Course

Florida Renewal Bundle

Course Highlights


  • In this course we will learn about the various communication types, threads, and barriers you will encounter during daily practice.
  • You’ll also learn the basics of critical thinking education, followed by common exercises
  • You’ll leave this course with a broader understanding of how to better apply nursing ethics into your daily practice.

About

Contact Hours Awarded: 27

Course By:
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The following course content

This Florida License Renewal Bundle meets all renewal requirements for Florida LPNs, RNs, and APRNs.
Upon completion of this course, you will receive a certificate for 27 contact hours and your completion will be reported to CE Broker automatically.

This course is accredited and approved by the Florida Board of Nursing (Provider Number: 50-23983).
Per the Florida Board of Nursing’s requirements, all Florida nurses are required to pass a test with a score of 80% or higher to receive their certificate.

Course Outline

  1. Domestic Violence (Meets FL BON requirement)
  2. HIV/AIDS (Meets FL BON requirement)
  3. Florida Laws and Regulations (Meets FL BON requirement)
  4. Medical Errors Prevention (Meets FL BON requirement)
  5. Recognizing Impairment in the Workplace (Meets FL BON requirement)
  6. Human Trafficking (Meets FL BON requirement)
  7. Key Concepts of Critical Thinking in Nursing
  8. Effective Communication in Nursing
  9. Ensuring Patient Confidentiality in Nursing
  10. Nursing Documentation 101
  11. Nursing Ethics
  12. Infection Control and Barrier Precautions
  13. PTSD in Nurses

Florida Domestic Violence

This fulfills the continuing education requirement of Domestic Violence for the state of Florida.

Florida domestic violence is defined as violent or aggressive behavior occurring within the home and usually involves the abuse of a spouse or partner.  In the United States alone, it is estimated that more than 10 million adults have been subjected to domestic violence during the course of a year. This statistic translates to an incident of domestic violence occurring every 3 seconds.  Due to the increasing prevalence of domestic violence in society, there is a high probability that all healthcare professionals will evaluate and treat a victim (and quite possibly a perpetrator as well) of domestic violence at some time during their healthcare career.  The importance of ongoing education and global awareness cannot be understated.  

Introduction

Domestic violence is defined as violent or aggressive behavior occurring within the home and usually involves the abuse of a spouse or partner. In the United States alone, it is estimated that more than 10 million adults have been subjected to domestic violence during the course of a year. This statistic translates to an incident of domestic violence occurring every three seconds. The National Coalition Against Domestic Violence reports some daunting statistics [1][6] 

  • 1 in 3 women and 1 in 4 men have experienced some form of physical violence by an intimate partner.  
  • 1 in 4 women and 1 in 7 men have been victims of severe physical violence (such as beating, burning, strangling) by an intimate partner in their lifetime.  
  • On average, more than 20,000 phone calls placed to domestic violence hotlines nationwide.  
  • The presence of a gun in a domestic violence situation increases the risk of homicide by 500%; 19% of domestic violence involves a weapon; Most intimate partner homicides are committed with firearms. 
  • 1 in 15 children are exposed to intimate partner violence each year, and 90% of these children are eyewitnesses to this violence.  
  • From 2016 through 2018, the number of intimate partner violence victimizations in the United States increased 42%.  

Due to the increasing prevalence of domestic violence in society, there is a high probability that all healthcare professionals will evaluate and treat a victim (and quite possibly a perpetrator as well) of domestic violence at some time during their healthcare career. The importance of ongoing education and global awareness cannot be understated.  

In 2020, the COVID-19 pandemics' stay at home/shelter in place orders resulted in spikes in calls to domestic violence hotlines. From layoffs and loss of income to decreased availability of shelters and backlogged courtrooms, fewer resources were made available to victims of domestic violence. These measures resulted in increases in both the incidence and severity of domestic violence. Sadly, the effects of this pandemic, especially on this issue, continue well into today [2].

Quiz Questions

Self Quiz

Ask yourself...

  1. What are interventions/resources currently available at your facility to assist a victim of domestic violence? 
  2. What resources are currently available for domestic abuse perpetrators?  

Forms of Domestic Violence  

Domestic violence may encompass physical abuse, sexual abuse, emotional and verbal abuse, and spiritual and economic abuse. Defined as a pattern of behavior used to gain power or control over an intimate partner, a domestic violence abuser may use tactics that frighten, intimidate, hurt, blame, or injure a person. These behaviors often escalate over time in intensity and have resulted, at times, in life-threatening injuries or death of a victim [3].  

Intimate partner violence (IPV) is abuse or aggression that occurs in a romantic relationship. The term "intimate partner" refers to both current and former spouses and dating partners, including heterosexual and same-sex couples. The Centers for Disease Control and Prevention (CDC) further delineates IPV into four separate groups: physical violence, sexual violence, stalking, and psychological aggression [4].  

  • Physical violence may include hitting, kicking, and punching someone.
  • Sexual violence may include using force to get a partner to partake in a sexual act.
  • Stalking may include unwanted and threatening phone calls or text messages.
  • Psychological aggression may include insults, threats, name-calling, or belittling a partner.  

Teen Dating Violence (TDV) is defined as dating violence affecting millions of teenagers annually [5]. In addition to the threats from physical and sexual violence and other forms of aggression, TDV is often done electronically through repeated texting and placing sexual pictures of a person online without permission.  

The CDC statistics on teen dating violence report:  

  • Nearly 1 in 11 female and about 1 in 15 male high school students report having experienced physical dating violence in the last year. 
  • About 1 in 9 female and 1 in 36 male high school students report having experienced sexual dating violence in the last year. 
  • 26% of women and 15% of men who were victims of contact sexual violence, physical violence, and/or stalking by an intimate partner in their lifetime first experienced these or other forms of violence by that partner before age 18.  

Domestic violence transects every community and affects all people, regardless of age, socio-economic status, race, religion, gender, or nationality [6]. Whether the violence results in physical or psychological injury, the effects can last a lifetime and affect multiple generations.  

Healthcare professionals are in a pivotal position to impact the lives of those affected by domestic violence positively. Oftentimes, they may be the first person to encounter a victim of domestic violence. Their ability to effectively evaluate the situation and provide time-sensitive, patient-centered care (including but not limited to treatment interventions, appropriate referrals, and follow-up care) can enhance immediate victim safety and reduce further injury, and improve the home front circumstances, moving forward.  

Healthcare professionals must be able to identify and assess all patients for suspected abuse, and be able to offer treatment, counseling, education, and referrals, as appropriate. These referrals may extend out to shelter options, advocacy groups, child protection services and legal assistance [7].  

 

 

Profiles of Victims and Abusers  

Anyone can become a victim of domestic violence. Victims of domestic violence come from all walks of life, all age groups, all socio-economic groups, all religions, and all nationalities [8]. Violence can occur in any relationship when one person feels they are entitled to control another person through whatever means of abuse possible. This abuse is cyclical and usually increases in frequency and intensity. Victims of such violence report feelings of isolation, helplessness, guilt, anxiety, and embarrassment. They may become suicidal, start abusing drugs and alcohol, and feel that they have no one to turn to for help.  

Although there isn't a specific set of factors that result in "being a victim," there are many thoughts as to what might affect a person's active willingness to remain in a violent relationship. The following lists serve only as general guidance to inform the healthcare professional of possible underlying causes. Again, anyone can become a victim of domestic violence.  

 

Victims of Domestic Abuse

There is no single "characteristic" or risk factor that automatically causes a person to become a victim of domestic violence. Instead, it may be a series of events that cause a person to become more vulnerable and enter and remain within an abusive relationship [9].  

Domestic violence victims may have experienced violence during childhood, experienced total financial dependence on another person, or lacked basic social support (family and friends). These factors affect both the physical and psychological make-up of a person. Without intervention, these victims can develop personal esteem and confidence issues, further social isolation, economic dependency, and general feelings of insecurity. These effects may negatively affect the decision to stay in an abusive relationship.  

Researchers have found the following factors may place a person at a higher risk of becoming a victim of domestic violence, including (but not limited to) [10]:  

  • Poor self-image/ low self-esteem 
  • Financial dependence on the abuser 
  • Feeling powerless to stop the violence or leave the relationship 
  • Personal belief that jealousy is an expression of love 

Common characteristics of victims of domestic violence include, but are not limited to:  

  • A history of abuse  
  • A history of alcohol or substance abuse (for themselves or their partners) 
  • Financial and family stressors- low income, limited family/friends contact, poverty status 
  • A member of an ethnic minority/ immigrant group; Limited English vocabulary 
  • Holds traditional beliefs that they should be submissive in a relationship 

Reasons a victim may choose to stay in the relationship:  

  • A desire to end the abuse but not necessarily the relationship; they do love their abuser  
  • Feelings of isolation and helplessness  
  • Fear of judgment if they reveal the abuse by seeking help 
  • Feelings that they may not be able to support themselves if they leave their abuser 
  • Fears for the safety of children involved in the relationship  
  • Fear of backlash from community or family and friends/lack of knowledge of services available  
  • Strong religious/cultural belief system that reinforces staying in a relationship at all costs  

 

Abusers/Perpetrators of Domestic Violence

As with the DV victim, there is no one set of traits to identify a domestic violence abuser/perpetrator correctly. There are, however, some signs that may raise the red flag of suspicion when observed in a suspected domestic violence case.  

The National Coalition on Domestic Abuse has created a list of "red flag" indicators, including but not limited to the following [11]:  

  • Extreme jealousy and possessiveness  
  • Verbally abusive  
  • Extremely controlling behavior  
  • Blaming the victim for anything bad that happens  
  • Control over all the finances in the relationship  
  • Demeaning the victim publicly or privately  
  • Humiliating or embarrassing the victim in front of other people  
  • Control over what the victim wears  
  • Abuse of other family members, including children (and even pets)  

The following is a general list of indicators that "may" help identify an abuser [12].  

  • History of abuse within one's family  
  • History of personal physical or sexual abuse  
  • A lack of appropriate coping skills  
  • Low self-esteem  
  • Codependent behavior  
  • Untreated mental illness  
  • Drug or alcohol abuse
  • Socio-economic pressures related to the lower income status
  • Prior criminal history

 

Quiz Questions

Self Quiz

Ask yourself...

  1. What screening tools are currently available at your facility to assess for possible domestic abuse? Do you feel that they are effective?  
  2. Domestic abuse victims may seek medical attention for issues unrelated to abuse (chronic headache, vague aches, and pain, anxiety, or depression). What further assessments can be done to assess for domestic violence? 

Importance of Trauma-Informed Care  

While nurses play a critical role in recognizing suspected domestic abuse victims, they often do not feel confident in their role or the screening process itself. This may be due to a lack of communication skills, ongoing training on domestic violence or simple confusion over what victim assistance programs and resources are available [17].  

Facility-wide education on domestic violence should be ongoing. Policies and procedures should be on file, and collateral relationships should be in place with the local community and national resources. Finally, nurses should be trained in the delivery of trauma-informed care to ensure the highest quality of interaction with victims of domestic violence, much less all victims of trauma.  

Trauma-informed care has been defined as the patient-centered approach that encourages healthcare professionals to provide care that does not retraumatize the patient and the staff [18]. Trauma-informed care ensures that policies and practices in the healthcare setting are not only safe but non-threatening to the physical and mental well-being of those involved. Perceived threats can cause a "flight or fright" mentality that impacts both the ability to administer care and receive immediate care and follow-up recommendations.  

The experience of seeking medical care, whether in an emergency department setting or a clinic, can in and of itself bring another source of trauma. Trauma-informed care aims at reducing the impact of trauma on both the patient and provider by focusing on various checkpoints overseeing all interactions: safety, trustworthiness, empowerment, and respect.  

The following examples are practical tips that encourage trauma-focused care, ensuring the delivery of care in the least threatening manner to a suspected human trafficking victim (as well as each patient you may intersect with).  

  • Always introduce yourself and your role within the patient's care with every interaction.  
  • Use open body language (direct eye contact, avoid standing "over" the patient as it may be perceived as threatening).  
  • Explain procedures and timelines for results ("wait times") to give patients a sense of control. Keep them informed of any changes/delays in their care.  
  • Always ask before you touch a patient. This is a sign of respect and gives the patient a sense of control over their own bodies.  
  • Protect patient privacy. Ask them who they would like present during their care; limit visitors if requested; close room doors (with their permission).  

During the interview and intervention process, it is also equally important that some things not be said to a suspected victim of domestic violence, such as negating, challenging, or doubting the victim. Examples include:  

  • Why haven't you called the police before now?  
  • Some level of fighting occurs in all relationships.  
  • Maybe you're both going through a phase; it will probably stop on its own.  
  • You wouldn't stay in this situation if you really care about yourself/ your kids.  
  • What did you do to make them get so angry?  
  • Why didn't you leave the first time you were hurt?  

By applying trauma-informed care to all your patients, you lower the risk of perceiving any (nursing and medical) interventions being perceived as a threat. This ensures a higher level of trust and respect, and safety for all patients (and staff) across the care spectrum.

Quiz Questions

Self Quiz

Ask yourself...

  1. What are some possible consequences of doubting a victim of domestic violence? 
  2. What can you do as a healthcare professional to ensure all patients are screened for domestic violence?  

Legal Issues: Florida Mandatory Reporting Laws  

The United States Department of Justice, defines domestic violence to include felony or misdemeanor crimes of violence committed by [19]:  

  • a current of former spouse or intimate partner of the victim,   
  • by a person with whom the victim shares a child in common,  
  • by a person cohabitating with or has cohabitated with the victim as a spouse or intimate partner,  
  • by a person similarly situated to a spouse of the victim under the domestic or family violence laws of the jurisdiction receiving grant monies,  
  • by any other person against an adult or youth protected from that person's acts under the jurisdiction's domestic or family violence laws.  

The Florida Department of Children and Families defines domestic violence as patterns of actions or behaviors that adults or adolescents use against their partners or former partners to establish power and control. It can potentially include physical abuse, sexual abuse, emotional abuse, and economic abuse. It may also include threats, isolation, pet abuse, using children, and a variety of other behaviors used to maintain fear, intimidation, and power over one's partner (19)." [28]. 

Under Florida law [21], Domestic Battery is classified as a first-degree misdemeanor, with penalties including up to one year in jail or twelve months' probation and a $1,000 fine [21][29][30]. In addition, the accused may face additional penalties of a mandated Batterer Intervention Program [31] 

RAINN (Rape, Abuse, and Incest National Network) is the nation's largest anti-sexual violence organization [22]. Under the “Laws of your state” section, they outline the mandatory reporting laws for Floridaall states. Florida’s mandated reporting law can be viewed there or on the Florida Courts website. 

 

Mandatory Reporting Requirements on Children 

Children are defined as any unmarried person under the age of 18 years who has not been emancipated by court order.  

Who is required to report (from a healthcare professional standpoint):  

  • Physicians 
  • Osteopathics physicians 
  • Medical examiners 
  • Chiropractors
  • Nurses
  • Some hHospital personnel
  • Nursing Home and assisted living facility staff
  • Health or mental health professionals
  • Social workers
  • Paramedics
  • Emergency medical technicians 

When is a report required:  

  • When any person knows or has cause to suspect that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or another person responsible for the child's welfare, or that a child is in need of supervision and care and has no one to provide care.  
  • When any person knows or has cause to suspect that a child is abused by an adult other than a parent, legal custodian, or another person responsible for the child's welfare.  
  • When any person knows or has cause to suspect that the child is a victim of childhood sexual abuse or the victim of a known or suspected juvenile sexual offender.  

  

Reports can be made to the Department of Children and Families abuse hotline at 1-800-96-ABUSE (1-800-962-2873) or at Florida DCF Reporter Portal.

Quiz Questions

Self Quiz

Ask yourself...

  1. What policies and protocols are in place at your facility regarding mandatory reporting? 
  2. Who can initiate a report? 
  3. What departments are notified, at your facility, if a report is made? 

Elements of a Safety Plan (Escape Plan)  

Abusers may go to extremes to prevent a victim from leaving. This may result in the decision to escape an abusive relationship – one of the most dangerous times for the victim of domestic violence. The creation of a safety plan can assist in enhancing the safety of a victim during all phases of a relationship and during the planning phase of actually leaving the abuser.  

Knowledge of the various elements of a safety plan will enable the healthcare professional to initiate dialogue with a victim and guide them in the development of a personalized plan of safety moving forward. Discussion of safety plans/escape plans can be very difficult during the limited interactions of an emergency room or clinic visit; therefore, familiarity with the key elements of a plan will help navigate the victim to the most appropriate resources for their situation.  

The following overviews of a safety plan are from Safe Horizon and the National Domestic Violence Hotline [23][24]. The Safe Horizon is a victim assistance nonprofit for victims of violence and abuse in New York City since 1978. The following outline provides a detailed overview of the many aspects to consider when formulating a safety plan. Review the entire plan outlined on their website Safe Horizon. Consider creating a template handout for your facility to distribute to domestic violence victims.  

A safety plan is an outline that includes ways to remain safe while in a relationship, planning to leave, or after you leave [23]. A personalized safety plan assists in coping with emotions, telling friends and family about the abuse, and the steps to be taken in the event of necessary legal action. An effective safety plan should have specific details tailored to your unique situation.  

Considerations in creating your safety plan:  

  • Do you have a trusted confidant - a friend, family member, or neighbor?  
  • What are some areas in your neighborhood you could go to in an emergency?  
  • Are there phone numbers you need to memorize in the event of an emergency?  
  • Do you have children that need to be part of your safety plan? Where would your children go if they witnessed violence?  
  • Do you need a safety plan for work or school?  
  • Where can you safely store your safety plan? Computer? Phone?  

 

Before Leaving  

The decision to leave an abusive relationship requires courage and preplanning. Consider these measures before leaving to reduce the risk of violence [23]:  

  • Record evidence of physical abuse  
  • Plan with children and identify a safe place where they can go during moments of crisis. Reassure them that their job is to stay safe, not to protect you.  
  • Call ahead to see what the shelter's policies are. They can provide information on how they can help and secure a space when it is time to leave.  
  • Try to set money aside or ask trusted friends or family members to hold money for you.  

 

When Leaving  

The following list of items serves as a guide for what to take [23]:   

Identification 

  • Driver's license or state I.D. card, social security card  
  • Birth certificate and children's birth certificates  
  • Money and/or credit cards   
  • Checking and/or savings account books  

Legal papers  

  • A protective order, if applicable  
  • Health and life insurance papers  
  • Legal documents, including divorce and custody papers 
  • Marriage license  

Emergency numbers 

  • Local domestic violence program or shelter  
  • Trusted friends and family members  
  • The Hotline  

Other items to keep in mind: 

  • Medications and refills (if possible)  
  • Emergency items, like food, bottles of water, and a first aid kit  
  • Multiple changes of clothes   
  • Emergency money  
  • Address book  
  • Safe cell phone, if possible  

 

After Leaving  

The safety plan should always include ways to ensure your continued safety after leaving an abusive relationship. Here are some precautions to consider [23]:  

  • Change locks and phone numbers if possible.  
  • If possible, change work hours and the typical route.  
  • Alert school authorities of the situation.  
  • If a protection order is present, keep a certified copy present at all times, and inform friends, neighbors, and employers that you have a protection order in effect.  
  • Consider renting a post office box or using a trusted friend's address for mail (remember that addresses are used for restraining orders and police reports) 
  • Use different stores and frequent different social spots.  
  • Alert neighbors and work colleagues about how and when to seek help.  

If comfortable, tell people who can take care of your children or transport them to/from school and activities. 

Again, these suggestions provide an extensive overview of an escape plan. They are meant to assist a victim in the required methodical preplanning of a safety plan that reduces the threat of violence. Not all sections will apply to every victim, but healthcare professionals should be comfortable in discussing any aspects of a safety plan specific to the individual victim. 

 

 

The Effects of COVID-19 on Domestic Violence  

As discussed at the beginning of this course, the COVID-19 pandemic has negatively affected domestic violence incidence. Stay at home /shelter in place orders, job losses, mounting financial concerns, and lack of available shelters in many areas became the norm. Domestic violence victims were met with further hurdles to their safety and well-being, as they found themselves sheltering in place with their abuser, along with fewer resources available to them in their time of crisis.  

Domestic violence hotlines prepared for an increase in calls. However, many organizations found the opposite occurring. Calls to hotlines dropped, in some places greater than 50 percent. Victims were not able to safely connect with necessary services [25].  

Due to the restrictions of movement (curfews, travel bans, 14-day quarantine advisories), not only was it more difficult to escape, but injury from abuse may have gone unnoticed by family and friends as face-to-face interactions had been sidelined. In addition to job losses and financial insecurities, this isolation may have forced a victim to become even more dependent on their abuser [26].  

In March 2020, U.S. police departments reported an increase in domestic violence calls as high as 27% after stay-at-home orders were implemented. The number of Google searches for family violence-related help during the outbreak had been substantial. This increase in domestic violence had not only affected the United States. In the United Kingdom, calls to the Domestic Violence Helpline increased by 25% in the first week after implementing lockdown measures. Furthermore, in China, domestic violence had reportedly increased three times in Hubei Province during the lockdown [27]. The importance of ongoing domestic violence education and awareness cannot be overstated.  

In review, healthcare staff often treat victims of domestic violence. Trauma-informed care that is patient-focused affords both the staff and patient (victim) the best outcome in terms of successfully navigating the challenges of domestic violence and mandatory reporting laws.  

Facility-wide protocols should be in place regarding all aspects of patient care for suspected victims of domestic violence, including national hotline numbers, community resources, scene safety protocols, and house-wide education. Staff should be regularly educated on interviewing techniques, suspected DV victim indicators, and ongoing community collateral relationships. Improved recognition of these victims and knowledge on how to proceed with specific treatment protocols will lead to a higher level of positive outcomes for domestic violence victims and other forms of abuse.  

Time is of the essence when dealing with victims of DV. There may be a small window of opportunity to help these victims when they come to your facility. There may be numerous needs identified quickly (transportation, housing, interpretation services, crisis intervention, case management, safety planning, transitional shelter, and protective orders, to name a few). Staff must feel confident in their abilities to identify possible victims, guide them through the process of seeking help, and advocate for their safety and well-being. Knowledge of their facility protocols and community, state, and national resources will afford them the opportunity to deliver optimal care.  

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. Can you give examples of what your facility is doing to address the issue of domestic violence?  
  2. How had COVID-19 affected your facility in terms of the availability of community resources for victims of domestic violence?  
  3. What improvements can be made at your facility regarding domestic violence education and awareness?  

Case Study  

Mary, 26 years old, presents to the emergency department with complaints of abdominal pain, vague body aches, and a headache. During the triage screening, Mary has minimal eye contact with the nurse and appears inadequately dressed for the cold weather, arriving in only jeans, a t-shirt, gym shoes, and a light sweater. While the nurse helps Mary change into a hospital gown in a private examination room, she notices various bruises on Mary's lower back, arms, and legs, all varying size and color. Mary states she slipped and fell recently at home. You observe that Mary is now avoiding all eye contact, staring down at the ground. She keeps looking at the door, and wall clock, mumbling, “He can't know I'm here.”  

  • What are your initial thoughts about Mary's physical appearance?  
  • What can you do to make Mary feel more relaxed, comfortable, and safe during her emergency room visit?  

Mary lives with her boyfriend, Bill. He works part-time; she is currently unemployed. She admits to the occasional use of alcohol and recreational use of marijuana “to help me relax. My anxiety is very bad lately.”  She mentions that her anxiety has increased because “Bill's hours at work have been cut due to COVID-19 and we’re strapped for money. He is under a lot of pressure.”  

On further examination and laboratory testing, including a pelvic examination, it is confirmed that Mary is approximately six weeks pregnant and has a suspected sexually transmitted infection. Mary bursts into tears and says, “He is going to kill me. We can't afford a baby. What am I going to do?!”  

  • What are your concerns about this scenario? How will you address these concerns with your patient Mary?  
  • Why might healthcare professionals, in general, feel uncomfortable speaking with Mary?  
  • What are the top priorities of Mary's care at this time?  
  • What information would you document in the patient record during this visit?  

Mary begins to feel comfortable speaking to you about her situation. She reluctantly tells you that Bill pushed her down the back stairs yesterday after an argument but quickly apologized afterward. On another occasion, Bill “beat me up” when he ran out of beer before payday. She states he has been really angry lately over his hours being cut at work and is looking for another job. “A baby now,” Mary confides, “would be a terrible thing for Bill, but I want it. It's my first, and I want it. Please help me.” Mary gives consent for you to contact your department social worker for additional guidance but does not want law enforcement notified.  

  • What other key staff members need to be part of the care team for Mary?  
  • What local and national resources can you refer Mary to at this time?  
  • How would your plan of care change if Mary did not give consent for the social worker to be notified?  

Mary wants to “go back home” tonight so as not to upset Bill when he returns later this evening. “It will be better this way.” She promises to leave him tomorrow and follow-up with the community referrals you gave her. Knowing that these plans may change, you advise Mary to create a safe escape plan “just in case.”  

  • What items should be part of a safe escape plan?  
  • How safe is it for Mary to return home?  
  • What are your legal obligations to Mary regarding Florida's mandatory reporting laws?  

