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Communication Issues in Nursing
Communication failures rank first among the most common causes of medical errors, significantly impacting hospitals and healthcare delivery. And because nurses are at the forefront of patient care, the situation puts the spotlight directly on them.
Communication is crucial in healthcare because it builds trusting nurse-patient relationships and facilitates inter-professional collaboration. Communication must be understood in a different context as that of information. Information is something that you just give out or disseminate, while communication is getting your message across and receiving a reply in the process.
Nurses serve as a common gateway that accommodates the messages relayed among various professionals. Physicians give the orders out and ask about the patient’s condition through nurses. RNs coordinate the care of other clinicians and therapists. Nurses talk to the patient and their families to know their concerns. They act as a liaison between care providers and patients, so their role calls for excellent collaboration skills. When nurses fail to properly communicate, various patient care processes, as well as the interrelationships within the organization, will be on the line.
Here are common communication problems that nurses need to address in the workplace:
1. SPEAKING WITHOUT CLARITY. When there is not enough clarity as nurses speak, errors are bound to happen.
Consider this scenario:
The nurse says to the patient, “Take your pill for hypertension once a day.” The patient obliges. But because the patient considers their diuretic as the main medication for hypertension, the patient took it before bedtime. The next day, the patient complains of a lack of sleep during the night because they were up too many times to go to the bathroom. Being clear, in this case, is saying, "Take one tablet of Quinapril every night before bedtime," while showing them the medication.
2. USING A DISRESPECTFUL TONE OF VOICE. Whether talking with a patient or colleague, the tone of voice conveys the most meaning. If someone says “sorry” without really meaning it, we would certainly know that they are not sincere. A disrespectful tone is a formidable barrier to communication. It breeds anger, resentment, and the need to retaliate. It fosters a culture of fear, where bullying and incivility become an accepted part of a nurse’s job. Additionally, using a monotonous, robotic tone to talk with a patient, conveys a lack of sensitivity and empathy, which will make the patient hold back information and become uncooperative.
3. FAILURE TO RECEIVE OR GIVE FEEDBACK. Receiving feedback makes communication closed-loop. Without affirming that a message is understood, the message becomes open to misinterpretations that can easily lead to errors. Without receiving or message becomes open to misinterpretations that can easily lead to errors. Without receiving or giving a reply, the nurse is simply informing, not communicating. So, if a nurse performs health teaching with a patient without evaluating what they understood, proper communication has NOT taken place. Similarly, when a staff nurse consults the charge nurse and does not receive a reply, they readily interpret this as lack of interest on the part of their supervisor. In a fast-paced environment such as the operating room, it is important to be completely understood as a speaker and to understand clearly as a recipient. Closed-loop communication is tantamount to saving patients’ lives. The success of the unit lies primarily on this concept of collaboration.
4. FAILING TO SPEAK UP. Nurses who consider themselves to be “at the bottom of the food chain” rarely speak up when they see a potential error or become witness to a mistake. Keeping quiet about matters of safety is as dangerous as injuring a patient. Both put patients’ lives in jeopardy. Nurses tend to be quiet when they see that their own interests are at stake if they take a stand, so they choose not to get involved and live with the difficulties. But failing to point out possible areas of improvement blocks the way for solutions and results in both unsafe practices and unhealthy inter-professional relationships.
Nurses cannot be effective in their work if they do not master the art of communication. Failing to get your message across and be understood will ultimately lead to career setbacks and negative feelings about nursing. Proper communication must, therefore, be learned and practiced.
Posted: 9/29/2017 6:48:06 PM
Calmness Within, Amidst Chaos: A Nurse’s True Strength
Have you ever had a day when a patient with several tubes attached to them becomes cranky and uncooperative? Or have you experienced cruising through the morning only to find out that as your shift is nearing its end, you have to change an IV set? Any nurse would say that if they have only these challenges in a day, then they are definitely having a good day at work.
