Changing perceptions of risk could improve compliance with infection-control measures
It’s often said that knowledge is power. But a new study finds that when it comes to nurses’ compliance with infection-control measures, it’s more appropriate to say attitude is everything.
The study, published in the American Journal of Infection Control, examines the relationship between infection-control compliance, knowledge, and attitude among home healthcare nurses. Researchers surveyed 359 home healthcare nurses in the U.S., and evaluated their knowledge of best practices in relation to their compliance with infection-control measures.
Over 90% of nurses self-reported compliance for most of the measured behaviors. The researchers also found there was not a direct correlation between knowledge of infection-control practices and compliance with those practices. However, there was a relationship between the level of compliance and the participants’ favorable attitude toward infection control.
“This study tells us that knowledge is not enough,” said one of the lead authors, Jingjing Shang, PhD, of Columbia University School of Nursing in New York City. “Our efforts to improve compliance need to focus on ways to alter nurses’ attitudes and perceptions about infection risk.”
The authors suggest that efforts to improve compliance with infection-control practices should focus on strategies to alter perceptions about infection risk. Changes should start on an organizational level, and seek to create a culture of positivity in relation to infection-control compliance.
Among other takeaways from the study:
- Protective equipment lapses: While most of the participants reported compliance on most issues, many reported lapses when it came to wearing protective equipment; only 9% said they wear disposable face masks when there is a possibility of a splash or splatter, and 6% said they wear goggles or eye shields when there is a possibility of exposure to bloody discharge or fluid
- A culture of “presenteeism:” Presenteeism, coming into work despite being sick, has become a patient safety issue over the last few years, especially as it relates to infection control; only 4% of participants felt it was easy for them to stay at home when they were sick, which could be a major contributor to rates of infection
- Hand hygiene is still an issue: 30% of respondents failed to identify that hand hygiene should be performed after touching a nursing bag, which could transport infectious pathogens as nurses travel between patients
“Infection is a leading cause of hospitalization among home healthcare patients, and nurses have a key role in reducing infection by compliance with infection-control procedures in the home care setting,” Shang said.
This story was originally posted on MedPage Today.
As we described in Part 1 of this series, there are important ways for nurses to speak with other providers in order to keep their patients safe. Likewise, there are crucial strategies for them to use when speaking with the patients themselves.
Again, 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 safely communicate with patients.
What strategies can nurses use when communicating directly with their patients in order to keep them as safe as possible?
Effective communication with patients is just as important to ensuring positive outcomes in high-risk situations. Patients seek out health care for personal and often complicated medical conditions. They can be fearful, concerned, uncomfortable, worried, or even terrified when they visit a health care facility. Be mindful of your patients’ emotions and how these emotional states will affect the way they describe their symptoms and problems, how they interact with you, and how information and instructions are received.
The following list of patient communication strategies is straightforward and can be incorporated into any conversation with a patient:
- Start with a warm introduction. Some providers walk into a waiting room and introduce themselves to their patients. This makes patients feel important. It indicates that the provider is not in a rush and is taking the time to greet them rather having them ushered into an empty exam room by office staff.
- Greet the patient by name. Greet patients by their formal name. “Hello Mrs. Jones, I am Cathy and I’ll be your nurse today.” If you prefer to be less formal or you know the patient well enough, use first names. By nature, people like to hear their own names. When you know and use patients’ names throughout the medical process, stronger bonds and relationships are created.
- Make eye contact. This feature of a personal interaction cannot be underestimated! If you don’t make eye contact with patients, they may assume that your thoughts are elsewhere or you are not interested in their medical issue. Eye contact is a sign of confidence, and patients want to feel confident that they are in good hands.
- Be engaged. Patients know when you care, patients know when you are prepared; and patients know when you are authentically engaged. Consistency of communication is an art. Whether you are stressed, fatigued, or otherwise preoccupied due to any number of reasons, you must learn the art of being consistently engaged with all patients.
- Listen to and acknowledge patient concerns. It is important that you listen, understand, and acknowledge what patients are saying. Take time to ask appropriate questions to ensure that important pieces of information were not overlooked by the patient. When you take the time to listen, miscommunication is–for the most part–averted and medical errors are significantly reduced.
- Avoid interrupting the patient if possible. Allow the patient to finish explaining. Physicians and nurses often interrupt patients with questions in the middle of a conversation. Let patients complete their thoughts before questioning further. If patients go off on a tangent, politely interrupt and refocus them on what needs to be communicated.
- Confirm understanding via “teach-back.” Rather than asking patients if they understand their health issues, intervention plans, or any aspect of their care, it is often more efficient to use an easy technique such as “teach-back” to confirm full comprehension–have them repeat what they understood. Simply ask the patient something like: “Mrs. Jones, since you will be taking home three different medications, just to be sure you fully understand the instructions, please explain to me how and when you will take each one.”
