Trauma-informed care

I stood in the doorway of room 630 and observed her staring out the window, consumed by thought. She was a 20-year old young woman who had been admitted to the medical unit due to gastrointestinal bleeding. I walked into the room, introduced myself and told her that I needed to perform my initial physical assessment. I put on my stethoscope and motioned closer, then she raised her hands and said “Please, don’t.” I stepped back, confused, and informed her that I needed to check on her bleeding and to make sure everything was ok. She shook her head as tears filled her eyes. I asked her why she was crying and she stated “because I don’t feel comfortable having a stranger touch me.” I assured her that I wouldn’t hurt her and after several more minutes of silence she stated, “I was sexually abused as a teenager.” I thanked her for sharing that very personal and painful information and asked how I could make her more comfortable. She was grateful and just asked for more time. It was early in my nursing career, and I didn’t have any specific training or experience dealing with trauma victims.

trauma-informed-care.jpgTraumatic events, such as sexual abuse, domestic violence, elder abuse, and combat trauma, can have serious long-term detrimental effects on the physical, emotional, and mental well-being of an individual. These life events may lead to depression, distrust, smoking, substance abuse, shame, and low self-esteem. Traumatic events can also shape an individual’s comfort level and attitude toward health care.1 Routine preventative health care visits that involve invasive physical exams and close contact with a health care provider could trigger fear and anxiety in the patient.

Trauma-informed care (TIC) is a term that has been used in recent years in a variety of areas, including social services, education, mental health, and corrections to address the needs of people who have experienced traumatic life events. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma-informed care as a methodology to respond to those who are at risk or have experienced trauma.2 There are four essential approaches and six principles of trauma-informed care.

The four essential approaches of trauma-informed care can be found in a program, organization, or system that2:
  1. Realizes the widespread impact of trauma and understands potential paths for recovery.
  2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others.
  3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices.
  4. Seeks to actively resist retraumatization.
The six key principles of trauma-informed care include2:
  1. Safety – make sure your patient and family members feel safe, both physically and psychologically.
  2. Trustworthiness and transparency – trust between patients, staff, and management is vital in building strong relationships.
  3. Peer support – identify individuals with similar experiences of trauma helps to create safety, builds trust, enhances collaboration, and promotes recovery and healing.
  4. Collaboration and mutuality – emphasize that all members of the team, including patients, are equal.
  5. Empowerment, voice, and choice – identify individual strengths and differences and utilize them as the foundation for recovery and healing. Provide the patient with choices and an opportunity to share in the decision-making process, which results in a sense of control.
  6. Recognition of cultural, historical, and gender issues – set aside cultural stereotypes and biases.
How do we put these principles into every day practice? For patients who openly share their trauma history, clinicians should be careful when delving into their psychological histories, unless they have specific training in trauma.1 Many patients, however, feel ashamed and are not comfortable exposing their past. Every member of the health care team should be trained on universal trauma precautions, which is the idea that every person potentially has a history of trauma.2 There are several strategies that clinicians can utilize to implement the TIC approach in general patient care. 1

1. Patient-centered communication:
  1. Ask every patient what can be done to make them more comfortable during their appointment.
  2. Before the physical exam, explain what parts of the body will be involved and allow the patient to ask questions.
  3. Give the patient the option to shift their clothing out of the way instead of putting on a gown.
  4. Provide a pillow for back support for patients who are anxious in the supine position.
  5. Offer a mirror to see procedures or examinations that a patient cannot see.
  6. If a patient seems moderately to highly anxious, offer ways for patients to signal distress either verbally or by raising their hand during a procedure.
2. Understanding the health effects of trauma:      
  1. Understand that poor coping mechanisms, such as smoking, substance abuse, overeating, and high-risk sexual behavior, may be related to trauma history.
  2. Engage with patients in a collaborative, non-judgmental manner when discussing health behavior change.
3. Multidisciplinary collaboration: 
  1. Maintain a list of referral sources across disciplines for patients who disclose a trauma history.
  2. Keep referral and educational material on trauma available in waiting rooms.
  3. Engage in inter-professional collaboration to ensure continuity of care.
4. Understanding your own history and reactions:
  1. Reflect on your own trauma history (if applicable) and how it might influence patient interactions.
  2. Learn the signs of professional burnout and prioritize good self-care.
5. Screening:
  1. Decide if your organization will screen for current trauma or a history of traumatic events.
  2. Consider if screenings will be face-to-face or self-reported by the patient.
  3. Provide all staff with communication skills training about how to discuss a positive trauma screening with a patient.
  4. Ensure your organization has the resources available to properly care for the patient, or have processes in place to refer patients to other resources.
Unfortunately, traumatic events occur more often in our society than we think. Caring for patients with a history of traumatic life events requires a high level of sensitivity and compassion. Health care organizations can assist their staff in navigating delicate and difficult situations by providing educational training, tools and resources on the trauma-informed care approach.
 
