Informed Consent and Informed Refusal in Managing Patient Expectations

Informed Consent and Informed Refusal in Managing Patient Expectations

Insights from the new Nurse Practitioner Claim Report: 4th Edition from CNA and Nurses Service Organization (NSO) show that the majority of claims against nurse practitioners developed from a failure involving core competencies, such as diagnosis, medication prescribing, or treatment and care management. Allegations related to failure to diagnose and improper prescribing/managing of controlled drugs occurred most frequently.

What the report also found was that in many claims, the nurse practitioner met the standard of care, but the patient was nonetheless dissatisfied, often due to a lack of communication or understanding. The informed consent discussion represents the first step in managing patient expectations, thus reducing the possibility of a misunderstanding and mitigating the risk of a consequent lawsuit.

Additionally, documenting the informed consent process provides the best defense in the event a patient alleges that the proposed treatment, other options, or the potential for injury were not adequately explained to them. Refer to state statutes for guidance on the informed consent process, as there is considerable variance among states. This is especially true when it comes to caring for minors or cognitively impaired patients, and emergency situations.

The informed consent process involves two main components:

  • Discussion, providing the patient with sufficient information about and time to consider:
    • The nature of the proposed treatment, including rationale, anticipated benefits and prognosis.
    • Alternatives to the proposed treatment, including specialty referral options or no treatment at all. This should also include an explanation of why, according to one’s professional judgment, the recommended treatment is preferable to alternatives.
    • Foreseeable risks, including potential complications of the proposed treatment and risks of refusing it.
  • Documentation of the discussion and the outcome of the discussion in the healthcare information record, which often includes the use of a written informed consent form in addition to the verbal component.

The informed refusal process is similar to, but goes beyond, the process for informed consent. Refusal of care increases the potential liability exposure for the nurse practitioner, but nurse practitioners can help minimize their liability exposure by being aware of their consequent responsibilities and documenting the informed refusal process.

Nurse practitioners who continue caring for a patient after they decline treatment recommendations must be aware of their responsibility to:

  • Continue to examine and diagnose the patient for the duration of the practitioner-patient relationship and as long as the patient continues to refuse treatment.
  • Continue to inform the patient about the condition and its associated risks, while the practitioner-patient relationship is in place, the condition exists, and the patient continues to refuse treatment.
  • Continue to inform the patient how their refusal of treatment may affect treatment of other conditions or problems, when discussing these conditions.

After discussing the potential consequences of refusal with the patient, nurse practitioners should complete a comprehensive progress note and document the refusal using a written form, which should be incorporated into the patient health care information record. Progress notes should document:

  • The individuals present during the discussion.
  • The treatment discussed.
  • The risks of not following treatment recommendations, listing the specific risks mentioned.
  • The brochures and other educational resources provided.
  • The questions asked and answers given by both parties.
  • The patient’s refusal of the recommended care.
  • The patient’s reasons for refusal.
  • The fact that the patient continues to refuse the recommended treatment.

As the data proves, it is imperative for nurse practitioners to protect their patients and their practice by documenting all phases of medical treatment, discussing (and documenting) the nature of all proposed treatments with patients as well as educating them about the need for follow-up, and signs and symptoms that should prompt a follow-up call.

In addition, today’s nurse practitioners must continuously evaluate and enhance their patient safety and risk management practices by remaining current regarding their clinical practice, medications, biologics, and equipment utilized for the diagnosis and treatment of acute and chronic illnesses and conditions related to one’s specialty and obtain regular continuing education.

Disclaimer: This article is provided for general informational purposes only and is not intended to provide individualized business, risk management or legal advice.  It is not intended to be a substitute for any professional standards, guidelines or workplace policies related to the subject matter.

This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500.

Heart Health for Busy Nurses

Heart Health for Busy Nurses

February is American Heart Month — what better time to reassess how well you are taking care of your heart health?

Know Your Risk Factors

As a minority nurse, you probably know certain minority groups have higher risks for heart disease. According to the American Heart Association, African Americans, American Indians/Native Alaskans, and Hispanics have an increased risk of heart disease and its associated problems like high blood pressure, heart attack, and stroke.

