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My name is Favor Wallace, a Liberian Australian completing my final semester of a Bachelor of Nursing at the University of Canberra. I have completed over 500 hours of clinical placement in acute care, surgical, neurorehabilitation, aged care, and mental health, where I provided evidence-based, person-centred care within multidisciplinary teams. Having worked in numerous teams, I am adaptable and can communicate effectively with my colleagues to work as part of a team to provide safe, respectful, and holistic care in diverse clinical settings. Being from a cultural background and having lived in my homeland Liberia until the age of 12, I have cultural awareness that enables me to respect diverse cultures by delivering compassionate, evidence-based care that recognises that individual needs, values and preferences are unique (McCormack & McCance, 2021), while maintaining safety and dignity.

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A 90-year-old, female, admitted to the acute geriatric care unit following a fall at home resulting in a sternal fracture and significant bruising to the chest wall. The patient was on Patient-Controlled Analgesia (PCA) and oral opioids for pain management, receiving 5 L oxygen via High-Flow Nasal Prongs (HFNP). Medical history includes chronic obstructive pulmonary disease (COPD), and aspiration pneumonia.

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As per standard 1.1 of the Nursing and Midwifery Board of Australia (NMBA) (2016), to provide safe, quality care for this patient, it was important to use a holistic approach and access the best available evidence to understand their overall clinical presentation. In this case, this included recognising the interaction between COPD and aspiration pneumonia, as these coexisting conditions can compound risks and significantly influence treatment decisions (Matsunaga et al., 2020). Research shows that aspiration pneumonia is an acute complication of COPD, which increases the risk of respiratory compromise due to the inflammatory response of excess mucus build up in the respiratory tract (Sanivarapu et al., 2024). The nurse demonstrated this understanding by implementing a multidisciplinary care plan in collaboration with doctors, physiotherapists, and speech pathologists. This plan included regular pain and oxygen monitoring, maintaining aspiration precautions, and modifying diet and fluids, all of which illustrate critical thinking to analyse practice and promote safe, evidence-based and person-centred care as per NMBA (2016) Standard 1.

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In my future practice, when caring for patients with COPD at risk of aspiration pneumonia, particularly if they have pain related to fractures, I will focus on careful respiratory monitoring to identify immediate signs of respiratory compromise. In particular. Extensive sternum fracture pain can cause shallow breathing, further impairing gas exchange and respiratory function, by increasing hypoventilation, weakening cough reflex and making it difficult to clear secretions there by increasing pneumonia risk (Burdge et al., 2022). It is important to enhance lung mechanics and airway protection, as maintaining an upright posture can reduce gastroesophageal reflux and lower the chances of aspiration pneumonia (Yu et al., 2024).  To achieve this, I will use evidence-based, non-pharmacological strategies, including frequent repositioning, encouraging upright sitting during and after meals, and providing back support with pillows while in bed. These actions enhance lung mechanics and airway protection, as maintaining an upright posture can reduce gastroesophageal reflux and lower the chances of aspiration pneumonia (Yu et al., 2024).

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The use of PCA showcases NMBA (2016) Standard 2.3, which recognises individuals as experts in their own experiences of care. PCA empowers patients to self-manage pain according to their tolerance (Pastino & Lakra, 2023) and fosters autonomy and aligns with person-centred care as per standard 2.7. According to the Canberra Health Services (CHS) policy, PCAs must be managed exclusively by nurses who have completed the necessary competency training to ensure they can provide safe and appropriate care, as outlined in Standard 3 of the NMBA (2016) standards. During the patient’s admission, the attending nurse, recognised their limited recent experience with PCA management, they refreshed their knowledge through policy review and consultation with a Clinical Development Nurse. This showed accountability and commitment to lifelong learning (Standard 3.3). The nurse also provided clear explanations of PCA use and monitoring to me and the patient, including safety measures such as the five-minute lockout period, thereby empowering the patient to participate in her care as per Standard 3.2 of the NMBA (2016). Ongoing monitoring of vital signs hourly and two hourly PCA checks were done in strict adherence to CHS policy, demonstrating accountability for patient safety in accordance with standard 3.4 of the NMBA (2016).

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Although I was not yet competent to manage the PCA independently, I ensured patient safety by closely monitoring vital signs and promptly alerting the nurse to complete PCA checks, particularly as they were responsible for multiple patients on the acute ward. This was essential, given the patient was also prescribed PRN opioids, which  if combined with PCA increases the risk of respiratory depression (Australian Commission on Safety and Quality in Health Care, 2021). Moving forward, I aim to complete competency training in PCA management, strengthen my knowledge of CHS policies, and continually engage with current research to ensure safe, evidence-based practice.

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For example, when the patient could not tolerate thin fluids, the nurse recommended mildly thickened fluids and referred to speech pathology  for further evaluation and recommendations in accordance with NMBA (2016) standard 2.6. Following assessment, the speech pathology team identified a high aspiration risk and discussed the potential for a percutaneous endoscopic gastrostomy (PEG) tube with the patient and family. This approach promoted informed decision-making, comfort, and reduced stress, aligning with NMBA (2016) Standard 2.6 and 2.7. The patient declined the PEG, and her wish was respected as per standard 2.5 of the NMBA (2016).

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I will foster therapeutic and professional relationships in my future practice by involving patients in care planning, encouraging feedback, and respecting preferences in line with NMBA Standard 3. For example, I will conduct bedside handovers that promote transparency and involve patients in decision-making. In conclusion, by acknowledging my strengths and limitations, seeking guidance, and committing to ongoing professional development, I can uphold the NMBA standards while ensuring patient-centred, evidence-based, and safe nursing care.