Resources for Health Care Providers:
Child Welfare Information Gateway
National Council for Behavioral Health
Substance Abuse and Mental Health Services Administration
The Trauma Informed Care Project
 
References:
  1. Raja, S., Hasnain, M., Hoersch, M., Gove-Yin, S., & Rajagopalan, C. (2015). Trauma Informed Care in Medicine: Current Knowledge and Future Research Directions. Family Community Health, 38(3), 216-226.
  2. Koetting, C. (2016). Trauma-Informed Care: Helping Patients with a Painful Past. Journal of Christian Nursing, 33 (4), 206-213.
Myrna B. Schnur, RN, MSN 

 
Posted: 11/10/2016 2:29:07 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety


Nurses ARE the Safety Net!

nurses-are-the-safety-nets.PNGThis year’s Nurses Week theme focuses on safety – “Culture of Safety – It Starts with YOU.”  Immediately many of us think of patient safety, and that’s as it should be – patients come first. We know that hospitals can be hazardous to patients because of nosocomial infections, medication errors, slips and falls, increased stress because of lack of sleep. Because of our around-the-clock presence, nurses have always been the sentinels, shepherding our charges towards discharge with no complications.

The ANA defines a culture of safety “as one in which core values and behaviors — resulting from a collective and sustained commitment by organizational leadership, managers and workers — emphasize safety over competing goals.”  That’s a great concept but not one that every hospital has put into practice.

Staffing, of course, has to be key – how can nurses fulfill one of our most critical functions – assessing and monitoring patients – if there are too few of us to be able to spend time with patients? How can we prevent pressure ulcers and promote return to strength and mobility if there are too few of us to safely assist patients to ambulate?  Patients who’ve been in and out of hospitals – the “experienced” patient – know that nurses are the key to recovery. I unearthed this from an AJN article published in the 1970s:

The patients were then asked what they felt was the most positive aspect of their experience on the intensive care unit as well as the most negative. Thirteen responded that the most positive aspect was “knowing that the nurses were there every minute”; 10 answered simply, “nurses.”

But a true culture of safety has to include our own individual commitment to safety. The 12-hour shift has come under fire as evidence is mounting that it’s not the best solution for nurses or for patients. (We’ve covered the issue in AJN in a March 2014 news article as it relates to fatigue, and also in the AJN blog, Off the Charts.)  The shifts often extend to more than 12 hours, often without breaks; and some nurses may pick-up extra shifts, working four or five straight days of 12-hour shifts. I don’t work in a hospital but in an office,  yet when I’m on deadlines and working 10-12 hour days, my brain is fried after four days and I know I’m not thinking as clear as I should be. I’d be afraid to have that kind of fatigue and have to give medications and make critical decisions with lives at stake.

We know nurses have been involved in auto accidents (In the February 2014 issue of AJN, we reported on a nurse who was killed on her way home) and involved in near-misses on the drive home from long shifts – my sister, a former NICU night nurse, always put the car in park when she came to a stop light after she found herself falling asleep and coasting through an intersection on her way home.

So for this Nurses’ Week, make a commitment to safety – your patients’ and your own.

Shawn Kennedy, MA, RN, FAAN


 
Posted: 5/11/2016 9:41:11 PM by Lisa Bonsall, MSN, RN, CRNP | with 3 comments

Categories: Patient Safety


Violence Against Nurses

Recently, there has been growing attention given to violence in the workplace. This new attention is extremely important because previously there was relative silence about violence against nurses and other health care workers, although it happens very regularly in our work settings. Personally, I have worked in a wide range of health care settings, including home care. Safety was a priority in home care because nurses must travel alone, often in unknown areas and situations. Do you know, however, that most workplace violence occurs in the hospital setting, particularly in psychiatric units and emergency departments? According to a recent study, 80% of emergency nurses reported that they experienced some level of violence in the past year, for home care that was 60%. As you are reading this, you may not think this is possible, but I suggest that you answer the following question to see if you have experienced workplace violence.

While performing your role as a nurse in a clinical, administrative, management, or education role, has a patient, resident, family member, or coworker ever: yelled at you, harassed you, threatened you, hit, punched, or scratched you, spit or thrown any other bodily fluid or waste at you?

Workplace violence, according to the Occupational Health and Safety Administration (OSHA), covers a range of behaviors from bullying to committing homicide, and it also covers actions that are from patients or residents who may be fully aware of their actions, as well as those who may have dementia, delirium, drug or alcohol intoxication, or mentally incompetence. Unfortunately, OSHA has no specific standards that they are requiring of all employers to prevent workplace violence.2 What exists is a general duty of employers to ensure safety and prevent workplace injury and illness.2

Quote-Karen-Innocent.pngPreventing Workplace Violence
First, it is very important to understand that as a nurse, or any type of employee, you have a right to be safe at work. Safety concerns at work were taken very seriously since 1970 when the United States Congress passed the Occupational Safety and Health Act, which set mandatory standards to prevent injury to employees for all types of causes, including violent acts. The OSHA website contains links to several health care and professional organizations and government agencies that provide guidelines for workplace violence prevention.

