessional conduct?. Australian
Nursing and Midwifery Journal.22(9). p.21.
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