Nursing is a stressful job. So when you think that a patient may have been misdiagnosed by another health care worker, it’s important to know exactly what to do—especially if the misdiagnosis could cause permanent harm or death. It’s important to protect your patients as well as yourself.
Jennifer Flynn, CPHRM, risk manager for Nurses Service Organization (NSO), took time to answer in detail what nurses need to do when they suspect a patient is not receiving the care they need.
What should a nurse do if s/he thinks that a patient is not receiving the care they need from another health care worker? What are the specific steps that s/he needs to take? Are these steps different depending on the procedures of the facility?
Every day, nurses are challenged to provide patients with the safest and most effective care possible. Many factors can affect clinical performance. For example, being sleep deprived, running late, being assigned to more patients than usual, or experiencing a breakdown in communication with other providers can influence a nurse’s ability to provide safe patient care.
According to the 2015 NSO/CNA Nurse Professional Liability Exposures Claim Report, failure to invoke the chain of command was identified as a common allegation. Nurses are responsible for invoking the medical chain of command when necessary, in order to trigger a practitioner’s intervention for the patient. Closed claims involving the failure to invoke or utilize the chain of command accounted for 7.5% of the treatment and care closed claims, and reflect a higher average payment as compared to all claims in the report.
Nurses must be comfortable with utilizing the medical chain of command whenever a practitioner does not respond to calls for assistance, fails to appreciate the seriousness of a situation, or neglects to initiate an appropriate intervention.
Consider this scenario: a nurse failed to initiate the chain of command when the practitioner would not respond to her concerns of identified non-reassuring fetal distress. The nurse called the practitioner several times to give an update on the patient’s condition, which continued to deteriorate. Each time the nurse requested that the practitioner come see the patient, the practitioner said it didn’t seem necessary. As a result, the infant suffered birth-related brain injury, requiring lifelong care. The nurse was named in the malpractice lawsuit alleging failure to invoke the chain of command and failure to report changes in the patient’s medical condition. While the nurse had documented making the phone calls to the practitioner, the nurse neglected to include what was told to the practitioner and the practitioner’s response.
Nurses know that treatment and care of every patient starts with timely attention to their needs and persisting to the point of resolution. However, nurses may feel apprehensive about chain of command issues. Fear of disciplinary actions, loss of their jobs, or being labeled as a “troublemaker” are other concerns.
The following strategies can help reduce apprehension regarding chain-of-command issues:
- Proactively address communication issues between nursing and medical staffs, and identify instances of intimidation, bullying, retaliation, or other deterrents to invoking the chain of command.
- Notify leadership of individuals or areas that prevent nursing staff from invoking the chain of command or impose punitive actions for doing so.
- If the organization’s current culture does not support invoking the chain of command, explain the risks posed to patients, staff, practitioners, and the organization, and initiate discussions regarding the need for a shift in organizational culture.
Are nurses usually taught this in nursing school? What should they know about speaking up?
Education in this matter is an ongoing effort. It starts in nursing school, but it must be continuously addressed, communicated, and supported for it to become part of practice.
The first step in protecting yourself from legal action is to know and understand your facility’s policy and procedures on invoking the chain of command to resolve concerns about patient care. In many facilities, policy and procedures manuals are readily accessible. If no chain-of-command policy or procedures exist, find out who in your facility is responsible to do so.
Don’t hesitate to call the appropriate practitioner when there’s a change in your patient’s condition. Most facilities have policies that require this. However, some nurses may feel intimidated by appearing to question a practitioner’s management of a patient.
Express clearly what, if any, action you would like the practitioner to take. If you think your patient needs to be seen, say so. After the conversation, document exactly what you told the practitioner about the patient’s condition.
If you believe the practitioner isn’t taking your concerns seriously, go to the next person in the chain. If necessary, go up your facility’s chain of command until the concern has been addressed. As you contact different staff members in the chain of command, be sure to make a note in the patient’s chart.
By invoking the chain of command, not only do nurses fulfill their obligations as patient advocate, but they protect themselves from liability.
What should nurses not do if they think their patients aren’t getting the care they need?