What’s a not-so-good day at work for a nurse look like? Here’s a scenario:
The unit is short-staffed, and several call lights are flashing at the same time. Everyone seemed to be at their wit's end, and their negative vibes fill in the air. You see that patients are waiting to be admitted and discharged. At the back of your mind, you know that something's about to give in, and someone is about to lose it. You think patients are lucky enough to have catheters attached to their bladders because you have been wanting to take a bathroom break for hours now but never had the chance to have one. Lunch? You almost forget what lunch means and what it is for. Missing or broken equipment? That's for dessert.
If there is one word to describe this kind of a day for nurses, it is C-H-A-O-S. When there is a great deal of pressure, and the nurse is still expected to perform safely, that is the ultimate challenge. How can a nurse survive a time like this? Here are some helpful tips for you to reach the end of your shift in one piece:
1. ALWAYS ANTICIPATE NEEDS
You never know when a day is set out to be chaotic so anticipate needs. Ensure that you have supplies readily available at the beginning of your shift every day. Think of it as a kit for not-so-good days.
2. KNOW YOUR PHYSICIANS
Doctors have developed a way of doing things, and each one is uniquely different in their problem-solving skills. Knowing them in this regard will help you work faster and more effectively with them.
3. DON’T LOSE YOUR FOCUS
Focus is what separates excellent nurses from the stressed out ones. Getting overwhelmed is a big no-no because it opens all avenues to errors that lead to all sorts of tensions and lawsuits.
4. PRACTICE CRITICAL THINKING AND SAFETY PROTOCOLS EVERY DAY
When you do safety checks at all times, it becomes a habit. During chaotic times, good habits will enable you to run on autopilot when it comes to safety protocols and keep you focused on more important matters during a hectic day. Critical thinking, on the other hand, keeps you rooted in evidence-based practice even if the going gets tough.
Developing a system of doing things allows you to perform several tasks at the same time. If you are pressed for time, for example, as you count the pulse, you must be making an assessment and evaluation at the same time.
6. JOT DOWN IMPORTANT DETAILS
Unless you have a computer for a brain that automatically saves data during accidental shutdown, your best pals at work should be that small notebook and pen that you keep in your pocket. Stress can affect your memory. Having too much going on in a day will make you forget details about the patient, making it necessary to repeat assessments and losing more precious time in the process.
7. IN EXTREMELY HIGH PRESSURE SITUATIONS, SUCH AS A DISASTER, LEARN TO TRIAGE
Emergency nurses usually receive training on how to follow triage protocols. If you are an ER nurse, triaging will save more patient lives and will give you a distinct path to follow so that you are still efficient amidst the chaos.
8. AFTER WORK, THINK HAPPY THOUGHTS AND GO TO A HAPPY PLACE
Calmness has to come, one way or the other. Even if reaching the end of your shift seems like an eternity, it will eventually be time to clock-out. It is important to ‘reset’ and replenish, for you know that tomorrow will be another day, another story.
Being a nurse makes you some sort of a superhero with superhuman abilities to remain calm, practice safely, and still be triumphant after a day of chaos. So chin up, embrace the challenge, and be proud of yourself today.
Posted: 9/1/2017 10:39:26 AM
Going Beyond the Zone of a Therapeutic Nurse-Patient Relationship
Patient care is always a part of a nurse’s life, which means that nurse-patient interaction is inevitable. But because the line between therapeutic and social relationships becomes blurry, nurses may find themselves in a dilemma, unable to control the situation and their feelings, and cross the line in the process.
