Quality and Safety Education for Nurses



It is recommended that instructors present the case study to their students in class. As questions are presented in the module, instructors should allow their students to respond, either as a class or in small groups. Case Study One: SarahSarah is a 22 year-old white female who was escorted to the emergency department by her boyfriend at 0120 with a chief complaint of extreme pelvic pain (9/10) and significant vaginal bleeding. When asked about the bleeding, Sarah does not answer, but her boyfriend says it started about an hour prior and stated no precipitating causes. Her physical exam showed signs of bruises and contusions to her abdomen, arms and thighs. Her abdomen is slightly rounded, soft and non-distended. Abdominal sounds are present; the bleeding has slowed on exam is scant.What are your first thoughts and actions? (Encourage students to think about physiologic needs, such as blood pressure management, oxygenation, etc. Also explore what initial questions they would like answered.)Emergency department staff responds to immediate physiologic needs. Sarah’s nurse asks the client if she is pregnant. Sarah, appearing horrified, shakes her head “no.” Her boyfriend becomes visibly agitated. When the nurse attempts to find out more information, the boyfriend exclaims, “She doesn’t have anything to say! She just started bleeding, why don’t you do something?”Discuss the situation. Here are some sample questions to provoke brain-storming: How would you respond? Would you ask the man to leave? What are your immediate concerns? What questions do you have for the patient? What assessments or tests would you expect to take place next?The whole story: Sarah was being trafficked by the man that brought her to the hospital pretending to be her boyfriend. Earlier that evening Sarah was meeting a client. During their time together, the client had become highly aggressive so Sarah attempted to leave. When she did, the client used a set of keys to molest her. Upon vaginal speculum examination, deep lacerations were seen in her vaginal wall, causing the bleeding. Discussion and debriefing: Now knowing the whole picture, would you change anything about how you approached the patient interaction? What did you originally assume was going on in this situation? –Intimate Partner Violence? Rough sex? If the vaginal trauma had been less severe, do you think sex trafficking would be considered a possibility? Unless providers are aware of sex trafficking, patients may not receive much-needed assistance. How would you assess the safety of yourself and your patient in this type of situation? What resources could you, as the nurse, use in this situation? Case Study Two: AliciaAlicia is a fourteen-year-old girl who presents to your pediatric clinic for her annual physical. As the nurse reviews Alicia’s chart, it is recalled that Alicia was a bit behind developmentally, not meeting all of the typical milestones. Last year, this was attributed to a lack of stability in Alicia’s life. Alicia has been in foster care since she was less than a year old and has been moved from home to home many times. It was also noted that Alicia has always been a friendly and talkative child. Alicia is brought into the office by Carol, her foster mom, who seems rather cold and detached. Alicia goes into the room by herself as Carol waits in the lobby. As the nurse begins the visit measuring Alicia’s height and weight, she notes that over the past year Alicia has lost six pounds and has a visibly sunken appearance. When asked about school and her extracurricular activities, Alicia mostly shrugs in response, and says that she mostly hangs around a group of older kids. When asked how she felt physically, she had no complaints. The nurse asked if she had started her period and Alicia said yes. She also mentioned about having “yellow stuff” sometimes and asked if that was part of having a period. Do you have any initial questions or concerns? How would you respond to Alicia’s question? Would you ask if Alicia was sexually active? Alicia tells the nurse that she has had sex before. She isn’t quite sure how many people she has had sex with. How would you as a nurse respond to this fourteen year old? What do you assume is going on in this situation – promiscuity, a desire for attention, sex trafficking? What other questions do you have? How might you try to support Alicia? What are your legal requirements in this situation? The whole story: Alicia used to go to the park near her middle school at the end of the school day before she would go home. Her foster parents both worked and she had a lot of time by herself, as she was the oldest of all of the children who stayed at this home, and the younger kids went to daycare. At the park she met an older boy, Derek, who was nice and showed her attention; he wanted to be her boyfriend. Derek would buy her things and take her places, and she thought they loved each other. First it was only Derek who wanted to have sex with her, but things changed. He made her have sex with other people who would come by his house. If she refused Derek would become aggressive and would hurt her. Alicia had not told anyone. Upon medical and psychological examination, Alicia was diagnosed with depression, anxiety and multiple sexually transmitted infections. Discussion and debriefing: Now knowing the whole picture, would you change anything about how you approached the patient interaction? What questions about abuse should you ask at every client encounter? What resources could you use in this situation? What safety concerns do you have for Alicia? For more case studies, please visit the Polaris Project module, Recognizing and Responding to Human Trafficking in a Health Care Context, located under Online Trainings (). ................
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