As you are getting ready to leave at the end of your shift hours later, you see Mary arrive by ambulance. She is visibly injured with a broken nose and bloody lip. The emergency medical response team stated the neighbors called 911 when they heard Mary screaming in her apartment next door. No one else was in the apartment when they entered, and Mary would not tell them who injured her. You escort them to a private examination room. Mary sees you and yells, “He's coming after me. Help me. He is going to kill me.”  

  • What are your top priorities for Mary and the staff at this time?  
  • What other hospital departments need to be notified?  

Mary’s boyfriend shows up, intoxicated, at the triage window, demanding to see Mary. He threatens to kick in the door to the main examination room if he cannot see Mary immediately. He is pacing back and forth in the triage area and refuses to sit down.  

  • What additional security measures need to be in place upon the boyfriend's arrival?  

Mary's boyfriend is removed from the premises by local law enforcement. Mary is given the national hotline number and is contacting the local shelter at this time. Upon discharge, she is escorted by security personnel to the exit and leaves the facility with a shelter representative.

 

 

 

Florida-Specific Domestic Violence Resources 

Community Legal Services of Mid-Florida  

A full service civil legal aid law firm that promotes equal access to justice, providing professional legal aid on domestic violence to help low-income people protect their health, and their families.  

https://www.clsmf.org/violence-protection/ 

 

Coast to Coast Legal Aid of South Florida  

The Family Law Unit primarily focuses on representing victims of domestic violence in family law matters, such as obtaining an injunction (restraining order), dissolution of marriage cases (divorce), and custody litigation.  

https://www.coasttocoastlegalaid.org/   

 

Domestic Shelters.org  

Overview of 58 Florida based organizations offering domestic violence services in 47 different cities.  

https://www.domesticshelters.org/help/fl.florida 

 

Florida Department of Children and Families  

Florida Family Policy Council  

Resources to assist victims (and family members) to find help, safe shelter, legal aid, transitional services, and counseling.  

https://www.flfamily.org/get-help/domestic-violence   

 

Florida Department of Children and Families: 

Child Protective Services:  

https://www.myflfamilies.com/service-programs/abuse-hotline/  

Florida Abuse Hotline:  

The Florida Abuse Hotline accepts reports 24 hours a day and 7 days a week of known or suspected child abuse, neglect, or abandonment and reports of known or suspected abuse, neglect, or exploitation of a vulnerable adult.  

1-800-96-ABUSE (1-800-962-2873)  

TTY: 1-800-955-8771  

https://reportabuse.dcf.state.fl.us/  

 

MyFlFamilies.com  

These services include emergency shelter, counseling, safety planning, case management, child assessments, information, and much more.  

These shelters may be viewed on the MyFlFamilies.com website. Healthcare professionals should be familiar with shelters available in their surrounding area.  

Domestic Violence Hotline: 1-800-500-1119  

https://www.myflfamilies.com/   

 

Harbor House of Central Florida  

Offering housing placements service, legal aid, safety planning, support groups, and crisis intervention.  

(407) 886-2856  

https://www.harborhousefl.com/get-help/safety/  

 

The 15th Judicial Circuit of Florida Batterers Intervention Program (BIP)  

The Florida BIP is a 6-month intensive program to address root causes of domestic violence; it is at least 26 weeks of group counseling sessions. A list of statewide providers is available on this site.  

https://www.15thcircuit.com/program-page/bip   

 

The Salvation Army  

Offering emergency and transitional housing, as well as counseling and rehabilitation services.  

https://salvationarmyflorida.org/domestic-violence-program/ 

National Domestic Violence Resources 

Amend, Inc.  

AMEND is a nonprofit organization working to end domestic violence by providing counseling to men who have been abusive, advocacy and support to their partners and children, and education to the community. Based in Colorado. 

http://www.amendinc.org/ 

 

Emerge  

Emerge is a Massachusetts Certified Batterer Intervention Program & Training Site, offering abuser education groups and batterer intervention. Based in Massachusetts. 

617-547-9879   

https://www.emergedv.com/  

 

National Domestic Violence Hotline  

1-800-799-SAFE (7233)  

https://www.thehotline.org/  

 

Domestic Violence Prevention, Inc   

501C3 nonprofit offering education, counseling, and support services to domestic violence clients in multiple counties in Texas and Arkansas.  

903-793-HELP (4357)  

https://www.dvptxk.org/   

 

National Center on Domestic Violence, Trauma and Mental Health  

Offering direct website links to multiple national organizations working with domestic violence cases. 

http://www.nationalcenterdvtraumamh.org/resources/national-domestic-violence-organizations/ 

 

National Network to End Domestic Violence  

Offers a range of programs and initiatives to address the complex causes and far-reaching consequences of domestic violence.  

https://nnedv.org/   

 

New York Model for Batterer Programs National Organization for Men Against Sexism (NOMAS) Model for DV Offender Accountability 

Court-ordered program for batterer education, which includes a court-imposed consequence if the offender does not attend. Based in New York. Formerly known as the New York Model for Batterer Programs. 

845-842-9125 

https://www.nymbp.org/ https://nomas.org/ 

 

Women's Law  

Providing state-specific legal information and resources for survivors of domestic violence.  

https://www.womenslaw.org/ 

Conclusion 

Domestic violence is a national crisis that can lead to poor outcomes for victims. Nurses have the responsibility to ensure that victims are properly screened, provided appropriate education, and supported with resources for safety. Creating a safe space for victims to share concerns, helping them to create escape plans, and respecting their decision to stay or leave the relationship is all a part of providing the best care possible.

Florida HIV/AIDS

This fulfills the continuing education requirement of Florida HIV/AIDS for the state of Florida.  

An estimated 1.2 million Americans are living with HIV. As many as 1 in 7 of them do not even know they are infected. The others utilize the healthcare system in a variety of ways, from testing and treatment regimens to hospitalizations for symptoms and opportunistic infections. Healthcare professionals in nearly every setting have the potential to encounter patients with HIV as the disease can affect patients of any age or stage of life (4). Proper understanding of HIV is important in order to provide high-quality and holistic care to these patients. For nurses practicing in the state of Florida, it is also important to understand the laws, statutes, and regulations regarding testing, treatment, reporting, and confidentiality related to Florida HIV and AIDS within the state.  

Introduction   

An estimated 1.2 million Americans are living with human immunodeficiency virus (HIV). As many as 1 in 8 do not even know they are infected (7). The others utilize the healthcare system in a variety of ways, from testing and treatment regimens to hospitalizations for symptoms and opportunistic infections.

Healthcare professionals in nearly every setting have the potential to encounter patients with HIV as the disease can affect patients of any age or stage of life. Proper understanding of HIV is important in order to provide high-quality and holistic care to these patients. For nurses practicing in the state of Florida, it is also important to understand the laws, statutes, and regulations regarding testing, treatment, reporting, and confidentiality related to HIV and AIDS within the state.  

Statistics 

Rates of infection are not equal across demographic groups, and certain factors may increase a person's risk. Patient information to consider when determining someone's risk includes:  

Age 

As of 2021, the age group with the highest incidence of new HIV diagnoses is 13-34 years, approximately 58% of new infections (7). Cases are down 18% in this age group from 2017.  

Race/Ethnicity 

African Americans had the highest number of new HIV cases in 2021, at approximately 40% (7). This is followed by Hispanic/Latinos at 29%, and whites at 26%.  

Gender 

Males are disproportionately affected by HIV, accounting for 81% of new cases in 2021 (7). Females accounted for 24% of new cases. This data refers to the sex of someone at birth. When looking at the transgender population, those who have transitioned male-to-female were 2% of new cases and female-to-male, less than 1% (7). 

Sexual Orientation 

Men who have sex with men (MSM) remain the population most at risk of HIV, accounting for around 70% of all new infections in 2021 (7). Cases are down 13.5% in this group from 2017.  

Location 

Different areas of the country are affected at different rates for a variety of factors, including population density, racial distribution, and access to healthcare. The southern states are unmistakably more affected than other regions, and accounted for 52% of new cases in 2021 (7). Western states account for 21%, Midwest 14%, and Northeast 14% (7). 

Transmission 

Perhaps the most elusive part of this virus for many years was how it spreads. We now know that HIV is spread only through certain bodily fluids. An accurate understanding of HIV transmission is important for healthcare professionals to provide proper education to their patients, reduce misconceptions and stigmas, and prevent transmission and protect themselves and other patients (8). 

Bodily Fluids 

Bodily fluids that can transmit the virus include (9):  

  • Blood 
  • Semen and pre-seminal fluid 
  • Rectal fluid 
  • Vaginal fluid 
  • Breastmilk 
  • Fluids that may contain blood such as amniotic fluid, pleural fluid, pericardial fluid, and cerebrospinal fluid   

If one of these fluids comes into contact with a mucous membrane such as the mouth, vagina, rectum, etc., or damaged tissue such as open wounds, or is directly injected into the bloodstream, then transmission of HIV is possible (8). 

Ways of Transmission 

Scenarios where transmission is possible include:  

  • Vaginal or anal sex with someone who has HIV (condoms and appropriate treatment with antivirals reduce this risk) 
  • Sharing needles or syringes with someone who has HIV 
  • Mother-to-child transmission during pregnancy, delivery, or breastfeeding (appropriate treatment during pregnancy, c-section delivery, and alternative feeding methods reduce this risk) 
  • Receiving a transfusion of infected blood or blood products (this is very rare now because of screening processes for blood donations) 
  • Oral sex with someone who has HIV (though this is very rare) 
  • A healthcare worker receiving a sharps injury with a dirty needle (risk of transmission is very low in this scenario) 

HIV cannot be transmitted via:  

  • Saliva 
  • Sputum 
  • Feces 
  • Urine 
  • Vomit 
  • Sweat 
  • Mucous  
  • Kissing 
  • Sharing food or drink 
  • Ticks or mosquitos 

     

     

    Reducing Transmission & Infection Control 

    Patient education about risk and protection against HIV, testing, and what to do if exposed should be standard practice for healthcare professionals in nearly all healthcare settings. Ideally, primary care should include risk screenings and routine patient education to help prevent infections from occurring (or preventing worsening of infections that have already occurred) (8). 

    Prevention Strategies 

    Strategies to help prevent the spread of HIV include (8): 

    • Identifying those most at risk, particularly MSM, minorities, and those who use drugs by injection 
    • Ensure patients are aware of and have access to protective measures such as condoms and clean needle exchange programs 
    • Provide routine screening blood work for anyone with risk factors or desiring testing 
    • Providing access to PrEP medications where indicated (discussed further below) 
    • Staying up to date on current recommendations by the U.S. Centers for Disease Control and Prevention (CDC), and HIV developments 
    • Maintaining a nonjudgmental demeanor when discussing HIV with patients, to welcome open discussion   

    Pre-Exposure Prophylaxis 

    For patients with a repeated or frequent high risk of HIV exposure, such as those with an HIV+ partner or those routinely using needles for drugs, pre-exposure prophylaxis (PrEP) may be a good choice to reduce the risk of contracting the virus. When used correctly, PrEP is 99% effective at preventing infection from high-risk sexual activity and 74% effective at preventing infection from injectable drug use (10).  

    Depending on the type of exposure risk (anal sex, vaginal sex, needle sharing, etc.), PrEP needs to be taken anywhere from 7-21 days before it reaches its maximum effectiveness (10). Most insurances, including Medicaid programs, cover PrEP at least in part (10). There are also federal and state assistance programs available to make PrEP available to as many people who need it as possible. Some side effects are commonly reported, primarily gastrointestinal symptoms, headaches, and fatigue (10).  

    Viral Load 

    For those who have a confirmed diagnosis of HIV/AIDS, the focus should be promoting interventions that will prevent further transmission. One of the biggest determinants for transmission is the infected person's viral load. Individuals being treated for HIV can have their viral load measured to ensure viral replication is being controlled as intended. A viral load lower than 200 copies of HIV per milliliter of blood is considered undetectable, meaning the virus is not transmissible to others (4). Even for those not receiving treatment, there are methods to reduce transmission (11). 

    Infection Control Methods 

    Methods of infection control for healthcare professionals include (3): 

    • Universal precautions when handling any bodily fluids 
    • Eyewear when at risk for fluid splashing 
    • Careful and proper handling of sharps 
    • Facilities having a standard plan in place for potential exposures 

    If an exposure or needlestick does occur, the patient would ideally submit to testing for HIV to determine if the staff member is at risk. If the HIV status of the patient is unknown or confirmed to be positive, post-exposure prophylaxis (PEP) may be advised to start within 72 hours of exposure (12).  

     

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What are some strategies to reduce Florida HIV/AIDS transmission?
    2. Have you or any of your coworkers ever had a needlestick occur?
    3. How did you handle that situation?

    Florida HIV/AIDS Treatment

    When HIV is appropriately treated, advancement from HIV to AIDS can be significantly reduced, and quality and longevity of life maximized. In 2018, the CDC estimated around 65% of all US citizens living with HIV were virally suppressed, and 85% of those receiving regular HIV-related care were considered virally suppressed at their last test (5). However, as mentioned earlier, an estimated 13% of all HIV cases do not know they are infected. Appropriate medical care and keeping viral loads undetectable is one of the single most effective methods of preventing transmission (4, 5).  

    For those receiving treatment, a multifaceted and individualized approach can reduce a person's viral load, reduce the risk of transmission, reduce the likelihood of developing AIDS, and preserve the immune system. Regardless of how early someone receives treatment, there is no cure for HIV, and an infected person will be infected for life. All individuals diagnosed with HIV (even asymptomatic people, infants, and children) should receive antiretroviral therapy or ART as quickly as possible after a diagnosis of HIV is made. The classes and available medications for ART include the following (1). There are many other combination formula HIV medications, for example emtricitabine/tenofovir (brand name, Truvada), although not listed here.  

    Nucleoside Reverse Transcriptase Inhibitors (NRTIs) 

    Nucleoside reverse transcriptase inhibitors (NRTIs) inhibit the transcription of viral RNA to DNA blocking reverse transcriptase (an enzyme needed for HIV replication). 

    • Abacavir 
    • Emtricitabine 
    • Lamivudine 
    • Tenofovir disoproxil fumerate 
    • Zidovudine 

    Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) 

    Non-nucleoside reverse transcriptase inhibitors (NNRTIs) inhibit the transcription of viral RNA to DNA by binding to and altering reverse transcriptase. As mentioned above, transcriptase is an enzyme HIV needs to make copies of itself. 

    • Doravirine 
    • Efavirenz 
    • Etravirine 
    • Nevirapine 
    • Rilpivirine 

    Protease Inhibitors 

    Protease inhibitors block HIV protease (another enzyme needed for HIV replication). 

    • Atazanavir 
    • Darunavir 
    • Fosamprenavir 
    • Ritonavir 
    • Saquinavir 
    • Tipranavir 

    Fusion Inhibitors 

    Fusion inhibitors prevent the virus from entering the CD4-T lymphocyte cells (CD4 cells) of the immune system. 

    • Enfuvirtide 

    Integrase Strand Transfer Inhibitors (INSTIs)  

    Integrase strand transfer inhibitors (INSTIs) block HIV integrase (an enzyme needed for HIV replication). 

    • Cabotegrevir 
    • Dolutegravir 
    • Raltegravir 

    Attachment Inhibitors 

    Attachment inhibitors prevent HIV from entering CD4 cells by binding to the gp120 protein on the surface of the virus’ cell. 

    • Fostemsavir 

    Post Attachment Inhibitors 

    Post attachment inhibitors prevent the virus from binding to and entering CD4 cells by block the CD4 receptors on the surface of some immune cells. HIV needs these receptors to enter the cells. 

    • Ibalizumab-uiyk 

    Capsid Inhibitors 

    Capsid inhibitors interfere with the HIV capsid (a protein shell that protects the enzymes HIV needs for replication). 

    • Lenacapavir 

    Pharmacokinetic Enhancers 

    Pharmacokinetic enhancers increase the effectiveness of HIV medications. 

    • Cobicistat 

     

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. How do fusion inhibitors work against HIV?
    2. How do entry inhibitors work against HIV?
    3. How soon after diagnosis should patients receive antiretroviral therapy?
    4. Make a mental list of treatments available for patients of Florida HIV/AIDS.

    Florida HIV/AIDS Laws

    The Omnibus AIDS Act is based on the premise that illness can be best controlled through public knowledge. If the public is aware of potential illness, and ways to avoid contracting and transmitting illness, that is the best method of prevention and further spread (2). The state of Florida became one of the first states with high rates of HIV infection within their population to enact legislation surrounding the AIDS epidemic. Transmission of HIV, as aforementioned, occurs through direct contact with virus-containing body fluids. Activities by which transmission involves such as sexual activity, needle stick, blood transfusion, or mother-to-baby, the government cannot regulate. Therefore, the governmental response to a disease epidemic must rely primarily upon the education of the public and its cooperation with their educational efforts and recommendations (2).  

     

     

    Informed Consent 

    The following are regulations surrounding informed consent and HIV testing in the state of Florida (2). 

    Information Requirements 

    Healthcare providers performing HIV tests must have advanced procedures in place regarding patient consent, testing samples, and informing patients of their results (2). “Since the 1998 amendments to the Act, health care providers must, as a matter of law, convey three pieces of information, all essentially involving the choice of a testing site, as part of the process of obtaining informed consent:  

     

    1. Disclose that the provider is required by law to report the test subject’s name to the local county health department if the HIV test results are positive; 
    1. Alert the patient that as an alternative, the patient may secure the HIV test at a site that tests anonymously, the locations of which the provider must make available; and 
    1. Relate the extent of the confidentiality rights that adhere to the test results in the provider's patient records.” 

    Minors 

    “The general rule that parental consent is required prior to medical diagnosis or treatment of a minor does not apply when sexually transmitted diseases such as HIV infection are involved. Indeed, Florida specifically forbids telling parents the fact of the minor's consultation, examination or treatment for a sexually transmissible disease, such as HIV infection, either directly or indirectly (such as by billing a parent or their insurer for an HIV test without the child's permission).” 

    “Infants and young children are treated as unable to make an informed decision and consent of their parents or legal guardian is required. For older children (such as teenagers), however, the provider must make an individual judgment whether the child, as phrased in Department of Health rules, ‘demonstrates sufficient knowledge and maturity to make an informed judgment,’ meaning, whether the child has the cognitive and emotional capacity to understand the risks and benefits of the test or treatment to which the child is being asked to consent.” 

    Documentation 

    “As with other medical procedures requiring informed consent, informed consent for HIV testing does not necessarily mean written consent. Except for donations of blood and other tissues and to obtain health or life insurance, Florida does not require providers to have the test subject sign a document authorizing the test. The health care provider need only enter a note in the medical record that the test was explained and consent was obtained.” 

    Exceptions 

    Exceptions to informed consent requirements by health care providers (2): 

    Pregnancy 

    “Following federal legislation and recommendations from CDC, Florida law in 1996 first imposed “mandatory offering” of HIV tests for all pregnancies upon presentation. In 2005, the statute was further amended to establish the present system of “opt out” testing, in which pregnant women are advised that the health care provider attending them will conduct an HIV test but that they have the right to refuse. The pregnant woman’s objection is required in writing, which must be placed in her medical record” (§384.31, F.S.)  

    Emergencies 

    “A provider may test without consent in "bona fide medical emergencies," but only if the provider documents in the medical record that the test results are medically necessary to provide appropriate emergency care or treatment to the test subject and the test subject is unable to consent” (§381.004(2)(h)3, F.S.).  

    Therapeutic Privilege 

    “The Act allows a "therapeutic privilege" that bypasses informed consent requirements when the provider's medical record documents that obtaining informed consent would be detrimental to the health of a patient suffering from an acute illness and that the test results are necessary for medical diagnostic purposes to provide appropriate care or treatment to the patient. This same privilege applies to all medical procedures for which informed consent is required. The statute emphasizes that this provision provides no basis for routinely testing patients for HIV without their informed consent” (§381.004(2)(h)4, F.S.).  

    Sexually Transmissible Diseases 

    “State laws permit HIV testing for sexually transmissible diseases on certain subjects, such as convicted prostitutes (§796.08, F.S.), inmates prior to release (§945.355, F.S.), and cadavers over which a medical examiner has asserted authority §381.004(2)(h)1.c., without the consent of the test subject. This exception includes exempting pregnancy “opt out” testing from informed consent requirements discussed above.”  

    Criminal Acts 

    “Victims of criminal offenses that involve transmission of body fluids may require the person charged with or convicted of the offenses to be tested for HIV infection by requesting a court to order the test” (§960.003(2), F.S.). “Similarly, when a defendant, prosecuted for certain offenses in which transmission might have occurred, has been ordered to or has voluntarily given a blood sample, the victim may request the sample be tested for evidence of HIV without the consent of the defendant” (§381.004(2)(h)6, F.S.).  

    Organ and Tissue Donations 

    “Various statutory provisions permit testing without informed consent in specifically identified specialty areas: certain blood and tissue donations; corneal removals and eye enucleation that Florida allows by law to be done without consent; autopsies to which consent to perform the autopsy was obtained” (§§381.004(2)(h)2, 5 and 9, F.S.).  

    Research 

    “Established epidemiologic research methods that ensure test subject anonymity is expected from informed consent” (§381.004(3)(h)8, FS) 

    Abandoned Infants 

    “When a licensed physician determines that it is medically indicated that a hospitalized infant have an HIV test, but the infant's parent(s) or legal guardian cannot be located after reasonable attempts, the test may be performed without consent. The reason why consent could not be obtained must be documented in the medical record and the test result must be provided to the parent(s) or guardian once they are located” (§381.004(2)(h)13, F.S.).  

    Significant Exposure 

    “The blood of the source of significant exposure to medical personnel or to others who render emergency medical assistance may be tested without informed consent” (§381.004(3)(h)10-12, FS).  

    Repeat HIV Testing 

    “Renewed consents are not required for repeat HIV testing either to monitor the clinical progress of a previously diagnosed HIV-positive patient or for conversion from a significant exposure” (§§381.004(2)(h)14 and 15, F.S.). 

    Judicial Authority 

    “A court may order an HIV test to be performed without the individual's consent” (§381.004(3)(h)7, FS). 

     

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What groups of individuals are exceptions to informed consent requirements when it comes to Florida HIV/AIDS?

    Florida HIV/AIDS Confidentiality

    The following are regulations surrounding confidentiality of HIV testing in the state of Florida (2). 

    Not every piece of medical information about a person who has been tested for HIV or assessed for AIDS is protected. “Only the fact that an HIV test was performed on an identifiable individual and any ‘HIV test result’ (negative as well as positive) are specially protected” (§381.004(2)(e), F.S.).  

    The statute definitions (11): 

    • HIV test: “test ordered after July 6, 1988, to determine the presence of the antibody or antigen to human immunodeficiency virus or the presence of human immunodeficiency virus infection” (§§381.004(1)(b), F.S.) 
    • HIV test result: “laboratory report of a human immunodeficiency virus test result entered into a medical record on or after July 6, 1988, or any report or notation in a medical record of a laboratory report of a human immunodeficiency virus test” (§§381.004(1)(c), F.S.) 

    “Only a laboratory report of an HIV test result entered in a medical record on or after July 6, 1988 (the effective date of the Omnibus AIDS Act), or any report or notation in a medical record of a laboratory report of an HIV test, falls within their scope.” 

    “Explicitly excluded from the definition of an HIV test result are reports from patients of their HIV status to health care providers. Consequently, patient reports of their HIV test status from Department of Health anonymous testing sites, from home access HIV test kits or from any other sources do not constitute ‘HIV test results’ unless separately confirmed by the provider through a laboratory report or a medical record containing a laboratory report. Patient disclosures of an HIV test or infection to persons other than health care providers caring for the patient under the provisions of the Act also do not fall within the statute's special confidentiality protections.” 

     

    Voluntary Partner Notification

    The following are regulations surrounding voluntary partner notification of HIV exposure in the state of Florida (2). 

    “The person ordering the HIV test (or that person’s designee), although under no liability exposure to the sexual or needle-sharing partners of their HIV-positive patients, is required to advise their patients with HIV-positive test results of the importance of notifying partners who may have been exposed” (§381.004(2)(c), F.S.). Practitioners are well advised also to tell the patient of the availability of voluntary partner notification services provided by the Department of Health. Under the authority provided in §384.26, F.S., county health department staff offers voluntary and confidential partner notification and referral services to persons infected with HIV. When notifying partners, county health department staff are required not to reveal the identity of the original client.” 

    Florida HIV/AIDS Infection Reporting 

    The following are regulations surrounding HIV infection reporting in the state of Florida (2). 

    “In 1996, Florida became one of the first states with a high incidence of AIDS to authorize regulatory procedures requiring physicians and laboratories to report to local health authorities HIV-positive test results with patient identifiers” (§384.25, F.S.). “Practitioners and clinical laboratories that fail to report HIV-positive test results are subject to a $500 fine and disciplinary action by their licensing boards” (§384.25(4), F.S.).  

    “This change was spurred in part by the Ryan White CARE Act. Enacted in 1990 and reauthorized in 2009 as the Ryan White HIV/AIDS Treatment Extension Act, this federal legislation now provides funding to urban areas, states and localities to improve the availability of care for low-income, uninsured and under-insured AIDS and HIV-infected patients and their families.”  