Recommendations include:
  • Employers should assess and mitigate risk, providing employee training, implementing safety programs, and report incidents.3
  • Your workplace may be at high risk for if you and your colleagues do not have training in early recognition and management of potentially violent situations; your facility does not have policies to ensure safety, like zero tolerance rules on violence, firearms, and carrying other weapons; or if the organization is frequently staffed inadequately and/or lacks security personnel.
  • OSHA relies on nurses and nursing administrators to speak out and report serious concerns about workplace safety, and protects those who report issues with whistle-blower laws.2 
  • Nursing organizations, including the American Association of Critical Care Nurses and the American Nurses Association, have also advocated for protection of nurses from workplace violence and have published position statements on the topic – Workplace Violence Prevention and Incivility, Bullying, and Workplace Violence, respectively.
  • Tap into your member organization for assistance with violence prevention programs in your workplace.
The Center for Disease Control and Prevention (CDC) is one of those government agencies that has resources to assist employers and workers in keeping their workplaces safe. For example, Workplace Violence Prevention for Nurses is a free course for nurses that is available on the CDC website. With so many factors that contribute to violence in health care settings, there is no single resource or solution that can be implemented to resolve the problem. Therefore, it is best to stay informed about the available resources and perhaps start by reading some of the workplace safety articles on Lippincott NursingCenter.com and take advantage of a National Nurses Week CE Collection discount this week.
References
1. Phillips, J. Workplace Violence against Health Care Workers in the United States. New Engl J Med. 2016; 374(17):1661-1669.
2. Occupational Safety and Health Administration. (n.d.) Workplace Violence: Enforcement. Retrieved on May 3, 2016 from https://www.osha.gov/SLTC/workplaceviolence/standards.html
3. The National Institute for Occupational Safety and Health (NIOSH). June 26, 2014 Recent NIOSH Research on Occupational Violence and Homicide, Retrieved from http://www.cdc.gov/niosh/topics/violence/traumaviol_research.html
Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN
Posted: 5/10/2016 10:27:58 PM by Lisa Bonsall, MSN, RN, CRNP | with 3 comments

Categories: Patient Safety


Medication Safety: Go beyond the basics

For any nurse working in a direct care setting, preparing medications and administering them to patients is part of the daily routine. Mistakes can happen at any point in the process. Administration errors are one of the most serious and most common mistakes made by nurses. The result may lengthen a hospital stay, increase costs, or have life and death implications for the patient. So, what can you do to safely administer medications?

Start with the basics
  • Verify any medication order and make sure it’s complete. The order should include the drug name, dosage, frequency and route of administration. If any element is missing, check with the practitioner.
  • Check the patient's medical record for an allergy or contraindication to the prescribed medication. If an allergy or contraindications exist, don't administer the medication and notify the practitioner.
  • Prepare medications for one patient at a time.
  • Educate patients about their medications. Encourage them to speak up if something seems amiss.
  • Follow the eight rights of medication administration.

do-not-disturb.PNGMinimize distractions and interruptions:
  • Know that interruptions and distractions have a marked effect on your performance, causing a lack of attention, forgetfulness, and errors.
  • Make sure you have all the required supplies and documents available before beginning preparation or administration activities.
  • Follow your facility’s policy related to the use of a “No Interruption zone” (NIZ), a practice recommended by the Institute for Safe Medication Practices (ISMP) to enhance patient safety. Your NIZ should be a discreet area where medication tasks are performed.  It may be a dedicated medication room or a quiet area sectioned off by visual markers.
  • If required by your facility, wear a special vest, apron, sash, lighted lanyard, or other item that indicates that you are administering medications and shouldn’t be interrupted.
  • If your facility utilizes mobile devices, temporarily transfer calls and other notifications to another staff member or place the device on pause during the most complex parts of the medication preparation and administration tasks.

safety-measures.PNGImplement these additional safety measures:
  • Be especially alert during high-risk situations, such as when you are stressed, tired, or angry or when supervising inexperienced personnel. Monitor and modify work schedules to minimize work- or fatigue-related medication errors.
  • Be familiar with all appropriate antidotes, reversal agents, and rescue agents. Know where they are stored on your unit and how to administer them in an emergency situation.
  • Be familiar with high-alert medication (such as anticoagulants, antidiabetic agents, sedatives, and chemotherapeutic drugs). Ask another nurse to perform an independent double check and rectify any discrepancies BEFORE administering the drug.
  • Be aware of the ISMP’s and your facility’s list of confused drug names, which includes sound-alike (such as Zocor and Cozaar) and look-alike (such as vinblastine and vincristine) name pairs.  Take extra precautions when administering drugs from these lists. Your facility may also have extra safeguards in place, such as requiring both the brand and generic name be recorded, including the purpose of the medication with all orders, or setting up computer selection screens to prevent look-alike names from appearing near each other.
  • Pay attention to Tall Man lettering, a visual safety feature that highlights a section of a drug’s  name using capital letters to help  distinguish look alike name pairs from each other, such as BuPROPion (an antidepressant) from  BusPIRone (an anxiolytic) or glipiZIDE from glyBURIDE (two different antidiabetics). 
  • Measure and document a patient’s weight in metric units (grams and kilograms) ONLY to allow for accurate dosage calculations. Also, weigh the patient as soon as possible on admission and don’t rely on stated, estimated, or historical weights.
  • For patients receiving IV opioid medication, frequently monitor respiratory rate, sedation level, and oxygen saturation level or exhaled carbon dioxide to decrease the risk of adverse reactions associated with IV opioid use. If adverse reactions occur, respond promptly to prevent treatment delays.
  • Administer high-alert intravenous medication infusions via a programmable infusion device utilizing dose error-reduction software.
  • Reconcile the patient’s medications at each care transition and when a new medication is ordered to reduce the risk for medication errors, including omissions, duplications, dosing errors, and drug interactions.
  • Educate and provide written instructions to the patient and family (or caregiver) regarding prescribed medications for use when at home and verify their understanding prior to discharge.
By being familiar with medications you administer and following safeguards, you can help protect your patients from medication errors.

