Nurses are always concerned about keeping their patients safe. Besides doing so by being professional with caring directly for them, nurses also need to be aware of how communication—with other health care providers and patients—can either keep patients safe or put them at risk.
Arnold Mackles, MD, MBA, Patient Safety Consultant for Innovative Healthcare Compliance Group and member of The Sullivan Group’s RSQ® (Risk, Safety, Quality) Collaborative took time to answer questions about exactly how nurses can do this.
In Part 1 of this series, we address what high-risk situations could be as well as how nurses can safely communicate with other health care providers. Part 2 will cover specific ways in which nurses can communicate with their patients while keeping them safe.
What is a high-risk situation and what kinds of patients could be involved in these?
High-risk clinical presentations occur throughout multiple areas of medical care. Medical errors in these critical situations can induce significant patient harm or even death. You might find a high-risk scenario:
- In the emergency department as you care for all comers presenting with a wide variety of complaints from back pain and chest pain to headaches and injuries to extremities
- In the ICU when caring for fragile patients with a life-threatening infection
- Before, during, or after a surgery
You might also encounter groups of patients that are inherently more high-risk. These include:
- Patients with multiple comorbidities
Effective communication between nurses and other clinical providers plays a vital role in the effective management of high-risk clinical situations. Unfortunately, traditional nursing and medical school programs do not include training in techniques to ensure successful communication in health care. As a result, a significant number of patients are harmed by breakdowns in communication.
What are the best ways for nurses to communicate with other providers to best keep their patients safe?
A study of over 23,000 malpractice claims by the Harvard Medical Industries, Inc. (CRICO) revealed that “communication failures were linked to 1,744 deaths in five years.” The study also found 7,149 cases where communication breakdowns caused patient harm, and 26% of those breakdowns involved a miscommunication of the patient’s condition among providers.
One critical strategy to improve communication among providers is the use of the “read-back” method. In high-risk clinical situations, physicians often give verbal medication orders to nursing personnel. Such orders must be “read back” or “talked back” to the ordering physician or practitioner to confirm accuracy. This same technique should be utilized when receiving verbal lab and test results as well.
In one case, a nurse answered a telephone call from the lab with a patient’s biopsy test. The pathologist called in the result as being an “adenocarcinoma,” a type of malignant cancer. However, perhaps due to a poor phone line, the nurse thought the pathologist said the specimen “had no carcinoma.” A simple “read-back” would have avoided the error. “Doctor, did you say that the biopsy did not have a carcinoma?” The pathologist could then have then replied, “No, it is an adenocarcinoma which is malignant,” and the error would have been avoided.
Fortunately, there are a variety of simple techniques that nurses can employ to improve communication in clinical settings. It has long been known that nurses and physicians often describe the same patient situation in different ways. Nurses have been trained to give detailed, specific descriptions of a patient’s condition. Physicians, on the other hand, speak in bullets or quick lists of clinical findings. This mismatch in communication style can easily lead to misinterpretation and misunderstanding.
One simple method to overcome this communication barrier is the use of CUS – concerned, uncomfortable, and safety – to demonstrate an increasing severity of a patient’s condition. For example, if a postoperative patient is running an elevated temperature, the nurse could say, “Doctor, I am concerned about Mrs. Jones, as she has a temp of 102 degrees.” The next level of severity would be, “Doctor, I am uncomfortable with Mrs. Jones as she is spiking a temp to 103 degrees and is tachycardic.” As the condition worsens, the conversation might be, “Doctor, I am worried about the safety of Mrs. Jones. She is febrile, tachycardic, and complaining of severe abdominal pain.”
Many medical errors are caused by the reporting of incorrect or incomplete patient medical information during a handoff. Health care handoffs are an extremely common time in which communication mistakes occur. Fortunately, the health care industry now has access to easy-to-use handoff techniques. The SBAR method was originally created to ensure correct communication on nuclear submarines and has been adapted for health care use. The technique utilizes a handoff worksheet that is created by the sender of the clinical information, and then discussed with and handed off to the receiver of the information.