    “Florida’s HIV infection-reporting requirements increases available Ryan White funding for persons with the illness and enables the Department of Health to link them to medical and support services earlier in the process of infection.” Under the rules by the Department of Health of Florida:  

    1. “Practitioners must report to their local county health department within two weeks of the HIV-positive diagnosis of all persons, EXCEPT infants born to HIV-positive women, which must be reported the next business day” (Rule 64D-3.029, FAC and Rule 64D-3.030(5), FAC). 
    1. “Clinical laboratories must report to the local health department HIV test results from blood specimens within three days of diagnosis” (Rule 64D-3.029, FAC).  

     

     

    Florida Laws and Regulations

    Chapter 464, known and often referred to as the Nurse Practice Act, is separated into two parts. Part I discusses the advanced practiced registered nurse, registered nurse, and licensed practical nurse. The purpose of this statue is to ensure that every nurse practicing in the state of Florida is held to and meets the minimum standards for safe practice. Because of this, nurses who do not meet the minimum standards or display a threat to society are barred from practicing nursing in the state of Florida. The Board of Nursing is the governing body for the Nurse Practice Act and deal with matters such as provide licensure, create rules, and manage disciplinary actions. Part II focuses on the certified nursing assistant. Chapters 456 and Division 64B9 are guidance and further statues that pertain to the nursing profession. 

    This course is designed to meet the requirements of Division 64B9-5 as it pertains to two continuing educational hours about Florida’s laws and regulations of the nursing practice.  

     

    Introduction   

    The state of Florida has several statutes that govern the practice of nurses. These statues consist of Chapters 456 and 464 located in Title XXXII Regulation of Professions and Occupations. The Florida Administrative Code is where Division 64B9 is located.  

    Chapter 464, often referred to as the Nurse Practice Act, is separated into two parts. Part I discusses the advanced practiced registered nurse, registered nurse, and licensed practical nurse. The purpose of this statue is to ensure that every nurse practicing in the state of Florida is held to and meets the same minimum standards for safe practice. Because of this, nurses who do not meet the minimum standards or display a harm to society are not allowed to practice nursing in the state of Florida. The Board of Nursing is the governing body for the Nurse Practice Act and deal with matters such as provide licensure, create rules, and manage disciplinary actions. Part II focuses on the certified nursing assistant.  

    Chapter 456 is a statute that is directed at all health care providers and professions. This statute lists the provisions that Chapter 464 is built on.  

    Division 64B9 is part of the Florida Administrative Code that provides specific rules that pertain to nurses and how the profession is regulated in terms of eligibility to take the examination of selected practice; set standards for nursing education curriculum and institutions; continuing education requirements; license renewal; rules for impairment of the nurse in the workplace and more.  

    This course is designed to meet the requirements of Division 64B9-5 as it pertains to two continuing educational hours about Florida’s laws and regulations of the nursing practice.  

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What prior knowledge do I have of Florida laws and regulations surrounding nursing practices?
    2. What prior knowledge do I have of laws/regulations terminology?
    3. How do these pertain to me in my areas of practice?

    Florida Laws and Regulations Terminology

    1. Advanced or specialized nursing practicecompletion of post-basic specialized, training, experience, and education that are appropriately performed by an advanced practice registered nurse. The advanced-level nurse can perform acts of medical diagnosis and treatment, prescription, and operation” under the authorization of a protocol with supervision of a physician (2). 

    2. Advanced practice registered nurse (APRN)any individual that is licensed in this state to practice professional nursing as defined above and holds a license in an advanced nursing practice, including (2):  

    • Certified Nurse Midwives (CNM or nurse midwife)
      -
      Able to perform superficial or minor surgical procedures as defined by a protocol and approved by the employing medical facility or with a backup physician in the case of a home birth
      - Start and perform approved anesthetic procedures.
      -
      Order appropriate medications based on patient and condition.
      -
      Manage care of the normal obstetrics patient and the newborn patient.  
    • Certified Nurse Practitioners (CNP):
      -
      Able to manage certain medical problems guided by facility or supervising provider protocols. 
      -
      Manage and monitor patients who have stable, chronic illnesses. Start, monitor, and adjust therapies for select, uncomplicated illnesses. 
      -
      Order occupational and physical therapy based on patient need. 
    • Certified Registered Nurse Anesthetists (CRNA):
      - Able to order preanesthetic medications as stated and approved by facility protocols and staff.
      - Determine and consult with supervising anesthesiologist about the proper anesthesia for patients based on labs, history and physical, and patient condition.
      - Assist with managing the patient in the post-anesthesia care unit. 
    • Clinical Nurse Specialists (CNS):
      - A nurse who is prepared in a CNS-focused program that meets the requirements of a typical APRN program.
      - Additionally, they are trained in the area of expertise as it pertains to the advanced practice of nurses.  

    3. Boardthe Board of Nursing (2). 

    4. Licensed practical nurse (LPN)any person licensed in this state or holding an active multistate license under s. 464.0095 to practice practical nursing as defined below (2). 

    5. Practice of practical nursing the performance of select actions including the management of certain treatments and medications, while taking care of the ill, injured, or infirm; prevention of illness, promotion of wellness, and health maintenance in others under the direction of a registered nurse, or a licensed provider: physician, osteopathic physician, podiatric physician, or dentist; and the teaching of general health principles and wellness to the public and to students other than nursing students. A practical nurse is responsible and accountable for making decisions that are based upon their educational preparation and experience in the profession (2). 

    6. Practice of professional nursingthe performance of actions requiring substantial specialized knowledge, judgment, and nursing skill based on applied principles of physical, psychological, social, and biological sciences which shall include, but are not limited to (2): 

    • The nursing process consisting of assessment, nursing diagnosis, planning, intervention, and evaluation, of care; teaching and counseling of the ill, injured, or infirm in matters of health; prevention of illness, promotion of wellness, and maintenance of health of others. 
    • The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner as they are authorized to do so by the laws of this state to prescribe such medications and treatments. 
    • The management and education of other individuals in the theory and performance of any of the acts described above such as nursing students. 

    A professional nurse is responsible and accountable for making decisions that are based upon the individual’s educational preparation and experience (2). 

    7. Registered nurse (RN)means any person licensed in this state or holding an active multistate license under s. 464.0095 to practice professional nursing as defined above (2) 

    8. Registered nurse first assistant (RNFA) — means a registered nurse who assists in surgery while in the hospital setting under a physician. They help maintain cost-effective and quality surgery for patients in the state of Florida. They must be certified in perioperative nursing via core curriculum approved by the Association of Operating Room Nurses, Inc. (2). 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What license do you currently hold? 
    2. Have you held another license in the past?  
    3. What types of other licensed providers do you work with? 
    4. What specifics of Florida laws and regulations pertain to your area of licensure?

    Board of Nursing: Members and Headquarters Location 

    Thirteen members sit on the Board of Nursing in Florida with their headquarters located in Tallahassee. These members are approved by the Governor of the state and consist of a diverse group of individuals. Seven of these members are RNs who have been practicing for a minimum of four years. One of these seven must be an APRN, a nurse educator from an approved program, and a nurse executive. Three of the total membership should be LPNs with a minimum of four years of practice, just as the RNs. The remaining three members are individuals who have no connection to the nursing profession and are not affiliated or contracted with a health care agency, facility, or insurance company. One member must be 60 years or older. All members of the Board must be residents of the state of Florida. Terms last for a total of 4 years, and at the end of each term the Governor can, but does not have to, appoint a successor to the position (2) 

    The members of the Board have a few duties. Their primary job is to ensure that nurses practicing in the state of Florida are doing so safely. They must ensure that nurses are abiding by Florida laws and regulations.  In order to do this, the Board members can create and implement rules or provisions to the Nurse Practice Act.  They must approve educational programs for institutions wishing to teach nursing. They can take disciplinary action against a nurse for violation of the Nurse Practice Act or other Florida laws and regulations. Citations, fines, or disciplinary guidelines can be issued by the Board as well (2)

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. How many members are on the Florida Board of Nursing?
    2. What does the board have to do regarding Florida laws and regulations?
    3. Who reports to the FL BON?

    Licensure by Examination and Endorsement

    Initial licensure requires an individual take an examination for their desired profession: NCLEX-RN, NCLEX-LPN, and either the American Nurses Credentialing Center (ANCC) or American Association of Nurse Practitioners (AANP) version for those wishing to become an APRN. In order for the Board of Nursing to approve an individual to sit for their desired examination, a list of requirements must be met in full (4) 

    • Must correctly complete an application for the desired examination and submit a fee set by the Board.  
    • Submit to a background check conducted by the Department of Law Enforcement. 
    • Must be in good physical and mental health and is a recipient of a high school diploma or equivalent. 
    • Has completed the following requirements: 
    • Graduate from an approved program on or after July 1, 2009 OR 
    • Graduate from a prelicensure nursing education program that has been determined to be equivalent to an approved program by the Board before July 1, 2009 
    • Must have the ability to communicate effectively in the English language as determined by the Department of Health through another examination. 

     It is important to note that there is a section dedicated to the scenario of it an individual fails the examination or does not take it within six months of graduating.  

    Any individual that does not pass their examination of choice after three attempts must take a Board-approved remediation course before they are allowed to sit for the examination again. From there, they are able to take the test three more times before remediation is required again. Reexamination must be done within six months of taking the approved remediation course (2) 

    If an individual does not take their examination within six months of their graduation, the individual must take an exam preparation course approved by the Board. It is to be advised that the individual must pay for the course without the use of federal or state financial aid (2) 

    Courses successfully completed in a professional nursing education program that are at least equivalent to a practical nursing education program may be used to satisfy the education requirements for licensure as a licensed practical nurse (2). 

    If a nurse holds licensure in another state or US territory decides to obtain Florida licensure can do so through endorsement. The state of Florida requires those who apply to submit a nonrefundable fee, completed application, and fingerprints for a criminal background check. The Florida Board of Nursing will not issue a license to an individual that is under investigation at the time of applying (2).   

     Military Spouses  

    Applying for a license through endorsement is a route that can be used for nurses who are following military spouses on official military orders. Nurses must have actively practiced nursing two of the three years prior to applying for a license. Military spouses also have the option of obtaining a 12-month temporary Florida license if they meet the requirements: holds a valid nursing license in another state, has a negative criminal background check, has not failed their licensure exam, and has not had any disciplinary action taken against them in another state (1). 

    Licensure by Compact 

    Over 30 states in the US have created legislation to allow nurses to work under one multistate license. This means that a nurse who is originally licensed in Florida could work in any other state that participates in the Nurse Licensure Compact without obtaining licensure for each state they wish to work in as long as they have a multistate license. This has proven to be very useful over the years due to the growing nursing shortage and global pandemic.  

    Many states like Florida are offering to provide multistate licenses to nurses during their initial examination. If a nurse does not obtain a multistate license initially, they are able to do so at a later time. They must pay a fee and submit fingerprints for a background check. Nurses must also meet any other requirements set by the state of Florida.  

    It is important to note that in the state of Florida, the nurse who holds the compact license must claim residency in the state. If the nurse were to claim residency in another state, they would no longer have a multistate license.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Do you feel as though Florida’s Board of Nursing has a diverse nursing population? 
    2. Who do you feel should appoint members to the Board? 
    3. What information were you required to provide to the Board of Nursing when you applied to take your exam? 
    4. Have you obtained licensure through endorsement, either it be in Florida or another state? 
    5. Do you think more states should participate in the nursing licensure compact? 

    Delegation to the Unlicensed Assistive Personnel (UAP) or Unlicensed Personnel (UP)

    Delegation is defined by the Nurse Practice Act as the transfer of a task or activity during a specific situation by a qualified nurse, through licensure and experience in the task, to a competent individual. Different facilities may have various ways of determining the competence of the individuals, but ultimately the decision rests with the RN or LPN. The licensed provider must determine the difficulty of the task, the potential for predictable or unpredictable harm or rapid change in patient condition, and level of communication required with the patient. They must also consider resources available and skills the UAP at their facility is allowed to do (4)  

    When delegating, it is important to assess the UAP’s skill set through validation or verification. The nurse should provide clear communication when it comes to the task delegated and explain the desired outcomes. They should also explain what undesired outcomes could occur, what should be done if an undesired outcome does happen when the task should be completed, and if supervision is required. The nurse should follow up to ensure that the task was done correctly and within the set time frame. The nurse should be aware that the delegated task and any outcomes of the task are the nurse’s responsibility, and they are ultimately held accountable for it. So, if it’s an important task, it may be better to do it yourself (4)  

    There are a few skills that cannot be delegated to the UAP: 

    • A skill that is not within the delegating nurse’s scope of practice  
    • Activities that require the use of the nursing process or require specific education, nursing judgement, training, or skills. 
    • Initial assessments and progress evaluation as it relates to the patient’s plan of care. 
    • Skills that an UAP has not displayed competence.  
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. When is it appropriate to have a UAP do a task?

    IV Administration by LPNs

    As mentioned above, LPNs and RNs have a few differences in their scopes of practice. LPNs are able to administer and perform some parts of IV medication therapy as opposed to the RN. The definition of IV therapy administration is defined as the infusion or injection of a medication via the intravenous system. This method involves several aspects including: evaluating, observing, monitoring, discontinuing, titrating, management, planning, documenting, and intervening as needed during the administration. RNs do not always have to be onsite when delegating IV administration to an LPN but is important to know policies and when an RN must be present (4) 

     LPNs cannot do any of the following (4): 

    • Initiate blood or blood products or plasma extenders. 
    • Mix IV solutions. 
    • Administer or initiate cancer treatments such as chemotherapy or investigational medications. 
    • IV pushes with the exceptions of heparin or saline flushes. 

     Note that LPNs may care for patients receiving these types of therapies, such as a patient who is actively receiving a blood transfusion, but they cannot do the above aspects.  

     LPNs are able to (4):

    • Calculate and adjust flow rates. 
    • Observe and report any signs of adverse effects of IV medications. 
    • Assess IV insertion sites and change dressings as educated and needed. 
    • Remove IV catheters or needles from peripheral veins. 
    • Hang IV hydrating fluids. 

    In order for an LPN to administer IV medications through a central line Florida laws and regulations dictate they must do so under the direction of a RN and have four hours of IV therapy education on central lines. This four-hour requirement can be applied to the 30 total hours LPNs must do on IV therapy (4)

    LPN Supervision in Nursing Homes

    According to Florida law LPNs are able to supervise other LPNs, certified nursing assistant (CNAs) or UAPs in the nursing home setting. In order to be considered for a supervisory position, the LPN must have completed 30 hours of Board approved, post-basic education courses under the supervision of a RN. The LPN must also have at least six months of full-time clinical experience either in a hospital or nursing home setting. If the LPN takes a course outside of the Board’s approval courses, the provider of said course must test the LPN and provide attestation of the LPN’s competency (4) 

    The supervisory LPN’s role is to provide other LPNs, CNAs, and UPAs with guidance and inspection of their completed task as their pertain to their appropriate scope of practice. The LPN can only delegate tasks within their scope of practice and be assured that the one they are delegating to demonstrates competency (4). 

    Certified Nursing Assistant (CNA)

    The certified nursing assistant is similar to the UAP but in order to be certified they must have competed a background check conducted by the Board of Nursing, prove they are able to read and write, and pass the nursing assistant examination. Once the criteria listed has been met, CNAs can provide general care and assist with activities of daily living under the direction of a RN or LPN. They can also participate in postmortem care and perform CPR.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Think of your facility. What types of UAPs do you have? CNAs, Patient Care Technicians (PCTs)? 
    2. Are you aware of what Florida laws and regulations say you can and can’t delegate to them? 
    3. Are there any LPNs where you work? 
    4. What are they able to do, and what types of patients are the able to take care of? 

    Maintaining Medical Records

    For RNs and APRNs in private practice the Florida Nurse Practice Act has two rules in place when it comes to maintaining medical records. The first applies to the death of the nurse. Whoever legally represents the RN or APRN must post a notification in the county newspaper stating where the medical records are being stored and who to contact if an individual would like to obtain the records. The records must be stored for at a minimum of two years after the death of the nurse (4) 

    At the 24-month mark, there must be several notices posted in the county newspaper, one notification for four consecutive weeks, that the medical records will be destroyed four weeks after the last day of the fourth week that the notice was published (4) 

    The second rule pertains to an RN or APRN that has terminated or relocated their practice. The rule states that the RN or APRN maintain and hold on to the medical records for a minimum of two years. They must let those that were patients know about the date of termination or relocation and where the medical records can be retrieved. The notice must be made public, such as in a newspaper, with a minimum appearance of four times over four weeks. A sign must be placed at the location of the business about the termination or relocation until the termination or relocation happens. This sign must tell patients about the opportunity to obtain their medical records (4). 

    Continuing Education (CE) Requirements

    Florida laws and regulations require that for renewal of a nursing license, the nurse seeking renewal must complete a set amount of CE hours. Over the two-year period, 24 hours must be completed, one for each month. Two of those hours must be on the Florida Nurse Practice Act and the other laws that pertain to the nursing profession. Two hours are required on medication errors and how to prevent them. A one-hour HIV/AIDS is required for initial renewal but does not have to be repeated. There must be a two-hour course on domestic violence done every third renewal. As of August 2017, a two-hour course on recognizing impairment in the workplace is required with each renewal (4).  

    In the state of Florida, completed CE courses are either automatically reported to a tracking system created by the Department of Health’s Division of Medical Quality and Assurance (MQA) or by the individual manually. Those who attend CE courses will obtain a certificate of attendance. It is advised that the attendee maintain a copy of those certificates for four years or more. For Florida, the provider of the course has 90 days to report to the tracking system, so if the date to renew is less than 90 days, it is suggested that the course be manually reported (4). 

    If a nurse has two licenses, such as RN and LPN or APRN and RN, they may be able to comply with both license requirements through one set of CE requirements. For example, an RN who holds an LPN license can meet all of the LPN license CE requirements by completing the RN requirements (4). 

    Nurses who serve as expert witnesses and provide expert opinions in a written format can obtain 2.5 hours for each case according to Florida laws and regulations. The case must cite at least two current articles of reference and are being reviewed in regard to the Nurse Practice Act (4). 

    There are a few exemptions to the CE renewal requirements (1):  

    • If the nurse is on active duty for the US military within six months of the renewal date. 
    • This does not apply to short periods of active duty such as summer or weekend drills. 
    • This does not apply to those on duty in the US Public Health Service. 
    • If the nurse’s spouse is a member of the US military and the nurse was absent from the state of Florida because of military duty. 
    • The nurse must provide adequate proof of the absence and the military status of their spouse. 
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What types of classes do you take to complete your continuing education? Online, in-person, webinar? 
    2. What Florida mandated classes do you have the hardest time obtaining? 
    3. Do you hold licenses in two aspects of nursing, such as LPN and RN, or RN and APRN? 
    4. If so how do you complete your continuing education requirements for both? 

    Disciplinary Action 

     The Florida Board of Nursing, as outlined in the Nurse Practice Act, holds power to discipline nurses as they see fit in regard to the violations of Florida laws and regulations. The Board created a variety of ways a nurse can be disciplined, ranging from probable-cause panels to citations to disciplinary hearings. The severity of the violation reflects on which method the Board of Nursing may take (2). 

    There are three probable-cause panels in Florida: North Florida, Central Florida, and South Florida. The purpose of these panels is to determine if there was “probable cause” or reasonable ground for the reported case. Essentially they decide if a case needs action taken when Florida laws and regulations are not followed. The members of the panel review each case and compare it to others of similar nature, how the Board treated the cases in the past, and what the Board’s guidelines entail. The panel can recommend and consider rules regarding procedures, penalties, and disciplinary actions.  

    Citations can be given in lieu of other forms of discipline. The citation is issued within six months of a complaint being filed and contains the request for the recipient to fix the violation within a specified time frame. These violations are usually classified as “minor” in nature, such as false advertising, falsely using a nursing title, or failure to report the change of address or updates of information required by the Board. Other reasons a citation can be issued are a failure to report a misdemeanor within 30 days of a ruling or failing to utilize the law-required prescription drug monitoring system. Each of these citations can come with a fine, usually ranging from $100 to $250 in amount; however, if a nurse is found guilty of sharing passwords, codes, keys, or other forms of entry to a secure medication administration or information technology system a fine of $1,500 can be given. In addition, the nurse would have to take a two-hour CE course on legal nursing aspects within 60 days of the citation being issued.  

    The Board of Nursing has the power to take appropriate action against nurses that confirmed violation of Florida laws and regulations or of the Nurse Practice Act (2): 

    • Probation, suspension, or revocation of a license 
    • Can be emergently done depending on the situation.  
    • Require CE course(s) to be done. 
    • Letter of concern 
    • Reprimand 
    • Give a fine 
    • Require a personal appearance in front of the Board of Nursing to monitor compliance. 
    • Restricting or limiting practice 
    • Referral to the Intervention Project for Nurses (IPN) 

    Any of these actions can be combined, depending on the severity of the violation. They can also accompany a fine determined by the Board (2) 

    The Board of Nursing has also created an extensive list of reasons why a nurse can be disciplined (2): 

    • Sexual misconduct 
    • Unprofessional conduct 
    • Participating in crime related to healthcare fraud. 
    • Making or filing a false report to appease state or federal law. 
    • Willfully hindering another individual in filing a report that is required by state or federal law. 
    • Testing positive on any drug screen when the individual has no medical/other reason for using the drug. 
    • Inability to practice nursing with satisfactory skill and provide safe patient care due to use of narcotics, drugs, alcohol, chemicals, or other substances that may impair an individual 
    • Inability to practice nursing with satisfactory skill and provide safe patient care due to an illness, physical or mental condition. 
    • Failing to meet minimal standards of acceptable nursing practice. 
    • Accepting and performing professional responsibilities the nurse knows or has reason to know they are not skilled to perform. 
    • Delegating or contracting for the performance of professional responsibilities by a person who the nurse knows or has reason to know is not qualified by training, experience, and authorization required to perform. 
    • Failing to identify the type of license the nurse is practicing under through written (can include a nametag) or oral notice to a patient. 
    • Performing or attempting to perform healthcare services on the wrong-site or wrong procedure on the wrong patient. This includes unauthorized procedures.  
    • Performing or attempting to perform healthcare services that are medically unnecessary or otherwise not related to the patient’s diagnosis or medical condition(s). 
    • Being convicted or found guilty of or pleading nolo contendere to a crime in any jurisdiction that directly relates to the practice of nursing or ability to practice nursing. 
    • Being convicted of or found guilty of, or pleading nolo contendere to misdemeanors, related to failure to protect an adult from abuse, neglect, and exploitation; fraudulent practices; theft and robbery; or having committed an act of domestic violence or child abuse. 
    • Defaulting on a student loan that has been issued or guaranteed by the state or federal government.  

    As with everything in life, the Board of Nursing has created guidelines for imposing discipline. They have a set minimum and maximum amount when it comes to fines. They have time frames for probation or supervision, conditions regarding probation or the reinstatement of a license. What route they decide to take depends upon the specific case being presented to them. Sometimes the circumstances presented to the Board are enough to elicit decisions that are outside the general guidelines. Some of these circumstances are (2): 

    • Length of time a nurse has practiced. 
    • Presents a danger to the public. 
    • Any visible effort at rehabilitation. 
    • Treatment and disciplinary hearing costs. 
    • Actual physical or other forms of damage caused by the nurse. 
    • Financial hardships. 

    The Board has a timeframe in which a complaint must be filled. Most of the time, it’s within a six-year window from the time the incident occurred. However, in certain circumstances—criminal actions, sexual misconduct, impairment of the nurse, or usage/diversion of controlled medications—the Board may go beyond the six-year timeframe. If action such as fraud, intentional misrepresentation, or concealment is utilized to hide the violation during the six-year period, the timeframe to file a complaint can be extended to 12 years from when the incident initially occurred (2) All is dependent on the severity and complexity of failure to follow Florida laws and regulations delegated.  

     If the Board of Nursing suspends a nurse’s license, or if the nurse agrees to have the licenses suspended to avoid further action against them, the nurse can file a petition to possibly have their license reinstated. Any final orders or terms issued during the initial suspension must be met in whole, and the nurse must be able to demonstrate the ability to perform nursing practice safely. Sometimes a time frame is placed for when a nurse can file a petition; sometimes, there is not. If this is the case, then a nurse can appeal as soon as they are able to do so after meeting the terms and conditions given to them by the Board (2) 

    The Board will determine what a nurse has to do in order to demonstrate safe practice. This is based on the violation. For example, a nurse who is working while under the influence of medications or alcohol may be ordered to attend a treatment program with proof of sobriety, references, and completion of any court-mandated sanctions. Nurses are often required to present to the Board of Nursing in person and speak on their ability to safely practice nursing (2) 

    The three-strike policy is utilized when it comes to reinstating a license. If a nurse has been found guilty on three separate occasions of a complaint pertaining to drug/narcotic usage or the diversion of medications from patients to the nurse for personal use or to sell, the Board will not reinstate the license (2) 

    Relicensing a nurse who has had their license revoked is similar to what happens when a license is suspended. However, the nurse must reapply for the license and meet all conditions set by the Board. Nurses may have to sit for another examination or take Board approved continuing education if the nurse has been out of practice for an extended period of time. They may require a nurse to participate in Florida’s Intervention Project for Nurses (IPN) program or at least be evaluated for it (2)  

    Nurses are held accountable for reporting the actions of other nurses and any misconduct to the Board of Nursing. They must document and report failure to follow Florida nursing and regulations.  They must report sexual misconduct or healthcare fraud. If they know or have reason to believe that another nurse is not practicing safely or is practicing under the influence of alcohol or medications, they are required to report it. 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Do you know anyone who has had action taken against them regarding the Nurse Practice Act? 
    2. If so do you know the outcome? 
    3. What are some other violations that you think might violate the Nurse Practice Act? 
    4. What do you think is the most severe violation? 
    5. Do you think that the Board of Nursing’s list of potential actions that could be taken against a nurse’s license is fair? 
    6. If you were on the Board what types of disciplinary action would you recommend when someone does not follow Florida laws and regulations? 