- Provide patients with written instructions. Patients are often overwhelmed with news of a diagnosis or the seemingly complex plans for home- or self-care, which includes taking medications. Preparing and distributing written instructions will help avoid misunderstanding of the treatment and follow-up plans.
What else do nurses need to know about communicating effectively to improve patient safety in high-risk situations?
Data from The Joint Commission consistently reveals that poor communication is a leading cause of medical mistakes that result in patient harm. In fact, during the years 2014 and 2015, communication was the third most frequent “root cause” of all sentinel events reviewed.
Medical errors continue to plague our health care system. Many of these mistakes cause significant patient harm and often result in malpractice litigation. Communication breakdowns, rather than a lack of provider skill and/or medical training, are responsible for far too many adverse events. The good news is that we now have simple techniques that can be easily utilized to improve nursing communication and decrease medical errors.
Nursing, as defined by the World Health Organization, encompasses care for people of all ages, families, groups, and communities, sick or well and in all types of settings. Nursing includes health promotion, illness prevention, and care of the ill. Regardless of your nursing role, or type of patient population you care for, health literacy is an essential competence necessary to effectively communicate and truly provide person-centered care. Health literacy is a precursor to health and considered a social determinant of health due to its influence upon health outcomes. It also includes engaging and empowering patients to access services and act upon health information to make informed decisions.
Early definitions of health literacy primarily focused on the skills or deficits of individuals when obtaining, processing, or understanding basic health information and services. The term has continued to evolve to reflect the complex, dynamic, multidimensional context-related components of health literacy. And while nurses have such a vital role in the promotion of health literacy, there is often a lack of understanding that health literacy is much more than the reading level of patient education material.
Nurses have a vital role in partnering with the 88% of the U.S. population that are not having their health care needs met. Nurses can make a difference beginning today!
Begin by checking out the 5 basic health literacy strategies every nurse should know.
1. Promote a shame-free environment.
Health literacy is the foundation to a successful nurse-patient interaction and necessary to promote patient safety. Writing all patient forms in plain language, providing assistance with paperwork, offering free interpretation services, and involving members of your community when designing materials or programs will assist with promoting a shame-free environment.
2. Use a health literacy universal precautions approach.
Always assume that everyone might experience difficulty understanding health information or navigating the complex health care environment. Even a well educated patient can have difficulty understanding the medical information provided.
3. Speak in plain language.
Plain language or “living room language” is beneficial for everyone! Using “everyday” words rather than medical jargon will allow you to meet your patients where they are and help clearly explain more involved concepts.
4. Confirm understanding with Teach-Back.
Respectfully ask patients to explain a concept or direction back to you. This helps ensure you were clear in all patient communications. It also gives you the opportunity to clarify any misunderstanding if needed. Teach-Back is not mimicking what you said—patients should use their own words to explain understanding.
5. Ask open-ended questions.
For example, “What are your questions?”, “What questions do you still have?, or possibly, “We just reviewed a lot of information. What parts would you like me to go over with you again?” Each of these examples can help encourage questions rather than “do you have any questions?, which often results in a quick response of “no”.
Learn more about health literacy and health literacy strategies in this award winning book, Health Literacy in Nursing: Providing Person-Centered Care. For additional resources or to request health literacy services, contact Health Literacy Partners.
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 CRICO, the medical malpractice insurer of the Harvard medical institutions, 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.
A new healthcare nonprofit organization in Maryland recently launched to better address rural patients’ needs. IMBUEfoundation will provide care and transportation services to Maryland’s Eastern Shore communities, to improve residents’ options for care and lifestyle choices.
“IMBUEfoundation was established to eliminate the barriers that prevent people from accessing healthcare and living healthy lives,” founder Dr. Seun Ross said. “We are working to address obstacles like health literacy, transportation, and care coordination.”
Recent research by Harvard’s T.H. Chan School of Public Health, the Robert Wood Johnson Foundation and NPR shows that receiving good healthcare is the second-biggest problem for rural American families. Major health concerns for rural Maryland residents include chronic disease, health literacy, care coordination, outreach and education, according to a 2017 assessment by the Maryland Rural Health Association. IMBUEfoundation notes on its site that the lack of services and coordinated care has led many Maryland residents to struggle in finding proper care.
“Healthcare is more than just going to the doctor,” Ross said. “For example, someone who lives in a place like Caroline County, which is both a food swamp and a food desert, is going to have a harder time making healthy food choices, which can lead to obesity— a major factor of chronic disease. It’s a domino effect.”