The simple mnemonic SBAR to be completed on the worksheet represents:
S – Situation: “What is going on with the patient?”
B – Background: “What is the clinical background or context?”
A – Assessment: “What do I think the problem is?”
R – Recommendations: “What would I do to correct it?”
Although the SBAR system is widely used today, some health care organizations are moving to a handoff technique that integrates the electronic medical record. One such method is I-PASS, in which the computer creates and prints out the handoff work sheet. The I-PASS worksheet mnemonic contains:
I – Illness severity
P – Patient summary
A – Action list for the next team
S – Situation awareness and contingency plans
S – Synthesis and “read-back”
Check out Part 2 for information regarding communication skills for nurses to safely speak with their patients.
Nurses often want to move ahead in their careers, and in order to do that, they need to learn more, understand more, and do more. One way to make this happen is to earn specialty certifications. Throughout the year, we’ll be giving you information about various certifications, what they mean, and how you can earn them.
First up: CCRN, CCRN-E, and CCRN-K.
According to Denise Buonocore, MSN, RN, ACNPC, CCNS, CCRN, CHFN, an Acute Care Nurse Practitioner for heart failure services at St. Vincent’s Multispecialty Group, St. Vincent’s Medical Center in Bridgeport, Connecticut and the chair of the national board of directors for the AACN Certification Corp.—the credentialing arm of the American Association of Critical-Care Nurses (AACN)—the CCRN certification program was founded in 1976. (Please note that the AACN Certification Corp. is a separate entity from the AACN.)
What do CCRN, CCRN-E, and CCRN-K stand for? While all of them are certifications, they are not abbreviations. So they aren’t short forms of any particular words and/or phrases.
“For more than 40 years, CCRN has been the hallmark specialty credential for nurses who provide direct care to acutely/critically ill adult, pediatric, or neonatal patients,” explains Buonocore. “Nurses interested in this certification may work in areas such as intensive care units, cardiac care units, combined ICU/CCUs, medical/surgical ICUs, trauma units, or critical care transport/flight. CCRN-E and CCRN-K are extensions of the CCRN certification program.”
Buonocore says that she decided to get certified because “I was fortunate that I had a few colleagues support and encourage me when I was considering taking my first certification exam. These were nurses who were CCRN certified and were well respected for their knowledge and skills within our unit. Their confidence in me and their encouragement inspired me to study and take the exam. In turn, I have paid their support forward, mentoring and encouraging several potential certificants through the years. That first certification was also a catalyst to further my education, eventually becoming a certified nurse practitioner and clinical nurse specialist.”
A CCRN-E is a credential for nurses introduced in 2007, initially as a certification renewal option. In 2011, it became an initial exam option. “The CCRN-E credential is for nurses who monitor and care for acutely/critically ill adult patients from a centralized or remotely-based tele-ICU location that is networked with the bedside via audiovisual communication and computer systems,” says Buonocore.
As for the CCRN-K, Buonocore says, “A growing number of acute and critical care nurses are shifting to roles where they influence patient outcomes by sharing their unique clinical knowledge and expertise rather than providing care directly. The CCRN-K certification program, launched in 2014, is for nurses who positively influence the care delivered to acutely/critically ill adult, pediatric or neonatal patients but do not primarily or exclusively provide direct care. These nursing knowledge professionals work in a multitude of roles, including educators, researchers, administrators, care coordinators and managers, and in a variety of settings, including hospitals, health networks and nursing schools.”
Buonocore answered additional questions about these three certifications.
How do certifications help nurses in their careers?