Other risk factors include hereditary factors (others in your family have heart disease), smoking, obesity, sedentary lifestyle, and poor diet.

Know the Signs

According to the Centers for Disease Control and Prevention, there are a few heart attack signs and symptoms that you shouldn’t ignore.

If you experience any of these symptoms, call 911 immediately.

  • Pain or discomfort in the jaw, neck, or back
  • Feeling weak, light-headed, or faint
  • Chest pain or discomfort
  • Pain or discomfort in arms or shoulder
  • Shortness of breath

Women also tend to have symptoms that are different from men and, therefore, aren’t always immediately considered as heart trouble.

Watch for these unusual signs:

  • Nausea or vomiting
  • Heartburn
  • Extreme fatigue
  • Feelings of unease or anxiety

Heart disease isn’t called the silent killer for no reason. If you feel something is off, whether that’s occasional chest pain with exercise or under stress, heart palpitations, or off-and-on chest discomfort, always be cautious and get it checked.

Reduce Your Risk

If you have risk factors for heart disease, you should monitor your blood pressure, your cholesterol, and your blood sugar. Try to reduce your risk by maintaining a healthy weight, getting enough physical activity, being sure to rest, staying connected with loved ones, and trying to keep your stress levels in check.

With the hectic pace of a nurse’s day, getting any time to bring your stress down a notch is a struggle. But one simple way to help with stress reduction is to step outside. Plenty of research backs up the idea that more time outside is better for your health. A few minutes walking at lunch, parking far enough away in a parking lot, or even just getting a few breaths of fresh air on a break can have huge benefits on your physical health and your mental health. Getting into nature can clear your mind, lower your blood pressure, and help you clear out the mental clutter enough to focus better when you come back to work.

Heart disease is the number-one killer of men and women in the United States, so paying attention to your own heart health is one of the best preventative measures you can take.

Nurse Anesthetists Offer Career Info for Student Nurses

Nurse Anesthetists Offer Career Info for Student Nurses

Certified Registered Nurse Anesthetists (CRNA) Week runs this week from January 21 to 27 and is an excellent opportunity for student nurses to find out more about this path in a nursing career.

With more than 52,000 nurse anesthetists and student nurse anesthetists, the career is thriving and attractive for several reasons. Many nurse anesthetists say the patient interaction they have is unsurpassed. They are with patients before, during, and after surgery, so there’s a necessary trust that is quickly established with the skill and care of the nurse.

Nursing students who are considering this as a career have many resources they can reference and various organizations that will help them succeed on this career path. The American Association of Nurse Anesthetists (AANA) is especially aware of promoting health and wellness among the student nurses who seek a career in this branch of nursing. The AANA’s 2017 report Wellness and Thriving in a Student Registered Nurse Anesthetist Population explored the significance of the relationship between student wellness and how well students do in their academic program.

To celebrate CRNA Week, Minority Nurse recently posed some questions to Michael Neft, DNP, MHA, CRNA, FNAP, FAAN, and assistant director of the Nurse Anesthesia Program University of Pittsburgh School of Nursing and nursing student Sara Wilkinson, BSN, RN, CCRN SRNA at University of Tennessee Health Sciences Center. The following are their answers.

Why is the AANA particularly aware of the health and wellness among student nurses looking to enter or actively studying in this field?

Student nurses are the future of the profession, and it is important to cultivate and prepare for a long and healthy career. Students who aspire to enter into nurse anesthesia programs must be healthy mentally and physically. They must have healthy outlets for stress relief, and healthy lifestyle habits that will support them throughout our educational programs.

Nurse anesthesia education programs are required by their accreditation standards to provide education content on wellness and substance use disorder. The AANA actively encourages members, students, as well as educational programs to engage whenever possible in healthy behaviors, whether that includes physical activity or simply reducing stress by encouraging individuals to take time for their loved ones or to engage in an activity they love.

The AANA is committed to providing resources and information about ways to become involved in establishing a healthy lifestyle and even offers fun runs, wellness tutorials and a massage therapy area at many of their conferences.

How does establishing good health and wellness practices now help a student nurse become better? And how will taking care of oneself now carry over once they graduate and are several years into a CRNA career?

