Certified Registered Nurse Anesthetists (CRNAs) provide important anesthesia care for many different types of surgeries and services. However, as they gain more and more autonomy, their risk for facing malpractice lawsuits increases as well.
“CRNAs practice with a high degree of autonomy, and they play a critical role in patient outcomes,” says Georgia Reiner, Risk Specialist, Nurses Service Organization (NSO). “This also makes them more vulnerable to a malpractice lawsuit if anything goes wrong.”
According to Reiner, although most states still require that CRNAs work under physicians’ supervision, some states—and the number is growing—are allowing them to practice independently. The good news is that, as Reiner says, CRNAs have been able to provide a lot more anesthesia care in more rural areas of the U.S. that otherwise wouldn’t be able to—such as including obstetric, surgical, and trauma services. “CRNAs are also trained and qualified to treat pain patients. With the ongoing opioid epidemic in the U.S., and with millions of patients still suffering from chronic pain at the same time, the services CRNAs provide are essential to promoting safe and effective pain management,” explains Reiner.
As for the top risks that CRNAs face, Reiner says, “According to claim metrics from NSO’s underwriter, CNA, some of the top allegations made against CRNAs in malpractice lawsuits involve improper treatment or intervention during a procedure, medication errors, inadequacies in the anesthesia plan, and failure to monitor the patient’s condition. CRNAs encounter these liability risks on a daily basis, so it is important for them to identify and manage these risks to protect their career and livelihood while also improving outcomes for their patients.”
The NSO recently reviewed two case studies and then identified six ways that CRNAs can manage risks. They are as follows:
1. Maintain competencies (including experience, training, and skills).
Competencies should be consistent and up-to-date with the scope of authority granted by state law, the needs of the CRNA’s assigned patients, patient care unit, and equipment.
2. Obtain and document informed consent for any planned anesthetic intervention.
Patients or the patients’ legal guardian must be informed of the potential risks, benefits, and alternatives to the planned anesthetic intervention and surgical procedure(s). CRNAs should verify that informed consent was obtained by a qualified member of the patient’s health care team and documented in the patient’s health care record prior to any intervention.
3. Document pertinent anesthesia-related information in the patient’s record.
Review the patient’s clinical history, including relevant social and family history; evaluate the patient and determine if they are appropriate for anesthesia and the proper method of anesthesia. CRNAs should document this process, including their rationale, and any discussions with the patient.
4. Communicate in a timely and accurate manner initial and ongoing findings regarding the patient’s status and response to treatment.
It is essential for CRNAs to report changes in the patient’s condition, any new symptoms displayed by the patient, or any patient concerns to the practitioner in charge of the patient’s care in a timely manner. Document patient responses to treatment, whether positive or negative.
5. Provide and document the practitioner notification of changes.
In addition to communicating any change in the patient’s condition or symptoms, or any patient concerns, CRNAs also need to document the practitioner’s response and/or orders in the patient’s health care record.
6. Report any patient incident, injury, or adverse outcome.
CRNAs should report any patient incident, injury, or adverse outcome, and the subsequent treatment and patient response to their organization’s risk management or legal department. If CRNAs carry their own professional liability insurance, they should alert their insurance carrier to any potential claims, as timely reporting ensures that an incident, if it develops into a covered claim and is not excluded for other reasons, will be covered.
“Facing a malpractice suit can be stressful and overwhelming because it is a long, unpredictable, and costly process. One step I recommend for CRNAs to take is maintaining their own professional liability insurance to help protect their careers,” says Reiner.
Nurses have intense experiences that most other health care workers don’t. As a result, they tend to have a great deal of stress. Having friendships with other nurses tends to alleviate it and help in more ways than you might imagine.
Only nurses understand what other nurses truly go through, says nurse practitioner, former attorney, author, and career/lifestyle blogger Meika Mirabelli, JD, MSN, FNP-C, founder of BeautyinaWhiteCoat.com, which helps both health care students and professionals live balanced, successful lives through sharing career and studying tips. Mirabelli knows firsthand how having friendships with other nurses can make a huge difference in the workplace—and how not having them can hurt.
“I have experienced horrible treatment by nurses who were in the field of nursing longer than I have been. During those times, I would have to lock myself in the bathroom to hide and cry. I would count the days until I was done with that job and celebrated when I turned in my resignation,” Mirabelli recalls. But the good has outweighed the bad. “I have also worked with great nurses with whom I still have a bond today. My experience with those wonderful nurses definitely reduced stress and made me a better nurse and a better person. I have thoroughly enjoyed my shifts when I have coworkers that I could call my friends. I also was able to sleep better at night and looked forward to going to work.”