RN licensure measures entry-level competence. Certification validates specialty knowledge and experience. Although certification is not mandatory for practice in a specialty such as critical care, many nurses choose to become certified. Like many other professional credentials, nursing certification involves a willingness to test one’s knowledge and expertise against national standards of excellence. Some employers prefer to hire certified nurses, because they have demonstrated a high level of knowledge in their specialty through successful completion of a rigorous, psychometrically sound exam, which is based on a comprehensive study of practice.
Becoming certified helps position nurses for recognition and advancement, and it spurs a critical sense of confidence, empowerment, and pride in their achievement. Research has found that certified nurses believe they make decisions with greater confidence and feel more satisfied in their work.
One salary survey found that specialty certified nurses in critical care in the United States make on average of $18,000 more per year than their non-certified counterparts.
What do nurses need to do to attain CCRN and related credentials?
Applicants must have a current, unencumbered U.S. RN or APRN license, and each certification program has specific eligibility requirements based on verifiable practice hours. For example, a critical care nurse must provide direct care to critically ill patients for a minimum number of hours with a single patient population (adult, pediatric, or neonatal) to be eligible for the CCRN exam.
Specifically, for CCRN, the clinical practice eligibility requirements include 1,750 hours of direct care in the previous two years, with 875 of those hours accrued in the year preceding application. Alternatively, candidates may have completed 2,000 hours and a minimum of five years in direct care of acutely/critically ill patients, with 144 of those hours accrued in the year prior to applying. CCRN-E and CCRN-K have slightly different eligibility requirements. For all three certification programs, the majority of hours for eligibility must focus on critically ill patients.
Nurses considering certification have access to many exam preparation resources including handbooks, test plans, practice questions, and review courses available through AACN. The exams are administered via computer-based testing at over 300 locations across the United States.
Certified nurses validate their continuing knowledge of current practices in acute/critical care nursing through a renewal process that includes meeting continuing education and practice hour requirements. CCRN, CCRN-E, and CCRN-K certifications must be renewed every three years.
Although delegating tasks occurs all the time in the workplace, there are often times in which nurses may not effectively delegate to unlicensed personnel. This carries major risk—to the nurse, the staff member, the patients, and the health care facility. Jennifer Flynn, CPHRM, Risk Manager, Nurses Service Organization (NSO), answered our questions about wrongful delegation.
What kinds of tasks could nurses be inappropriately delegating?
Unlicensed Assistive Personnel (UAP) assist registered nurses in the provision of patient care as delegated by and under the supervision of the registered nurse. UAPs assist nurses by performing patient care-related tasks that do not require nursing skill or judgment. Such activities can include the following: activities of daily living (feeding, drinking, ambulating, turning, grooming, toileting, dressing); collecting data (vital signs, weights); collecting simple specimens (stool, urine); transporting patients; restocking supplies; clerical duties; and housekeeping tasks.
To say that another way, a UAP cannot be asked to perform any activities on patients whose status is unstable—activities which require assessment, problem solving, judgment, or evaluation.
Before deciding on whether to assign a task to a UAP, nurses must first determine what your state’s nurse practice act and your facility policies say about task delegation.
What are the risks in delegating to non-nurse personnel?
Improper delegation can negatively impact patient care while also potentially exposing the nurse to liability lawsuits or Board of Nursing complaints. Effective delegation allows the nurse to do what they have been educated to do, that is, make effective judgements about patients and coordinate care. However, the nurse always maintains accountability for the task’s completion and is always accountable for the overall outcome of the patient.
The American Nurses Association developed the five rights of delegation to assist nurses in making safe decisions:
1. Right Task – Determine which tasks are appropriate for delegation. Some questions to ask include (1) Do your state rules and regulations support delegation? (2) Can I delegate these tasks based on my facility’s policies and procedures?
2. Right Circumstance – Consider the appropriateness of the patient setting and other relevant factors. Some questions to ask include (1) Are there appropriate resources available to perform the task? (2) Does the UAP have the appropriate supervision to accomplish the task? And, (3) Is the situation favorable for delegation? For example, a UAP may be allowed to feed a patient but if a high-risk stroke patient requires feeding, the nurse must first assess if the patient can safely swallow. The UAP can’t make that determination, and the nurses are expected to foresee possible harm to patients before delegating tasks.