    Florida’s Intervention Project for Nurses (IPN)

    Created in 1983 under the authority of the Nurse Practice Act, IPN was designed to protect the public through monitoring nurses whose skills have been compromised due to improper use of medications or alcohol or the impairment of mental of physical health. IPN is not a treatment center. Instead, they provide nurses with access to Board-approved practitioners who specialize in addiction, mental health, and other medical conditions. They also conduct monitoring after a nurse has been discharged from treatment, interventional training, consultations, and advocacy for those who participate (3).  

     As mentioned above, nurses have an obligation to report themselves or nurses who are or they have reason to believe are unsafely practicing nursing while under the influence of alcohol or medications. If a nurse self-reports or is reported to the IPN only and they successfully complete treatment and five-year monitoring, the report is confidential. If the Board of Nursing becomes involved, either through a failure to report or failure to complete treatment, disciplinary action may be taken (3) 

    Initially, nurses are not able to practice during the initial evaluation and when the determination of treatment is being made. After that, it is up to the discretion of the IPN and the providers involved in the treatment. Restrictions on a nurse’s practice are often implemented during the beginning phase of treatment (3) 

    In order to be determined “fit to practice”, the nurse must meet all requirements set by their providers and the IPN. They must sign an advocacy contract, submit to random drug tests, verbalize understanding any practice restrictions, and be involved in a weekly support group for nurses (3). 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Do you think the IPN should be a treatment center as opposed to a resource center? 
    2. Should the status of a nurse who has enrolled in this program, willingly or not, be confidential, even if they do not meet the requirements stated in Florida laws and regulations? 
    3. Do you think a nurse should be allowed to practice nursing with set limitations while involved with IPN? 

    Summary

    Despite the extensive outline of the Nurse Practice Act and other Florida laws and regulations provided in this course, it does not provide a complete narration of all Florida rules and/or laws pertaining to nurses. In addition to this course, it is imperative for nurses to stay on top of new legislation being proposed and put into effect regarding their profession and continually review the content in the state laws. Nurses who travel to other states to practice their profession should be educated on each state’s rules regarding nursing practice as it can differ from state to state. A conscious effort should be made to follow Florida laws and regulations set in place in order to practice safely and legally in the state of Florida.  

    Florida Medical Errors Prevention

    This fulfills the continuing education requirement for Medication Errors Prevention for the state of Florida.  

    For as long as there have been medical professionals, there have been medical errors.  Medical errors can be small and seemingly insignificant to a catastrophic sentinel event.    

    The Joint Commission (TJC) is a healthcare accrediting agency that sets the standard for patient safety.  Each year, TJC publishes a list of national patient safety goals.  These goals are focused on the prevention of medical errors.  In 2019, the World Health Organization (WHO) found that medical errors harmed up to 40% of patients within the global healthcare system.  These medical errors not only cause harm to millions of people worldwide, but they also cost billions of dollars on an annual basis (8). 

    There are many different types of medical errors.  They include, but are not limited to: medication errors, healthcare-acquired infections, surgical errors, lab errors, falls, documentation issues, and omitted care.  Healthcare workers must be aware of the possible harm that can be caused by medical errors and the ways in which they can be prevented.   

    Introduction   

    For as long as there have been medical professionals, there have been medical errors.  Medical errors can be small and seemingly insignificant to a catastrophic sentinel event.    

    The Joint Commission (TJC) is a healthcare accrediting agency that sets the standard for patient safety.  Each year, TJC publishes a list of national patient safety goals.  These goals are focused on the prevention of medical errors.  In 2019, the World Health Organization (WHO) found that medical errors harmed up to 40% of patients within the global healthcare system.  These medical errors not only cause harm to millions of people worldwide, but they also cost billions of dollars on an annual basis (8).

    There are many different types of medical errors.  They include, but are not limited to: medication errors, healthcare-acquired infections, surgical errors, lab errors, falls, documentation issues, and omitted careHealthcare workers must know the possible harm caused by medical errors and how they can be prevented.   

    Quiz Questions

    Self Quiz

    Ask yourself...

    1.  What prior knowledge do you have concerning errors in the medical field?

    Factors That Impact the Occurrence of Medical Errors 

    There are multiple factors that can increase the probability of a medical error occurring.  Healthcare worker behaviors and attitudes, staffing, and communication are among those that have the most significant impact on medical errors. 

    In healthcare, a risky behavior is an action that may lead to a compromise in patient safety.  Why would any healthcare worker engage in at-risk behaviors?   Healthcare workers, especially nurses, are generally compassionate and are ultimately looking out for the patients' welfare in their care.  Risky behaviors produce a quick, positive reward without any perceived risk of patient harm.  These risky behaviors can range from a simple short-cut like not checking two patient identifiers to a blatant disregard for hospital/facility policy.  In all instances, the risk for patient harm is real and will eventually occur (13). 

    Understaffing in the hospital setting continues to be a factor contributing to medical errors.  Poor nurse-to-patient ratios can lead to a variety of medical errors.  Ordered patient care may go undone, leading to further medical errors adverse patient outcomes (7).  Understaffing leads to fatigue and burnout.  A nurse in this state of mind is prone to committing medical errors. 

    Miscommunication between healthcare professionals and patients and miscommunication between healthcare professionals also contribute to the occurrence of medical errors.  As part of their national patient safety goals, TJC has had a communication component almost every year.  They have recognized that effective communication is paramount in the prevention of medical errors.  A lack of effective communication can be a leading cause of every type of medical error. 

    In an effort to decrease communication errors, TJC has taken measures to ensure that effective communication is promoted in a variety of different situations.  TJC has instituted a list of unacceptable medical abbreviationsThis list will decrease medication errors by removing confusion when medications are ordered (11).  They also developed a handoff communication protocol for facilities to implement.  The handoff communication occurs anytime that care is passed from one caregiver to another.  In Florida medical errors prevention, this communication protocol is used to ensure that all pertinent patient information is passed on to the next healthcare worker rendering care to the patient.  By using effective handoff communication, all information should be passed on, and mistakes should be avoided (10).  

    Quiz Questions

    Self Quiz

    Ask yourself...

    1.  Have I ever participated in at-risk behavior at my facility? 
    2. Did this contribute to the occurrence of a medical error? 
    3. Is my unit staffed appropriately? 
    4. Do healthcare professionals in my facility use an appropriate hand-off communication tool?   
    5. In Florida medical errors prevention, what communication tool can be used between healthcare professionals?

    Recognizing Error-Prone Situations 

     Studies have shown that the majority of medical errors occur in the inpatient setting.  The most common areas for medical errors are the operating room (OR), the emergency room (ER), the intensive care unit (ICU), and the medical/surgical floors (1).   

    What is it about the inpatient setting that makes it such an error-prone area?  More specifically, why do medical errors occur in the ICU, OR, and ER?  These are all high-stress areas where effective communication between all parties is vital.  Breakdown in communication in these areas will lead to catastrophic medical errors.  When the stress level rises, the probability of medical errors occurring also rises.  These are also fast-paced areas where the condition can change in the blink of an eye.  When we work in such a busy area, we can forget important details.  Effective communication is a big part of Florida medical errors prevention.  Miscommunication in these environments is a recipe for medical errors.  

    As the most common type of medical errors is medication errors, we do need to talk about medication administration.  Nurses are taught the five rights of medication administration in nursing school:  

    1. Right drug. 
    2. Right patient. 
    3. Right dose. 
    4. Right route. 
    5. Right time. 

    When working in a busy inpatient setting, nurses may fail to perform the five rights in order to save time (5).  Neglecting any one of the five rights of medication administration can cause a medical error.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Do I work in an error-prone environment? 
    2. What makes the area error-prone? 
    3. Why is communication so integral to Florida medical errors prevention?
    4. What can I do to decrease stress levels on the job? 

    Processes to Improve Patient Outcomes 

    In the technological age in which we live, it is more important than ever before that healthcare facilities consistently demonstrate good patient outcomes.  The Centers for Medicare & Medicaid Services (CMS) places great importance on the patient experience and their perception of their healthcare experience qualityEvery patient who experiences a hospital stay may be asked to complete a Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveyThe survey results are published quarterly on the CMS Hospital Compare website.  There, patients can compare the hospital's results and choose a hospital where they would like to have their care rendered (4).  A medical error could very well cause a patient to give a facility a poor rating on the HCAHPS survey. That is why we must take Florida medical errors prevention seriously.

    When medical errors have occurred, they will often result in a risk management response to investigate why the error has happened and how it can be prevented in the future a root cause analysis (RCA)An RCA will often lead to department-driven performance improvement projects (PIP) to eradicate the problem and improve patient outcomesA proactive facility trying to minimize medical errors will have multiple department and facility-wide PIP. 

    As previously stated, each year TJC publishes a list of patient safety goals.  These goals will often guide a facility on specific patient outcomes that have required attention for improvement on a national level.  They focus on the prevention of medical errors, and as such, they can steer PIPAccreditation hinges on the ability of a facility to improve and consistently deliver positive patient outcomes.  Below is the current list of TJC's patient Safety Goals: 

    1. Identify patients correctly.

    Use at least two ways to identify patients. For example, use the patient's name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.

     

    2. Improve staff communication.

    Get important test results to the right staff person on time.

     

    3. Use medicines safely.

    Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups, and basins. Do this in the area where medicines and supplies are set up. 

     

    Take extra care with patients who take medicines to thin their blood. 

    Record and pass along correct information about a patient's medicines.

    Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient.

    Give the patient written information about the medicines they need to take. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.

    4. Use alarms safely.

    Make improvements to ensure that alarms on medical equipment are heard and responded to on time.

    5. Prevent infection.

    Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.

    6. Identify patient safety risks.

    Reduce the risk for suicide.

    7. Prevent mistakes in surgery. 

    Make sure that the correct surgery is done on the correct patient and at the correct place on the patient's body. 

    Mark the correct place on the patient's body where the surgery is to be done. 

    Pause before the surgery to make sure that a mistake is not being made.

    (12)

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What are some PIP in my department?  
    2. What are some PIP in my facility? 
    3. What are some overal PIP in Florida medical errors prevention, that affect all state level facilities?
    4. What are the current JCM National Patient Safety Goals? 

    Responsibilities for Reporting as a Part of Florida Medical Errors Prevention

     

    Each individual facility across the nation may have different policies and procedures for the reporting of medical errors within their facilities.  There is, however, a growing trend throughout the healthcare industry of creating a culture of safety.  The culture of safety promotes the reporting of medical errors and "near misses" in an open, transparent and non-punitive manner.  Facilities are taking a stand to ensure patient and staff safety over other competing goals within their system (14)Near miss reporting allows for issues to be addressed and corrected before an actual error occurs.  Taking a non-punitive approach to self-reporting of medical errors promotes accurate reporting and allows for a true picture of what is happening in the facility. 

    The State of Florida has mandated that all licensed healthcare facilities implement an internal risk management program.  In Florida medical errors prevention, it is the responsibility of the risk management team to: 

    1. Investigate and analyze the frequency and cause of general and specific types of patient adverse incidents. 
    2. Develop measures to minimize the risk of adverse incidents. 
    3. Analyze patient grievances that relate to care and quality of services. 
    4. The development and implementation of an incident reporting system. 

    State law further requires that the Agency for Healthcare Administration (AHCA) post quarterly reports on adverse incidents (9). 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. How do I report a medical error in my facility? 
    2. Who is the Risk Manager in my facility? 
    3. Do I work in a culture of safety? 
    4. How do I play a role in Florida medical errors prevention?

    Safety Needs of Special Populations 

    There are certain groups of people that are especially vulnerable to experience a medical error.   

    Elderly 

    The elderly are especially susceptible to medical errors.  Generally, as we get older, we tend to start taking more medications.  Complex medication regimens offer a greater opportunity for medication errors.  Many medications require close monitoring of vital signs and/or blood levels.  Drug-related issues are a major driving force for both ER visits and nursing home admissions among the elderly (3)Declining cognition, poor vision, and increased forgetfulness associated with aging can also play a part in medication errors.  Education with frequent reinforcement and the use of support people are crucial to help prevent medication errors.   

    The elderly are also at a higher risk for falls.  Falls within a medical facility can lead to further medical complications, increased length of stay, and serious injury.  Patients at risk for falls need to be identified and place on a fall prevention protocol. 

     Children 

     Children are on the other side of the spectrum and are also another group that are at higher risk for medical errors.  Younger children may be unable to accurately voice exactly their problem is, or what symptoms they are experiencing.  They must rely on both parents and other caregivers for the coordination of their care.  Though a parent may know their child well, they may not be able to properly convey their child's issues to the healthcare professional.  It is also important to realize that children are not little adults.  Care plans must be catered to their specific phase of life. 

    Limited Health Literacy/Education

    Another population that is vulnerable to medical errors are patients with limited health care literacy or education.  These patients may have difficulty obtaining, retaining, and implementing health information to make proper decisions for their healthcare needs.  Populations within this group may include the elderly, low-income populations, immigrants, and minorities.  There is also a strong correlation between limited health literacy and the uninsured, undereducated, and unemployed populations.  It is important that information be presented to this group at a level that they can understand.  The use of interpreters can also be helpful if the patient does not have a good grasp of the English language (6). 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What is the level of health literacy in the community where I live? 
    2. What population to I work with on a daily basis?   
    3. Do I present information to them at a level that they can understand? 

    Public Education 

    Now, more than ever before, the general public has greater access to information of all sorts.  This includes access to health information, specifically, patient outcomes.  The public is able to make informed decisions on where they would like to be cared for by comparing healthcare facilities.   

    The public is seeking information not only on which facility is the safest with the best outcomes but also on ways that they can actively prevent medical errors from happening to them.  There are many resources that patients can find online to help them recognize scenarios that may place them at risk for the occurrence of medical errors.  The Agency for Healthcare Research and Quality (AHRQ) has published a list of 20 tips patients can use to help prevent medical errors: 

    Medicines 

    1.    Make sure that all of your doctors know about every medicine you are taking.
    This includes prescription and over-the-counter medicines and dietary supplements, such as vitamins and herbs. 

    2.    Bring all of your medicines and supplements to your doctor visits.
    "Brown bagging" your medicines can help you and your doctor talk about them and find out if there are any problems. It can also help your doctor keep your records up to date and help you get better quality care. 

    3.    Make sure your doctor knows about any allergies and adverse reactions you have had to medicines.
    This can help you to avoid getting a medicine that could harm you. 

    4.    When your doctor writes a prescription for you, make sure you can read it.
    If you cannot read your doctor's handwriting, your pharmacist might not be able to either. 

    5.    Ask for information about your medicines in terms you can understand—both when your medicines are prescribed and when you get them: 

    • What is the medicine for? 
    • How am I supposed to take it, and for how long? 
    • What side effects are likely? What do I do if they occur? 
    • Is this medicine safe to take with other medicines or dietary supplements I am taking? 
    • What food, drink, or activities should I avoid while taking this medicine? 

    6.    When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed? 

    7.    If you have any questions about the directions on your medicine labels, ask.
    Medicine labels can be hard to understand. For example, ask if "four times daily" means taking a dose every 6 hours around the clock or just during regular waking hours. 

    8.    Ask your pharmacist for the best device to measure your liquid medicine.
    For example, many people use household teaspoons, which often do not hold a true teaspoon of liquid. Special devices, like marked syringes, help people measure the right dose. 

    9.    Ask for written information about the side effects your medicine could cause.
    If you know what might happen, you will be better prepared if it does or if something unexpected happens. 

    Hospital Stays 

    10. If you are in a hospital, consider asking all health care workers who will touch you whether they have washed their hands.
    Handwashing can prevent the spread of infections in hospitals. 

    11. When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will follow at home.
    This includes learning about your new medicines, making sure you know when to schedule follow-up appointments, and finding out when you can get back to your regular activities.
    It is important to know whether or not you should keep taking the medicines you were taking before your hospital stay. Getting clear instructions may help prevent an unexpected return trip to the hospital. 

    Surgery 

    12. If you are having surgery, make sure that you, your doctor, and your surgeon all agree on exactly what will be done.
    Having surgery at the wrong site (for example, operating on the left knee instead of the right) is rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. Surgeons are expected to sign their initials directly on the site to be operated on before the surgery. 

    13. If you have a choice, choose a hospital where many patients have had the procedure or surgery you need.
    Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition. 

    Other Steps in Florida Medical Errors Prevention

    14. Speak up if you have questions or concerns.
    You have a right to question anyone who is involved with your care. 

    15. Make sure that someone, such as your primary care doctor, coordinates your care.
    This is especially important if you have any health problems or are in the hospital. 

    16. Make sure that all your doctors have your important health information.
    Do not assume that everyone has all the information they need. 

    17. Ask a family member or friend to go to appointments with you.
    Even if you do not need help now, you might need it later. 

    18. Know that "more" is not always better.
    It is a good idea to find out why a test or treatment is needed and how it can help you. You could be better off without it. 

    19. If you have a test, do not assume that no news is good news.
    Ask how and when you will get the results. 

    20. Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources.
    For example, treatment options based on the latest scientific evidence are available from the Effective Health Care Web site. Ask your doctor if your treatment is based on the latest evidence (2). 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What education do I provide to my patients vis a vis medical errors? 
    2. Have I ever researched a facility prior to using their services? 

    Case Studies 

    Mr. Smith is a 68-year-old male with diabetes type 2, hypertension, and chronic renal failure stage 4.  He takes both long-acting and short-acting insulin for his diabetes and a beta-blocker for his high blood pressure.  He is also taking a diuretic to help regulate his fluids.  Mr. Smith was recently admitted to the hospital for a hypoglycemic event.  Once in the hospital, Mr. Smith expressed to his nurse that he has been having difficulty reading his medication labels.  He also confided that he feels dizzy when he stands up and has fallen back onto his bed on more than 1 occasion.   

    After two days, Mr. Smith was ready to be discharged.  The diabetic educator brought him some pamphlets and educated him on proper blood glucose monitoring and insulin administration.  His blood pressure medicines were also changed, and Mr. Smith was given a new prescription to be filled once he left the hospital.  He was alone when discharge instructions were given, and his current medications were not removed from his medicine bag.   

    Two days later, Mr. Smith was readmitted to the hospital with hypoglycemia and hypotension (BP 87/52).

    Exercise

    1. What are some factors that lead to the occurrence of medical errors with Mr. Smith? 

    2. What are the medical errors that occurred? 

    3. What could the nurse/educator have done differently to prevent further medical errors, using steps addressed in this Florida medical errors prevention course? 

    Bernice is a staff nurse working in a busy ICU.  Due to the COVID-19 pandemic, the unit has been short-staffed, with each nurse taking care of 3-4 patients.  This is Bernice's fifth day in a row, working fourteen plus hours.  There have been multiple "code blue" situations in the ICU over the course of Bernice's workweek, some involving her patients.  She was only able to have a full lunch hour on her second day, and she has not been able to sleep much during the night.   

    One of her patients was having severe abdominal pain, 9/10 on the pain scale.  Bernice went in to administer the ordered narcotic and injected the wrong patient. 

    Exercise 

    1. What factors lead to Bernice's medical error? 

    2. What could have been done to prevent the error? 

    3. Is this a situation that could happen in a unit where you work?

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What can you take away from these case studies?

    Conclusion  

    Medical errors are an ongoing problem in the healthcare setting.  They affect patients in all phases of life and come with a large price tag of both money and medical resources.  It is everyone's responsibility to help prevent the occurrence of medical errors.  Though we may not be able to totally eradicate them, we can all play a big part in Florida medical errors prevention by learning from previous mistakes and taking measures to ensure that they do not happen again. 

    Florida Recognizing Impairment in the Workplace

    This fulfills the continuing education requirement of 2 contact hours on Recognizing Impairment in the Workplace for the state of Florida.   

    Up to 20% of nurses in the United States are chemically dependent. Substance use disorders, addictions, drug diversions, and other related impairment processes present a threat to the health and safety of those around them. Increasing in concern are overdoses and deaths that are on the rise due to substance abuse and addiction. Early identification of the signs and symptoms of a substance abuse disorder in the workplace contributes to reducing the risk and harm to patients and other healthcare team members. Co-workers play a crucial role in recognizing and reporting suspicious behaviors to their supervisors or appropriate personnel. 

    Introduction - Florida Recognizing Impairment in the Workplace

    Impairment within the workplace of a healthcare environment is, unfortunately, more common than one may realize. Impairment results when a healthcare professional cannot provide competent and safe patient care because they may be impaired by alcohol, prescription, or non-prescription drugs, or other mind-altering substances (2).  Impairments can also result from a psychological or neurological condition that may affect a person's judgment. Because of impairment, the healthcare professional is unable to perform duties essential to their profession safely. 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What prior knowledge do you have about impairments in the workplace?
    2. Take a moment to think about your experiences with individuals with impairments. How did you respond?

    Acknowledging the Problem 

    Ideally, from a professional standpoint, healthcare personnel should acknowledge their condition and seek help voluntarily without requiring intervention; however, this is often not the case. Co-workers play an important role in helping the impaired person get treatment. Often, the abuser has denial with the condition, the social stigma, or fear of potential job loss. Colleagues are often reluctant to report their co-workers because they feel it is not their responsibility. They feel like the individual they are reporting may be punished excessively. They may believe that someone else has already addressed the issue or fear the loss of their colleague's job or license. Despite these potential reasons, colleagues may have certain legal responsibilities in identifying and reporting. States may have specific reporting laws that could hold colleagues responsible for harm to patients if they fail to report.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Why might someone refuse report an impairment?

    Definitions 

    Substance Use Disorder:  a disease of the brain characterized by the recurrent use of substances such as alcohol and drugs that cause clinical and functional impairment such as health problems, disability, and failure to meet responsibilities at work or school.  

    The disease involves reward, withdrawal, memory, and motivation and can be classified as mild, moderate or severe depending on the level of impairment (1).  

    Addiction the most severe, chronic stage of substance use disorder. There is a substantial loss of self-control, indicated by compulsive substance use despite the desire to stop using (1). 

    Drug Diversion is the transfer of any substance from the purpose for which it was intended for any illicit use, such as personal use or sale (1). 

    Impairment: is the inability or impending inability to engage safely in professional and daily life activities as a result of physical, mental, or behavior disorders such as substance use, abuse, or addiction (1). 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Have you experienced a co-worker with impairment in the workplace? 
    2.  Have you known of someone you currently work with or have worked with in the past that has had an issue with drug diversion or addiction related to their profession? Was there legal action taken? 
    3.  What is the difference between addiction and drug diversion? 
    4.  What are different ways that drug diversion can be used for? 
    5.  Can you as a healthcare worker be held responsible for failure to report impairment of a co-worker in the workplace? 

    Impairment Behaviors in the Workplace  

    Some behaviors are associated with emotional problems but are specific to alcohol or other drug abuse. Some signs common to alcohol and other drugs may also be signs of psychological or psychiatric conditions (2). Each situation is individualistic to the person. Health care professionals must be educated appropriately regarding the signs and symptoms of chemical dependence. The workplace is often the last place that addiction may manifest; disruptions in family, personal health, and social life can happen while the workplace remains unaffected.

    Behaviors Associated with Substance Abuse

    • Severe mood swings/personality changes 
    • Frequent or unexplained tardiness, work absence, illness, or physical complaint 
    • Elaborate excuses 
    • Under-performance 
    • Difficulty with authority 
    • Poorly explained errors, accident, or injury 
    • Confusion, memory loss, difficulty concentrating 
    • Visibly intoxicated 
    • Refuses drug testing 

    Signs Associated with Substance Abuse

    • Unreliability in keeping appointments and meetings 
    • Trouble with relationships (professional familial, marital) 
    • Physical indications such as track marks or bloodshot eyes 
    • Signs indicative of drug diversion 
    • Deterioration in personal appearance 
    • Significant weight loss or gain 
    • Discovered comatose or dead 

    Signs and Behaviors Associated to Drug Diversion Specific to Anesthesia Personnel (1) 

    • Consistently uses more drugs for cases than colleagues. 
    • Frequent volunteering to administer narcotics, relieve colleagues for casework
    • Heavy wastage of drugs 
    • Frequent trips to the restroom or breaks 
    • Drugs and syringes in pockets 
    • Anesthesia record does not match up with drug dispensed and administered to patient 
    • Patient has unusually significant or uncontrolled pain after anesthesia.
    • The patient has a higher pain score as compared to other anesthesia providers. 
    • Times of cases do not correlate when provider dispenses drug from automated dispenser 
    • Inappropriate drug choices and doses for patients are made by the provider 
    • Missing medications or prescription pads 

    Substances such as opioids (e.g., morphine and fentanyl), inhalational anesthetics and volatile agents (e.g., sevoflurane, nitrous oxide), and intravenous anesthetic agents (e.g., propofol) are readily available to many healthcare providers (1). Despite medication dispensing and audit controls in place, drugs can be diverted for misuse. This may happen through the procurement of medicines directly from the pharmacy, automated dispensing units, retrieval from sharps containers of medication remaining in syringes, directly from patient medications, or indirectly through dilution of a medication that appears that nothing is missing from the container (1).