Research has shown that friendships between nurses can reduce stressful situations. A 2016 study published in PLOS ONE found that the “degree of cohesion among friends had a positive impact on the level of job stress experienced by nurses.” The study concluded overall that the “strength and density of such friendship networks were related to job stress. Life information support from their friendship network was the primary positive contributor to control of job stress.”
While it’s important to understand what research has discovered, it’s just as—if not more—crucial for nurses to know how this can help them in real-life situations.
Why Friendships Help
“There will always be bonds and friendships forged when you work with people in close proximity for long periods of time,” says James LaVelle Dickens, DNP, RN, FNP-BC, FAANP, who serves in the U.S. Department of Health and Human Services regional office in Dallas, Texas, as the senior program manager officer for the Office of Minority Health. “Having strong friendships at work is known to reduce stress. A study by Gallup found that people with a best friend at work are seven times more likely to be engaged with their job.”
“I can think of many times when friendships with other Nurse Practitioners (NPs) have made a difference in my life,” says Dickens. “Sometimes, it’s having someone lift our own spirits after we’ve delivered a difficult diagnosis to a patient. Sometimes, it’s offering a younger colleague with coaching to help them be the best professional they can be.”
“Nobody really understands what a nurse does like a nurse, so those relationships provide support, and that support helps bring stress down,” says Benjamin Evans, DD, DNP, RN, APN, PHMCNS-BC, president of the New Jersey State Nurses Association.
Evans explains that what makes nurses so different from other health care professions is that they are with patients more than anyone else. Other health care professionals may come and do a test, treatment, or procedure on a patient, but then they leave. The nurses are the ones who stay behind and help the patients cope with their stress, pain, or fear resulting from these processes or their conditions.
But this is just one example of why nurses have so much stress. Dickens says that other reasons are heavy caseloads, interactions with patients and their family members who may not recognize the significant challenges of their complex health conditions, and dealing with death.
“Oftentimes, the families are more demanding than the patients,” says Evans.
“Every decision a nurse makes affects the health status of their patients,” says Judith Schmidt, RN, MSN, ONC, CCRN, CEO of the New Jersey States Nurses Association. “The public doesn’t realize how stressful these areas can be. If a nurse makes a mistake, it can mean a patient’s life. You have the life-and-death situations with the patients, their families, and the administration.”
“Nurses have the type of job that requires a lot of mental clarity, physical demands, and empathy towards patients and their families,” says Flo Leighton, MS, RN, PMHNP-BC, a board-certified psychiatric nurse practitioner in private practice at Union Square Practice as well as an adjunct faculty member at New York University Rory Meyers College of Nursing.
The difficult work, both physical and mental, is why having friendships is necessary. It’s also great to have others who completely understand you.
Friends “Get” You
Erin Parisi, LMHC, CAP, owner of Erin C. Parisi Counseling & Consulting, LLC, learned about nursing friendships while working as a therapist in a residential treatment setting alongside nurses every day. “My biggest takeaway has been that having friends who are ‘in the trenches’ with you helps manage stress. In nursing, not only are you coping with the system you work in, with a boss/manager you may or may not like, and office politics, but you also have a really specialized knowledge that not everyone has,” says Parisi. “In a system where not everyone you work with is in the same role, you might end up feeling a little more alone in your job. Non-nurses who don’t have the same or similar training may not understand your jokes or fully wrap their heads around your stressors.
“A lot of nurses have a dark sense of humor, which not everyone has an appreciation for. Not only is the friendship of a fellow nurse providing stress relief, but being able to make dark/weird/gross jokes to someone else who will understand and also think it’s funny can reduce stress in a big way,” explains Parisi.
“Sharing a laugh in the midst of a stressful day lowers your blood pressure and helps put everything in perspective,” says Dickens. Having someone else who understands what makes nurses tick and what makes the profession unlike any other serves as the backbone of these types of relationships, he adds. “Having that support network and camaraderie does an NP’s mental health a ton of good.”
Shanna Shafer, RN, BSN, nursing expert, managing editor, and strategic communications manager at BestNursingDegree.com has spent ten years in the nursing field working in everything from home health, hospice, a community health center to vascular access, and in a burn intensive care unit. At the burn unit she says, “Friendships with other nurses blossomed and were essential to my own survival and mental health.” The bonds that nurses develop in various situations are amazing, she adds.