For more information on medication safety, go to:
CDC: Medication Safety Program
Institute for Safe Medication Practices
AHRQ Patient Safety Network: Medication Errors
US FDA: Medication Errors Related to Drugs
 
References: 
Institute for Safe Medication Practices. (2016). "2016-17 targeted medication safety best practices for hospitals" [Online]. Accessed April 2016 via the Web at http://www.ismp.org/tools/bestpractices/TMSBP-for-Hospitals.pdf

Safe medication administration practices, general. (2015). In Lippincott procedures. Retrieved from http://procedures.lww.com.

Nursing 2016 Drug Handbook. (2016). Wolters Kluwer: Philadelphia, Pennsylvania.
 
Joan M. Robinson, MSN, RN
Clinical Director
Lippincott Solutions

 
 
Posted: 5/9/2016 9:49:40 PM by Lisa Bonsall, MSN, RN, CRNP | with 3 comments

Categories: Patient Safety Technology


Who you gonna call? ...Bugbusters!

Bugbuster.PNGDon’t you wish it was that easy? You could just pick up the phone, hire Bugbusters, and they’d come out and use their Sci-fi equipment to rid your facility of all those nasty “bugs” or organisms that cause health care-associated infections (HAIs). Unfortunately, it isn’t that easy; there’s no Sci-fi equipment to magically rid your facility of organisms. We’ve made strides, however, towards reducing the incidence of these infections by using a variety of evidence-based best practices.


Progress report

The Centers for Disease Control and Prevention recently published the National and state healthcare associated infections: Progress report using 2014 infection data from national acute care hospitals. This report revealed significant progress towards reducing HAIs:

  • Central line-associated bloodstream infections declined by 50% between 2008 and 2014.
  • Catheter-associated urinary tract infections showed no change overall, but there was progress made in non-critical care settings between 2009 and 2014, and in all settings between 2013 and 2014.
  • Surgical site infection declined by 17% between 2008 and 2014.
  • Clostridium difficile infections declined by 8% between 2011 and 2014.
  • Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia declined by 13% between 2011 and 2014.
As you can see, we’ve made significant progress, but there’s still much more work to be done. Every day, nearly one in 25 patients in the United States has at least one infection that they acquired during their stay in a health care facility. This shows the need to improve infection control and prevention practices in health care facilities, and other various settings.


Bugbusting best practices

So, what can we do to bust those “bugs” and prevent HAIs in our health care facilities? To start, research shows that when members of the multidisciplinary team are aware of infections and join together to take steps to prevent those infections, infection rates can be reduced by more than 70%.  Developing a culture of safety that includes teamwork, evidence-based infection prevention processes, and accountability for preventing infections is key.


Making it real

Make infections real to all members of the health care team, including environmental services personnel, transportation staff, sterile processing department staff, patients, visitors, and volunteers; not just those directly involved in patient care. After all, everyone plays a role in preventing the spread of infection.
Share stories… nothing hits home like a story of a patient who suffered harm as a result of an infection that could’ve been prevented. Take for instance, the story of an elderly patient admitted to a health care facility for knee replacement surgery.  The surgical procedure itself went smoothly, but the patient soon developed a surgical site infection, the responsible organism was MRSA. The patient spent months in the hospital for IV antibiotics, prosthetic joint removal, spacer insertion, and eventually an above the knee amputation of the affected leg. The patient, the mother of a staff physician, eventually succumbed to complications of the MRSA infection.

How could a seemingly uncomplicated surgery result in an infection that ultimately resulted in this patient’s death? Was it by the hands of a health care worker who didn’t take time to perform hand hygiene? An operating room team member who failed to follow sterile technique during the procedure? An environmental services staff member who didn’t properly clean surfaces in the patient care area? A sterile processing staff member who didn’t properly sterilize surgical instruments? A visitor who failed to perform hand hygiene before visiting the patient? The patient herself who failed to properly perform personal hygiene after surgery? Any of these scenarios could’ve caused the patient’s infection and subsequent death. When this story was told, it was difficult not to feel accountable.