Trust, compassion and mutual respect should rule the nurse-patient interaction so that it is therapeutic to improve the patient’s health, but sometimes nurses fall into temptation, make poor decisions, and disregard professionalism and personal morals. Here are some situations where the boundaries have been crossed in different levels:
- receiving gifts from patients
- doing small favors for patients outside of duty hours (e.g., keeping them company, responding to a neighbor’s
call for help regarding a nursing care they need)
- visiting a patient after they have been discharged just to know their progress
- disclosing a patient’s personal information
- giving the patient personal contact numbers
- inappropriate restraints
- physical and emotional abuse
- sexual misconduct
- dating a patient while still seeking care, or even right after discharge
- having a sexual or romantic relationship with a patient
- sexual advances or suggestions to the patient or vice versa where the nurse consents
- verbal seduction
Of the many instances where nurse-patient relationships become inappropriate, nurses being attracted to patients and then acting on their interest is perhaps one of those behaviors that have early tell-tale signs that they are too close to the edge. Here are some warning signs that necessitate a review of the nurse’s behavior:
- often thinking about the patient even after duty
- spending free time with the patient or spending a lot of time with the patient even if other patients’ needs are
more of a priority
- showing favoritism
- sharing personal information and concerns
- needing to dress more attractively when anticipating interaction with the patient
- asking to be assigned to the patient
Nurses are not the only ones who show their vulnerability. On the other hand, a patient’s behavior can also signal that they are crossing the boundary lines, too:
- the patient demands that they are assigned to the nurse
- they show over-dependence
- they keep asking about the whereabouts of the nurse, or other information from the staff
- they give the nurse special attention, compliments, and gifts
The biggest problem with crossing the boundaries of nurse-patient relationship is that it reduces the benefits of nursing care to the patient involved and the others in their care. It is also clearly a sign of disregard for the Nursing Code of Ethics. These are the reasons why boundary violations are never acceptable.
When nurses find themselves in a situation where they are going beyond the zone of helpfulness, they must be aware of themselves and be quick to review and stop their behavior.
They should seek their supervisor’s help and refer to institutional policies. In receiving gifts, for example, some hospitals will allow small tokens to be received with gratitude right before discharge.
For other behaviors, nurses may check with their respective Board of Nursing and the National Council of State Boards of Nursing. These organizations define professional boundaries and give specific instances where behaviors already are deemed inappropriate.
Nurses also have a duty to report sexual misconduct to the supervisor or the Nurse Manager. These behaviors are never tolerated. Proper documentation must be made, and the misconduct duly reported to the board of nursing, which can take immediate action such as revoke their license.
RNs must also remember that if they became self-aware and educated on professional boundaries, they can prevent violations from harming their patients and their professional career.
Posted: 8/4/2017 11:20:48 PM
Ensuring Patient Safety - 24/7
There is a reason why safety is deemed important to human survival next to air, food, water, and shelter. It’s because it is hard to be healthy when there is injury. Injury and health are like oil and water. They do not mix. Therefore, to be healthy, one also has to be safe at all times.
In hospitals, patient safety is synonymous to positive patient outcomes. The ultimate goal is to cure a patient’s disease or to improve their health while keeping them away from harm at the same time.
The dangers lurking in acute care settings are all too real, and too perilous. It's no wonder almost half of the lessons and training obtained in nursing schools are about safety.
Medication errors, falls, pressure ulcers, misidentification and misdiagnosis of patients, infections, and missed or inappropriate treatments are some of the ways a patient can be injured while they are seeking medical care. Even if safety is a responsibility of all stakeholders, including that of the patient, nurses are on the front line of care and are also active facilitators of patient transitioning. Nurses must, therefore, be pioneers of safe practice.
What can you do as a nurse to embed in one's practice a culture of safety?
1. Keep yourself updated with new scientific findings on safety as well as new institutional policies that prevent patient harm. It is good to practice critical thinking in every aspect of care. The hospital is probably the only setting where asking a lot of ‘whys’ is beneficial.
2. Focus. A lot of errors are made due to doing an intervention while being distracted with other things. Alarms setting off, a physician calling your attention, and having to receive a phone call from the lab, are but a few situations that could keep you off-track and make you miss safety points. It may help to do a mental step-by-step check as you go.
3. Participate actively in patient safety huddles. Huddles are so important when you want to be error-free in a complex environment such as a hospital. Be vocal and precise when you discuss patient care. No gray areas. Never assume. Always seek clarification when needed, however busy you are.
4. Teach. Teach patients and their families how to be safe. Telling patients to be aware if there are medications offered them that are not their usual intakes or just plainly instructing them how to use the call light can help to keep themselves safe. Teaching patients and family alike to ask questions and seek clarifications if unsure about any concern, reminding the family caregiver to keep the wheels of the bed locked at all times, and reminding them to wash their hands before and after giving care procedures will go a long way in preventing patient harm.
