Amy Keller

Needlesticks: Avoiding the Hazard

by Amy Keller | Jun 17, 2016 | Career Advice, Clinical, Health & Wellness, Nursing Articles | 0 comments

During her second day on the job, the newly minted RN was tending to a febrile patient in the ICU and preparing to give him a shot of insulin. Because the patient was thin, she pinched a fold of flesh on his abdomen between her thumb and forefinger, as she’d been trained to do—but when she inserted the syringe it poked right through the patient into her own finger.

“He just looked at me and said, ‘oh, honey,’” the nurse recalled in an anonymous posting in an online discussion board for nurses. “That rang in my head the whole time as I was bleeding the puncture and washing my hands. Oh honey, indeed.”

She’s not alone. Nurses, not surprisingly, comprise the largest percentage of the estimated hundreds of thousands of U.S. health care workers who experience a needlestick injury on the job every year and run the risk of acquiring more than 20 diseases, including Hepatitis B (HBV), Hepatitis C (HCV), and Human Immunodeficiency Virus (HIV).

“Without hesitation, nurses, by far, have the highest percentage of needlesticks and splashes and splatters of any other profession in health care, mostly because they’re at the patient’s bedside more than any other worker,” says Amber Mitchell, DrPH, MPH, CPH, executive director and president of the non-profit International Safety Center.

While no one knows exactly how many needlestick injuries occur nationwide every year, data that the International Safety Center collects annually from about 30 U.S. hospitals and health systems provides a snapshot of the problem. In 2013, a total of 508 percutaneous injuries were reported by network facilities—a sharps injury rate of 21.37 per 100 occupied beds. More than 36% of the injured employees were nurses.

Although those figures represent a significant improvement in injury rates in the 15 years since President Clinton signed into law a federal needle safety bill, the reduction is of little consolation to the nurse who accidentally gets stuck.

Testing and re-testing for infection can last up to six months—and treatments can be grueling. The post-exposure prophylactic treatment sometimes given to prevent HIV infection, for instance, can cause nausea, vomiting, diarrhea, and fatigue. And while the risk of contracting a bloodborne pathogen from a contaminated needle is generally quite small, the mental anguish associated with a needlestick can be enormous. Weeks and months of waiting for test results can cause anxiety, depression, and other psychiatric disorders.

When it comes to needlesticks, there’s no denying that “an ounce of prevention is worth a pound of cure.” With that in mind, here are six strategies nurses can follow to better protect themselves.

1. Use safety devices.

Needlestick rates have declined precipitously since the enactment of the Needlestick Safety and Prevention Act, which requires hospitals and other employers to use safer needles. That said, not all safety devices are equal. Case in point: When Robert Wood Johnson University Hospital in New Jersey switched from using winged blood collection sets with a forward-shielding safety mechanism to one with a quick, in-vein retraction system, needlestick injuries dropped by 70%. Whenever possible, use a needle-free device, but if a syringe is your only option, choose one with a “passive” safety mechanism. Studies show that fewer accidental needlesticks occur with devices that deploy automatically, as compared to those that are manually activated. Whatever device you use, make sure you feel comfortable handling it, and request more training and practice if you don’t.

2. Never recap.

Once upon a time, the practice of recapping used needles was commonplace. While vigorous education campaigns about the dangers of the practice have helped reduce the incidence of recapping-related injuries, it’s still a problem. Recapping is dangerous in several ways: The needle can miss the cap and puncture one’s hand, it can pierce the cap and stab one’s finger, or an ill-fitting cap can slip off creating a hazard. In rare situations where recapping is absolutely necessary, the Occupational Safety and Health Administration (OSHA) recommends using a single-handed scooping method, where the cap is placed on a flat surface and scooping it onto the tip of the syringe. But safety experts say it’s best to avoid the practice entirely.

3. Plan ahead.

Before delivering an injection, envision how you will safely administer the shot and dispose of the contaminated needle. Locate the sharps disposal container—it should be within arm’s length, at eye level, and not overfilled—and explain to the patient everything that you will be doing. Patients are less likely to become startled and make a sudden movement if they are also prepared. If a patient is agitated, combative, or unpredictable, ask a colleague to assist you. Limit interruptions during procedures and dispose of used needles immediately after use only in the approved sharps container.