Zero tolerance

There are many opportunities for infection to spread in a health care facility.  It’s important to make sure that everyone is educated about measures to prevent infection, using methods that they understand. Start with the basics...we’ve all heard it before, hand hygiene is the single most effective thing you can do to keep infection from spreading. Make sure everyone performs hand hygiene properly, every time that it’s indicated.

Develop a culture that has zero tolerance for infection and zero tolerance for failure to follow proper infection prevention practices. Empower patients, family, and other staff to speak up when infection prevention practices aren’t followed. Getting to zero is the only sure way to keep our patients safe from infection.

What infection prevention practices have been successful at your facility? Have you done anything creative to engage staff, patients, and visitors; something outside the box that you’d like to share with us?
References:
Centers for Disease Control and Prevention. (2016). “National and state healthcare associated infections: Progress report” [Online]. Accessed April 2016 via the Web at http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf

Institute for Healthcare Improvement. (n.d.). “What zero looks like: Eliminating hospital-acquired infections” [Online]. Accessed April 2016 via the Web at http://www.ihi.org/resources/Pages/ImprovementStories/WhatZeroLooksLikeEliminatingHospitalAcquiredInfections.aspx

Yokoe, D.S., et al. (2014). SHEA/IDSA practice recommendation: Introduction to a compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates. Infection Control & Hospital Epidemiology, 36(5), 455-459.
 
Collette Bishop Hendler, RN, MS, CIC
Senior Clinical Editor
Clinical Project Manager, Lippincott Procedures

Wolters Kluwer, Health Learning Research & Practice


 
Posted: 5/9/2016 7:35:08 AM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments

Categories: Diseases & Conditions Patient Safety


Working Around Work-Arounds

nursing-workarounds.pngWe’ve all experienced it over the years…the frustration of having some piece of equipment, computer program, patient care process, person, or policy get in the way of getting the job done. Sometimes it’s because the thing or situation that’s standing in our way is broken. Other times it’s because there’s no rule in the playbook that addresses exactly an unusual circumstance. The end result is often the creation of a work-around…and nurses can be extremely creative!
 
Work-arounds circumvent established procedures, policies, and processes. In some cases, they truly may be needed to get an essential task accomplished because the current system has not yet caught up to the realities of clinical practice. The work-around may ultimately indeed be the right way, but just continuing to do it informally may be viewed as a much quicker and easier path to travel than the journey to making it a permanent solution. Depending on the nature of the issue and the organizational change process that’s needed, there may be tedious processes to follow, forms to fill out, a chain of command to invoke, a business case to make, committees to form, places to go, and people to see. 
 
In other words, the real solution can appear a far-off, daunting task that requires considerable expenditure of time and energy and quite possibly a measure of stretching way beyond a personal comfort zone into organizational bureaucracy. There’s a very real chance that the proverbial “squeaky wheel” that brings the matter to light could wind up the owner of the issue and be expected to be part of the solution. However, if the work-around makes things look like everything is working just fine, there’s no obvious burning platform as the catalyst for necessary change. The problem may remain invisible to the larger system and go unsolved. If leadership is unaware, there’s no opportunity to submit requests for maintenance or budget for new equipment, system upgrades, or even necessary material or human resources.
 
Another category encompasses the work-arounds that may simplify the job or allow it to be accomplished faster, but bypass safety measures put into place to reduce risk. Ignoring established safety practices that are perceived as cumbersome is an example. Staff may become so good at these that the work-around escapes detection. These types of work-arounds can evolve to become the usual practice or even the cultural norm.  They may be passed along to new staff members as tips or tricks to be more efficient to the point that staff stops seeing the strategy as a work-around at all. Direct observation might be the only way to spot this situation. Nurses who follow the rules can experience considerable moral distress when they discover that co-workers are using such work-arounds inappropriately. They are then placed into the very difficult position of either turning a blind eye (which has significant ethical and even professional regulatory implications), or acting as a whistle blower to management.
 
My advice is that if a work-around is felt to be necessary, there’s a problem with the current system that must be addressed. That includes those situations where the work-around is done to make the job easier or faster but bypasses safety measures. Perhaps the safety measures could be maintained and risks reduced if the system was re-designed in a way to make it easier to do the right thing while still meeting all of the standards and regulations. Our knee-jerk in healthcare often involves creating a new form to fill-out or coming up with a new tedious process that gives the illusion of a safety improvement, but instead just adds another barrier that people look for ways to overcome. We need to think broadly and be truly innovative. Strategies include researching current best practices, connecting with staff at other organizations to learn how they manage similar issues, and even investigating if there are applicable innovative solutions in industries outside of healthcare. 
 
We do need to make processes associated with nursing practice and healthcare in general safer, easier, more efficient, and more effective. The appearance of a work-around is a red flag for an improvement opportunity.  Rather than allow it to persist or remain obscure, bring the situation to light and be an advocate for necessary change.  Keep in mind the old adage: if you always do what you’ve always done, you will always get what you’ve always got. When confronted with a work-around, take on the challenge and demonstrate individual leadership, advocacy, and the courage to engage in true problem resolution. 
 