Teaching is not limited to patients and their families. Newly hired nurses need all the support they can get to successfully be a part of a team that aims to improve patient health. If you are a senior nurse, be generous with your knowledge and share what you know with the newbies.
5. Be a team player and collaborate. Positive patient outcomes are never a result of a one-man-do-all approach to care. Many errors in acute settings are brought about by faulty communication and lack of collaboration. To prevent errors, information and feedback should flow freely within a team to create a safe care environment. Look for collaboration tools that can address communication needs within and among units.
6. Practice medication reconciliation especially during the transition of patients. If only medication errors were included in the list of reasons for a patient’s demise, it would rank 3rd as the leading cause of death. And as for the ‘7 Rs’ of medication administration, these golden rules apply at ALL times. Remember, right medication, right client, right dose, right time, right route, right reason, and right documentation.
7. Never be too tired or too busy to enforce infection control. Remember that sick people are vulnerable individuals whose immune systems may be compromised. Handwashing protocols should always be followed, as well as the universal and transmission-based precautions.
Safety is always a big deal in every aspect of patient care. To keep patients protected 24/7, nurses must model a culture in which safety becomes second nature.
Posted: 10/24/2016 9:04:45 AM
Nursing Tips: When a Patient Leaves Against Medical Advice
“You can’t make me stay.” Although providers may seem shocked when a patient decides to leave the hospital Against Medical Advice (AMA), the patient is exercising his or her right to refuse recommended care or treatment. In an article for Mayo Clinic Proceedings, David J. Alfandre, MD, reports that about 2% of all medical admits result in an AMA discharge. When a patient leaves AMA, the risk of readmission for the same diagnosis increases, as well as establishing a precedent for future AMA discharges.
Who is most at risk for leaving AMA?
- Medicaid or no insurance
- Young adults
- Lives alone
- Alcoholism or substance abuse
- Psychiatric history
- Additional medical issues
- Family or financial obligations
The consequences of an AMA discharge vary by circumstance. Some patients are ready to leave, while others are quite vulnerable. In Dr. Alfandre’s article, retrospective analysis showed:
- Asthmatics had four times more ER visits and three times more hospital re-admits within 30 days.
- General medicine patients who were hospitalized had an almost seven times the likelihood of being readmitted within 15 days.
- Patients who had myocardial infarctions had a 40% higher chance of death or readmission for another MI within two years.
Nurses are likely to be the first healthcare professional that hears when a patient is considering an AMA discharge. Communication with the patient and the physician can be adequate in preventing an untimely discharge. Asking a patient to wait thirty minutes while you phone the physician or prepare the discharge plan may be enough time to calm an angry patient and allow for an honest conversation. The court has ruled in favor of a hospital using “a reasonable amount of time” to permit routine paperwork and procedure. (Bailie vs. Miami Valley Hospital)
Here are five tips for nurses who may encounter AMA situations:
1. Never threaten a patient by saying that if he or she leaves AMA that insurance will not cover the stay. Insurance will pay for care given up to the time of discharge.
2. Whenever possible, take time to talk with the patient to understand more about the reasons for seeking discharge. Patients sometimes have compelling reasons to leave and alternate care resources can be arranged. Document the conversation.
3. Using your facility’s AMA form, provide an informed consent regarding an AMA discharge. Elements of an informed consent include the patient’s acknowledgement that he or she is leaving AMA; that the risks have been explained and the patient understands; and that the patient knows he or she may return at any time. The patient’s signature indicates refusal of recommended treatment. If the patient refuses, the nurse can sign as the witness and document the refusal.
4. His or her rights to receive full discharge instructions and materials remain the same as other patients. Review the instructions with the patient. If the patient agrees, provide wheelchair or escort service from the unit. Document the events.
5. Psychiatric or violent patients may be retained if they are a threat to themselves or others. In these cases, the hospital may use legal means to keep the patient. Accurate documentation by the nurse is key in the process.
When a patient decides to leave AMA, the nurse can help provide as safe and responsible discharge process as possible. Respecting the patient’s autonomy while providing ethical and compassionate care are important nursing responsibilities.