Case Studies

Here you will find a selection of themes which an Advanced Nurse Practitioner, General Practice Nurse, Nursing Associate or Healthcare Assistant might face during their working day.

"To be "in charge" is certainly not only to carry out the proper measures yourself but to see that every one else does so too; to see that no one either willfully or ignorantly thwarts or prevents such measures. It is neither to do everything yourself nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appointed." - Florence Nightingale, Notes on Nursing: What It Is, and What It Is Not

Scenario 1: General Practice Nurse

During a busy morning in the treatment room the GPN calls the next patient in for ear irrigation. She is running 15 mins late. The nurse asks the patient if she has been oiling her ear ready for irrigation and the patient says 'no' she hadn't been told to do so. The nurse examines the patients ears which are dry and impacted with hard wax. She informs the patient that she can't perform the ear irrigation and they must rebook for the procedure. The patient is very upset as she had waited for 30 mins and was desperate for her ears to be irrigated. The nurse tries to explain the reasoning for her decision and the patient leaves her room very tearful.

A couple of days later the nurse receives a letter of complaint from the patient. The practice manager is informed and asks the nurse to write a letter of apology to the patient. The nurse does this and believes the complaint has been dealt with however a few months later the patient writes again to the nurse complaining about her treatment.

This complaint needs to be dealt with by the Practice Manager. The nurse has already made an apology and the patient is obviously not satisfied. The Practice Manager may discuss the complaint with the Practice Partners. There may be more to this than just the nurse appointment and it may be about care she has received or not from the practice. This needs to be explored and all issues discussed with the patient and Practice Manager.

It may be worth reviewing protocols/procedures involving ear irrigation and preparation for appointments as this may have helped prevent the complaint in the first instance.

Written guidance prior to tests/procedures is useful as patients do not always remember instructions. These can be given out by clinicians, reception staff or put on the surgery website.

Scenario 2: HCA

An HCA is performing some basic wound care as per protocol. Her elderly patient has a wound on her leg which appears more inflamed than usual and she decides to ask one of the practice nurses to look at the leg. The nurse is busy and quickly comes to assess the wound but feels that there is no infection.

The HCA feels that the wound does show signs of infection but doesn't feel she can argue with the nurse. The patient is not concerned and in no pain. The HCA dresses the wound and arranges a follow up appointment.

Two days later the patient returns for redressing of the wound. She has an obvious wound infection and is in pain. She calls another practice nurse to assess the wound, it was agreed to take a swab and the duty GP prescribed a course of antibiotics. The patient is sent home with advice and a follow up appointment is made for 2 days.

The HCA feels this could have been prevented or at least reviewed better. She goes to the Lead Nurse to discuss her concerns.

This is always difficult and none of us have a crystal ball. Sometimes we have a 'gut' feeling however we need evidence of signs of infection before we can begin to treat it.

No one is at fault and the Lead Nurse needs to support both the HCA and nurse to ensure they understand the situation and take into account personal views and opinions. This would be a good piece of joint learning. Perhaps the nurses could do a 'lunch and learn' about managing wounds, dressings and infections.

A practice protocol is useful to ensure everyone follows the same procedures. It may also highlight a need for further training and could be used as a piece of reflective practice for revalidation.

Scenario 3: Advanced Nurse Practitioner

At the end of a busy Friday afternoon clinic the ANP was asked to see a child who was febrile. The child's parents were very concerned and had arrived at the surgery without phoning first. They refused to accept a call from the GP or ANP and refused to go home without a consultation. They were 'squeezed' into the end of the clinic. After examination and discussion with the parents the ANP did not feel that the child needed admission or further review and sent the child and parents home with advice and guidance. They appeared satisfied with the consultation and had some written guidance to take home with them.

On Monday morning the ANP found out that the child had been admitted to the local hospital on Saturday evening. A receptionist made a comment to her that maybe she should have admitted the child on Friday evening as the parents had been very worried.

The ANP felt concerned that she may have made the wrong decision although she was sure she had not 'missed' anything significant. She went back to her room and re-read her consultation notes.

We all think about our patients and wonder if we have made the right decisions. Children are even more difficult to assess and can recover or deteriorate very quickly. In these circumstances it would be appropriate to speak with a GP and review the notes together. Talking through consultations helps professionals learn how to become more confident at decision making and supports learning. It was agreed the ANP had made the correct clinical decision at that time and she went on to use it as a piece of reflective practice for revalidation.