Happy Nurses Week!
 
Linda Laskowski-Jones, APRN, MS, ACNS-BC, CEN, FAWM, FAAN
Editor-in-Chief, Nursing2016
Vice President: Emergency & Trauma Services
Christiana Care Health System – Wilmington, Delaware


 
Posted: 5/8/2016 6:09:52 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Leadership Patient Safety


Safety in the Healthcare Workplace: How Safe Do You Feel?

workplace-safety.PNGSafety is something we think about constantly in our daily lives. We look both ways when we cross the street, we buckle our seatbelts when we get into the car, and we put on helmets when we participate in outdoor activities, such as biking, skateboarding and skiing. For many, safety is not an all-consuming concern at work. As health care providers, however, we are exposed to a multitude of dangers every day. According to the United States Department of Labor, Occupational Safety & Health Administration (OSHA), a hospital is one of the most hazardous places to work.1 Health care workers experience some of the highest rates of nonfatal illness and injury – surpassing both the construction and manufacturing industries.2 In 2011, U.S. hospitals recorded 253,700 work-related injuries and illnesses, a rate of 6.8 work-related injuries for every 100 full-time employees.1

At work, I regularly lift, turn and transfer patients with limited mobility, strength and balance. I often encounter confused and combative patients who pose a great risk to themselves and the clinical staff. The threat of a needle stick injury and the possible exposure to infectious diseases are two dangers that are perpetually at the forefront of my mind. In nursing school, we were taught basic ergonomic techniques to protect our backs. We were instructed on procedures to prevent unintended exposure to blood borne pathogens. But in the fast-paced world of health care, where patient loads are high, many of these safety strategies fall by the wayside. By nature, nurses often put their own health and safety at risk for the benefit of the patient.3 So, how safe do we really feel at work and what are hospital administrators doing to protect their employees?

In 1979, Congress passed the Occupational Safety and Health Act, which resulted in the creation of the OSHA. OSHA is the government body responsible for ensuring a safe and healthy working environment for employees by setting and enforcing standards and by providing training, outreach, education and assistance.3 When I began working in the intensive care unit many years ago, I remember having to complete my first annual competency checklist, which incorporated mandatory lectures developed by OSHA. Topics included blood borne pathogens, fire hazards, fall prevention and methicillin resistant staphylococcus aureus (MRSA). Today, those topics have expanded to include latex allergy, equipment hazards, workplace violence, and workplace stress.4 These topics are just a subset of the hospital-wide OSHA standards spanning every department from dietary to central supply to housekeeping.

One area of hospital workplace safety that has received great attention in the media in recent years is the use of Personal Protective Equipment (PPE). This issue was highlighted in the news when the first laboratory-confirmed case of Ebola was diagnosed in the U.S. in September 2014.5 Controversy surrounded this story, which began when a man, who arrived from Liberia initially without symptoms, walked into a Texas emergency room complaining of fever and other flu-like symptoms. After being discharged, he was readmitted several days later and diagnosed with the Ebola virus. Personal Protective Equipment was provided to the staff assigned to the infected patient. Despite these safeguards, however, two clinicians were exposed and ultimately contracted the deadly virus. Thankfully, both nurses survived, but fingers pointed to the hospital administrators, placing blame on their inability to properly educate and ensure the safety of their staff.  Were they at fault or just inadequately prepared with minimal resources to deal with this seemingly rare occurrence?

Ebola is an extreme example that emphasized the importance of hospital workplace safety and one that forced hospital administrators across the country to evaluate current policies and procedures. All workers, regardless of the industry, have a right to a safe work environment. Have you noticed any areas of your hospital where improvements could be made to increase overall safety? Do you have recommendations or a success story to share? We would love to hear from you – please leave your comments below.

Resources
Occupational Safety & Health Administration (OSHA): Worker Safety in Hospitals 
Occupational Safety & Health Administration (OSHA): Hospital eTools
Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation (Joint Commission)
References
1. U.S. Department of Labor: Occupational Safety & Health Administration. (2016) Worker Safety in Hospitals: Caring for Our Caregivers. Retrieved from: https://www.osha.gov/dsg/hospitals/index.html

2. The Joint Commission: Improving Patient and Worker Safety. Retrieved from: http://www.jointcommission.org/assets/1/18/tjc-improvingpatientandworkersafety-monograph.pdf

3. U.S. Department of Labor: Occupational Safety & Health Administration. (2016) About OSHA. Retrieved from: https://www.osha.gov/about.html

4. U.S. Department of Labor: Occupational Safety & Health Administration. (2016) Hospital eTools: Intensive Care Units. Https://www.osha.gov/SLTC/etools/hospital/icu/icu.html

5. Centers for Disease Control and Prevention (2016). Cases of Ebola Diagnosed in the United States. http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/united-states-imported-case.html

Myrna B. Schnur, RN, MSN


 
Posted: 5/7/2016 5:56:22 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Leadership Patient Safety


Every Day in Every Way

As health care professionals, there are few things more agonizing than listening to a grief stricken mother describe how her young daughter, bravely fighting cancer, died during a hospital stay as a result of delays and failed communication. Looking at the audience at the Patient Safety Seminar that day, you could see that all of us felt her pain. After all, we got into the medical field to help people, to heal the sick and care for the most vulnerable, but in this case, we failed. Sadly, I have heard versions of that mom’s story many times throughout the years. The specifics change, but the result is the same -- the loss of life or permanent injury as the result of a medical error.
 
