Being a Professional Nurse: Critical Analysis Essay of a Case Study by Priya Deo
In the Nursing Field and other health care setting, all healthcare workers such as nurses are required to
follow all the standards of nursing practices and boundaries to provide the safest and highest quality of
care to their patients. The case study provided shows nurses demonstrating unsatisfactory nursing
practices. Through this essay we will discuss and investigate the case study, identify the relevant
professional practice errors that may have contributed to the case and compare them to the NSW
health policies and finally discuss how an individual’s professional practice might be changed,
developed or influenced as a result of this incident.
In the case study provided, the case demonstrates a decision statement from the Nursing and
Midwifery Council of New South Wales, in the against of Registered Nurse (RN) Harvadan Pandya and
RN Sumitra Prasad and their unsatisfactory nursing practices which lead to a stage three mental patient
committing suicide. According to the HCCC v Pandya and Prasad case, RN Pandya violated five
professional nursing practice boundaries which included, RN Pandya not advising or giving advance
notice in regards to him leaving early to do another shift, not providing correct/ no handover , him not
carrying out proper observations and not keeping legible/proper records. Mr. Pandya’s actions
throughout the course of this shift revealed his negligence resulting in death, lack of care and safety
about his work environment, team members and patients and unsatisfactory nursing practices. RN
Pandya failed to inform his in-charge Rn, RN Khan that he would be leaving early to attend another
shift. As this case studies findings suggest, RN Pandya through he was helping out the hospital by
doing the other shift, hence why he thought he did not need to inform his in charge about his departure.
The findings in the case study suggest that RN Pandya had not obtained consent to leave the ward and
communication between him and his in-charge RN was not clear. Additionally, before leaving the ward
RN Pandya had also not giving any handover to any of the nurses taking over in regard to any of his
patients. The only information that RN Pandya did provide was that he stated that his patients were all
back from the court yard and all of them were ‘fine.’ During this conversation with the RN, RN Pandya
did not verbalise to her that this was his handover and that he was leaving early to attend another shift.
The findings from the case study further suggest that RN Pandya’s desire to go and attend another shift
took over his obligations as an RN to provide safety to his patients, resulting the unfortunate death of a
mentally ill patient. In addition, RN Pandya and RN Prasad incorrectly failed to document and take vital
signs/ behavioural charts for their patients. As RN Pandya had not taken observations between
1400hrs and 1420hours and stated he only saw the patients and saw they were ‘fine’ and did not
understand the rational for the behavioural observations, however RN Prasad still signed the
observational charts without correct handover or having any direct contact or interaction with the
patients.
In this case study many nursing practices errors are uncovered that lead to the unfortunate event of a
patient taking their own life. As displayed in the case study the first error that RN Pandya did was
leaving his shift without informing his nurse in charge RN Khan as displayed by the Policy Documents
of WSLHD in the case study all health case staff must obtain permission from their Team leaders/ nurse
in charge before going for breaks, completion of duty or departing the ward for any reason. Even
though RN Pandya was an experienced RN and knew all the policies of the Bungarribee House he still
violated his duties as a Registered Nurse. The Bungarribee House also has a policy that states that
“two nursing must be present and provide continuously support and supervision to Acute clients
between 0700 hours and 2300 hours” and both RN’s violated these rules and performed below the
professional nursing standards required, RN Pandya by not getting permission to leave the ward, not
informing his nurse in charge and also by leaving the ward without the present of two nurses taking
over care and RN Prasad by leaving the floor to go get handover and leaving RN Pandya’s patients
unsupervised although RN Prasad did mention in the case study that she thought there was enough
staff on the floor but did not check to see if there was enough staff to come and supervise the acute
ward. The second breach that both nurses violated was the National Safety and Quality Health Service
(NSQHS) Standard for communication and critical information standard 6.11 which illustrates “Relevant,
accurate, complete and timely information about a patient’s care is documented and communicated in
the healthcare record to support safe patient care.” Both nurses failed to communicate properly with
each other as well as with their nurse in charge which lead to them not be able to get enough staff to
take over while they were absent. Additionally RN Prasad signed behavioural charts without interacting
with RN Pandya’s patients as well as RN Pandya only doing observational records for that patient
which displayed how his need to go and attend his other shift overlooked his obligations as an RN to
provide safety to his patients as well as breaching standard 6.11 Documentation of information
(NSQHS) which states “Documentation is an essential component of effective communication....