    Regardless of the substance being abused, impairment in the workplace can negatively impact patient and provider safety. Facilities should have policies and education addressing symptom awareness, prevention, and reporting to help minimize the risk of diversion and adverse outcomes. Studies have shown that substance use disorder is a disease of the brain (1). As a responsible healthcare provider, by arming yourself with knowledge and the signs and behaviors of impairment in the workplace, it will prevent further harm. 

    Healthcare providers are usually successful at disguising their issues or potential signs are ignored because they are respected or an intelligent member of the healthcare team. Significant changes in behavior in the workplace may various many causes. If signs of substance abuse and drug diversion are left unrecognized or reported, the user may be placed in danger and patient safety compromised. Impaired health professionals sometimes develop coping mechanisms that allow them to cover up their diminished capacity to provide safe and efficient patient care. Eventually, mistakes are made, including medication and procedural errors that become apparent to their co-workers (3).

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What are some of the signs and behaviors associated with substance abuse? 
    2. What are some examples of substances that can be misused in the healthcare workspace? 
    3. Are you familiar with the systems in place in your institution related to substance abuse, reporting, and addiction? 

    Consequences of Drug Diversion and Substance Use in the Workplace  

    Healthcare providers are responsible for their patients' safety, including their duty to deliver safe and competent care without impairment. Impairment in the workplace can create a disorganized environment (1). The consequences to associate with substance use and drug diversion in the workplace may cause the following consequences for the patient themselves, their colleagues, and the facility in which they are employed. 

    Patient

    • Pain, anxiety, and side effects from improper dosing 
    • Allergic reaction to wrongly substituted drug 
    • Victim of medical errors
      Loss of trust in the healthcare system
      Communicable infection from a contaminated needle (1) 

    Impaired Professional

    • Adverse health effects related to abuse 
    • Chronic health problems (heart disease, liver impairment) 
    • Familial and financial difficulties 
    • Loss of social status 
    • Felony prosecution, incarceration, and civil malpractice 
    • Actions against a professional license 
    • Accidents resulting from physical harm (1) 

     Colleagues

    • Injury or infection from blood-borne pathogens from improperly stored equipment 
    • At risk for shared-patient care responsibilities with an impaired professional resulting in adverse patient outcomes 
    • The stress of increased workload from an impaired healthcare team member 
    • Disciplinary action for false witness of leftover medication, improper disposal, or failure to report (1) 

     Facility   

    • Costly investigation 
    • Civil liability for patient harm 
    • Damaged reputation due to public knowledge of mandatory reporting or drug diversion instances, especially those that led to patient harm 
    • Poor work quality 
    • Loss of revenue from diverted drugs or reimbursement from adverse events due to impaired provider (1) 

    The use of addictive substances over time may result in the deterioration of the healthcare professional's overall health. For example, the use of stimulants may result in cardiovascular problems such as angina, hypertension, and Myocardial Infarction. Alcohol can lead to liver disease, such as cirrhosis. Depression, suicide, and anxiety are mental health disorders that are often coexisting problems with substance abuse. The healthcare workers' impairment can also lead to traumatic injuries such as falls, fractures, and head injuries (1).

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What are some of the adverse health affects that substance abuse can have on a user?  
    2. What are potential detrimental effects that substance abuse of a healthcare professional can have on a patient? Have you experienced any of these in your workplace?

    Florida Rules and Regulations  

    Many states have rules and regulations regarding the use of alcohol and controlled substances that include disciplinary action. Drug diversion is a significant offense that is taken very seriously. Almost every state requires the reporting of a health practitioner who is suspected of impairment in the workplace. The penalties associated with this vary state by state. Florida requires that all nurses take a Florida Recognizing Impairment in the Workplace CE course every other renewal to improve the recognition and outcomes of workplace impairment.

    The state of Florida has an efficient reporting system. Nurses report to the Florida Department of Health or Intervention Project for Nurses (IPN). The IPN’s mission is to enhance public safety by assisting nurses and other nursing related personnel whose practice may have been impaired by substance abuse (4). Their call of the acknowledgment of impairment remains confidential. The Intervention Project for Nurses in Florida allows for an opportunity for intervention and the monitoring of nurses that are using alcohol or controlled substances (4). 

    The IPN after receiving a referral of impairment will:  

    • Initiate a consultation 
    • Provide an intervention 
    • The nurse will be required to stop practicing within 1-3 days-the entire process may take up to 12 months
    • Assist the person in obtaining the appropriate treatment needed
    • Evaluate the progress of the person and the adherence to their treatment plan
    • Continuously monitor the person for 2-5 years
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What does the state of Florida require for impairment reporting?
    2. After receiving an impairment referral, what steps will the IPN take to address the referral?

    Reporting and Intervention  

    Once a nurse or other employee has determined that there is an issue with a coworker regarding impairment in the workplace, an intervention must occur to prevent further harm from happening to patients, themselves, or other co-workers. According to the Intervention Project For Nurses, the co-worker determines that there is sufficient evidence and documentation to support their concerns of the impairment of a health professional, an intervention should be planned (4). The planning and participation related to such intervention is usually the responsibility of the employee's nursing manager. 

    • Intervention process steps: (4)  
    • Prepare a plan 
    • Review documentation 
    • Request help from others 
    • Ask the person to listen to what is said before allowing them to respond 
    • Stick to their job performance 
    • Have evaluator options ready 
    • Expect denial 
    • Report as necessary to the Board
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What are the steps to report impairment in the work place?

    Return to Practice 

    A recovering nurse's return to practice requires planning and oversight by a nursing manager. Once a nurse has been determined that they are safe to return to practice, several things must fall into place. These things include developing a return to practice guidelines for that specific employee, such as returning to work agreement. Experts must also advocate for the employees to return to work, provide support, review expectations, monitor requirements, and answer questions (4).

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Who supervises a nurse's return to work when they are recovering?

    Considerations Of Relapse 

    Substance use is a chronic illness that comes unfortunately with periods of remission and exacerbation. The rate of relapse among nurses is lower than the general population (4). This is due to several factors, such as support programs and stringent state monitoring programs. Despite the fact, some nurses relapse. Knowledge of the management of relapse in the workplace is a crucial part of impairment in the workplace and plays a significant role in the safety of patients and other employees (4).

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. In the state of Florida, who do nurses report impairment to? 
    2. What are some things the Intervention Project for Nurses will do once they have received a referral? 
    3. Can a nurse return to practice after disciplinary action for substance abuse? 

    Conclusion - Florida Recognizing Impairment in the Workplace

    Substance abuse is a chronic and progressive disease. Being able to recognize impairment in the workplace is imperative for the safety of patients, the impaired person, and other co-workers. Impairment can come in many forms. Being knowledgeable of the signs and symptoms as well as reporting responsibilities and policies will not only improve safety but also improve the overall practice environment. Nurses can be very good at picking up subtle clues as to another individual's impairment. Be aware, be knowledgeable, and be supportive. 

    Florida Human Trafficking

    This course meets the Florida Human Trafficking requirement for nurses in the state of Florida.

    Human trafficking is a significant humanitarian issue in the United States and the world that has continued to grow in the past several years despite government and public efforts to combat it. With increasing news coverage of high-profile human and sex trafficking cases, the problem was recently brought into the American public’s eye. However, the results published by the Polaris Project make it evident that human trafficking is not just a problem of the elite or occurring in poorer areas. It is within our own neighborhoods, workplaces, and throughout the State of Florida. 

    For healthcare workers in Florida, human trafficking can be prevented through gaining the knowledge to recognize the warning signs and specific characteristics of a potential trafficking victim; the most effective ways to intervene, which will enable the victims to gain access to help; and where to garner additional support in addressing the issue. 

    Prevalence and Definitions

    The Polaris Project estimates that collectively there are over 25 million victims of human trafficking worldwide. These are individuals that have been forced into sexual or labor servitude. Of those, several hundred thousand are estimated to be in the United States (1). It is very difficult to estimate accurately as so often this is a crime that is unseen and hidden from the public eye. Since 2007, there were  20,415 contacts made concerning human trafficking reported within Florida to the National Human Trafficking Hotline via telephone calls, texts, or online submissions. Of those, there were 6,168 cases of human trafficking with 15,063 victims being identified.These numbers exemplify the number of potential victims that are not reaching out for help. 

    Often, when human trafficking is discussed, a common misconception is that it is simply the transporting of humans. Human trafficking covers a much broader scope than this. It is this a modern age form of slavery and involves the exploitation of individuals for monetary or sexual gain. As stated by the Department of Homeland Security, “Human trafficking involves the use of force, fraud, or coercion to obtain some type of labor or commercial sex act” (3). 

    As defined by U.S. law, there are three categories of human trafficking (all from 1): 

    • Children under the age of 18 induced into commercial sex 
    • Adults (age 18 or over) induced into commercial sex through force, fraud, or coercion 
    • Children and adults induced to perform labor or services through force, fraud, or coercion 

    The majority of trafficking in the United States involves sex crimes, followed by labor.  An increase of rates with 16% for sexual exploitation and 25% for labor was noted in North America during Covid-19 restrictions (4). These crimes may be occurring simultaneously to the same victim. Types of trafficking can include forced prostitution, pornography, strip dancing, criminal enterprise and bonded labor in domestic servitude or migrant work. Outside of street prostitution, sex trafficking is most likely to be occurring in venues such as strip clubs, massage parlors, or other fictitious business fronts for prostitution. A major difference with sex trafficking of minors is that, unlike adults, force, coercion, or fraud does not need to be present for prosecution (6). As there are a number of different avenues for and types of human trafficking, recognition can be challenging. 

     

     

    Risk Factors

    The profile of the human trafficking victim is not easy to define. Victims of human trafficking come from varied backgrounds that may or may not be what is expected or stereotypical. Victims may come from any race, socioeconomic status, color, religion, age, gender, sexual orientation or gender identity, and on. The main commonality is that there is a layer of deception whereby the human trafficker is targeting a vulnerability in the victim. As stated by the Department of Justice, trafficking victims are deceived with “... false promises of love, a good job, or a stable life and are lured into situations where they are made to work in deplorable conditions with little or no pay” (5). There are some trends noted that do make certain populations more at risk, but keep in mind that this does not encompass all potential victims and vigilance should be taken to avoid assumptions. 

    The risk factors for human trafficking are just as varied and dependent upon the type of trafficking and method by which the abuser is able to hold the victim indentured or captive. This figurative prison may be physically, emotionally, or monetarily induced. The Center for Disease Control and Prevention (CDC) lists the following characteristics and factors: 

    • Many victims are women and girls, though men and boys are also impacted. 
    • Victims include all races, ethnicities, sexual orientations, gender identifies, citizens, non-citizens, and income levels. 
    • Victims are trapped and controlled through assault, threat, false promises, perceived sense of protection, isolation, shaming, and debt.           

    Several higher risk populations have been identified through the data gathered from the Polaris Project. It was found that children who were or had been within the foster care system or runaway homeless youth were more likely to encounter sexual victimization. Other factors include substance abuse, recent relocation or migration, unstable housing situations, and underlying mental health disorders (7). 

    As a population that is often overlooked, shamed, or lacks resources, members of the lesbian, gay, bisexual, transgender, queer, or questions (LGBTQ) community are more vulnerable to being subject to human trafficking. Up to 40% of homeless youth are part of the LGBTQ community and may not seek assistance for fear of being shunned (8). 

    Illegal and sponsored immigration remains at a higher risk of trafficking and exploitation. The NHRTC reports a significant number of calls that reference foreign nationals (2). Individuals wishing to become American citizens are lured with the promise of freedom in exchange for large fees that are made impossible to be worked off. While there are laws in place to prevent, this type of servant bondage is forced upon the victims who are in a new country and often lack resources or are unable to seek assistance due to cultural, language, and accessibility barriers. Further, cases have been reported where the employer or trafficker withhold visas or identification barriers in order promote compliance and essentially are holding the victim hostage (9). 

     

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What percentage of homeless youth are a part of the LGBTQ+ community?
    2. What are some of the risk factors for human trafficking?
    3. Can boys and/or men be victims of human trafficking?
    4. What are the different methods that perpetrators use to control victims?

    Recruitment Techniques

    A major tactic of the perpetrators of these crimes is to prey on vulnerable individuals with a lack of resources. Thus, a primary ploy used is a layer of deception whereby the human trafficker is targeting the needs or wants of the victim. 

    Traffickers are often individuals that the victim has come to trust. This may be a girlfriend or boyfriend, spouse, or other family member. Victims are also commonly sold to outside parties. 

    In cases of sexual trafficking, typically young women and men are groomed and given preferential treatment, gifts, and drugs until they become reliant upon the “John”. In other cases, individuals are tempted with the promise of a better life, or in the case of immigration, the sponsorship for a visa (9). 

     

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What ploys do perpetrators use to deceive and lead their victims into sex trafficking?
    2. In Florida, human trafficking victims are commonly immigrants. What is a common promise that perpetrators make to these victims?

    Florida Human Trafficking & Mandatory Reporting

    Mandatory reporting of human trafficking by health care professionals is incorporated into the law in a growing number of locations in the United States. Health care professionals are already mandated reporters through previous existing laws that require reporting of child abuse, domestic violence, as well as knife and gunshot wounds (10). 

    The following states the criminal and civil liability of failing to follow the law as a mandatory reporter in some states: 

    In a civil action, the mandated reporter may be held liable for all damages that any person suffers due to the mandated reporters’ failure to file a report. In a criminal action, the mandated reporter may be found guilty of a misdemeanor punishable by imprisonment for up to 93 days and a fine of $500. 

    Reporting of suspected adult human trafficking is not as clear in regard to mandatory reporting. However, vulnerable adults suspected of being abused, exploited, or victimized fall under the same guidelines and are reported to CI in the same manner as above.  

     

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Who can be held liable if they fail to report any act of human trafficking?
    2. In Florida, human trafficking must be reported immediately by which healthcare workers?

    Federal Laws

    Today, there are 39 states that have committed to the crusade of establishing a statute banning human trafficking.  

    A specific U.S. Federal law addressing trafficking crimes was first enacted with the Trafficking Victims Protection Act of 2000. The bill has since been revised several times; however, the fundamental of it is to provide guidance and authorization for their “three-pronged approach that includes prevention, protection, and prosecution” and covers both sex and labor trafficking (11). 

    Preventing Sex Trafficking and Strengthening Families Act of 2014 and The Justice for Victims of Trafficking Act of 2015 are both aimed at providing victims increased protection for exploitation and increased resources specifically aimed at prevention and support for child and youth sex trafficking crimes (11). 

    The Customs and Facilitations and Trade Enforcement Reauthorization Act of 2009 is aimed towards prohibiting the importation of goods made by the benefit of human trafficking (11). 

     

    Recognizing Signs of Human Trafficking

    According to the Department of Health and Human Services, close to 90% of human trafficking victims visit a health care facility at least once while in servitude and are not identified as such by health care providers (14). This is due to a lack of education, lack of consistent use of identification and screening tools, and time constraints within the current health care system. As a mandatory reporter and healthcare team member, it is imperative to use best practice in recognizing the signs and symptoms as well as the tools that are available. 

    Signs and Symptoms

    Human trafficking victims may present to a healthcare setting with primary or underlying signs that may be related to physical or mental abuse. These signs and symptoms may be related to the reason that they are seeking treatment or may be identified by the healthcare provider during a thorough assessment. The following physical and psychological sequelae may be noted during an assessment as potential evidence of victimization (all derived from 9, 15): 

    Physical
    • Unexplained or implausible injuries
    • Bruising
    • Wounds and Cuts
    • Missing or broken teeth
    • Closed head injuries
    • Blunt force trauma
    Neurological
    • Headaches
    • Migraines
    • Memory loss or difficulty concentrating
    • Vertigo
    • Insomnia
    • Brain trauma
    Gastrointestinal
    • Diarrhea
    • Constipation
    Dietary
    • Malnutrition
    • Anorexia
    • Severe weight loss
    Cardiovascular and Respiratory
    • Tachyarrhythmias
    • Hypertension
    • Respiratory Distress
    Reproductive System
    • Sexually transmitted disease
    • Vaginal and/or anal fissures
    • Previous Abortions
    Psychological
    • Depression
    • Suicidal Ideation
    • Anxiety
    • Self-harm including cutting or branding
    • Drug and alcohol abuse
    • PTSD symptoms
    • Regression
    • Anger
    • Dissociative and depersonalization tendencies

    Red Flags and Indicators

    There are several characteristics that should be kept in mind as red flags during the interview and assessment that may indicate potential trafficking. These include, but are not limited to (all derived from 9, 15, 14): 

    • Tattoos that indicate ownership, a number, or tracking system or are out of character/obscene
    • Inappropriate clothing for climate
    • Workplace violence or abuse
    • Unsanitary living conditions
    • Multiple families or people sharing a living space that is too small
    • Shares living space with employer
    • Is not in control of financial assets
    • Refusal to speak alone with health professionals
    • Accompanied by individual that refuses to allow patient to speak for themselves or be alone
    • Sex work under age 18
    • Answers are scripted
    • Answers are implausible or contraindicate
    • Appears younger or older than stated age
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What red flags really stand out to you? 
    2. Have you seen any of these in your practice? 
    3. What are some of the signs and symptoms that victims of human trafficking may present with? 
    4. What are a few red flags or indicators that someone may be a victim of human trafficking? 

    Interview Tools and Techniques

    Check with your facilities protocol for specific guidance on assessment and examination protocols for suspected abuse victims. There are also many scripted interviewing tools available online that assist with asking targeted questions. First and foremost, it is important to establish the patient’s safety and to gain trust. 

    Gaining trust can be difficult and conducting assessments and interviews should be completed in a non-threatening environment with an unbiased and non-judgmental tone. Creating a space that is quiet and will not be interrupted is important. This will ensure that the potential victim feels safe communicating and is not concerned that she or he will be overheard. Present your demeanor in a non-threatening manner, at eye level, and focus on being attentive with observant listening. Maintain respectful eye contact to convey interest and reflective listening. If taking notes during the interview is required, explain to the patient what will be documented and what it will be utilized for (15). 

    The National Human Trafficking Resource Center (NHTRC) offers a plethora of resources and scripted questions. The following are general questions on assessing if the individual is being forced into a situation and can be applied to any of the specific types of human trafficking (all from 15): 

     

    “Did someone control, supervise or monitor your work/your actions?”
    “Was your communication ever restricted or monitored?”
    “Were you able to access medical care?”
    “Were you ever allowed to leave the place that you were living/working? Under what conditions?”
    “Was your movement outside of your residence/workplace ever monitored or controlled?”
    “What did you think would have happened if you left the situation?"
    "Was there ever a time when you wanted to leave, but felt that you couldn’t?"
    "What do you think would have happened if you left without telling anyone?”
    “Did you feel that it was your only option to stay in the situation?”
    “Did anyone ever force you to do something physically or sexually that you didn’t feel comfortable doing?”
    “Were you ever physically abused (shoved, slapped, hit, kicked, scratched, punched, burned, etc.) by anyone?”
    “Were you ever sexually abused (sexual assault/unwanted touching, rape, sexual exploitation, etc.) by anyone?”
    “Did anyone ever introduce you to drugs or medications as a method of control?”

    While screening tools provide a base for asking difficult questions, the NHTRC advises “Before screening, users should also be prepared to draw upon the expertise of local legal and medical staff and to refer identified trafficking victims to appropriate housing, health, and social services in their area . . . the tool is a complement to, not a substitute for, specialized training in human trafficking, good professional practice and victim-centered service” (15). 

    The NHTRC also provides a 24-hour national hotline that is able to guide health professionals through completing assessments and determining the next best steps to intervene or offer the victim assistance. 

     

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. How would you approach and interview a patient victim of human trafficking? 
    2. Are there any additional questions that you would ask them other than tools learned within this course? 

    Interventions and Collaboration

    When presented with a suspected human trafficking victim, it is likely that the individual will not be alone. Maintaining safety and support for the patient may require separation from the suspected trafficker. While this may not be possible, an attempt should be made to bring the patient to a room or examination area unaccompanied. 

    Be conscious of any cultural preferences that may affect the patient. If there are language barriers preventing meaningful communication, enlist the assistance of a professional interpreter. This is especially vital in cases where the accompanying visitor or family is attempting to interpret for the patient and may be filtering the victim’s responses. 

    For patients that seek healthcare related to sexual abuse, a SANE assessment and rape kit should be obtained per facility protocol. With permission, patients should be tested for sexually transmitted infections including HIV, gonorrhea, UTIs, syphilis, and pubic lice, as well as a pregnancy test for females. Forced and coerced abortions are frequent among minor females in the sex industry (16). 

    Thorough documentation of the patient’s reported reason for visit, physical and neurological assessment including any trauma, bruising, wounds, affect, and pertinent statements should be noted in the patient’s electronic medical record. 

    Educate yourself on local resources and be able to provide assistance with finding access to healthcare, mental health, and rehabilitative resources that are available in the community. Victims may not want to take pamphlets with them that may be found, so providing locations or addresses of shelters or clinics with operating times may be a safer option. 

    Collaborate with the healthcare team, law enforcement, and social work for suspected child or vulnerable adult trafficking. 

    Mandatory reporting of suspected cases of child abuse or trafficking is not encumbered by HIPAA disclosure when reporting to authorities; however, when reporting suspected adult trafficking, disclosure and permission must be granted unless there is an imminent threat to the safety of the patient, or the patient has been identified as a vulnerable population. Thoroughly assess if the individual meets criteria as a vulnerable adult and proceed accordingly. If the adult does not meet criteria, permission must be gained to report. 

    If a competent adult does disclose that they are a trafficking victim, determine if the patient is in immediate, life-threatening danger. If so, follow facility protocol and encourage and support the patient in reporting to a law enforcement agency. If there is no immediate danger, supportive care and assistance should be provided. The patient should be informed of the options available for social services, reporting, and resources. The creation of a safety plan is highly recommended (13). 

     

    Prevention

    Prevention of human trafficking requires public education, awareness, and knowing how to properly respond when faced with suspicions. The Blue Campaign is a strategy from the Department of Homeland Security to bring national awareness to the issue and provide specialized training to law enforcement and federal employees. Blue Campaign pamphlets and other materials are available at their website, www.dhs.gov/blue-campaign, for distribution. 

    The Center for Disease Control takes the stance that sex trafficking is preventable via community awareness and acknowledging exploitation when it does occur. They state “Strategies based on the best available evidence exist to prevent related forms of violence, and they may also reduce sex trafficking. States and communities can implement and evaluate efforts that: 

    • Encourage health behaviors in relationships
    • Foster safe homes and neighborhoods
    • Identify and address vulnerabilities during health care visits
    • Reduce demand for commercial sex
    • End business profits from trafficking-related transactions” (6).

    One of the largest barriers to prevention in the healthcare system is the inability to recognize signs and symptoms. As cited above, a significant number of human trafficking victims have filtered in and out of healthcare systems without being recognized. This misses the opportunity to connect, provide resources, and offer further assistance. The NHTRC provides many resources for training within healthcare facilities and standardized forms and interviewing questions that may be tailored to individual situations and facility needs. 

    Patient Education

    UNICEF provides excellent resources for human trafficking prevention. Below is an excerpt from UNICEF, with “key messages” for children, which can help prevent trafficking. 

    1. Educate yourself on the issue, and learn the signs of a trafficked victim.
    2. Don’t accept friend requests from people you don’t know on social media. Traffickers commonly use sites like Twitter, Facebook, and Instagram to lure their victims.
    3. Be aware of how traffickers recruit people, and pay attention to your surroundings.
    4. Don’t reveal too much about yourself (i.e. your full name, address, school, or living situation) to people you don’t know, whether on your social media sites or in person, no matter how friendly the person may be.
    5. Never agree to meet someone you don’t know without first consulting a trusted adult (i.e. parent, teacher, guidance counselor).
    6. If you feel uncomfortable or are hesitant about a situation, confide in an adult who you can help you make the best choices.
    7. Making a decision to leave a situation or relationship where you feel unsafe or are being harmed or threatened can be hard and scary. If possible, talk to someone you trust, like a friend, family member, counselor, or youth worker.
    8. If you are in immediate danger or are being physically harmed, call 911 for help.
    9. If running away from home, try to find a safe place to go or call the runaway switchboard at 1-800-Runaway.
    10. If you suspect you or a friend are at risk trafficking, call the National Human Trafficking Hotline at 888-3737-888 or text “BeFree” (233733)

    Resources - How to Help

    Children and adults can be victims of human trafficking.

    “If you see something, say something.”

