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Reflection Presentation Discussion

Question One

According to NMBA standard 1.6, Registered Nurses (RNs) should apply strategic

thinking in decision-making and provide safe, high-quality nursing care. Failure to adhere to set

standards has been associated with adverse outcomes (Vaismoradi et al., 2020). The coronial

evaluations scrutinize nurses' duties and responsibilities, pinpointing the critical negligence in

nursing practices that led to patients' demise. Disclosure of malpractices motivates nurses and

other healthcare practitioners to improve the quality of care in related incidences (Lopes et al.,

2018). In MARA 2018, nurses demonstrated failure to implement effective decision-making by

disconnecting the oxygen nasal prongs, withdrawing the catheter, and making the patient shower

unattended, leading to Aiden's collapse and consequent deterioration of his condition, causing his

death. Planning and decision should effectively contribute to improved care (Reis et al., 2018).

Moreover, in EDWARDS, 2019, nurses failed to make timely documentation of the patient's

condition as required by NMBA standard 1.6, leading to adverse patient health outcomes.

NMBA 1.6 standards provide for the delivery of accurate and timely care. In WILLIAMS, 2019,

there was an apparent lack of escalation of care in the duration preceding Naomi's final

presentations. The three cases demonstrate the necessity for critical reasoning and reflection by

nurses to diminish the exposure of patients to harm (Karaca & Durna, 2019). Hence, the findings

from Coroner’s cases prompt nurses to reflect on their practices to recognize and rectify errors to

meet the required standards of nursing practice (Wood et al., 2019).

Question Two
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The clinical governance standards aim to put clinical governance systems in place to

ensure patients receive safe, high-quality health care (ACSQHC, 1.06 (a). Failure to have such

systems could result in adverse patient outcomes (Lopes et al., 2018). Coroner’s examination of

negligence cases in nursing practice plays a central role in enhancing the quality and safety of

healthcare. In EDWARDS, 2019, the nurses breached the ACSQHC code 1.06 (a) standards by

failing to provide a patient-safe environment because while the patient was excessively agitated

before his death, he received no concerns from the nurses on duty. Leadership and patient care

systems are highly recognized for creating an organizational culture that enhances the delivery of

quality care in line with ACSQHC 1.01 (a) standards (Grubaugh & Flynn, 2018). In YOUNG,

2015, there was evidence of the absence of a culture that enhances quality healthcare because the

patient encountered cardiac arrest and lost her life due to clinical malfunctions in the healthcare

system. Leadership competencies in clinical governance systems improve the safety and quality

of patient care (Salvage et al., 2019). Patient care is affected when collaboration and professional

relationships are not established (Wei et al., 2019). In WELLS, 2019, the nurses failed to apply

critical thinking based on their level of professionalism because they failed to detect the life-

threatening injury. Therefore, highlighted three cases show the requirement for providing quality

healthcare systems that guarantee a safe environment for patients, competent healthcare workers,

and practical clinical governance systems (Wei et al., 2019).

Question Three
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According to the ICN 2.1 code of ethics, nurses must hold themselves accountable for

ethical nursing practice and maintain competence through continuous professional development

and learning (ICN 2.1). Several cases have been reported where nurses' competence has been

questioned. In MARA, 2018, nurses wasted time with inappropriate patient assessment. The

nurses breached professionalism by violating ICN 2.1 conduct that focuses on personal

responsibility and responsibility, yet they disconnected the urinary catheter containing fluids.

The practice of nurses within limits of competency level when they thought faulty equipment

misled them into getting the patient's pulse other than using other assessments in critical cases

(Wood et al., 2019). Nurses promote patient safety and ethical conduct when errors occur (Lopes

et al., 2018). In TALBOT, 2016, nurses failed to escalate and inform the doctors of the patient's

situation leading to adverse patient outcomes due to miscommunication and lack of escalation,

raising questions about nurses' ethical conduct and professionalism. In PERRIN, 2018, a lack of

supervision of the novice nurse attending to the patient, a lack of observation, which was ordered

but not executed, and an unresponsive nursing team leader was documented among the reasons

leading to the patient’s death. The analysis of the three Coroner’s cases prompts nurses to

practice within the scope of their competence and authorization and to use professional judgment

when accepting or delegating tasks (Hoeve et al., 2018). The reflections prompt nurses to

provide patient-centred care through effective clinical governance to increase patient satisfaction

(Delaney, 2018).
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