4. Get involved.

Under the law, hospitals and other health care facilities are required to solicit input from frontline workers like nurses to help evaluate and select safety devices. Your input is valuable and you’ll likely adapt better to technology you’ve had a hand in selecting.

5. Avoid fatigue.

Research shows that working excessively long hours can contribute to job-related injuries like needlesticks. According to one study, needlestick injuries in hospital nurses increased by 16% for every additional 10 hours they worked, and a 2015 study found a 32% increased risk of a needlesticks for newly licensed RNs working overtime. One of that study’s authors, Amy Witkoski Stimpfel, PhD, RN, an assistant professor and researcher at New York University’s Rory Meyers College of Nursing, says shift work contributes to chronic partial sleep deprivation, which can lead to performance impairments. “Our attention lapses – even briefly – and we make mistakes when we are sleep deprived. The slightest lapse of attention can lead to a needle being stuck in the wrong place.”

6. If you get stuck, report it.

Lack of time, embarrassment, and a perceived low infection risk are just some of the reasons nurses often don’t report needlesticks. But the potential consequences of an accidental exposure are simply too big to ignore—and time is of the essence. While the risk of contracting HIV from a contaminated needle is around 0.3% (1 in 300), according to the CDC, risk goes up with a deep injury or when a patient has a high viral load. Swift reporting of an accidental needlestick provides a better opportunity to get consent from a patient to test their blood for infectious diseases and for you to start on prophylactic therapy, if it’s warranted. PEP must be started within 72 hours after a possible exposure to HIV. If you are accidentally stuck, gently wash the puncture area with soap and water, report the incident to your supervisor, and follow your employer’s procedures.

How to Talk to Doctors

by Amy Keller | Apr 26, 2016 | Career Advice, Nursing Articles | 0 comments

Talking to physicians can be one of the scariest parts of the job for a new nurse. For the rookie RN, a 3 a.m. call to the doctor can be fraught with terror that they’ll say something stupid, get yelled at, or even have the physician hang up on them. Without the cushion of experience, many new nurses stress over what sort of situations even warrant a call to the doctor, and which ones don’t.

“It was intimidating. It can still be intimidating and I’ve been doing this for 20-some years,” says Jodi Wendel, RN, an oncology nurse in Muncie, Indiana.

In her early days, Wendel says she remembers her fellow nurses warning her about doctors with reputations for being rude or difficult. “They’d warn me, ‘doctors A, B, and C aren’t going to give you any trouble… and doctors D, E, and F are going to give you trouble, question you, or get mad at you.’”

In time, Wendel says, she gained confidence in her interactions with physicians and learned how to handle those with more difficult personalities. With the right mindset, and by following these tips from Wendel and other seasoned nurses, the new nurse graduate can speak to doctors with poise, rather than a pit in the bottom of their stomach. [et_bloom_inline optin_id=optin_20]

Be Prepared

Doctors are busy people, so before dialing the MD, make sure to have all your ducks in a row. Know the patient’s diagnosis, have their latest labs and vitals on hand, know what medications they’re taking, and be aware of any allergies. “Know what you’re calling for and what you’re hoping to get. That way it’s just cut and dry and you’re not doing the ‘let me check, let me check, let me check,’” advises Wendel.

Try to anticipate what other questions the doctor might have. If you’re calling about a patient with a low O2 sat, make sure you’ve got the respiratory rate. If the patient’s blood pressure has plummeted, know the patient’s heart rate and have other vital stats available. Be sure to keep the patient’s chart open so you’re not fumbling for an answer—and document the communication.

Alana Aghassi, RN, a staff nurse on a busy neuroscience unit in a St. Petersburg hospital, urges nurses to follow the SBAR (Situation, Background, Assessment, and Recommendation) technique to relay information efficiently. Following this rubric, the nurse: identifies the patient and the problem (situation); provides a brief explanation of the patient’s admission and pertinent medical history (background); presents any concerning findings, including symptoms and vital signs (assessment); and then asks the physician what they need (recommendation).