Advocating for a patient may not always be easy, but it is part of a nurse’s responsibility. Advocacy includes the duty to invoke both the nursing and medical staff chains of command to ensure timely attention to the needs of every patient, and persisting to the point of satisfactory resolution. Not following the chain of command puts the patient’s safety at risk and exposes nurses to the potential of a malpractice lawsuit.
Document each of the steps taken, and the reasons they were taken, to advocate for the patient’s care. Refrain from speculative or subjective comments, including ones regarding colleagues and other members of the patient care team.
Can a nurse get in trouble for reporting something like this? How should they approach this so that they do what is most professional?
To be an effective advocate, nurses first need to understand the laws and regulations governing their practice. Nurses who understand their scope of practice, state practice act, and facility policy and procedure are best able to use established processes to advocate effectively for their patients while protecting themselves from retaliation and litigation.
Effective communication is key. One technique available to nurses is SBAR, which is an acronym for Situation, Background, Assessment, Recommendation. This communication style can be used to facilitate prompt and appropriate communication. It is a way for nurses to communicate effectively with one another, and between the health care team. It allows for important information to be transferred accurately.
Allegations of malpractice can result from miscommunication or lack of communication between practitioners and nurses. By carefully documenting the information about the patient shared with other members of the patient’s care team, nurses can significantly reduce communication-related risks.
By enhancing their communication skills, nurses can minimize the risk of claims. Some communication strategies include:
- Clearly articulate your concerns so that others are able to respond.
- Consider what information to share, when to share it, and with whom it should be shared.
- Ensure communication among caregivers is professional and respectful.
- Carefully and timely communicate patient assessments and observations to other members of the health care team.
- Read back or repeat verbal orders to the practitioner who issued them to verify accuracy and understanding.
Nurses can ask to become more involved in developing and influencing facility policy around advocacy and communication. Nurse leaders, health care administrators, and organizations can change the culture of retaliation and blame, which tends to point fingers instead of recognizing issues and problem solving.
All nursing jobs have instances of stressful situations in them. It’s the nature of the field. But working at a Shock Trauma Center can be even more so.
Rashidah B. Francisco, BSN, RN, CCRN, CPAN, TCRN, with the Lung Rescue Unit at the University of Maryland R Adams Cowley Shock Trauma Center (STC), took some time to answer our questions about her amazing job.
What follows is an edited version of our Q&A:
As a Shock Trauma Nurse, what does your job entail? What do you do on a daily basis?
On the Lung Rescue Unit, our shifts are extremely unpredictable. Taking care of some of the sickest patients in the state of Maryland—and possibly the world—at the only Primary Adult Resource Center is something that demands skill, dedication, communication, and a sense of teamwork like no other.
Our exclusive Veno-Veno extracorporeal membrane oxygenation (VV ECMO) unit at Shock Trauma is one of the only units of its kind in the country. Our patient population on this unit consists of patients in need of a machine that bypasses their lungs to deliver 100% oxygen to the patient’s blood, as their lungs are incapable of this function. Having the critical care skills, knowledge, and critical thinking to recognize when your patient is in trouble is half the battle of managing this patient population.
Our patients are suffering from acute illnesses and come to us at the most critical moment in their lives. Because of this, we have little time to think, but must come together as a team and put our skills and expertise to work. The interventions for our VV ECMO patients can also be very different from your typical ICU patients, but are directly in line with evidence-based practices. We may prone our ECMO patients, walk them, and get them out of bed daily and into a chair to optimize their recovery.
Why did you choose to work at Shock Trauma? How long have you worked there? What prepared you to be able to work in such a stressful environment?
Coming to Shock Trauma was not my initial plan, but critical care has always been a dream of mine. I have been in the nursing profession for almost 20 years (three as a patient care technician, 11 as an LPN, and seven as an RN). After going through a critical care fellowship at a large hospital in Virginia, and spending a couple of years on their complex critical care unit, I felt that I was ready for something bigger and more challenging. I wanted something that would enhance my skills, and push me to go further in bettering myself and my career.
When asking myself where I could go to be a part of the best, where only the best is expected of me, and where my skills and education would be the only determining factor in how far I can go in my career, I chose Shock Trauma. I have been at STC for over 4 years, and there is not one day that I have not been pleased with my career choice.