Parisi adds that nurses witness and work on a daily basis with experiences that most people do not. While everyone else in a nurse’s group outside work—non-nurse friends, family, spouses, and significant others—can provide support, they simply can’t connect with nurses like other nurses or coworkers can.
“Given the fact that nurses spend so much time at work—sometimes even more time than at home with loved ones—having friends at work can help make a shift more enjoyable. Nurses who work with you know what the day-to-day struggle looks like on any given shift,” explains Leighton. “The ability to get perspective from a work friend who understands how to handle on-the-job situations builds resilience and normalizes stressful situations. It makes us feel like we’re understood and not alone in the tasks that challenge us.”
Having someone who “gets” you, can reduce stress and make you feel better in various workplace situations. “Research has shown that social health is an importance factor in stress management. Therefore, friendships among nurses could influence rewarding benefits in processing work-related stressors,” says Amy Moreira, LMHC, owner of More MH Counseling, LLC. “The nursing field is a challenging, demanding, and rewarding job with its own characteristics that are, at times, not fully understood by the general public…A nurse who finds friendship with other nurses can benefit from their shared direct experience, allowing themselves to feel better heard and understood—which is an important part of healing in stress management. Potential solutions can be offered from a different perspective with a more solution-focused outcome than advice from other friends and family. Workplace friendships among nurses allows for in-the-moment support and allows for open processing without the need to explain certain contextual aspects.”
Nurses Eat Their Young
There’s the old adage that “Nurses eat their young.” Some more experienced nurses have been known to let the young ones flounder. Nurse.org, though, has a new campaign to dispel this adage called “Nurses support their young.” The campaign is significant because when nurses are friends, the stress of the entire unit, floor, or facility can decrease.
“It’s important for nurses to friend new nurses to allow for effective learning and adjustment on the team, including the patient,” explains Moreira. “Establishing friendships and aiding newer nurses can contribute to a more positive workplace environment and job satisfaction. Friendships between nurses can allow for a more experienced nurse to take on a ‘coaching’ role that enables stress-free learning with laughter, support, and understanding. Working past any frustrations associated with newer nurses lacking knowledge can often be processed when reflecting upon past mishaps in the experienced nurse’s own career.”
“It makes for a healthy work environment when there are coworkers whom you work with whom you can be friends with and discuss difficult issues and challenges that you couldn’t to someone outside the profession,” says Schmidt.
And a healthy workplace will influence other people and environments as well.
The Ripple Effect
When nurses are friends, they aren’t just nice to each other, but they look out for each other. While working as a staff nurse, Leighton developed a core group of nursing friends. “We collectively pitched in to make sure that if someone needed a day off or a last-minute shift coverage, we helped one another. It was an unspoken understanding that we took care of one another,” she recalls.
“While I think that friendship is important in all aspects of our lives, we do know that workplace friendships are tied to higher levels of job satisfaction, engagement in work and performance, as well as overall team cohesion,” says Dickens. “I wholeheartedly believe that a support system at work and in our personal lives is key.”
Nurses who have friends in their workplace can also assist each other during stressful situations by giving each other someone to vent to. “It can put that nurse who is stressed in a better frame of mind. It almost permeates an entire unit if one nurse is stressed and could cause others to become stressed,” he says.
Dickens adds that if a nurse is stressed, patients can sense it in the nurse’s voice and body language. But the opposite is true as well: a happy nurse can make a happy patient.
And sometimes a happy nurse, can just make a happy nurse. That can be essential enough. Nurses who are less stressed because of friendships can have improved mental, emotional, and physical wellness, says Moreira. “Nurses with reduced stress often prioritize self-care, which allows them to give their best selves to others.”
Working as a nurse can be tough. Because they are so focused on patients, they may not see when they’re experiencing burnout—and that can lead to problems with themselves or with being able to properly care for patients.
But there are ways to recognize it and to counteract it. Sarah A. Delgado, MSN, RN, ACNP, a Clinical Practice Specialist with the American Association of Critical-Care Nurses says that there are ways to identify burnout as well as ways of coping with it.
What are some tips for nurses so that they can prevent burnout?
The first step with burnout is to recognize when it’s happening. Some signs of burnout include:
- Feeling that you have to drag yourself to work, and that tasks at work take more energy than you can muster
- Feeling irritable, critical, or cynical with coworkers
- Having physical symptoms such as headaches or stomach pains or trouble sleeping
Nurses may try to dismiss these symptoms, especially in the busyness of the holidays, because they feel compelled to power through, no matter what. The truth is that recognizing and addressing burnout can actually be energizing; just realizing that you deserve to feel better is the first step toward positive change.