3. Right Person – Ensure the right person is delegating the right task to the right person, to be performed on the right patient. Consider the UAP’s knowledge and experience to complete delegated tasks safely. Ask the UAP the following key questions before assigning the task:
- Have you been trained to do this task?
- Have you ever performed this task with a patient?
- Have you ever done this task unsupervised?
- How confident are you about performing this task accurately?
- What problems have you encountered with this task in the past?
Based on these answers, the nurse may decide to delegate, not to delegate, or provide direct supervision while the UAP is performing the task.
4. Right Supervision – Nurses are required to provide appropriate monitoring, evaluation, intervention, and supervision for all delegated tasks. Remember, nurses are accountable for the outcome of the patient.
5. Right Direction and Communication – Nurses must communicate a clear description of the task, including its objective, limits, and expectations. Consider telling the UAP exactly what you want them to do and by what time to do it. Also request specific feedback about the task at a specific time. Even if you’ve worked with the UAP for a long time, don’t make assumptions about what they may understand. Delegation requires mutual understanding and trust on the part of both the nurse and the UAP. The UAP should be allowed to ask questions, seek clarification, and request additional training.
What kinds of lawsuits/actions from nursing boards could a nurse face by doing this?
If nurses perform activities which are a violation of nursing laws and rules, this may result in either a malpractice lawsuit or even disciplinary action by the Board of Nursing. The most common potential violations related to delegation are failure to supervise over those who practice under the supervision of a nurse, and inappropriate delegation when the nurse may have reason to know the UAP was not qualified to perform the task. In a malpractice lawsuit, your actions or failure to act will be judged against professional practice standards in your state.
Consider this question before deciding to delegate “Would a reasonable prudent person have delegated this task given all aspects of the situation, and under similar circumstances?” If a nurse is unsure of the answer, it is recommended to contact your facility’s risk manager, ask an experienced colleague for advice, practice delegation with written or simulated cases, or request a peer review of your delegation decisions.
Can you give me any real-world examples of wrongful delegation claims?
Some examples of wrongful delegation would include allowing a UAP to feed a high-risk stroke patient without the nurse first assessing the patient’s ability to swallow. You may allow the UAP to report on a patient’s urine output for a determined timeframe, but the UAP shouldn’t report the output is “low” for that requires interpreting assessment date which only the nurse can do.
How could this become even worse with the continuing nursing shortage?
Nursing shortages and increases in patient complexity have driven the need for delegation to be a necessary component of today’s health care environment. In response to various economic and business pressures, the health care industry has sought to increase the utilization of UAPs to refocus the role of nurses on patient care and coordination. Both the ANA and the National Council of State Boards of Nursing have provided insight and direction to address this process, so that nurses can practice safely. Nurses who are familiar with their state’s practice act, applicable state rules and regulations, their facility policies and procedures, and the ethics of the profession will be well positioned to appropriately use UAPs in delivering safe patient care. A clear understanding of these guidelines is a nurse’s best protection against inappropriate delegation and reducing the likelihood of a malpractice lawsuit or disciplinary action.
Gaining any additional education can assist you in making strides in your career. This year, we’ll be focusing on various certifications to let you know what you need to do to attain them, what they mean, and how they can help.
Patricia A. Mucia, BSN, RN, CRRN, CCM works at Shriners Hospitals for Children—Chicago and is the Current President of the Northern Illinois Association of Rehabilitation Nurses. She answered questions for us about becoming a certified rehabilitation registered nurse (CRRN).
What does it mean to be a certified rehabilitation nurse?
Certification in rehabilitation nursing validates professional standing as an experienced rehabilitation nurse. It means you are an expert in the field and your knowledge has been verified. It also means you keep current with evidence-based practice specific to the needs of the rehab patient.