Nursing has unique stressors like dealing with patient care situations that require critical thinking, fast decision making, and autonomy is tough. If the student nurse does not have the ability to cope with these situations autonomously, it is very difficult to care for patients. Maintaining both mental and physical health and wellness are at the foundation of successful practice.

Developing healthy lifestyle habits early, helps students handle stress more effectively, set clear goals, and develop a clear plan to achieve them. They also assist students with discipline, good study habits, prepare for clinical experiences properly, and self-evaluate objectively. It also helps to establish diet and exercise plans that can be adjusted as one transitions to practice, to avoid elimination of healthy habits out of inconvenience.

Maintaining a school-life balance is also important to develop a support system and find time for small, pleasant breaks to gives a fresh perspective and recharge. Establishing healthy behaviors and habits early is vital to long-term health, wellness, and maintenance of a successful career.

Do you have any advice for student nurses about considering this field and being aware of any challenges unique to this branch of nursing?

For student nurses considering the field of nurse anesthesia, awareness about the depth and breadth of study is valuable, but is important to be well, so that an individual will have the endurance to graduate. A strong support system and personal discipline are necessary to allow for healthy stress relief and appropriate professional conduct. Anesthesia remains the field with the highest incidence of drug abuse and unhealthy coping behaviors, due to high stress and access.

Think about what you do when stressed. Review your lifestyle habits: exercise, eating, alcohol use, and other substance use. Some prospective students may want to employ a lifestyle coach who can look at a person individually and help one to develop positive lifestyle habits that will set one up for success in graduate school and a stressful career. Good study habits, a healthy respect for one’s self and career, use of study resources, and strong, supportive relationships will be required to succeed and thrive in this field.

Why Are Communication Skills So Essential for Nurses?

Why Are Communication Skills So Essential for Nurses?

When nurses think of the big responsibilities in their careers, patient safety is predominant. But communication skills? Those aren’t often at the top of the list.

Nurses train for years to ensure the safety of their patients. Their unwavering advocacy for patients has done nothing less than transform healthcare. But patient safety can’t happen without clear communication skills. Nurses must have excellent communication skills to provide the best care for patients and to earn the respect of their peers.

What kinds of communication skills will nurses use? Here is just a small sample of how nurses use various communications skills throughout the day:

  • Communicating with healthcare team members on a patient’s condition, diagnosis, treatment, complications, progress
  • Explaining to patients about self care, about their diagnosis and prognosis, about resources, and about everything from medications to diet and exercise
  • Talking with family and loved ones about patient needs, follow-up care, disease, recovery, medication
  • Communicating with professionals in non-healthcare fields to help secure grants, influence policy, or explain a professional need
  • Educating the public on healthcare issues that are important to their age, region, or personal health, or educating students on nursing practices or nursing career options

How can you improve your communication skills? Here are a few pointers:

  • Be precise and clear. If you need information or you need someone to do something, say so. If you are giving information, present it in basic terms.
  • Ask if anyone has questions. Your audience could be a roomful of academics at a conference, a team of colleagues in your unit, or a single patient—always ask if anyone has follow-up questions. Don’t assume that your audience heard and understood everything you said. This last step gives you an opportunity to recognize where your communication can be strengthened and to convey the needed information.
  • Write clearly. Whether you are writing a memo or a research paper, use fewer words and make them have greater impact. Decide what you are trying to say, use short paragraphs for ease, add bullet points to emphasize your main points, and make sure you reread everything before you send it..
  • Consider your tone and body language. The way you speak and hold yourself can support your words and intent, but if they are out of whack, your unspoken actions can cause confusion. Make sure you speak in even tones when possible and that your body language is approachable.
  • Learn about best practices. You’ll find books, seminars, presentations, and even casual discussions that can all help you sharpen your skills. If you’re a nurse manager, bring this up in each employee review and ask for it in turn from your own supervisor.

Communication can always be improved. Each time it is, your capability as a nurse is strengthened.

5 Easy Ways to Make the World a Kinder Place

5 Easy Ways to Make the World a Kinder Place

The modern holiday season has become more of a mad dash from November though the new year. There are so many school plays to see, cookies to bake, family and friends to visit, shopping to do, packages to ship. With all that added to a normally jammed work and life schedule, the holidays become a blurred jumble to get thorough rather than enjoy.