    • Contact the Florida Abuse Hotline 1-800-96-ABUSE (1-800-962-2873) to report known or suspected child abuse, neglect, or abandonment; and known or suspected abuse, neglect, or exploitation of a vulnerable adult.
    • For help,contact the National Human Trafficking Hotline 1-888-373-7888.
    • Text HELP to 233733 (BEFREE):  To get help for victims and surviviors of human trafficking or to connect with local services.
    • Visit the National Human Trafficking Hotline online at:  https://humantraffickinghotline.org.
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Who might you call within the community as a resource if you suspect a child or vulnerable adult is a victim of human trafficking?
    2. In Florida, human trafficking is an ongoing problem. What state and national hotlines can you call if you suspect that someone is in danger?

    Key Concepts of Critical Thinking in Nursing

    How many times did you hear the phrase “critical thinking” in your training to become a nurse? I must have heard it a thousand times, and I still don’t think I ever had a clear definition of it in my mind. What exactly is critical thinking? In this course, we will answer those questions and provide insight into how you can teach critical thinking in nursing. Also included are some self-guided exercises to practice critical thinking skills. After all this, you will be ranting about the vital importance of critical thinking, too.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. How would you define critical thinking in your mind? 

    2. Do you think of yourself as a critical thinker?

    What is Critical Thinking? 

    Critical thinking is a term that is difficult to define because it is, by nature, somewhat subjective. The National Council for Excellence in Critical Thinking defines it as “the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action,” (4). That’s a long definition. Essentially, critical thinking is a way of thinking that allows a person to recognize important information and process it to solve problems. Let us break this down further into the key characteristics of critical thinkers.

    How are “text-book smart” and “street smart” different from each other? 

    Information Gathering 

    There are some key characteristics of critical thinkers that appear consistently throughout the literature. The first of these attributes is information gathering (1). Critical thinkers are adept at gathering information from situations. They pay attention to details and pick up on the information that others may miss. Critical thinkers try to uncover the particulars to ensure they are well informed in their thinking and decision-making. Critical thinking is not a passive acceptance of information but rather an active collection of data. In terms of nursing, the critical thinker will place a lot of importance on their assessment. Rather than focusing simply on the tasks that need to be completed, critical thinking in nursing means staying in tune with assessment findings and changes. For example, if a patient has labs drawn, the critically thinking nurse will watch for the results of these labs to have the most up-to-date information and be alert to any changes. 

    How do you incorporate “information gathering” into your routine?

    Investigating 

    Another important attribute of critical thinkers is their habit of investigating (1). They do not accept information at face value. They have a tendency to question information, especially that which contradicts other data. When critical thinkers see the information that doesn’t seem right or raises questions, they investigate it. This way of thinking goes together with seeking out information.  

    With critical thinking in nursing, a nurse may ask themselves, “What else do I need to know? What comes next?” Rather than simply reporting one change to the physician, they think “what could this change represent? What other information would support this idea?” Continuing our example of following labs, if the nurse notices that the white blood cell count has increased, they will investigate to see why that might be. They would likely assess the patient for signs of infection, such as fever or chills.  

    If you get the feeling that “something isn’t right,” what do you do next? 

    Evaluation 

    Critical thinkers also can evaluate the information they have gathered to create new ideas or hypotheses (1). This is the cognitive “connecting the dots” that allows critical thinkers to synthesize pieces of data into a complete picture of what is happening.  

    Critical thinking in nursing doesn’t mean just collecting and reporting information; they process it and form ideas of their own. They ask questions like “how do these pieces of information fit together? Does this fit with any knowledge I already have?” Going back to our example, let’s say after the nurse notices the white blood cell count and assesses the patient, they find the patient has a fever and cloudy urine. Evaluation of this information would lead the nurse to think the patient has a urinary tract infection (UTI).  

    Think of a time you diagnosed a patient’s problem. How did you come to this conclusion? 

    Problem Solving 

    An important aspect of critical thinking is problem solving. After gathering and evaluating information, the critical thinker tries to solve any problems that surface (1). This is a key point that separates critical thinking from merely being perceptive. Recognizing important information and problems is vital but being able to then think through and solve the problem is what makes critical thinking stand out. Looking at our example again, once the nurse has recognized symptoms consistent with a UTI they will begin formulating ideas on how to treat the problem. The first action would likely be notifying the provider of all the information gathered, the nurse’s hypothesis and a recommendation to solve the problem. You may recognize this format as being similar to Situation-Background-Assessment-Recommendation (SBAR). SBAR is a tool that is used to help guide critical thinking in nursing (1).  

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What information/assessments do you focus on for the patients you care for? 
    2. What characteristics do you think a critical thinker should have? 
    3. Have you recognized patterns in how your providers/institution solve common problems? 
    4. Have you ever had a provider recommend a treatment you disagree with? Why did you disagree? 
    1. What information/assessments do you focus on for the patients you care for? 
    2. What characteristics do you think a critical thinker should have? 
    3. Have you recognized patterns in how your providers/institution solve common problems? 
    4. Have you ever had a provider recommend a treatment you disagree with? Why did you disagree? 

    Why is Critical Thinking Important? 

    Now that we understand what exactly critical thinking means, let’s ask: why is it so important? You may have already formulated some ideas about how critical thinking in nursing can be helpful in practice. Critical thinking is a pattern of recognizing and reacting to the most important pieces of information. This is crucial in nursing, where we are presented with a plethora of information and expected to use the most important pieces to save lives and make people healthy. Now, let us get more specific on what areas would benefit from critical thinking in nursing.  

    Patient Outcomes 

    First, and maybe most important, is that critical thinking improves patient outcomes (3).  

    Studies have shown that critical thinking skills in nurses are linked to lower hospital costs to patients, as well as to the facility thanks to lower in-hospital complications (3). Critical thinking by nurses also decreases the length of hospital stay (4). It has also been shown to improve outcomes and lower complications in surgical patients when the operating room nurses had a higher level of critical thinking (3). Despite these positive results and every nursing instructor ranting on the importance of critical thinking, there is a lack of research into the connection between critical thinking in nursing and patient outcomes. This is primarily because of the difficulty of assessing critical thinking skills specific to nurses and linking these skills to a measurable outcome without confounding factors (3). 

    Staff Satisfaction 

    You will be pleasantly surprised to learn that critical thinking in nursing leads to higher staff satisfaction! Research has found a strong correlation between critical thinking ability and perceived autonomy and job satisfaction in nurses (5). It is believed that critical thinking fosters autonomy or at least increases the sense of autonomy, which generally leads to higher job satisfaction. Critical thinking has been shown to improve confidence as well, and feeling confident in your work generally improves satisfaction as well (5). Interestingly, there has also been research that shows that critical thinking is linked to higher satisfaction with life decisions and less adverse life events (6). The idea here is that critically thinking through a decision before making it leads to less regret. So, this course will make you happier with work and help you make better life choices – you’re welcome. 

    Efficiency 

    Another important benefit of critical thinking is that it improves efficiency. Studies found that nurses with higher critical thinking skills work more efficiently (1). If you are thinking critically you are better able to prioritize and plan to avoid wasting time and energy. As we all know, nursing can be very demanding, and efficiency is important for tending to all our patients’ needs. Also, if the nurse manager of a unit has higher critical thinking skills, they implement changes that improve overall efficiency and morale (7). This highlights that critical thinking is important to all nursing forms and how one person practicing critical thinking can impact others. 

    Healthcare Complexity 

    A large reason why critical thinking has become so important is the ever-increasing complexity of healthcare. As we develop new treatments, we are always being asked to learn new processes and how to monitor patients receiving these treatments. Also, as the healthcare system improves treatments, the average patient is becoming older and has more co-morbidities (4). This adds to the complexity of each patient. Critical thinking is a great skill that aids in learning new tasks and comprehending more complicated patients. Nurses arguably have the most complex set of tasks, as we are often asked to perform some of the duties of other healthcare professions. Being adaptable to whatever changes come and taking on new responsibilities is a great benefit of critical thinking.  

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Have you ever seen a colleague miss something that may have harmed the patient? 
    2. Have you or a colleague ever had a “good catch” that you feel benefited the patient? 
    3. How do you think critical thinking increases autonomy? 
    4. When have you been asked to make a change to your practice? How did you adapt to this change? 

    5. How could you make your work routine more efficient? 

    Critical Thinking Education 

    Now that we understand what critical thinking is and why it’s important let us discuss how critical thinking is taught. Critical thinking in nursing has become an integral part of many programs. Many healthcare institutions are looking for ways to incorporate critical thinking into their training process as well (1). Critical thinking is, however, an abstract concept and truly is a whole new way of thinking. So, how do we teach someone how to think? There are several factors that should be considered when trying to teach or learn critical thinking. 

    Educator Influence 

    First, educators have an important influence on the instruction of critical thinking skills. Educators that are effective at teaching critical thinking skills are open-minded, flexible, and supportive of their students (1). Showing flexibility and not firmly holding to one set way of doing things allows the students to adopt their own version of critical thinking. Role-modeling, guiding, and being knowledgeable about critical thinking also leads to a more effective educator (1). The educator should guide learners through their understanding of critical thinking while role-modeling critical thinking behaviors. 

    Environment 

    The learning environment also plays an important role in a nurse’s ability to learn critical thinking skills. The environment should be inclusive, non-judgmental, and allow for open discussion (1). This applies to both nursing schools and nurses being trained into a new unit. Feeling accepted on a unit allows for better learning and has a positive impact on critical thinking skills (1). It is important for nurses looking for a new work unit to find one with a welcoming, safe environment to aid in learning. On the other side, we should always strive as nurses to be inclusive and facilitate this type of environment as it benefits everyone. I was always told that “nurses eat their young,” and this attitude does not foster learning or growth. 

    Education System 

    The education system also impacts the teaching of critical thinking. Education systems, for one, largely shape the learning environment and educators. The education system should strive to create the type of learning environment where critical thinking skills can grow. Too much emphasis on classroom lectures and power dynamics between teachers and students hinders the development of critical thinking skills (1). Teaching critical thinking as its own subject also helps students learn the skill (1). 

    Individual Factors 

    Lastly, there are some individual factors that affect a person’s ability to cultivate critical thinking skills. Chief among these are a lack of confidence and fear of questioning an instructor (1). You can see how all these concepts seem to be centered on the fact that learners perform best when they are comfortable and have the freedom to discuss ideas. This is the central concept that should be understood and practiced by both mentor and mentee, as well as the education system as a whole. So, as we move into the next section teaching critical thinking skills, put yourself in a comfortable place – physically and mentally. Be sure to keep thinking of questions and follow your own ideas. 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What training or education did you receive on critical thinking?
    2. Who was your favorite instructor/mentor? What did they do to stand apart from others?
    3. What factors make you more comfortable and likely to learn? 
    4. What were the dynamics like at your nursing school?  
    5. Have you ever felt afraid of asking a 'stupid' question? 

    Strategies to Promote Critical Thinking 

    Now that we have an understanding of the right mindset to have when learning critical thinking, let us actually discover how to teach and learn it. Some common strategies that appear to be effective are targeted questioning, case studies and simulation (1). These are all approaches that require more than one person, so they are best practiced as part of training. If you have a colleague or mentor, you may try some of these strategies with them as well. 

    Targeted Questioning 

    First, we have targeted questioning, which is a tactic of asking questions in order to promote further thinking (8). This often involves asking questions of increasing difficulty to encourage the learner to think deeper about what the facts represent. It is the educator’s equivalent of a toddler asking “why?” over and over. The purpose is not to be annoying but to discover how deep down the rabbit hole the learner will go. Socratic questioning is another common type of targeted questioning designed to encourage learners to think further on the subject matter. This is commonly used in continuing education (check the italicized text), and helps to promote further thinking on facts rather than just accepting them at face value.  

    Case Studies 

    The next exercise that helps teach critical thinking is case studies. Case studies help promote critical thinking by allowing learners to think through a real-life scenario without the stressors of experiencing the scenario (1). 

    It is important for learners to acknowledge how they might feel in that scenario so that they can be better prepared for the pragmatic aspects and the personal aspects of dealing with the presented problem (4). Case studies typically move chronologically through a scenario and often guide learners through the critical thinking behaviors of information gathering, investigating, evaluating and problem-solving. This helps build the mental framework of moving step-wise through a problem in order to find the best solution.  

    Simulation 

    Finally, simulation has proven to be useful in fostering critical thinking. Simulation, similar to case studies, promotes thinking through a scenario in a low-risk, low-stress environment with the added benefit of going through the physical motions involved (8). This allows the learner to physically experience the situation as well as think through the problems. This can help familiarize someone with the actual physical interventions involved so they are more comfortable when practiced in real scenarios. This is often used in life support training so that learners understand how to actually connect the defibrillator and which button to press, so there is less fumbling in the high-stress scenario where these motions are used (8).  

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Did you ever have an instructor “grill” you on facts? What did this do for your learning? 
    2. Have you ever found yourself comparing a problem to a similar previous problem?  
    3. What is your experience with simulation? 
    4. Think of a stressful situation you were confronted with at work. Could that situation be captured in a simulation? 

    Critical Thinking Exercises 

    We have examined ways to teach critical thinking skills to others, but what about developing critical thinking within ourselves? Luckily, there are a couple of exercises that can be practiced individually to foster critical thinking skills. This is helpful to those of us who are finished with our training and looking to better ourselves. Start with a desire to improve, as none of us are perfect. These exercises are best practiced by focusing on a specific scenario, particularly if there is a scenario that you didn’t fully grasp or that felt overwhelming.  

    Concept Mapping 

    The first exercise is concept mapping. Concept mapping is the practice of visually representing ideas on paper and showing connections between these ideas (2). They are often presented in either a hierarchical or web pattern with the key ideas at the top or center of the diagram, respectively. 

    This helps a learner visualize their thinking process and further think about what connected and how. For example, let's think of our scenario earlier with the suspected UTI. We might see a change in vital signs as a central idea which connects us to signs of infection and then to interventions. This can help us see the progression of ideas, how they are connected, and possible other explanations. 

    Reflective Writing 

    Our final means of learning critical thinking in nursing is reflective writing. Reflective writing or journaling helps to identify thought patterns and promote critical thinking skills (1). Again, this is most useful for examining a specific situation. Breaking down a complex situation when you have more time to analyze it will help you learn more from that challenge. 

    It may seem silly to write a journal but reflecting and processing your ideas is an important practice for growth. The act of formulating your thoughts into written words helps to make more sense of the ideas and feelings you have. You don’t have to keep a daily journal, but if you have a challenging shift it may help to reflect on it and write down your ideas. It is important to treat this exercise as a learning opportunity, and to not ruminate on failures or beat yourself up for not being perfect. 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Practice drawing a concept map of the key concepts of critical thinking from this course.
    2. Write down a tough scenario you have dealt with at work. What made this experience hard?
    3. How have you or will you change your practice based on this scenario?

    Conclusion 

    In summary, critical thinking in nursing is essential. It impacts our efficiency, the well-being of our patients, and our own happiness. Critical thinking is a broad way of thinking that involves gathering information, investigating, and evaluating the information in order to solve a problem. Critical thinking is best learned and practiced with an open mind. We can foster critical thinking in each other through case studies, simulations and targeted questioning. We can improve our critical thinking in nursing skills ourselves by practicing reflective writing and concept mapping. If you are a nurse educator or preceptor, I hope you have found something you can use to shape future nurses. If you are a nurse looking to better understand critical thinking, I hope you have learned something you can take to your nursing practice.  

    Effective Communication in Nursing

    Introduction   

    Communication in nursing is key, and the ability to communicate effectively can be our lifeline. We depend on ourself and others to be fluent and effective in the art of communication in order to perform our role as nurses successfully. When any link in our communication chain fails, we immediately see poor outcomes, wastage of resources, reductions in patient and staff satisfaction as well as a decline in the quality of patient care (1). 

    Types of Communication

    In order to master effective communication in nursing, it is important to understand the various types of communication, their definitions and the impact they can make.


    Non-Verbal

    This form of communication relies solely on the utilization of body language, including body and facial mannerisms, and completely lacks spoken words or sounds (2). We perform and identify non-verbal communication in nursing daily without giving it a second thought. We may see a newborn sucking on their hands, providing us a non-verbal cue that they are hungry. When assessing a patient holding their abdomen, we would look to initially target that area because they have communicated (non-verbally) that this is where they are experiencing discomfort. Smiling when the next shift nurse is walking in the door communicates to them that you are happy to see them, and that it's about time for you to go home!

    Since we perform non-verbal communication so often, it can become an incredibly powerful tool or a very negative one quickly. This form of communication in nursing can be used positively to show our patients and co-workers that we have compassion, and we are engaged. Negative forms can make patients uncomfortable with sharing their medical history and result in a lower quality of patient care. Additionally, it can lead to dysfunctional teamwork among staff. 

     

    Verbal

    Verbal communication occurs when we use words or sounds to discuss concepts with others (2). This form of communication in nursing has the conception to be a very easy notion, but it can create unfavorable consequences when used ineffectively. In order to produce clear verbal messages, we should always speak concisely and with confidence. As health care professionals, we have our own language, and understanding when to incorporate our medical jargon into conversations versus when to not is crucial in providing care. When communicating among co-workers, our medical knowledge can showcase professionalism and it is evident that they can follow along. However, when speaking with patients and their families, this may not always be the case and we must be able to effectively gauge our audience and ensure that they have a clear understanding of what we are teaching or explaining; this is an extremely valuable tool.  

     

    Written

    This form of communication can be either a formal or informal transcription of words that are intended to serve as a direct communication form (2). Written communication in nursing is used daily and incorporates one of our most important duties, documentation. Throughout our nursing practice, we have learned the importance and necessity of our documentation; it can be useful for legal protection or provide critical data to other health care professionals. Written communication can also be accessed through the policies and procedures we employ to perform various tasks. Having sound, written communication, and interpretation skills is vital to the overall success of our nursing career.  

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What type of communication is being interpreted while watching a patient walk to the bathroom? 

    2. Upon admission of a female patient for a fall, you are performing normal intake questions and a physical assessment. The patient is quiet and uses minimal verbal communication and looks down at the floor while you are in the room. What communication types are you interpreting?

    Receiving Communication 

    The most common communication perception is usually directed to producing communication through non-verbal, verbal, or written forms. While the production of communication is important, the reception of it potentially holds even greater value. In nursing, ensuring our communication is received correctly affects every clinical, orientation, or job experience we have encountered thus far. Think about it...  

    • Taking notes in class or during a shift 
    • When a preceptor or instructor educates you on a brand-new skill or piece of equipment 
    • Teaching your patient, family, or student about a new diagnosis  
    • Watching your patient breathe for rate, depth, and effort 

    We must provide and receive communication in nursing through verbal, non-verbal, or written forms successfully. If communication fails, we will experience extremely negative effects throughout our entire nursing system. 

     

    Hearing & Listening

    Hearing describes the process or act of perceiving sounds or spoken words (2). We hear sounds upon auscultation, varying frequencies of alarms, and patient concerns when they are voiced. Hearing all of these sounds are heavily dependent on how they are used. To achieve successful implementation of these sounds, we must also listen to these sounds and words.

    To listen, we must hear and then interpret these sounds carefully (2). We interpret these sounds and words by asking additional questions, performing additional assessments, or paraphrasing the information presented.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What is the best way to ensure a patient was actively listening while performing patient education? 
    2. Which type of scenario requires active listening skills?
        
      a. Putting blood tubing into a pump.
         b.
      Watching a EKG monitor.
         c.
      Performing a pain assessment.
    3. What techniques show others you are actively listening?
        
      a. Reading a document while being talked to.
         b.
      Making eye contact.
         c.
      Making noises while someone is talking.

    Communication Transmission Threads

    Communication in nursing occurs multiple times a day between a wide range of communication threads. The type of communication, whether non-verbal, verbal, or written, must be effectively performed. Success and implementation is heavily dependent on the communication between the nurse and the communication thread 

     

    Nurse - Nurse

    Communication among nurses is continuous throughout a shift while working within a team environment. Whether it is passing documentation on to another nurse for review or vice versa, there is consistent communicative flow of all variants (non-verbal, verbal, and written) between the team in order to provide care for patients. 

     

    Nurse - Ancillary Staff

    Your team members will vary depending on your nursing career setting, but some items will remain consistently important despite wherever you are. We must provide clear verbal communication when delegating or reporting critical information from the nurse to ancillary staff participating in patient, client, or resident care 

     

    Charge Nurse - Team

    When stepping into a charge nurse role, there will always be unexpected tasks, staff conflicts, or emergent situations. In this position, you will be taking all of the communication skills you have acquired and putting them into practice at an all-time high. As the charge nurse, you will be viewed as a leader, meaning that you are a role model for your fellow team members. Now, in addition to producing and receiving communication effectively, you will now be identifying poor communication and assisting with its correction 

     

    Nurse - Patient

    The nurse-to-patient communication thread is one of the ultimate and most important exchanges in the nursing profession. Patients need us, so we must be able to keep consistent and effective communication flow with them because any assessment, report, and administration of medication is contingent upon it. 

     

    Nurse - Family

    The thread between the nurse and the patient’s family can be the foundation for your nurse-to-patient communication and its effectiveness. The family could be the responsible party or guardian for your patient and could potentially serve as your sole historian for patient information if the patient is unable to communicate at the time of data collection. Ensuring that the family is aware of and understands discharge instructions can further help them to recognize any potential signs or symptoms that could result in calling a physician or visiting the emergency room in the future. 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Which of the following is a beneficial way to ensure effective communication throughout multiple threads?
        
      a. One to one conversations.
         b.
      Reviewing a policy.
         c.
      Bedside report. 

    Barriers & Improvements to Communication in Nursing

    Barriers of communication in nursing happen frequently and are sometimes out of our control. These barriers include:

    Language Barriers 

    Utilizing available resources for language barriers through interpreter staff members or interpretation devices can ensure effective communication pathways between two individuals.

    Cultural Differences 

    Identification of cultural differences during admission and cultural awareness will allow for effective communication management throughout each culture you are presented with.

    Patient Acuity, Staffing Levels, and Time Constraints 

    Patient acuity, staffing levels, and time constraints can be improved by utilizing staff huddles and working together with administration in order to overcome conflicts.

    Emergent Situations 

    Emergent situations that arise during your shift can be relieved through adequate knowledge of the policies and procedures and by performing debriefs after the situation resolves. Debriefings hold valuable insight into reflections of the emergent situations we face as nurses, especially on communication performance. 

    In each thread and form of communication in nursing, we must remember the following items to receive information. While producing communication, we must always be clear, concise, and accurate with the correct corresponding tone when expressed to others. When we are receiving the information, we must ensure we are understanding, investigating, and acting according to the communication presented to us. Utilizing various communication platforms, including emails, boards, and group messaging apps, can help to assist in ensuring education is received. 

    Benefits of Effective Communication in Nursing 

    When we achieve effective and therapeutic communication between both our team and patients, it will create opportunities for enhancements throughout our practice. Fostering a unity of teamwork with co-workers will increase satisfaction and reduce burnout rates. Reduced health care costs through reduced readmissions or emergency room visits will be established by successful patient education and understanding. Our quality of patient care will be heavily influenced by the nursing communication threads created through their care.

    Ensuring Patient Confidentiality in Nursing

    Introduction

    In order to provide the best care possible to patients, there must be a foundation of trust that the patient-provider relationship is built on. If the foundation is not stable, the rest of the relationship is at risk of crumbling. One way that trust is built is by maintaining patient confidentiality or privacy.  

    When it comes to the medical field, the wrong medicines or treatments may be administered or performed. This could result in further complications. Medical conditions, treatments, and results can often be sensitive topics and things patients do not necessarily want shared with society for a variety of reasons. Patients rely on their providers to keep the information they communicate in confidence, and only sharing it under certain circumstances.  

    With the ever-growing platform of social media and advancements in technology, there is a grey area that exists when it comes to patient confidentiality and what can and cannot be shared. The purpose of this course is to educate on the aspects of patient confidentiality and its importance.  

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What do you already know about patient confidentiality?

    The Privacy Rule 

    The Health Information Portability and Accountability Act of 1996 (HIPAA) became the groundwork for the Standards for Privacy of Individually Identifiable Health Information (Privacy Rule) issued by the U.S. Department of Health and Human Services (HHS). It was designed to meet the requirements set by HIPAA regarding how healthcare providers used and disclosed a patient's private health information. It also addressed patients having the right to know and dictate how their health information is utilized. Overall, the Privacy Rule's goal was to set clear boundaries when it came to properly protecting health care information while allowing the exchange of pertinent information to protect the health and well-being of the public (2). 

    Many groups are included under HIPAA's term of "covered entities.” These entities have connections to personal health care information on a variety of levels. Groups such as healthcare providers, health plans, healthcare clearinghouses, and business associates are all covered entities. The protected information they encounter is anything that can or is believed to identify an individual: name, date of birth, address, and Social Security Number. Any past, present, or futured mental or physical health, condition, or payment and health care provisions for an individual are also classified as protected information (4). 

    Quiz Questions

    Self Quiz

    Ask yourself...

    Think of where you work.

    1. What type of facility do you work in? 
    2. What does your work consider patient identifiers?
    3. Is there anything you think should be added to that list when it comes to what can identify a patient? 