Coworkers can help each other call attention to burnout. If you notice someone is struggling, it may be worthwhile to check in and ask how they are doing. Burnout can be a team problem if it is pervasive on a unit because it’s hard to come to work when the people you work with are dissatisfied, short tempered, or unable to sense the value of their work. So recognizing the symptoms and checking in with colleagues is an essential strategy.
Burnout is a complex phenomenon and while there are self-care actions that nurses can take to address it, factors in the work environment contribute to burnout. Worry that patient care is compromised by an inadequate staffing mix, feeling that administrators are not responsive to clinical issues, and poor communication among health care team members are examples of issues in the work environment that can led to the mental, physical, and emotional exhaustion of burnout.
Issues in the work environment are not insurmountable but a single member of the environment cannot address all of these issues alone. If you are a nurse working in an unhealthy work environment that contributes to burnout, maybe create a New Year’s resolution to talk to your colleagues about it. If you find that they share your feelings, there may be factors beyond your control contributing to the problem.
Consider forming a group and seeking support from management to identify specific steps toward a healthy work environment. The American Association for Critical Care Nurses has resources including the AACN Standards for Establishing and Sustaining Healthy Work Environments and an online assessment tool that units can use to evaluate their environment and identify ways to make it healthier.
What are the best action steps they can to take?
There is some evidence that mediation and mindfulness practices can significantly reduce anxiety and worry. There are resources online and applications to help learn these techniques. The National Academy of Medicine provides a list of resources.
Attending to the basics—sleep, exercise, and nutrition—also helps with the physical, mental, and emotional exhaustion of burnout. Sometimes, it is easier to advise others on self-care than to take the time to do it for ourselves. The American Nurses Association initiative Healthy Nurse, Healthy Nation provides a structure for nurses to think about their own self-care and develop healthy habits.
When you find yourself feeling relaxed and rested, think back to what you were doing at that time. Were you talking to a friend, exercising, drawing, spending time with family, reading a novel, or watching a movie? Being deliberate in engaging in the activities that bring joy can reduce the stress of burnout.
What kind of self-care should they do?
I think a key antidote to burnout is satisfaction in your work. There are some shifts that are so frustrating and so exhausting! Then there are also moments when you comfort a frightened family member, catch a change in a patient’s condition, or hear “thank you” from a colleague—moments when you know your actions have a positive impact on someone else. Those moments are priceless. Keep a log or a journal by your bed or create a note in your phone with a list of your priceless moments as a nurse, and take time to re-visit them from time to time. The way you felt in those moments is as real and as powerful as the negative emotions.
What else do they need to be aware of?
Leaders and organizations in health care are increasingly taking action on the issue of burnout. As mentioned, the ANA launched the Healthy Nurse, Healthy Nation project. The Critical Care Societies Collaborative, a collection of four professional organizations, also identified burnout as a priority issue. Information and videos from their summit on this topic can be found here. Finally, the National Academy of Medicine created an online resource, the Clinician Well-Being Knowledge Hub, that offers individual and system level strategies to combat burnout. I think this website can be validating; it is important to recognize that you are not alone in feeling burnout as a member of the health care workforce.
While the holiday season can be a lot of fun, it can also be a time that makes a lot of people become depressed. Whether it’s because they’ve lost family or friends, they’re experiencing rough times, or they are in the hospital and/or are ill, it can make many sad.
There’s a difference between regular sadness and depression, though. And it’s important to be able to recognize if your patients are experiencing depression. According to Sharon R. Kowalchuk, RN, DPN, Director of Nursing at Silver Hill Hospital (an academic affiliate of the Yale University School of Medicine, Department of Psychiatry), nurses can recognize symptoms of depression in their patients. “In any setting, patients may come to our attention with reports of loss of energy, anxiety, aches and pains, headache, insomnia, changes in appetite, or a significant weight loss or gain in a short period of time. These symptoms are not necessarily signs of depression, but they call for further exploration,” says Kowalchuk.
What are the specific signs that you can recognize as being those of depression? “It is easiest to recognize depression when the patient reports feeling sad, empty, hopeless, having difficulty enjoying usually pleasurable activities or sex. The more subtle signs may be irritability, restlessness, becoming more cranky than usual, having difficulty keeping up with everyday routines, or focusing on TV or reading. Expressing feelings of pessimism, guilt about one’s life, thinking a lot about losses or failures, believing things will not get better—these are more concerning symptoms,” explains Kowalchuk. As difficult as it might be, she says, “You will need to ask if they have thought about suicide.”