What additional training does a nurse have to have to be classified as such?
To sit for the exam, you must have:
- Two years of practice as a registered professional nurse in rehabilitation nursing within the last five years, or
- One year of practice as a registered professional nurse in rehabilitation nursing and one year of advanced study (beyond baccalaureate) in nursing within the last 5 years.
What additional skills do CRRNs have?
It is not as much about skills as it is a competency level and knowledge base specific to the care of patients after a disabling event or chronic illness. Rehabilitation is philosophy of care, not a work setting or phase of treatment.
What kinds of things can CRRNs do that RNs can’t?
They are empowered to give care based on a higher base of knowledge in the field. They establish themselves within a group of nurses who have specialized expertise and experience. They are part of a network of nurses as members of the Association of Rehab Nurses.
Why is it important to have this certification when working at Shriners Hospitals for Children?
It is important for our hospital to be competitive with other rehab facilities. Patients and families are making choices about health care. Having nurses that are certified in rehab (CRRN) defines the level of expertise of our patient care delivery.
If a nurse wants to become a certified rehabilitation nurse, what kinds of training would you suggest that s/he gets?
Experience in the field is a requirement for certification. Take advantage of all continuing education opportunities.
Why do you like being a certified rehabilitation nurse?
I love being a CRRN! I have collaborated with nurses in my community and throughout the country. I have attended, presented posters, and spoken at the annual education conference. I have learned so much at these events and met the best people.
I have been a board member of NIARN since 2013. Our Chapter has planned and presented local seminars for rehabilitation nurses.
When did you decide to become one?
In 2005. I have worked with children with spinal cord injuries for many years, and I feel so privileged to be a part of their recovery and ongoing care.
For the past 37 years, Kathy Catalano, BSN, CPN, RN, has worked as a nurse. About six years ago, she began a Certified Pediatric Nurse (CPN) and is glad that she did.
Working in the outpatient department of Shriners Hospitals for Children—Chicago, Catalano set a professional goal to become a CPN. “I like being a CPN because it makes me feel better about my chosen profession. It makes me feel good that I put effort into being a better and more knowledgeable pediatric nurse,” says Catalano. “I love our patients and want to provide the best care possible.”
To become a CPN, Catalano worked a required amount of clinical hours. She says that this prerequisite is good because “it means you will have years of knowledge and experience as a nurse first.”
While she wasn’t required to have additional training, she needed to have experience with a pediatric population before she could take the exam to become a CPN. Although it’s not necessary, she adds that “Being a parent also helps!”
But you don’t just show up one day to take the exam. Catalano says that there are review courses that you can take to help you prepare for the CPN exam. These courses provide you with examples and scenarios that you may face or that you have already dealt with as a nurse who treats children.
“I liked my review course,” says Catalano. “It was helpful that there was someone reviewing things that I had not thought about since I was in nursing school. That was helpful for the test.”
In addition, Catalano says that because she works in a specialty pediatric hospital that focuses on orthopaedics, there are certain aspects of pediatric care that she doesn’t see on a daily basis. But, of course, she needed to review them before taking the CPN exam. “The review course helped me with that,” she says.
Although Shriners Hospitals for Children—Chicago doesn’t require a pediatric nursing certification to work there, certain hospitals do in order to show that you have the required expertise to work with children.
Theresa Martinez, RN, MSN, CCRN-K, Director of Patient Care Services/Nurse Executive at Shriners Hospitals for Children—Chicago, says that they do like having nurses with CPNs working there, even though it’s not required. “Having certified nurses within our hospital organization shows a commitment to deliver the best possible patient care. Certifications demonstrate the nurses’ commitment to a specialty knowledge with consistent, continuing education,” says Martinez. “In essence, it demonstrates their expertise in a designated specialty which positively impacts quality of care and patient outcomes.”
To learn more about pediatric nursing, visit here.