    De-Identifying Patients to Ensure Patient Confidentiality

    There are many steps involved in de-identifying a patient for those who use or share patient information, as it applies to HIPAA. De-identifying a patient is the act of removing as many identifiers as one can in order to eliminate the chances of an individual being recognized through the scenario or situation (3).  

    There are two methods to de-identifying:  

    1. Formal evaluation by a qualified expert.

    A qualified expert must be a person with significant knowledge and experience with knowing scientific and statistical standards or methods to ensure patient information is not identifiable. They do this by determining if the risk of using the information is very small. They often document what methods they use to make the determination (3).  

    2. The act of removing individual identifiers.

    Many of these identifiers are things one would expect to be removed when identifying a patient, such as a name, age, date of birth, home address, Social Security Number, full-face photos, and phone numbers. However, some of them include any form of vehicle identifier—serial or license plate numbers—internet protocol (IP) addresses, biometric identifiers like finger or voice-prints, serial numbers or device identifiers, and web universal resource locators (URLs). An entire list of the 18 identifiers is located on the Department of Health and Human Services website (3).   

    Neither of these methods are 100% perfect in their goal, but they decrease a patient's chance of being identified significantly. Once the patient has been de-identified, the information is no longer restricted by the Privacy Rule since all patient identifiers have been removed. This means that the information can be used without worry of violation (3). 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Which version of de-identifying a patient do you think is better? 

    2. Have you ever had to de-identify a patient or patients?

    3. What was it for?

    4. Did you expect some of the listed identifiers to be on the list? 

    Professional Statements  

    Over the years, professional medical organizations have released statements regarding patient confidentiality and how it pertains to their target audience. Many medical organizations such as the American Nurses Association (ANA) and the American Medical Associations (AMA) often create position statements to reflect the organization's overall stance and thoughts on a specific topic. These positions may be used to guide education, policies, or individual opinions on the topic.  

    The ANA released a statement regarding patient privacy and confidentiality. As mentioned before, the ANA believes that the patient-provider relationship is important, and confidentiality is essential in that relationship. The organization supports legislation, standards, and policies that protect patient information. In the professional statement document, the ANA goes on to give recommendations regarding the protection of patient information. These recommendations support the patient's right to have protected information and to select who is the recipient of medical information. They encourage that patients be given information regarding HIPAA and the Genetic Information Nondiscrimination Act—an act passed in 2008 to prohibit individuals' discrimination based on genetic information (5). They acknowledge that the patient has the right to access their information and use it to make healthcare decisions. They note that patients should be notified when and how their information may be used. There is a heavy emphasis on not using patient information if consent has not been given unless there is an extenuating circumstance regarding legal requirements. This will be discussed in the next section (1).  

    Since patient confidentiality is extremely important, the ANA supports healthcare organizations in creating safeguards to protect patient confidentiality. They also support organizations enforcing ways to alleviate violations done by health care workers and protect them from retaliation (1).   

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Have you read the ANA's statement on patient confidentiality before? 

    2. Are you in any professional organizations? 

    3. Do these organizations have any statements about patient confidentiality?

    4. Are there any differences between them and the ANA's statement? 

    Disclosure  

    Overall, patient information is discouraged from being shared; however, there are several instances where the sharing of information is allowed. The patient may give the provider(s) or healthcare organization permission to share the information with whoever the patient decides. By providing consent, the patient is essentially waving the right to keep that information confidential but determines who can receive the information. This can be done through written or verbal consent, though most facilities require a written one. This written form is placed in the patient's medical records (6).  

    If another healthcare agency or provider is going to be involved with the patient's care, medical information can be exchanged on a "need to know" basis. For example, if a patient is being transferred to another facility, the accepting nurse and care team would need a thorough report to ensure that they knew the patient and what had already been done for them regarding medical care (6).  

    While protecting patient information is important, there are a few circumstances—called extenuating circumstances—that allow healthcare providers to share information regarding a patient without permission outside of the above reasons. Certain information is required to be reported to public health departments or authoritative organizations: communicable diseases, suspected child or elder abuse, gunshot wounds, release to insurance companies for payment, or worker's compensation boards after a claim has been submitted are allowed (6).  

    In the case of protecting the public, healthcare providers can report patient information to a specific organization if it comes down to the health of the public. As mentioned above, testing positive for communicable diseases can be reported to public health departments 

    It should be noted that one important exception applies to this rule. Making assumptions, especially about if a spouse has the right to know the medical history of a patient just because they are married, is not advised. Patients should be encouraged to inform their spouse about the information that may put the spouse at risk, such as sexually transmitted infections. If the individual's direct safety is threatened, then the provider can tell them (6).  

    In order to protect society, healthcare providers have the duty to warn if they have detailed and documented proof that the patient is targeting a select individual or group. Providers are encouraged to document instances of threats, whether it be against them, another provider, or another individual outside of the healthcare setting. Often this is a legal or ethical duty to report the threat to the authorities or possibly warn the potential victim (6).  

    If a provider is concerned about what can or cannot be disclosed at any time, it is encouraged that the provider consults hospital policies before releasing any information (6).  

    Quiz Questions

    Self Quiz

    Ask yourself...

    1.  What policies does your facility have when it comes to disclosing information? 

    2. How do you obtain consent for sharing information?

    3. Have you ever shared information outside of the "need to know" basis with other providers when it comes to a patient? 

    4. Have you ever had to report a patient to another organization such as Child Protective Services or the county Department of Health? What was it for?  

    Consequences of Disclosure Violations 

    Healthcare providers may be subjected to a variety of consequences when it comes to the violation of HIPAA or the Privacy Rule. The healthcare provider and the facility in which they work may be subjected to civil suits in a variety of ways. Disclosing sensitive information or photos about the patient are a breach of legal duty—intentional or unintentional—are both forms of civil suits that can occur. Nurses may face disciplinary action from their state's board of nursing. With the ever-growing form of social media, boards of nursing have been cracking down on improper use of social media and breaches in patient confidentiality. Job loss and fines are other consequences that may occur by themselves or in addition to any of the others listed above (6).  

    Quiz Questions

    Self Quiz

    Ask yourself...

    Think back to your hospital policies. 

    1. Do you recall any consequences listed in the policy?
    2. Are you required to complete education regarding patient confidentiality at work?
    3. What kinds of consequences do you think would be appropriate for violating patient confidentiality?
    4. What do you think of healthcare providers using social media at work?  

    Patient Confidentiality in the Technology Era 

    There are many forms of technology today and there are many ways patient confidentiality can be violated by using it. Cell phones have become a staple in nearly everyone's day-to-day life, so it would make sense that both healthcare providers and patients alike have them. While they are useful, cell phones can also cause problems. Unintentional or intentional filming or recording of patients or medical information can happen by staff, family members, or other patients. Family members or friends may call to ask about a patient, and it is important for the nurse to know hospital policy when it comes to verifying the identity of those calling and what information can be given over the phone. Verifying with the patient who can be told what information is important as well (6). 

    Since charting has become electronic, many nurses are using computers, laptops, or tablets to complete their charting. Healthcare providers need to ensure that privacy is always maintained when utilizing these devices.  

    Even though most things can be transferred via email, call, or secured text message, some information still needs to be transmitted via fax machine. Since there is room for human error, coversheets should be used along with a clear identifier that the information being sent is confidential. If a number is used often, it is encouraged that it is preprogrammed into the fax machine to help decrease the chance of the number being mistyped (6).  

    Quiz Questions

    Self Quiz

    Ask yourself...

     Think of your work area.

    1. What types of devices does your facility to use to chart?
    2. What steps has the facility taken to protect patient information when it comes to these devices?
    3. What steps do you take to protect patient information?
    4. What things could be improved on when it comes to securing patient information?

    Best Practices of Patient Confidentiality 

    Overall, healthcare providers must make decisions on how to protect private information. Despite recommendations from professional organizations and policies from facilities, it is the provider's responsibility and decision on how to go about it. Sometimes there are several ways to solve the same problem. Best practices, like the ones listed below, can be used with hospital and Board of Nursing policies and rules (6). 

    • Utilize coversheets for person notes regarding patient care or when faxing sensitive information. 
    • Be mindful of what is said in semi-private rooms or rooms that have visitors. Curtains and walls are not soundproof. 
    • Verify callers before providing any patient information as determined by hospital policy. Remember to also verify with the patient if able to do so. Some patients may not want family or friends to know about their condition. 
    • Do not leave patient information in a place where it can be easily seen by others. This includes personal notes, electronic or printed medical records, unlocked communication devices, etc. 
    • Ensure that all patient information is properly disposed of or destroyed prior to leaving work. 
    • Be mindful of what is posted on social media and be aware of possible unintentional disclosure.  
    • Provide education to staff regarding potential areas of misuse when it comes to patient information. Policies regarding improper use should be implemented. These policies should include email use, personal electronic data devices, and electronic transmission of data.
    • Have staff and others who may need access to patient information such as students sign confidentiality agreements.  
    • Refrain from speaking about patients or their private information in areas where information can be overheard, such as cafeterias, hallways, elevators, waiting rooms.  
    • Ensure that policies are reviewed and updated periodically or as needed to reflect current healthcare laws and guidelines.  

    This is not a comprehensive list, and healthcare providers must use common sense and caution when sharing private patient information. 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. From this list what do you already do to protect patient information? 

    2. From this list what would you add to your own list?

    3. What would you add to this list regarding protection of sensitive information? 

    Summary  

    The topic of patient confidentiality is very important to the patient-provider relationship. Without it, the entire relationship can deteriorate, leading to significant emotional and possibly physical damage. This can be detrimental to the patient and provider. It is important to follow hospital policy and healthcare laws regarding sensitive information. All healthcare providers are strongly encouraged to stay up to date on new legislation that may affect patient confidentiality.  

    Nursing Documentation 101

    Nursing documentation is at best a useful tool for communication and at worst a necessary evil. It is well-known that documenting is one of the most tedious aspects of bedside nursing. It takes time away from patient care and may be used for (or against) you in court. In this CE module we will learn how to document properly. Proper documentation is an essential for defense against claims and continuity/quality of care in nursing.

    Introduction to Nursing Documentation

    “I just love charting,” said no nurse, ever. If you ask most people why they want a career in healthcare, their response is that they want to help people. They did not want to spend hours in front of a computer clicking boxes. This time-consuming task of documenting in the medical record, or charting, is dull, repetitive, and sometimes disconcerting. It takes time away from being able to provide care for the patient. Yet documentation in the medical record is truly a vital part of patient care.

    Nursing documentation fills a significant portion of the medical record. Nurses need make sure what they are adding is accurate and complies with the guidelines set by their facility and the state board. This principle is the same, even though there are differences to be aware of now that the electronic medical record has become the standard.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What are your experiences with charting?  Have you seen examples of correct charting, as well as incorrect nursing documentation charting practices in your field?

    The Who, What, When, Where, Why, and How of Nursing Documentation

    Who

    There are approximately 2.9 million working RNs in the United states, with about 1.6 million working in hospitals (1). Nurses on a med-surg unit typically spend about one-third of their total working hours documenting (2). Considering a nurse on a med-surg floor spends about 2.5 hours per shift charting, that roughly translates into 7 billion hours spent charting nursing documentation each year. And that is only for the nurses!

    Every discipline of the healthcare team contributes to the patient’s medical record. These different clinicians may not have the opportunity to report off to one another, and they must refer to the medical record to gather the information they need in order to care for the patient. Even kitchen staff responsible for preparing meals for patients must be able to see the dietary order for the patient. The following are a few examples of the clinicians who contribute to or review the patient’s medical record:

    • Medical Team: physicians, nurse practitioners, physician assistants, surgeons, specialists, residents
    • Nurses and LPNs
    • Medical Assistants, CNAs, patient care assistants or technicians
    • Specialty technicians: radiology, anesthesia
    • Therapists: physical, speech, occupational, respiratory
    • Pharmacists
    • Dieticians
    • Case managers or social workers
    • Coding and billing specialists
    • Researchers

    What

    The primary purpose of the medical record is to communicate data about the patient and care provided between different members of the healthcare team. The bulk of the medical record is a collection of assessment data obtained from the patient. Details concerning assessments and results from lab tests or radiology comprise a large portion of the data. Assessment data is usually collected on a flow sheet system. Progress notes are written by the medical team or therapists and help to guide the intended plan of care for the patient. This is considered narrative charting. The medical record also includes orders for prescribed medications and treatments from the medical team. The following are typical components found in a patient’s medical record.

    • Patient demographics: name, age, gender, contact information, language, and insurance information
    • Past medical history: surgeries, chronic conditions, family history, allergies, and home prescriptions
    • History and Physical (H&P): this can contain information about admitting diagnosis or chief complaint and narrative of the story leading to admission
    • Flowsheet of assessment data: vital signs, head-to-toe assessment, intake and output record
    • Laboratory test results
    • Diagnostic test results: from radiology or procedures
    • Clinical notes: progress notes from the medical team, procedure notes, notes from consulting clinicians, education provided, and discharge planning
    • Treatment orders
    • Medication Administration Record (MAR)

    When

    The medical record should document every interaction the patient had with a member of the healthcare team. An encounter is created upon admission and everything occurring during a particular admission becomes part of the medical record. Phone calls made to patients and/or families may also become a part of the medical record.

    Where

    Medical records are stored in various ways depending on their format and the facility. Paper records from small outpatient offices may be kept onsite. Records are now largely kept electronically. This is referred to as the electronic medical record (EMR) or electronic health record (EHR) and consists of Protected Health Information (PHI). They will be stored on a secure server, typically only accessible by authorized personnel.

    Why

    The medical record is essential to nursing documentation for several reasons. The primary reason for the medical record is that it allows members of the healthcare team the ability to review and analyze data in order to deliver appropriate care. It allows clinicians to keep track of all the care that has already been completed for the patient. It also provides the patient with a record of the treatment they received for as part of their lifetime medical history. The medical record is used for coding and creating a bill for the services the patient received. Medical records may also be used for reviewing processes and research purposes. Ultimately, it is also a legal document and may be used in a court of law as applicable.

    How

    Medical records are in the final stages of evolution from a paper chart to an electronic medical record system (EMR). By 2017, 96% of acute care hospitals and over 80% of physician offices possessed certified health IT (3). This migration of medical records from paper to electronic format was made possible with advances in technology in the last 30 years. The EMR allows members of the healthcare team to access the medical record instantaneously and improves continuity of care. Utilization of the EMR ultimately reduces costs in healthcare (4) and increases efficiency.

    While EMR does have some drawbacks, the benefits that it provides are substantial enough that the government has encouraged its adaptation. The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted in 2009. This program provided tens of billions of dollars in financial incentives for healthcare facilities to adopt an EMR system (5,6).

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Make your own reference chart of the Who, What, When, Why, and How of nursing documentation.

    Privacy and Security in Nursing Documentation

    Since 1996, HIPAA, The Healthcare Information Portability and Accountability Act, has been the governing legislation that provides for the privacy protection of medical records. Compliance with HIPAA mandates that anyone who interacts with patients receives training that will ensure that they will maintain privacy for the patient. Part of the HIPAA legislation also allows the patient to request their medical records.

    The patient also has the right to request to amend their medical record. Patient permission must be given prior to a third party’s access to their medical record (7). HIPAA legislation was introduced at the advent of EMR technology. A provision of HIPAA provided a framework to ensure privacy of electronic health records (8). However, breaches in security by hackers or cyberterrorists remains a potential threat.

    Benefits of the EMR

    • Immediate data accessibility and communication of patient status
      1. Clinicians can view records remotely, analyze the findings, and place orders immediately for faster patient treatment.
      2. Multiple clinicians can view the chart at one time.
      3. Records can be viewed easily from previous admissions and/or outpatients visits easily.
      4. Records can be instantly shared between facilities (in instances of shared systems).
    • Reduction in errors
      1. Errors due to misinterpretation of handwriting in nursing documentation are eliminated.
      2. Allows for increased safety checks. The EMR can be set to flag missing components of information, tasks that were not yet completed or are overdue, recognize duplicates, and present warnings if documentation has not yet been validated or “signed.”
      3. Scanning medications is possible with EMR systems to reduce the risk of medication administration errors.
    • Assists with appropriate billing by capturing charges of services provided to the patient.
    • The EMR can provide reminders for necessity of certain preventative health screenings or vaccines.
    • Automatic “signature” of data is completed simply by the user logging in with a unique ID and password. All entries are date and time stamped. If a correction is made, the original data can be accessed.
    • Accessing patient EMR is tracked and can be audited to protect patient privacy from unnecessary viewing.

    Downsides of the EMR

    It is expensive to convert records system to an electronic system:

    1. The initial cost of the EMR software is very expensive
    2. More work hours must be paid for staff training and coverage of patients during initial implementation of the program
    3. Maintaining appropriate encryption and cybersecurity technology against viruses and hacking are also a costly component

    Computer systems can be temporarily inaccessible, for example when updates and reboots are required. Paper charting is still necessary in the interim.

    Template charting has limitations (9). Templates for nursing documentation may not exist for a specific problem and does not accurately reflect the patient’s condition. Atypical patients may have multiple problems or extensive interventions that must be documented in detail.

    Templates may also encourage cloned or copied documentation. It creates unnecessary redundancy and at times inaccurate information in the EHR. Some EHR systems are designed to facilitate cloning with such popular features as:

    • “Make me the author” to assume the content of another person’s entry
    • “Demo recall” of “Duplicate Results” to copy forward vital signs or assessment data
    • “Smart phrases” pulls in specific identical data elements

    Automated insertion of previous or outdated information through EHR tools, when not modified to be patient-specific and pertinent to the visit, may raise significant quality of care and compliance concerns.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Create a T-chart of the benefits versus downsides to EMR.

    The Legal Requirements

    If it wasn’t documented, it wasn’t done. Every healthcare practitioner has had this mantra ingrained in them from the very beginning of their career. Nurses are trained to document defensively, that is, if they are taught at all.

    In a 2014 study, only 20% of new graduate nurses had received electronic medical record training as a part of their nursing school curriculum (6). It is not uncommon for clinicians to have the tendency to view the medical record as a defense tool against potential legal problems, rather than its more significant role as a communication tool for patient care.

    Regardless, accurate and complete documentation is essential. Your career, and more importantly, patient care, depends on it.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Did you receive proper training on documentation in your nursing program?
    2. How can programs be improved to better prepare nurses?

    When Nursing Documentation Becomes Your Defense

    In the dreaded event of a legal problem, medical records will be scrutinized to every detail. It is usually the primary source of evidence for the case. A malpractice lawsuit requires four elements to be proven (10):

    • That a medical professional assumed a duty to provide care for the patient.
    • The clinician failed to provide appropriate care within their scope of practice for the patient.
    • The failure in appropriate care caused an injury to the patient.
    • The injury resulted in damage to the patient.

    Potential legal problems that may arise include the following (11):

    • Administrative liability – Professional licensure discipline and/or discharge (firing) from position.
    • Civil Liability – Malpractice lawsuit, failure to provide necessary care.
    • Criminal liability – Misdemeanor or felony charges for cases of gross negligence.

    The Cost

    Fortunately, medical malpractice claims have begun to drop since 2001. In 2004, the medical practitioners involved who were known as the defendants won the case 83% of the time. The legal fees can still amount to $18,000 if the case is dropped, to as much as $93,000 even when the case is won (12,13).

    In 2018, there were 8,718 malpractice cases that resulted in payments to injured patients (14). Of those events, 310 reports of malpractice suits that resulted in payments related to nursing care.

    However, 180 of those, about 60% of those had payments to the injured patient that were over $50,000 (14). However, there were nearly 15,000 adverse action reports filed against nurses, which was more than the number combined filed against physicians, NPs, and PAs combined.

    The majority of medical malpractice cases primarily target the physician and the facility. However, anyone who made an entry into the patient’s medical record may be required to participate in legal proceedings.

    Most common malpractice claims against nurses include failure to (15):

    • Follow standards of care
    1. Follow safety protocols
    2. Perform procedures according to guidelines
    3. Use equipment properly

    Use or operate equipment within the manufacture’s details

    • Failure to correctly document
      1. Communication with the provider
      2. The care you completed
    • Follow assess and monitor
      1. Report a change in status of the physician
      2. Assess a patient with change in status
    • Communicate pertinent data
      1. Provide appropriate discharge education and information
      2. Communicate properly and completely between shifts
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Think about the last difficult shift you had. Did you properly complete nursing documentation?
    2. How would you prioritize documentation differently after reading this module?

    What is Required for Nursing Documentation?

    Necessary medical record nursing documentation can vary significantly depending on the care area. For example, the documentation a circulating nurse in the operating room completes will be very different from what is documented on an emergency room patient. While the basic principles of documentation stay constant, the nurse needs to be familiar with the documentation requirements for that area based on requirements of the state board of nursing, the facility, and the unit.

    There are standard requirements for medical record documentation that are applicable in all patient care settings, and in both paper and EMR systems. These standards include the following (16):

    • Accurate: Clinicians must be careful to proofread documentation to make sure it is free from errors. A small typo can have serious repercussions, as it is more likely to be misinterpreted by others.
    • Relevant, concise, organized and complete: It is important to keep the information concise and relevant so that other care providers can quickly find the pertinent information that they need. Assessment data should be entered in a systematic way. Complete documentation ensures all of the unit policies for documentation are addressed.
    • Free of bias: Clinicians should only include information that is pertinent to the care of the patient and remain free from personal bias. Direct quotations within the proper context should be utilized with proper context.
    • Factual: Clinicians should not exaggerate or minimize findings. Charting is to be completed after completing a task, not before. Do not speculate data. Observations need to include exact times and measurements. Avoid approximations. Make sure to chart on the correct patient.
    • Timely: What occurred during the shift should be documented during the shift. Documentation should be done as soon as possible after completing tasks. If something needs to be added in after the shift was completed, it should be denoted as a late entry with a reason as to why. Your facility likely has strict requirements regarding late entries.
    • Legible/decipherable and clearly written: Paper documentation must be clearly legible. Writing must clearly convey meaning.
    • Standardized: Clinicians must use appropriate medical terminology and approved acronyms and abbreviations.
    • Labeled and Auditable: Paper documentation must be signed with credentials and must include date and time of the entry. When charting in the EMR, all entries and corrections are recorded and time stamped. Password sharing or having another clinician assist in documenting under incorrect username is fraudulent.
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Do you currently incorporate all of the above principles in your documentation?
    2. If not, how can you change your practice to improve your documentation?

    Examples of Effective and Ineffective Charting

    The following will show some examples of these principles in action. These are based on the scenario of a patient admitted in the Emergency Department for chest pain.

      Example of Effective Documentation Example of Ineffective Documentation
    Accuracy Patient stated she took 800mg of Tylenol at 4pm, an hour after she began to feel chest pain. Patient reports she took pain med for chest pain.
    Relevant Patient stated she has never experienced chest pain prior to this event, and does not have a history of cardiac problems. Patient was a competitive athlete 20 years ago and used to be in great shape. Patient thinks she is still pretty healthy.
    Concise Vital signs taken, telemetry monitor applied, lab samples collected and PIV started per the chest pain protocol. Patient was triaged and immediately brought to exam room. In accordance with the chest pain protocol, vital signs were taken first. Then the patient had a telemetry monitor applied. Next, the patient had blood samples drawn through the inserted PIV catheter.
    Organized

    Patient reports no allergies

    Prescriptions include hormone replacement therapy

    Past medical history includes hysterectomy and foot surgery from a few years ago

    Patient family history includes cardiovascular disease on her father’s side of the family

    Patient denies smoking, illicit drug use, but does drink 3 times a week

    Patient reports feeling fine until 1 hour after lunch when chest pain began.

    Patient was feeling fine until one hour after lunch, when she started to feel chest pain. Patient has no history of cardiac problems. However there is family history of cardiovascular disease on the father’s side. Patient had a hysterectomy and foot surgery a few years ago. Patient denies smoking and illicit drug use. Patient does take hormone replacement therapy prescription. Patient does not have any allergies. Patient reports drinking alcohol x3/week.
    Complete Patient complaining of 8/10 chest pain, described as “stabbing.” Pain has been experiencing this pain for three hours. She has taken Tylenol, but nothing is able to alleviate the pain. Patient is complaining of chest pain.
    Free of Bias Education provided per chest pain protocol. Patient was instructed to call 911 immediately if experiencing chest pain in the future. Patient verbalized understanding. Patient was given needed education about chest pain since she clearly didn’t understand that chest pain cannot wait 3 hours and she needs to call 911 right away because she can die of a heart attack.
    Factual Patient reports last meal was around 1300 which consisted of spicy foods. Her chest pain onset was 30 minutes after. She waited an additional three hours before seeking emergency care. Patient presented to ER after lunch.
    Legible/Decipherable Patient was instructed to call for assistance with ambulation and how to utilize call light. Patient cannot safe walk by she self. Call light assistance. Bathroom walk with me.
    Standardized Morphine Sulphate 2mg IV push, once PRN for 8/10 pain per chest pain protocol. MSO4 2.0 mg, IV push, x1.
    Timely Documentation is completed in real-time, all documentation completed before transferring patient to telemetry. Nurse documents three days later due to high volume of patients.
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. How can you ensure that your charting is free of bias?