Undocumented or poorly documented information can lead to a loss of information, which can result in
misdiagnosis and harm of patients and other healthcare staff.” Furthermore, both nurses also violated
the National Safety and Quality Health Services Standard 6.7 Clinical handover which illustrates that
“accurate and relevant information about a patient’s care is communicated and transferred at every
clinical handover to ensure safe, high-quality patient care.” All relevant information about the patient
such as harm risk, medications, Obvs and allergies should be effectively and clearly communicated at
the beginning of a handover in timely order (Nursing and Midwifery Board of Australia (NMBA), 2018,
Standard 3). As seen in the case study both RN’s failed to abide by the professional standards required
to give a handover as RN Pandya did state that Patient A’s obvs were stable and he was fine, when in
fact this was not the case. Failures at multiple points of clinical handover and lack of effective
communication can leading to a poor patient outcome. (Manias et al., 2018). In conclusion, the
standards of practice and policies listed above were only a handful of the many standards that RN
Pandya and RN Prasad violated on this shift at the Bungarribee House resulting in a patient’s death
and performing below the nursing standards required to ensure patient safety and positive patient
outcomes.
This case study has allowed me to reflect and acknowledge the significance of following the rules and
professional nursing standards as I transition into my career as registered nurse. During my career as
an RN I will experience situations where I will need to leave the ward to go pick up kids early or do
overtime and in these situations I need to always keep in mind that my patients are my biggest priority
and their care comes first. Before leaving early I must get approval from my nurse in charge and make
sure that all the documentation for my patients are all completed, clear and precise and that I have
done my handover correctly to my nurses taking over before I leave following the NSQHS standard
6.11 (2012) standard which stated timely effective communication and correct documentation will
ensure safe care for patients and as stated by NMBA standard 1.4 (2016) nurses must comply with
legislations and other standards when providing care to patients and decisioning making around patient
care to ensure positive patient outcomes. One of the issues in this case study was RN Pandya’s failure
to observe his patients resulting in Patient A committing suicide. Making sure that I as a nurse follow
standards 6.4 standards of practice for Registered Nurse which displays that nurses should supervise
and use timely direction to provide patient safety and correct nursing practices. The most common
mistake in this case study was both RN’s lack of sight and negligence which in turn had a negative
patient outcome. Throughout my nursing career I will try to avoid making severe mistakes that could
endanger my patients and staff and always follow all of the protocols and produces to ensure patient
safety. In turn I believe that this case study is a good foundation to reflect on as it allows nurses and
future nurses like me to understand the significant of following protocols and policies in order to
guarantee positive patient care and safety.
In conclusion this essay conversed and investigated the case study, it examined the different situations
that occurred on the ward that day that lead to the unfortunate death of a patient. It also discussed all of
the relevant nursing professional errors and all the contributing factors of the incident while looking at
the NSW health policies that were breached. It further defined different protocols and standards of the
hospital and nursing practices that both nurses also breached and finally it demonstrated how an
individual nursing practice might be influenced and change as a result of this case study.
Reference List
Australian Commission on Safety and Quality in Health Care. (2012). National Safety and
Quality Health Service Standards. https://www.safetyandquality.gov.au/standards/nsqhsstandards/communicating-safety-standard/communication-critical-information
Health Care Complaints Commission v Pandya and Prasad [2017] NSWNMPSC 2
Manias, E., Geddes, F., Watson, B., & Della, P. (2018). Communication failures during
clinical handovers lead to a poor patient outcome: Lessons from a case report - Elizabeth
Manias, Fiona Geddes, Bernadette Watson, Dorothy Jones, Phillip Della, 2015. SAGE
Journals https://journals.sagepub.com/doi/10.1177/2050313X15584859.
Nursing and Midwifery Board of Australia. (2016). Registered Nurse Standards for Practice
https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professionalstandards/registered-nurse-standards-for-practice.aspx
Nursing and Midwifery Board of Australia. (2018). Code of Conduct for Nurses.
https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professionalstandards.aspx
New South Wales Government Health. (2017). Policy Directive e Engagement &
Observation in Mental Health Inpatient Units.
https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2017_025.pdf