The new non-profit is helping those in need with nurse practitioners, acting as “clinical concierges” who provide counseling, monitoring, and stewardship activities. The nurse practitioners assist with coordinate care delivery for patients, explain healthcare plans and treatment options, and provide education on alternative care, in addition to other necessary tasks.
Modes of services provided by IMBUEfoundation include the Rural Health Collaborative, Care Coordination, and Transportation Service, in partnership with Lyft.
“From providing transportation to helping patients coordinate between doctors, IMBUEfoundation is working to make sure Maryland’s mid-shore residents have the resources they need to be healthy and happy,” Ross said. “But there’s still so much work to be done.”
For more information about IMBUEfoundation, visit imbuefoundation.org.
Stress manifests among nurses in various forms and can affect patient outcomes
Being a nurse can be fulfilling and rewarding. We get the privilege of helping new lives enter the world, comforting those who are exiting this world, and everything in between. Yet nursing is also taxing and draining at times. Off-shifts (nights and weekends), hectic workloads, violence from patients and families, and incivility among staff members can all cause physical and emotional wear and tear among nurses.
Unfortunately, issues like depression, burnout, and fatigue are extremely prevalent among nurses. As Alexandra Wilson Pecci writes in a recent article, one 2016 study found that nurses experience depression at twice the rate of those in other professions.
This is bad not just for nurses but also for patients. Another study Pecci highlights found a link between nurses reporting poor health, particularly depression, and higher rates of reported medical errors.
That’s a serious issue and one that certainly needs to be addressed.
Some recent HealthLeaders articles offer solutions to address stress among RNs.
Beating Clinician Burnout
There’s a common belief that burnout is a personal failing and that resolving dimensions of burnout — emotional exhaustion, cynicism, inefficacy — are that individual’s responsibility. Eat a salad, go for a walk, take a yoga class, and you’ll be fine. In reality, however, burnout is a sign that something is amiss within an organization, and healthcare leaders need to uncover both the prevalence of burnout at their organizations as well as its root causes.
“There needs be a framework to understand where the pain points are, and then how an organization can do something about that,” said Karen Weiner, MD, MMM, CPE, chief medical officer and CEO at Oregon Medical Group (OMG), a physician-owned, primary care–based multispecialty group of about 140 healthcare providers, with offices in the Eugene and Springfield area.
Weiner advises that leaders implement system-wide changes to address the factors contributing to burnout. After administering the Maslach Burnout Inventory at OMG, the organization made multiple changes including creating a physician-organization compact, developing new compensation practices, and redistributing workloads.
Creating Culture of Caregiver Support
A 2015 Gallup survey found that more than half of all healthcare workers report thriving in none or only one element (purpose, social, financial, community, physical) on the Gallup-Healthways Well-Being Index.
To better help employees cope with the emotional demands of caring for others, some organizations are implementing programs to prevent problems like burnout, suicide, and substance abuse.
“Strategies that could support employees include reducing the stigma about mental health concerns, providing resilience training and care for the caregiver support programs, and providing health and wellness benefits, including policies that allow for time off for mental health concerns as well as for physical health concerns,” said Celeste Johnson, DNP, APRN, PMH CNS, a member of the board of directors of the American Psychiatric Nurses Association and director of nursing, psychiatric services at Parkland at Green Oaks Hospital in Dallas.
For example, the University of Missouri Health System’s forYOU program provides support to healthcare workers experiencing symptoms of “second victim syndrome.”
Parkland provides universal screening for suicide risk, including for those employees seen in the employee clinic.
How to Handle Cyberbullying in the Nursing Unit
Another source of stress among nurses is workplace violence, and cyberbullying meets that definition. Thanks to technology, bullying behaviors can now occur in digital form via means such as instant messaging, email, text messaging, social networking sites, or blogs.
According to the National Council for the State Board of Nursing’s policy on social media, any online comments posted about a co-worker may constitute lateral violence — even if the post is from home during non-work hours.
To confront cyberbullying, the policy states, individual nurses should save evidence of bullying comments. Then, during a private conversation, present the evidence to the person who made the comments. Document the conversation and its outcome and if there is a second instance of cyberbullying, report it to the nurse manager. If the behavior continues, alert the chief nursing officer.
Nurse managers should verbalize to their staff that there is a zero-tolerance policy for bullying of any kind, including comments made online. Managers should also educate staff on standards and polices regarding cyberbullying and should take derogatory remarks seriously.
Creating a work environment that addresses issues that contribute to nurse stress and burnout is more than something that’s just nice to do; it’s also a way to improve patient care. There are plenty of reasons to improve. Research by Linda H. Aiken, RN, PhD, at the University of Pennsylvania in Philadelphia, has found that patients who had surgery at hospitals with better nursing environments and above-average staffing levels have better outcomes at the same or lower costs than other hospitals.
Need any more proof?
This story was originally posted on MedPage Today.