How do you keep yourself from bringing the stress of the job home? What do you do to relieve your stress?
Gratefulness and self-reflection helps me to de-stress. Reflecting with my team and relying on them while I am at STC helps me to keep things into perspective.
What are the biggest challenges of your job?
The biggest challenge of my job is knowing that I cannot save everybody—that everyone’s story is not to be taken on as my burden, but it is my duty to do the best that I can. Knowing that I am human, and I can only do so much. Remembering that I am here by choice, and that some of my patients, no matter what choices they have made, are there because they have to be, and are depending on me to utilize my skills to help them in their most critical hour. Remembering that it could be me lying in the bed, and them taking care of me.
What are the greatest rewards?
Seeing a patient get off of ECMO and return home or go to one of our critical care units. Just seeing that they have reached a point where they are able to evade such a lifesaving piece of equipment is a reward. Hearing a patient’s voice after they have been extubated. Seeing them walk after being in the prone position intermittently for days. Hearing that a patient who has been waiting months for lungs has finally gotten them.
Being a part of a team—that these things are just as important to them as they are to me—is also a reward in itself. To have someone who is going through the struggle with you and cares as much as you do.
What would you say to someone considering this type of work? What kind of training or background should he or she get?
No matter what your background, come with a sense of teamwork, with a sense of family, and with the ability to take on the most challenging situations, but with the humblest attitudes. Be ready to learn, no matter what you think you know. At STC, you will see and learn things beyond what you even thought. Have a strong critical care background for some of our units, but if not, have an open mind and a willingness to learn. Be ready to see and care for people who are very different from what you may have experienced, but be ready to save them, and care for them as if they are one of your family members.
Is there anything else that is important for fellow nurses to know?
Wearing the pink uniform is something that for the last four years I have been very proud of. It is to me like putting an “S” on my chest when getting ready for my shift. However, it is something that comes with a heavy responsibility and a possession of skills that I am expected to have and use when I walk through the doors of STC. My days are not blissful, my days are not easy, but they have been more rewarding at STC than they have my entire nursing career.
DeeQuiency M. Donerson is studying in nursing school, but unlike some students, he already knows what he wants to be after he becomes an RN: a travel nurse. Since May 2010, Donerson has been working as a Certified Surgical Technician with Trustaff, and he likes what he does so much that he now wants to take on more and become a nurse.
“Every contract is 13-week assignments. I am almost always offered an extension because of my knowledge of surgical procedures. The longest contract I have done was nine months in Miami, Florida, which was a great experience,” says Donerson. “I wanted to become a traveler to gain as much experience as possible of surgical procedures, doctors’ preferences, instrumentation, and sterile supplies.”
Before 2007, Donerson wasn’t in the health care field at all. In fact, he worked as manual laborer making minimum wage. At the time, he even had to live out of his car. He decided that he wanted to attend surgical technology school, but when he had to fill out the application and include his address, Donerson wrote in his license plate number. Luckily for him, college staff realized that he was homeless and arranged for him to live in a dorm for the rest of that school year.
When a Trustaff representative spoke to college students about becoming a traveling health care worker, Donerson was interested. After graduating and getting a year of experience, Donerson became a travel CST. His first assignment was in the Virgin Islands. After that, he traveled the country, working in Louisiana, California, North Dakota, and in several cities in Florida.
Donerson says that he loves working with his recruiter, Danny Laurence. “He basically knows exactly what I’m thinking before each contract and after,” says Donerson. He also recommends that nurses thinking of becoming travel nurses be on a first-name basis with their recruiters. “Not having a great recruiter will more than likely end in disaster for a contract,” he says.
Dealing with negative patients is never easy. They can monopolize your time, make you angry, and frustrate everyone they come into contact with. What can you do?
According to a number of experts, quite a lot.