We aren’t perfect, I tell myself, as I hear those excruciating stories. We are human beings and sometimes, despite our best efforts, we come up short. But inevitably, as I let their brave messages sink in, I use those heartbreaking stories to motivate me -- to dig deeper and try harder and to become a more determined advocate for improving patient safety.    
 
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The American Nurses Associations (ANA) theme for National Nurses Week this year is Culture of Safety – It Starts with you. Since the landmark Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System was released in 1999, creating a culture of safety has been a major focus in our profession. The notion that medical errors resulting in patient harm are largely preventable and a result of system failures provided the platform for health care culture reform. 
 
The IOM report provided clear recommendations to address medical errors. The government, professional organizations, and health care organizations have all worked towards reducing preventable medical errors. There is a plethora of information on culture of safety, including webinars, how to guides, frameworks, guidelines, etc. While we have made progress, preventable harm occurs in hospitals every day. 
 
So what is a culture of safety? A culture of safety is an environment in which patient care is safe and effective, and patients are free from preventable harm. The complexity of systems in which health care is provided makes this challenging, but not impossible.
 
So, how can every nurse take a leadership role in creating and sustaining a high reliability culture of safety?
  • Actively engage patients and their family as partners in care.
  • Approach care delivery with interprofessional collaboration and teamwork.
  • Promote a culture of blame-free reporting of adverse events and near misses; analyze and learn from them.
  • Implement evidence-based best practices; remove barriers to ongoing sustainment.
  • Maximize the use of technology as intended.
  • Improve hand-off communication and transitions of care.
  • Maintain a high level of situational awareness in your work area to anticipate problems ie., rounding, huddles.
  • Speak-up if you witness or identify unsafe behavior or safety hazards and hold each other accountable to safe practices.
  • Establish goals, measure outcomes and promote transparency of data.
During Nurses Week this year, let us all make a commitment to ourselves, our teammates and those we care for, that we will become better patient advocates. Let us learn from those heartbreaking stories of loss and take whatever steps are needed to create and sustain an environment founded in a culture of safety -- every day and in every way.
 
Susan Mascioli MS, BSN, RN, NEA-BC, CPHQ, LSSBB
Director, Nursing Quality and Safety
Christiana Care Health System


 
Posted: 5/6/2016 7:31:48 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Leadership Patient Safety


Creating a Culture of Safety: Blog Series for Nurses Week 2016

2016-NNW-blog-series.pngHappy National Nurses Week! As we approach the celebration this year, I’d like to take some time to share all that we have coming up for the week and into the rest of the month. There’s a lot of buzz online about what a Nurses Week gift should look like (Read: Not another water bottle. How about safe staffing?) As a leading web resource for nurses, we’d like to do our part to create a culture of safety this Nurses Week by providing you with up-to-date resources based on the latest evidence and reviewed by our peers. Be sure to check out all of our Nurses Week plans and take advantage of CE collections, free articles, eBook offers, and some opportunities for fun!
 
I’m excited to share that right here on our blog, we have a wonderful series of posts from nurse experts who’ve shared their insights and knowledge. I’ve enjoyed working with these colleagues – they’ve inspired me and taught me so much as we put together this series. I think you’ll enjoy it! 

Here’s what’s ahead: 
ashpe-award_2016-(1).jpgOn another note, I want to let you know that Lippincott NursingCenter.com received the Gold Award from the American Society of Healthcare Publication Editors (ASHPE) for Best Use of Social Media for our campaigns for National Nurses Week in 2015! Thank you to all of you for your likes, follows, comments, shares, retweets, etc. You were instrumental in helping us to achieve this goal! And congratulations to all the winners of these prestigious awards!

Be sure to follow us on all of our social media channels as we head into National Nurses Week 2016! We’ve got some special offers that you don’t want to miss!
 
fb.jpg   twitter.jpg   linkedin.jpg   g.jpg   youtube.jpg     

Have a great week, everyone!

 
Posted: 5/4/2016 10:29:46 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety


Is there a Cure for Gun Violence?

gun-violence.pngThere’s no doubt that gun control is a hotly debated topic today. Supporters of tight gun control argue that access to guns is too easy. Those on the opposition believe it is unconstitutional and that despite a rise in gun ownership, gun homicide rates have dropped. Irrespective of this debate, the statistics are staggering. There have been over 200 mass killings (defined as four or more victims) in the United States since 20061. The rate of people killed by guns in the U.S., is almost 20 times higher compared to similar socio-economic countries in the world. It is clear that Americans experience too many senseless deaths associated with firearm violence and that we need to work harder to find a solution to this devastating problem.