If you recognize these signs in patients, it’s important to get more information about any action they may have taken to prepare for suicide. “A key question is whether they have attempted suicide or began a suicide attempt that was interrupted by another person—or they stopped of their own volition,” says Kowalchuk. She adds that these questions are outlined in the Columbia-Suicide Severity Rating Scale (C-SSRS), a protocol that uses simple, plain language questions that anyone can ask to assess risk.
Depending on the level of risk or the particular setting, says Kowalchuk, the nurse caring for this patient may need to refer him or her to a mental health professional.
“Holidays are times that bring up life events, feelings of loss or loneliness, placing all of us at risk. The consequence of undetected depression is death by suicide,” she says. “According to the suicide experts at The Lighthouse Project, ‘Just ask, you can save a life.’”
This past spring, Chenjuan Ma, PhD, and Amy Witkoski Stimpfel, PhD, RN, both assistant professors at NYU Rory Meyers College of Nursing, published a study in the Journal of Nursing Administration that examined whether working overtime can negatively influence how nurses collaborate with other nurses and physicians. In their study “The Association Between Nurse Shift Patterns and Nurse-Nurse and Nurse Physician Collaboration in Acute Care Hospital Units,” the researchers concluded that one third of all nurses work longer than they are normally scheduled, and as a result, their ability to collaborate decreases.
Drs. Ma and Stimpfel took time to talk about the study and its results.
Why did you decide to do this study in the first place?
Dr. Stimpfel: There has been increasing interest in how to manage shift work and overtime hours for nurses due to the impact of fatigue on patient safety and quality. Collaboration has been identified as being a factor that is influential in patient safety and quality as well. We know that our ability to work effectively and regulate emotions—key to collaboration—diminishes with increasing wakefulness and fatigue. We could not find literature to support the relationship between work hours/overtime and collaboration in the nursing literature, which is why we conducted this study.
It’s interesting that nurses who work regular shifts of 11.88 hours or longer regular shifts of 12.17 hours don’t have a decrease in collaboration. But if nurses working that first shift of 11.88 hours had to work a shift of 12.17 hours—which would mean overtime—they would have a decrease in collaboration. Did you discover why this happens?
Dr. Stimpfel: Our data did not detail why working overtime resulted in decreased collaboration. However, the conceptual model in our study helps guide our hypothesis about why this relationship occurs. As nurses work longer shifts, often unexpectedly, this increases wakefulness. Prolonged wakefulness can result in less ability to make decisions and regulate emotions, which may lead to greater difficulties in collaboration. As suggested by our findings, this is more likely to happen when nurses have to unexpectedly work longer than scheduled.
Does any amount of overtime cause problems with collaboration between nurses and other health care professionals?
Dr. Ma: With our current study design (i.e., observational, cross-sectional design), we were not able to detect the minimum amount required to lead to changes in collaboration. However, as the very first study of its kind, our study provided empirical evidence of a significant association between work hours/overtime and collaboration. Our current study suggested that one hour of overtime was associated with 0.17 decrease on the RN-RN scale. In other words, a 0.17 decrease from mean score of the RN-RN scale suggest that a unit’s rank on the RN-RN score would drop from 50th percentile to approximately 30th percentile.
Why is collaboration so important?
Dr. Ma: Collaboration is critical for quality care and patient safety. When working collaboratively, different parties in the patient-care team—including nurses and physicians—will share objectives, responsibility, decision making, and power to achieve patient care goals.
Previous studies have shown that patients receive superior care and have better outcomes in hospitals where nurses collaborate well with other health care providers. Without good collaboration among health care providers, quality patient care may be compromised.
Were you surprised by the results of your research?
Dr. Ma: Not really. Maybe the high number of nurses—one in three nurses—reported working longer than scheduled.
Do you have any suggestions for what should be done so that collaboration doesn’t diminish?
Dr. Ma: One highlight of our findings is the significant association between longer overtime and decreased collaboration. This finding suggests that one strategy to improve collaboration is to minimize nurse overtime as much as possible by a variety of means, better shift scheduling, and predicting and ensuring adequate staffing, etc.
Is there anything regarding this research that you think is important for readers to know?
Dr. Stimpfel: Our findings have broad implications, not just for nurses, but also for other health care providers who are at risk for shift work-related fatigue. Effective teamwork and collaboration are critical to patient outcomes, thus, managing shift work and overtime hours are important for the entire heath care team.