The Handover Clash
On a 24-bed surgical ward, staff nurse Róisín (three years' experience) raises a handover issue: a patient's prescribed analgesia was administered 90 minutes late overnight, and the drug chart was signed as if it had been given on time. The night nurse, Karen, has twenty years' experience and is a close friend of Tom, the newly appointed clinical nurse manager, who is six weeks into the post. In front of six staff, including a first-year student, Tom says: 'A ninety-minute delay on a busy night is nothing. Let's not blow this out of proportion.' Róisín knows the patient's pain score was recorded as 8/10 at the time the dose was due, and that the patient later asked why nobody came. Two other nurses look at the floor; one later tells Róisín privately that 'this happens a lot and nothing is ever done.' The patient's family has already asked the ward sister why the pain relief was late.
1. What is the most likely explanation for Tom's response, and what evidence in the scenario supports your view?
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Tom is most likely responding to the social situation rather than to the clinical facts. He is six weeks into a management post and dependent on experienced staff; Karen is a close friend; he speaks in front of six staff, which makes a public defence of a friend more likely; and his phrase 'let's not blow this out of proportion' reframes a documented false entry as a trivial delay. The delay itself is not the central issue - the signature saying the drug was given on time is a records-integrity problem. A charitable alternative is that Tom genuinely believes short delays are common, but that belief is contradicted by the 8/10 pain score and the patient's question, both of which were available to him and which he did not ask about. The evidence therefore points to loyalty and conflict avoidance rather than to a reasoned clinical judgement.
2. What should Róisín do next? Give the order of steps and justify them.
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First, make a factual, contemporaneous note of what was said and observed, including the chart entry and the pain score. Second, ensure the chart and related records are preserved. Third, escalate in writing to the ward sister and, if the response is inadequate, to clinical governance or the appropriate regulator. Fourth, speak to the patient or family only within her role and with the ward sister informed. She should not confront Tom publicly again, and should not let the matter rest on a colleague's private comment that nothing is ever done. The justification is that the issue is not the 90-minute delay but a record stating a medicine was given when it was not, which could mislead the next prescriber and conceals a patient-safety event. Escalation protects the patient and also protects Róisín, who is exposed if she stays silent.
3. How does the student's presence change the situation?
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The student is learning what the ward does with concerns, not what its policy says. Tom's public dismissal teaches that raising a concern earns humiliation, and the two nurses looking at the floor confirm that this is the expected response. A student who sees this is less likely to report an error later, which is a patient-safety risk extending well beyond this incident. Róisín should not turn the handover into a debate in front of the student, but she should ensure the student sees the correct process - factual reporting and escalation - and the ward sister should debrief the student afterwards. The student's presence also increases Tom's accountability, because his words are now witnessed and are relevant to any later review.