While the recommendation step can be difficult for new nurses, it’s a key part of the call—and the nurse should know what he or she wants from the doctor. “They’re asking for your professional opinion, so you need to have one,” says Tina Stevenson Reed, RN, a longtime hospice nurse in Tampa. “If your patient has been on two antiemetic medications, and is still vomiting, have an alternative in mind. “You might say, ‘we tried Compazine, and it didn’t work. We tried Reglan and that didn’t work. I’m thinking Zofran, what do you think?’”

Be Confident, Not Apologetic

Kathleen Bartholomew, RN, MN, a nurse leader, consultant, and speaker based in the Seattle area, recalls an encounter during her first nursing job with an “egotistical” doctor who made poor eye contact with nurses and was known for hanging up on them. One day, when that physician finally decided to speak with Bartholomew, she jumped on a chair, locked eyes with the six-foot-four physician and asked him what he needed. Stunned, the doctor walked away—but Bartholomew says she earned his respect. The next time she talked to the same doctor, he was more attentive and they soon developed a good working relationship.

While not all new nurses may have that panache on day one, learning to be assertive is essential—and don’t be afraid to “fake it” till you make it. “You can’t let people walk all over you,” says Aghassi. “You approach respectfully, but confidently, even if you are not feeling the most confident.”

And by all means, never apologize for calling a doctor, says Bartholomew, author of the book Speak Your Truth: Proven Strategies for Effective Nurse-Physician Communication. “When it’s 2 o’clock or 4 o’clock in the morning, we have a tendency to say ‘I’m sorry to bother you.’” Chances are, the doctor doesn’t apologize when he calls the nurse—and nurses simply perpetuate a power imbalance when they apologize for doing their job, Bartholomew says.

If possible, cultivate friendships with the physicians, advises Bartholomew: “You can talk about what to do, and skills and tactics, but what matters is the relationships. Until you feel like you can ask a physician out for a cup of coffee and they say yes, you have work to do—because sharing a cup of coffee means collegiality in this culture.”

Be Your Patient’s Advocate

Poor communication can have a big impact on patient safety. In fact, communication breakdowns have been implicated as the root cause in nearly two-thirds of serious medical errors.

Paula Bungay, an RN who has worked in Canada and Florida, says she learned early on in her career that the stakes are too high not to speak up. “I was a student and I had a patient go very, very bad first thing in the morning in the middle of report, and she ended up dying. Nobody would listen to me because I was a student. They just kept blowing me off. From that point on, I swore I would never let that happen again.”

For the new nurse struggling to decide whether a situation is urgent enough to call the doctor immediately, or wait till rounds, Bartholomew prescribes this litmus test: imagine the patient you’re concerned about is your own daughter, mother, or father. In that situation, Bartholomew says, you’d do anything. “If you’re afraid to speak up, then your patient is at risk, and we have not met our ethical obligation.”

Report Bad Behavior

While doctors’ behavior has improved over the past couple of decades, “you still have physicians who are rather intimidating and use intimidating tactics,” says Bartholomew. Those tactics can be subtle, such as not knowing a nurse’s name, even though she’s been working the floor for six months, looking at a nurse with a “hurry up” or “get-it-over-with” look on their face, or making no eye contact at all.

In a 2013 survey on workplace intimidation by the Institute for Safe Medication Practices, 87% of nurses reported a “reluctance or refusal” by physicians to answer questions or return phone calls or pages, and 74% said doctors had used “condescending language” or made demeaning comments.

Nurses need to remember that if a physician is really acting like a jerk, they can and should report them. “Hospitals have a lot more standards and policies about this stuff than they used to and that’s important for new nurses to know,” says Aghassi. “Know your chain of command and what to do to report abusive physician behavior because a lot of physicians have really toned it down—because a lot of these hospitals really go after these nasty doctors. The culture is changing; it’s no longer acceptable.”

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