According to the Centers for Disease Control and Prevention (CDC), in 2013 there were 33,636 deaths attributed to firearms or 10.6 deaths per 100,000 Americans2. That same year, there were 33,804 motor vehicle traffic deaths or 10.7 deaths per 100,0002.  Auto accidents have declined over the last several decades largely due to mandatory education and government regulations. You cannot drive without first taking a driver’s test, acquiring a license and paying for car insurance. In addition, your car must pass emissions and inspection testing on a regular basis. Guns manufactured in the U.S. do not need to pass federal safety standards.

Last week President Obama proposed “executive actions” on gun violence, a set of recommendations to close loopholes in gun control legislation in an effort to prevent future mass shootings. A few of the initiatives include increasing mental health treatment, improving universal background checks, requiring gun dealers to be licensed and keep formal sales records, and advancing technology on safety locks and “smart guns” that can only be fired by the registered owner. The presidential proposal will likely meet resistance and possible reversal should Americans elect a Republican in the upcoming election.

Regardless of the outcome of the new gun control initiatives, what role can healthcare providers play?  Nurses, who often treat victims of violent crimes and their family members, are uniquely trained to promote safety, public health and education. Several nursing organizations have issued position statements on gun control, including the American Nurses Association (ANA) and the National League for Nursing. In addition, over 30 nursing organizations signed a call-to-action letter to national, state, and local governments requesting better access to mental health services, a ban on assault weapons, and other gun control reforms.

The following recommendations could help us come closer to finding a cure for gun violence.

 

  1. Increase access to mental health programs for individuals, families, and students from elementary school through college:

    a. While the majority of people with mental illness are not violent, serious psychosis and schizophrenia combined with substance abuse could lead to erratic behavior. Funding should be increased to train nurses and health professionals to recognize signs of violent tendencies, as well as community and hospital based psychiatric care, housing, and access to medications.3

  2. Include a gun safety assessment as part of routine health screenings for all patients:4

    a. Several states continue to propose legislation to ban practitioners from documenting gun ownership in the patient’s record. However, the American Academy of Pediatrics endorses counseling parents on gun safety measures.This philosophy is also supported in adult dementia and elderly patient populations.

  3. Develop and implement Evidence-based Hospital Violence Intervention Programs focusing on:

    a. Intimate partner violence

    b. Behavioral health including anti-bullying

    c. Substance use

  4. Improve Community engagement/outreach and education programs with initiatives targeting:

    a. Life skills

    b. Anger management

    c. Conflict resolution

    d. Suicide prevention

    e. Violence prevention programs: successful research-based community programs that have proven to decrease homicide rates include Cure Violence, Aim4Peace and Wraparound Project.6

  5. Gather more data, conduct research and educate families on how to best protect themselves and their families from gun injuries:4

    a. Keep guns away from household members who would not safely use them such as children or people with dementia.

One measure alone is not the answer. Rather multiple strategies implemented in our local communities, within the mental health system, and ultimately at the federal level are needed to make an impact on the number of gun-related fatalities. We as a society need to strike a balance between maintaining individual constitutional rights and protecting the lives of each and every American. Perhaps by focusing on empathy, public health, and education we can change our culture, protect our freedoms, and save lives.

 


References:
  1. Overberg, P., Hoyer, M., Hannan, M., Upton, J., Hansen, B., & Durkin, E. (2013) Behind the Bloodshed: The Untold Story of America’s Mass Killings. USA Today. Retrieved from http://www.gannett-cdn.com/GDContent/mass-killings/index.html#title
  2. Centers for Disease Control and Prevention (2016) FastStats; All Injuries; Motor vehicle traffic deaths; All firearm deaths. Retrieved from http://www.cdc.gov/nchs/fastats/injury.htm
  3. The American Nurses Association. (2016) Call to end violence. The American Nurse. Retrieved from http://www.theamericannurse.org/index.php/2013/03/01/call-to-end-violence/
  4. Domrose, C. (2013) Nurses debate their role in firearm safety education. Nurse.com. Retrieved from https://news.nurse.com/2013/04/08/nurses-debate-their-role-in-firearm-safety-education-2/
  5. Graziano, M. & Pulcini, J. (2013) Policy & Politics: Gun violence and the role of healthcare: A confusing state of affairs (2013). The American Journal of Nursing. 113(9). Retrieved from http://www.nursingcenter.com/JournalArticle?Article_ID=1590663&Journal_ID=54030&Issue_ID=1590611
  6. Jacobson, J. (2015) A cure for gun violence. The American Journal of Nursing. 115(4). Retrieved from http://www.nursingcenter.com/JournalArticle?Article_ID=2794833&Journal_ID=54030&Issue_ID=2794782

 Myrna B. Schnur, RN, MSN


 

Posted: 1/12/2016 10:08:21 AM by Lisa Bonsall, MSN, RN, CRNP | with 3 comments

Categories: Patient Safety


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