“I approach patient interactions using the nursing process of assessment, planning, intervention, and evaluation. These steps are taken with patience and understanding,” says Cynthia Rochon, MBA, BSN, RN, Director of Nursing, Behavioral Health Services, Largo Medical Center. “In order to assist with a problem, you first have to understand the root cause. Never make assumptions because that can lead to more negativity. After gaining a clear understanding of the problem or patient care need, you provide an explanation of how the nurse can assist to remedy the problem or facilitate access to the resource who can provide further assistance. The last step is evaluation—validate that the patient has a clear understanding of how to follow up on directions that have been provided. Patient education is an important component of nursing care. When communicating with empathy, the patient experience will usually change from a negative experience into a positive interaction.”
Oftentimes, patients become negative because they are scared, says Jodi De Luca, a licensed clinical psychologist working in the Emergency Department at Boulder Community Hospital in Colorado. “Firm empathy and compassion are an example of setting structure and limitations. Be kind, respectful, and validate the patient’s feelings, but remain professional and clarify unacceptable behavior and/or unrealistic patient expectations.”
“Although it’s true we deal with these patients in the same manner we would other patients, it does take a lot of listening on our end to determine where the negativity is coming from,” says Debra Moore, RN, Director of Nursing of the BrightStar Care Edmond/Oklahoma City as well as the Midwest Region Nurse of the Year for 2017. “They could feel mad because they’re sick, missing a spouse from a recent death, or they may have just heard some bad news or had a frustrating experience in some other area of their lives. After we determine the cause, we talk with the patients and reassure them that we are going to care for them as much as they will let us. These patients may also need a lot of education on their diagnosis and what we can do to help. While it may take time for them to trust us, they will see that we are there for them and that they still have free rein over their lives. We honor them. It will take them sitting back and observing exactly what great care we can provide them. This will, in turn, help them relax and trust us in the end.”
Kristin Baird, RN, BSN, MHA, president and CEO of the Baird Group, is a consultant who coaches and trains nurses and nurse leaders. She shares two of her training points:
1. Suspend judgement and assume a neutral position.
By doing this, you position yourself for great empathy. Empathy is portrayed more through non-verbal behaviors than verbal, but both matter. When a patient feels you are showing empathy, they will have greater trust.
2. Use empathy statements and body language that will diffuse anger.
Try sitting by the patient, touching his/her arm or hand, and saying something like, “You sound upset.” By validating them with your words and showing compassion with touch, you are demonstrating that you care.
Nurses do so much more during one day than the average person may think. We know that they do more than take vitals, change bedpans, and give shots, but others may not. In fact, we know that nurses often make amazing differences in the lives of their patients. And they love doing it.
Here are a couple stories from nurses who have done just that.
Shortly before his 60th birthday, life had become exceptionally difficult for one of Huda Scheidelman’s patients. Scheidelman, RN, and a home care nurse with the Visiting Nurse Service of New York, saw these terrible changes. Once a man who loved to explore the city, she saw his health going downhill. He was severely depressed after a recent divorce, he wasn’t following the meal plan from his dietitian, his blood sugars were out of control, and he quit his job as his diabetes made walking painful. Scheidelman decided to mix compassion, facts, and some tough love to get her patient back to his former health. It took some time, but he slowly changed his ways—he quit smoking, got back on insulin, and began following his diet. “Thank you,” he said on a recent visit. “I don’t know what I would have done without you.”
The Social One
Patricia O’Berg, PCCN, RN, BSN, a clinical instructor at the State College of Florida as well as an ICU nurse at Englewood Community Hospital in Englewood, Florida, had a passion for nursing that began at an early age. She didn’t pursue nursing, though, until later in life. After she had a career in public relations and raised a family, O’Berg decided that her passion for being a nurse was “alive and well.”
While earning her bachelor’s degree in nursing, O’Berg decided to participate in a study abroad program in Nicaragua. She immediately realized that missionary nursing touched a special place in her heart, allowing her to care for many underprivileged residents of small villages. By contributing her nursing talent and compassionate care with a small team, O’Berg helped to treat more than 1,000 patients with a variety of health conditions over the course of only five days.
Since then, O’Berg commits to annual visits to the villages of Nicaragua as a clinical instructor to help save patients who wouldn’t otherwise receive care. That’s how she garnered the nickname The Social One—because she has such a passion for people and loves to heal.