• Subject Name : Nursing

Effective Measures to Improve Nursing Practices

Table of Contents


Incident Description.


Nursing Action Plan.

Reflection on the Incident



Introduction to Peter James McBride Case Study

Peter James McBride was an 86-year old patient suffering from Dementia. He was formerly admitted in Port Pirrie Hospital and later shifted to Royal Adelaide Hospital where he died due to multiple organ failure. The patient had developed bedsores, medically termed as ‘sacral pressure ulcer’. Owing to the age and the disease it was natural for the patient to developed bedsores. Proper care was lacking and there were some unnecessary treatment techniques were applied which affected the condition of the patient.

The thesis question of this essay is ‘What could be the effective measures to improve care quality for serious and old patients’. Here, the patient was suffering from a serious psychological disease, dementia. The nurses should have specialized care measures and plan of action for dealing with such patients. Immediate response by the nurses to a mental or physical problem of the patient can reduce the chances of fatality to a greater extent. This essay will at first describe the incident, devise the best nursing action plan and then present a reflective summary of the incident.

Incident Description

Mr. Peter James McBride was a dementia patient and was admitted in the Port Pirrie Hospital after the fall("Hospital staff failed elderly regional patient who died from bedsore", 2020) . His case history suggested the hospital authorities to restrict him to bed, following the hospital policy. As per prescriptions the nurses gave him anti-psychotic drugs which slowed down the activity of his brain. (Hallett & Brooks, 2017) had observed that sedative drugs relaxe the brain and reduce anxiety. On the negative side, unnecessary or overdose of such drugs could even lead to non-functioning of the brain making the patient immobile.

The immobility caused by the drugs prescribed to Mr. Peter led to the increase in the bedsore. The nurses failed to report the matter to the doctors due to which the appropriate measures could not be taken. A number of hospital staff and nurses were attending Mr. Peter but the required protocols in his treatment were not maintained. Each attendee staff was taking individual decision and implementing on the patient. The catheter was attached to the patient’s body by one doctor and removed by another doctor and then again re-attached to the patient’s body. The nurses failed to communicate the problems of the patient and the uneasiness he faced due to his illness and bedsores to the doctors.


The patient was in extreme patient due the dual problem of his illness and the carelessness of the nurses. The fact that he was unable to walk after the fall perhaps broke his mental stamina. The bedsore developed in the initial days of treatment restricting him to bed, which resulted in bedsores. (Soffer, 2014) had observed that bedsores are painful and eventually become prone to infections if timely cure is not provided. As a consequence, he did not receive the appropriate treatment to rescue from pain and infection. His family members strongly believe that dementia was not reason behind his death. It was the negligence of the hospital staff and the inadequate care of the nurses that led to his untimely death.

The findings about the unfortunate death of Mr. Peter have revealed serious level of carelessness of the hospital authorities in providing the appropriate treatment and care. The findings have pointed fingers towards nurses for failing to communicate the problems of the patient to the doctors. These findings and analysis will have negative impact on the morale of the nurses. The attendee nurses might have to hear harsh words from the superiors. As observed by (Teipel & Grothe, 2015), negative environment at workplace can lead to job dissatisfaction for healthcare workers.

Nursing Action Plan

The National Safety and Quality Health Service (NSQHS) has laid down standards for comprehensive care of patients (2020). The Action plan for the nurses to prevent the re-occurrence of the above situation like scenario has been drafted below in a tabular format:

Issues (problem of the Patient)

NSQHS Standards

Actions to be taken

Pressure Injuries (bed sores)

Identify best practices to develop an effective wound management and monitoring standards.

· Summarize the case history of the patient in keywords

· Record the nature and location of each and every pressure injury.

· Develop a wound management framework by identifying the intensity of each and every injury

· Monitor the progress of the wound’s respond to the treatment in a time-bound manner

Fall of the Patient

Three-pronged strategy for preventing falls, minimizing falls and post fall care.

· Categorize patients as high-risk, moderate-risk and low-risk based on harm caused to their health due to fall.

· An alarm clock can be kept at the bedside table for the patient to call for the nurse whenever he/she feels the need to get up

· Maintain a fall-risk assessment for each individual patient

Cognitive Impairment

Early recognition, prevention and treatment

· Talk with the patient about personal life, occupation, family members.

· Note sudden change in behaviour, if any, while interaction

· Identify areas or topics about which the patient cannot recollect anything

· Keep a time-bound track of patients treated with sedatives and in case of any change in behaviour or physical health immediate communicate to the doctor.

· Reduce the amount of sedative drugs if possible and replace with cognitive care therapy.

(Table: Drawn by the author)

Reflection on the Incident

(Rolfe, 2002) present three steps to reflect on an incident and its impact on the person. I find this model appropriate to prepare my personal reflection of the above scenario, which I have presented below:

  1. What is my feeling about the incident: In my opinion, the death of Mr. Peter is disturbing. It is also discouraging for young nursing students like me who are here to learn various ways to cure for people. I personally feel that the hospital management was also ineffective in noticing the mistakes committed by nurses in this case. A coherent and a co-operative approach could have saved the patient from an untimely death.
  2. So what: This incident has taught me that for patients having mental ailments like dementia and having fall history, it is important for nurses to continuously track the activities of the patient. Another important thing that I have learnt is that a smooth and effective communication between doctors and nurses is necessary for treating serious patients.
  3. Now what: I will learn the extra care techniques for cognitive treatment so that on personal level I am able to communicate well with such patients. Secondly, I will motivate myself by reading some positive news article whereby I can relate to good nursing and learn and motivate myself at the same time.

Conclusion on Peter James McBride Case Study

The thesis question of this essay demanded effective measures to improve care quality for serious and old patients. The essay discusses a real life scenario of a dementia patient who has a fall summary in this timeline of illness. Unfortunately, he dies in hospital and the findings and analysis held the care providers responsible for his untimely death. His family is heartbroken as in their opinion he was not supposed to succumb to his illness at such an early time.

Investigations have revealed loophole in communication among doctors and nurses and careless attitude of the nurses towards the gradually deteriorating condition of the patient, which turned out fatal. The NSQHS standards have been studied to chalk out effective measures in the form of action plans for three types of health issues in an old dementia patient. A personal reflection at the end of the essay is gateway to understanding nursing principles in a better way.

References for Peter James McBride Case Study

Books and Journals

 Hallett, C., & Brooks, J. (2017). One hundred years of wartime nursing practices, 1854-1953. Project Muse.

Rolfe, G. (2002). Reflective practice: where now?. Nurse Education In Practice, 2(1), 21-29. https://doi.org/10.1054/nepr.2002.0047

Soffer, A. (2014). Tracing detached and attached care practices in nursing education. Nursing Philosophy, 15(3), 201-210. https://doi.org/10.1111/nup.12052

Teipel, S., & Grothe, M. (2015). P4-094: Predictors of cognitive response to cholinergic treatment in patients with Alzheimer's disease dementia. Alzheimer's & Dementia, 11(17), 809-810. https://doi.org/10.1016/j.jalz.2015.06.1799


(2020). Retrieved 17 August 2020, from https://www.safetyandquality.gov.au/standards/nsqhs-standards/comprehensive-care-standard#background-to-this-standard.

Hospital staff failed elderly regional patient who died from bedsore. Abc.net.au. (2020). Retrieved 17 August 2020, from https://www.abc.net.au/news/2018-09-07/staff-failed-to-provide-care-to-elderly-patient/10214890.

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

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