Here are five easy ways to make your holiday season a little nicer, a little kinder, and a lot more satisfying.

1. Give What You Can

Part of the reason giving is so satisfying is because it requires you to share something valuable to you with someone else. If you have money to give, buy some extra presents for kids who might not get much. Spend some of your extra on gift cards to grocery stores and drop them off at a local food pantry. If you have extra goods in your home (unused sweaters, coats, blankets) find places that need those items and drop them off.

2. Spend Your Time

If you don’t have much extra money, spend your time in ways that are equally valuable. Take an afternoon to visit with shut-ins in your town. Bake some homemade goodies to share with neighbors or a senior center. Volunteer your nursing know how to teach a group of kids about health and wellness. Walk some dogs at the pet shelter. Knit baby caps or pack up hurricane relief boxes for areas hard hit this year. The world needs a lot of things right now and time is in short supply. Give some of yours and watch what an impact it has.

3. Work Hard to Spread Cheer

Hustle and bustle doesn’t always make for happy people. The lines in stores, the traffic on the roads, and the time spent on extra errands can make even the most even-keeled person cranky. But a lot of cranky people make everything that much worse. Make an effort to be the person who is kinder than the next. Feed the birds. Hold the door open for someone. Let the person with two items go ahead of you in line. Chat with someone sitting next to you at a community event or a professional gathering. When you are kinder, it spreads to others.

4. Reflect Alone and Together

Take time to think about what the season means to you. Dig deep and uncover what will make the season more joyful and more joy-filled. Do you want to hear more music or do you need silence? Do you need to be around people or do you need a day to yourself? What purpose do you want to fulfill in the new year? Find others who have similar thoughts about this time of year and spend some time talking and hearing each other. Then move into the next month with intention and a vision for making the season better for you.

5. Connect with Others

Connect face-to-face with people you care about or with people you have lost touch with. It’s easy to lose connections in today’s online environment, but the real joys of something as simple as a cup of coffee with a friend can soothe your soul. Reach out to others. Heal old wounds or repair the relationships worth fixing (don’t even consider wasting your time on the ones that aren’t). Recognize that we all carry our own burdens and that together they may be lessened.

How will you make the world a kinder place this year?

3 Tips to Improve Conflict Resolution Skills

3 Tips to Improve Conflict Resolution Skills

Conflict resolution is an essential skill for every nurse. Conflict in the workplace may be unavoidable, but it can be minimized and resolved. Learning to resolve your conflict effectively and early—in a way that does not increase your stress level—is important.

Nurses can experience different types of conflicts including personal, interpersonal, and interdepartmental conflicts. Any conflict can interfere with workflow and harmony. Conflicts can also decrease productivity and damage self-esteem. However, not all conflicts are bad; occasionally a conflict can be good for change in the workplace.

Here are some tips to improve your conflict resolution skills.

1. Practice active listening and communication skills.

Practice listening to what the other person has to say, without interrupting. Make sure you understand what the other person is telling you. Communication provides an opportunity to share thoughts and problems as well as the reason why they are having conflicts. Face-to-face communication is more effective than other forms because it allows for an active exchange of information. It also allows you to observe important nonverbal cues from the other party. It is important that you use open-ended questions to make sure each side understands what the other person thinks and how he/she feels. This invites people to delve deeper into the problem and find the root cause for the conflict.

2. Stay calm and recognize the conflict.

Being calm and aware of your emotions are vital aspects of conflict resolution. Recognizing the legitimacy of conflicting needs and analyzing them in an environment of compassionate understanding will lead to successful problem solving. Use critical thinking skills to analyze the problem and plan your strategy, including what you want to say, and then write it down and rehearse it. Create a note card, if necessary, with your main talking points.

3. Maintain a positive attitude and practice managing your emotions.

A positive attitude is what you need to solve half of the problem. Emotions play a greater part in most decisions so recognizing and understanding your emotion will help you control your emotional response.

“Anybody can become angry – that is easy, but to be angry with the right person and to the right degree and at the right time and for the right purpose, and in the right waythat is not within everybody’s power and is not easy.” — Aristotle