    Common Documentation Errors

    • Falsification of a record. This can happen when charting an action isn't completed in a timely manner, or from charting information before that action was completed.
    • Fraudulent charting is the act of knowingly making a false record. Criminal charges of forgery can result if the misrepresentation is done for personal gain. An example of this would be a nurse documenting at administration of a controlled substance but instead was diverting the medication.
    • Inappropriate use of cloning features. Information “copied and pasted” from a different patient’s record or that is completed by another provider. Data copied from previous shift assessments that isn’t updated to reflect current status is also a false record (9).
    • Fail to document communication. Notification of the medical team of a change in patient status or critical lab values should always be included. Clarification or confirmation of orders should also be documented (17). Include notification of other providers who assisted with patient are. This includes failure to document transfer of care to another nurse.
    • Failing to document a reason why something isn’t done. If a patient doesn’t receive a prescribed medication, the reason why the medication isn’t given needs to be described. If you communicate with the provider, this should also be included.
    Quiz Questions
    1. If you could alter your documentation, how would you better document in this situation?
    2. Have you ever failed to document or failed to document a critical portion of care?

    Self Quiz

    Ask yourself...

    Conclusion

    Including all of the necessary information into each patient’s medical record can be a daunting task. The nurse must make sure that they have included all of the relevant and accurate information that is required by their facility guidelines. It must usually be done in a loud environment and is frequently interrupted by actually having to provide care to the patients.

    It is not only a tedious chore, but it also tends to cause a lot of apprehension. There is usually a worry of “did I chart enough?” or “did I chart everything I needed to?” This is due to the defensive practices and attitudes healthcare workers have adapted to protect against malpractice lawsuits. In this way, charting is similar to paying taxes. No one likes it, but it still has to be done.

    Perhaps a way to develop a healthy perspective toward charting is to change the focus to its original purpose: to communicate care about the patient. The purpose of charting is to relay to the other healthcare team members what is going on with the patient. With this objective in mind, the nurse will inevitably cover all the necessary details and it may also be a bit more satisfying to know that even though they are in front of the computer, they are performing and completing important information for the patient. 

    Nursing Ethics

    Introduction   

    Ethics are an important aspect of all professions, but in this case, we are going to touch on its role in nursing. From the beginning, Florence Nightingale was a strong advocate and initiated nursing ethics and morals. For the 19th consecutive year, nursing has been ranked number one by the Gallup Poll as the most honest and ethical profession (1). The designation creates a larger responsibility to understand the American Nurses Association (ANA) Code of Ethics and how to apply them to practice. Daily, nurses face ethical challenges and are confronted with situations with competing values and interests (2). How do we identify the issues? How do we respond to them? To understand our responsibilities as nurses, one must be aware of the details and applications of the ANA Code of Ethics with Interpretive Statements that give voice to nursing’s social mandate (3). 

    History 

    Did nursing exist before Nightingale?  Yes, but not in an organized fashion, as the formalization of an ethical model began in the mid-1800s with Nightingale. Prior to the development of a formal training program, nursing was thought to be disreputable, and many persons providing care-giving services were sex workers. Nightingale was the first to instill morals and ethics into education and practice. In 1889, the Trained Nurse and Hospital Review journal was published, including a six-part series on ethics (3).   

    Following, in 1893, the Nightingale Pledge was written by Listra Gretter to be used at the Farrand Training School for Nurses in Detroit, Michigan (4). The Pledge is as follows:  

    "I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician in his work and devote myself to the welfare of those committed to my care." (4) 

       The Pledge was written 128 years ago; the changes and challenges in nursing over these years are immeasurable.  

    Professional Ethics 

    Each profession has its own board with specific rules of ethical standards and principles; these standards and principles include honesty, respect, adherence to the law, avoidance of harm, integrity, and accountability. The specifics may differ per profession, but the basics are the same.  

    Nursing Ethics, Principles and Values 

    Although nothing had yet been formalized, the idea of ethics in nursing began to spread during the early 1900s. The ANA developed the first Code of Ethics in 1950, and did not revise it until 2015. The principles of ethics rely on several terms, defined as follows: 

    Autonomy: This can be as simple as listening to a patients' individual rights for self-determination, including informed consent and patient choices. How this is viewed depends on the situation (5). It is important to note, in cases of endangering or harming others, for example, through communicable diseases or acts of violence, people lose this basic right (5). 

    Beneficence: This term refers to doing good and is part of the Nightingale Pledge and the Hippocratic Oath. Showing acts of kindness and facilitating wellbeing are great examples.  However, it is important to understand that we as nurses, may think that we know what is best for our patient, but it is never a guarantee if they will agree with us; this is referred to as paternalism (5).  

    Justice: This is including the principle that covers normative aspects that are often discussed in terms of solidarity and reciprocity. Fair distribution of resources and care is an important aspect of this principle (5).  

    Non-maleficence: This term almost directly translates to ‘do no harm,’ and can be part of confidentiality or other acts of care that can involve possible negligence. Additionally, it is used in end-of-life situations and decisions of care with terminally or critically ill patients (5).  

    Fidelity: This is the basic principle of keeping your word, and can be included in providing safe, quality care (5). If you tell a patient you will be back to check on their pain level, and you in fact, do check back, that is fidelity – you have kept your promise.   

    Veracity: This term requires that you be truthful, accurate, and loyal to not only your patients and their families, but your co-workers as well. Are we telling our patients the truth? Are we holding back information about their conditions? Things to think about include pain medication and dosages (5). Placebos are an example of veracity. 

    Accountability: This is your responsibility of judgment and actions. To whom are you accountable? Examples include yourself, your family, colleagues, employer, patient, and the nursing board. We must take responsibility for our own actions (5). The following are components of accountability: 

    1.  Obligation: a duty that usually comes with consequences. 
    2. Willingness: accepted by choice or without reluctance. 
    3. Intent: the purpose that accompanies the plan. 
    4. Ownership: having power or control over something. 
    5. Commitment: a feeling of being emotionally compelled (5).

    When examining nursing ethics, one must consider that the profession has three entry levels: diploma, Associate, and Baccalaureate degrees. This can affect what each nurse learns about, including values and ethics as well their real-life application.  

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. When did nursing ethics begin to develop? 
    2. How do you define ethics? 
    3. What are the six principles of ethics? 
    4. How do you view patient autonomy? 
    5. Do you think the different entry levels for nursing make a difference in ethics? 

    Foundations of Nursing Ethics 

    Nightingale was the first to teach ethics in nursing and set strict codes for those under her supervision; today, the ANA Code of Ethics serves as a concise statement of ethical obligations and duties of every person that enters into the profession.   

    The first three provisions of the ANA Code of Ethics describe the most fundamental values and commitments a nurse must make. The following three include boundaries of duty and loyalty, and the last three demonstrate aspects of duties beyond individual patient encounters.   

    Values are an important provision that remind us (as individuals) that we all have morals.  As young children that are developmentally progressing, we start learning or inheriting these values from our families. What happens when your personal values are different from the values of the profession? This can also be a part of spiritual, ethnic, and cultural differences (5). 

    The Worldview is inclusive of ethical and moral discussions, as well as dilemmas for nurses around the world and primarily focuses on four elements: people, practice, profession, and co-workers (6). The International Council of Nurses (ICN) is more directed toward the Worldview. Not all are included in the ANA Code of Ethics. 

    An interesting factor to note is that the ICN Worldview focuses on co-worker relationships: "Nurse bullying occurs in almost all care settings and units, from the patient floor to the executive suite. In fact, 60% of nurse managers, directors, and executives in one 2018 study said they experienced bullying in the workplace, and 26% considered the bullying "severe" (7). Workplace intimidation is any intimidating or disruptive behavior that interferes with effective healthcare communication and threatens patient safety; it is often categorized as horizontal or relational aggression. Improving how management addresses such issues in nursing may be critical not only for staff turnover, but for patient outcomes.   

    There is some reluctance to specify the sorts of behavior that will not be tolerated, but effective anti-bullying practices must include a statement of exactly what constitutes bullying. From an ethical perspective, the acceptance of nurses who “eat their young” should no longer be tolerated.  

    Quiz Questions

    Self Quiz

    Ask yourself...

    1.  What is the background of the ANA Code of Ethics? 
    2. Have you read the ANA Code of Ethics? 
    3. Evaluate and review horizontal aggression in the workplace. Have you experienced it? 
    4. How does your personal culture and background affect your practice? 
    5. What workplace behaviors should not be tolerated? 

    Application 

    As patient advocates, nurses work as part of an interdisciplinary team to provide patient care. Nursing ethics have kept pace with the advancement of the profession to include a patient-centered focus rather than a physician-centered focus. Due to its main focus of providing care, nursing ethics are often different than medical ethics; and it is important for us to understand the differences.  

    As we discuss application, one must take into consideration the workforce of nurses today.  In many facilities, nursing staff may encompass at least three and maybe even four generations. This also applies to our patients. Those generations are identified as follows: 

    • Traditionalists or Silent Generations (1922- 1946):  

    - Respect authority, are hardworking, and sacrificial for their work. 

    - Many have delayed retirement (8). 

    • Baby Boomers (1946- 1964): 

    - Possess a belief that workers must pay their dues, are a workaholic, and typically rely on traditional learning styles (8). 

    • Generation X (1965-1977): 

    - Independent, a skeptic of authority, and self-reliant (8). 

    • Generation Y (1978-1991): 

    - Team-oriented, tech-savvy, entrepreneurial, and has a desire to receive feedback (8). 

    • Generation Z (1992- 2010): 

    - Tech savvy, understand the power of text and social media (8).

    No matter what generation you fall into, it is important to understand different personalities and their learning styles.  

    A prime example of the generational learning styles differing and potential issues that may arise is the usage of electronic health/medical records (EMR) and various other health information technologies that are often incorporated into daily nursing practice. Nurses that come from older generations may struggle with these more, as they have experienced its transition and had to adapt.   

    Following, as the prevalence of social networking platforms continue to rise, it is important for nurses to understand the ethics of social media. Issues of privacy confidentiality and anonymity are ethical concerns when mixing personal and professional information on a social media platform; it is also important to note that most healthcare facilities have strict policies regarding social media. 

    End-of-Life 

    End-of-life issues are filled with nursing ethics and dilemmas. If the advanced directive is not clear, family issues and other complications trigger many of the ethical principles. Self – determination (the right to stop or refuse treatment) is complicated, the patient may not always have their wishes on paper, and often, families often do not want to let go. Nurses are the backbone of allowing the patient's wishes to be known. It is important that nurses know that they can request an ethics committee review for their patients if they feel their wishes are being violated.  

    Additionally, physician-assisted suicide can be an extraordinarily complex issue. For both the Hippocratic Oath and the Nightingale Pledge, there are ethical issues. Currently, the following states have made physician-assisted suicide legal: California, Colorado, Hawaii, Maine, New Jersey, Oregon, Montana, The District of Columbia, and Washington (9). With the ever-expanding ability to both prolong and end life, nurses must be cognizant and prepared for all repercussions associated with life and death situations (10). 

    With recent societal and technological advancements in science and medicine, choices involving both life and death are seeming to become more complicated. As a result of this worldwide controversy in healthcare, many nurses nation-wide are now forced to deal with this ethical dilemma head on (10). There are and will be many debates as to the ethical issues involved in physician -assisted suicide and something on the forefront for nursing to consider. 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Evaluate your work environment and the differences in generations.  
    2. Think about what ethical dilemmas you face daily. 
    3. Has technology increased the ethical dilemmas in your practice? 
    4. Do you know how to access your facilities ethic committee? 
    5. What are your thoughts on physician-assisted euthanasia? 

    The ANA Code of Ethics 

    The ANA Code of Ethics serves to guide nurses in maintaining ethical standards and in ethical decision-making. Additionally, it outlines the obligations nurses must have for their patients and the nursing profession. The provisions focus on the following as stated by Lockwood (11):  

    1. Respect for human dignity: The nurse must show respect for the individual and consider multiple factors (belief systems, gender/sexual identification, values, right to self-determination, and support systems) when planning and providing care. The nurse ensures patients are fully informed and prepared to make decisions about their healthcare and to carry out advance healthcare planning.
    2. Commitment to patients: The nurse must always remember that the primary responsibility is to the patient and help resolve conflicts between the patient and others and avoid conflicts of interest or breach of professional boundaries.
    3. Protection of patients’ rights: The nurse must be aware of legal and moral responsibilities related to the patients’ rights to privacy and confidentiality (as outlined by HIPAA regulations) and research participation. 
    4. Accountability: The nurse bears primary responsibility for the care of the patient and must practice according to the Code of Ethics and the state nurse practice act and any regulations or standards of care that apply to nursing and healthcare.
    5. Professional growth: The nurse must strive always to promote health, safety and wellbeing of self and others. The nurse must, in all circumstances, maintain personal integrity and report violations of moral standards. The nurse has a right to refuse to participate in actions or decisions that are morally objectionable but cannot do so if this refusal is based on personal biases against others rather than legitimate moral concerns.
    6. Improvement of healthcare environment: The nurse must recognize that some virtues are expected of nurses, including those associated with wisdom, honesty, and caring for others, and that the nurse has ethical obligations toward others. The nurse is also responsible for creating and sustaining a moral working environment. 
    7. Advancement of the profession: The nurse must contribute to the profession by practicing within accepted standards, engaging in scholarly activities, and carrying out or applying research while ensuring the rights of the patients are protected.
    8. Health promotion efforts: The nurse recognizes that health is a universal right for all individuals and collaborates with others to improve general health and reduce disparities. The nurse remains sensitive to cultural diversity and acts against human rights violations, such as genocide, and other situations that may endanger human rights and access to care.
    9. Participation in goals of the profession: The nurse must promote and share the values of the profession and take action to ensure that social justice is central to the profession of nursing and healthcare.

    Conclusion 

    In conclusion, nurses face ethical dilemmas in practice almost every day, which is why it is so valuable for nurses to understand the philosophy of nursing ethics and its application in practice.  

    Infection Control and Barrier Precautions

    Healthcare professionals have the responsibility to adhere to scientifically accepted principles and practices of infection control in all healthcare settings and to oversee and monitor those medical and ancillary personnel for whom the professional is responsible.

    Introduction   

    The healthcare industry is held accountable to keep patients safe with nursing having a pivotal role. Nurses must adhere to the guidelines set in place to ensure that care is aimed at infection prevention for both healthcare workers and patients. Modes and mechanisms of transmission of pathogenic organisms in the healthcare setting and strategies for prevention control are necessary. As is the use of engineering and work practice controls to reduce the opportunity for patient and healthcare worker exposure to potentially infectious material in all healthcare settings.  Creation and maintenance of a safe environment for patient care in all healthcare settings through application of infection control principles and practices for cleaning, disinfecting, and sterilization is extremely important.


    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Why is it important to adhere to infection control guidelines?

    Element I

    Healthcare professionals have the responsibility to adhere to scientifically accepted principles and practices of infection control in all healthcare settings and to oversee and monitor those medical and ancillary personnel for whom the professional is responsible.

     

    Element I Objectives

    At the conclusion of course work or training on this element, the learner will be able to: 

    • Recognize the benefit to patients and healthcare workers of adhering to scientifically accepted principles and practices of infection prevention and control. 
    • Recognize the professional’s responsibility to adhere to scientifically accepted infection prevention and control practices in all healthcare settings and the consequences of failing to comply. 
    • Recognize the professional’s responsibility to monitor infection prevention and control practices of those medical and ancillary personnel for whom they are responsible and intervene as necessary to assure compliance and safety. 

    The healthcare industry is held accountable to keeping patients safe, with nursing having a pivotal role. Nurses must adhere to the guidelines set in place to ensure that care is aimed at infection prevention for both healthcare workers and patients.

    Statements from Relevant Professional and National Organizations

    As the largest healthcare workforce in the nation, nurses are able to positively affect the rates of infection at the bedside. The Center for Disease Control asserts the minimum accepted practice of preventing infection is with the use of Standard Precautions, with the number one action in prevention being proper hand washing (3). 

    The American Nurses Association refers to similar basic tenets of infection prevention: thorough hand washing, staying home when ill, ensuring vaccinations are complete and up to date, using appropriate personal protective equipment, and covering face when coughing or sneezing (4). 

    In 2017, the CDC, ANA, and 20 other professional nursing organizations collaborated to create the Nursing Infection Control Education (NICE) Network. This team effort is aimed at introducing clear obligations and competencies for nursing and all healthcare providers to stop the spread of microorganisms within health care systems. Within these cores is the responsibility of nursing as leaders within healthcare, “To be successful, infection prevention programs require visible and tangible support from all levels of the healthcare facility’s leadership” (5). 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Which organizations have collaborated to put guidelines in place?
    2. What does this say about the importance of infection control?

    Implications of Professional Conduct Standards

    As healthcare professionals that participate in and supervise care of patients, nurses are responsible for being knowledgeable of the guidelines set by State and federal bodies. Several of these will be touched on throughout this course. 

    The responsibility also applies to delegated activities. The nurse must ensure that the five rights of delegation are considered when assigning a task to unlicensed assistive personnel and that appropriate infection control policies and protocols are being followed appropriately. Always refer to facility policies and procedures to avoid potentially adverse outcomes. 

    Failure to follow the accepted standards of infection prevention and control may have serious health consequences for patients, as well as healthcare workers. Hospital acquired infections (HAI) have improved by 16% from 2011 to 2015; however, the CDC reports that in 2015 there were still approximately 687,000 HAIs with 72,000 resulting in death (6). 

    In cases of nurses observing incompetent care or unprofessional conduct in relation to infection control standards, the chain of command should first be utilized. Taking consideration into the type of misconduct, the improper infection control infraction should be addressed according to facility policy. Charge nurses and managers would be wise to first address the issue with the nurse involved to gather information and address any education deficits. 

    In cases where clear misconduct is evident, the National Council of State Boards of Nursing advises, “A nurse’s practice and behavior is expected to be safe, competent, ethical and in compliance with applicable laws and rules. Any person who has knowledge of conduct by a licensed nurse that may violate a nursing law or rule, or related state or federal law may report the alleged violation to the board of nursing where the conduct occurred” (7). 

    Consequences of failing to follow accepted standards of infection prevention and control may result in a complaint investigation from your various state of employments Professional Misconduct Enforcement Systems. Upon investigation, penalties include, but are not limited to, reprimand and censure, fines totaling thousands of dollars per violation, and probationary terms. 

    Severe misconduct may result in the loss or revocation of a nursing license. As well, in cases where the neglect to follow appropriate conduct has resulted in harm to a patient or co-worker, there is potential for professional liability through a malpractice suit brought against the nurse.

    Methods of Compliance

    Nurses are responsible for being knowledgeable of the licensure renewal requirements and targeted education in their state of practice. Refer to your specific state’s Board of Nursing for further guidance beyond the above-mentioned licensing requirements. 

    Education of infection control best practice, complying with state requirements, and following the facility practices and policies will provide the best protection for self, patients, and staff in preventing and controlling infection during patient care.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Can you list some requirements in your specific state, regarding infection control?

    Element II 

    Modes and mechanisms of transmission of pathogenic organisms in the healthcare setting and strategies for prevention control.

     

    Element II Objectives

    Upon completion of course work or training on this element, the learner will be able to: 

    • Describe how pathogenic organisms are spread in healthcare settings 
    • Identify the factors which influence the outcome of an exposure to pathogenic organisms in healthcare settings 
    • List strategies for preventing transmission of pathogenic organisms 
    • Describe how infection control concepts are applied in professional practice

    Definitions

    Pathogen or infectious agent:  A biological, physical, or chemical agent capable of causing disease. Biological agents may be bacteria, viruses, fungi, protozoa, helminths, or prions. 

    Portal of entry: The means by which an infectious agent enters the susceptible host. 

    Portal of exit: The path by which an infectious agent leaves the reservoir. 

    Reservoir: Place in which an infectious agent can survive but may or may not multiply or cause disease. Healthcare workers may be a reservoir for several nosocomial organisms spread in healthcare settings. 

    Standard precautions: A group of infection prevention and control measures that combine the major features of Universal Precautions and Body Substance Isolation and are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. 

    Susceptible host: A person or animal not possessing sufficient resistance to a particular infectious agent to prevent contracting infection or disease when exposed to the agent. 

    Transmission: Any mechanism by which a pathogen is spread by a source or reservoir to a person. 

    Common vehicle: Contaminated material, product, or substance that serves as a means of transmission of an infectious agent from a reservoir to one or more susceptible hosts through a suitable portal of entry. 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. In what context have you used this terminology in your facility?

    Overview of Components of the Infectious Disease Process

    The infectious disease process follows a particular sequence of events that is commonly described as the “The Chain of Infection.” Nurses must have a solid understanding of this process in order to identify points in the chain where the spread of infection may be prevented or halted. The sequence involves six factors: pathogen, reservoir, portal of exit, portal of entry, mode of transmission, and a susceptible host. The cyclical and consistent nature of the chain provides ample opportunities to utilize scientific, evidence-based measures in combating infection spread. 

    Pathogens within healthcare are widespread and plentiful, putting patients and healthcare workers at particular risk for contamination. The manifestation of symptoms and mode of transmission is varied depending upon the characteristic of the specific infectious agent. Healthcare workers are at a much higher risk for bloodborne pathogens such as human immunodeficiency virus (HIV), hepatitis B virus, and hepatitis C virus. Influenza, methicillin-resistant Staphylococcus aureus (MRSA), and Tuberculosis (TB) also poses a higher risk (1). Due to the immunocompromised systems of patients, these and many other pathogens cause a considerable risk and can result in HAIs such as Central Line-associated Bloodstream Infection (CLABSI), Catheter-associated Urinary Tract Infections (CAUTI), Surgical Site Infection (SSI), and Ventilator-associated Pneumonia (VAP) (1). 

    Pathogens require a reservoir, which is typically a human or animal host; however, may also be from the environment, such as standing water or a surface. From the reservoir, the pathogen is spread via a mechanism such as body fluid, blood, or secretions. Common sites for contact within patient care include the respiratory, genitourinary, and gastrointestinal tracts, as well as skin/mucous membranes, transplacental, or blood. From here, the mechanism must come into contact with another portal of entry. Transmission may occur through respiratory, genitourinary, and gastrointestinal tracts, skin and/or mucous membranes, transplacental, and parenteral pathways. Some of these sites may have become compromised during patient care due to percutaneous injury, invasive procedures or devices, or surgical incisions. 

    In order to acquire a pathogen, a mode of transmission must be provided. These can be from contact, transmission via a common vehicle, or vector borne. 

    Contact with a pathogen may be categorized as direct, indirect, droplet, or airborne. Contact transmission is through direct or indirect contact with a patient or objects that have been in contact with the patient. Pathogens related to this include Clostridium difficile and multi-drug resistant bacteria such as MRSA. Droplet transmission occurs when a pathogen can infect via droplets through the air by talking, sneezing, coughing, or breathing. The pathogen can travel three to six feet from the patient. Airborne transmission occurs when pathogens are 5 micrometers or smaller in size and are capable of being suspended in the air for long periods of time. These types of pathogens include tuberculosis, measles, chickenpox, disseminated herpes zoster, and anthrax (2). 

    Transmission may also occur through a common vehicle which affects multiple hosts and can come from food, intravenous fluid, medication, biofilms, or equipment that is shared and often leads to widespread outbreaks. Vector borne pathogens are derived from a living vector such as mosquitoes, fleas, or ticks. 

    The last factor in the chain of infection is a susceptible host with a mode of entry. This is the reason that patients are at a much higher risk for developing secondary infections within the healthcare system.  

    Factors Influencing the Outcome of Exposures

    The human body provides several natural defenses to prevent infection from a pathogen. The most prominent defense is the integumentary system and focus should be on maintaining skin integrity to prevent a mode of entry. Respiratory cilia function to move microbes and debris from airway. Gastric acid is at an optimal pH level that prevents the growth of many pathogens. Bodily secretions provide defense through flushing out and preventing back-flow of potential infectious agent colonization.  The normal flora also provides a layer of defense that must take care to not be compromised through use of antibiotics. Probiotics are commonly administered to patients on antibiotics to prevent a secondary infection due to the normal flora being disrupted (3). 

    Host immunity is the secondary defense that utilizes the hosts own immune system to target invasive pathogens. There are four types of host immunity (all from 3): 

    • Inflammatory response is pathogen detection by cells in a compromised area that then elicit an immune response that increases blood flow. This inflammatory response provides delivery of phagocytes or white blood cells to the infected site response. The phagocytes are designed to expunge bacteria. 
    • Cell mediated immunity uses B-cells and T-cells, specialized phagocytes, are cytotoxic cells which target pathogens. 
    • Humoral immunity is derived from serum antibodies produced by plasma cells. 
    • Immune memory is the ability of the immune system to recognize previously encountered antigens of pathogens and effectively initiate a targeted response. 

    Pathogen or Infection Agent Factors

    For each type of infectious agent, there are specific factors that determine the risk to the host. Infectivity refers to the number of exposed individuals that become infected. Pathogenicity is the number of infected individuals that develop clinical symptoms and virulence is the mortality rate of those infected. The probability of an infectious agent to cause symptoms depends upon the size of inoculum (amount of exposure), and route and duration of exposure (4). 

    The environment is another factor that warrants attention in limiting the probability of exposure in the healthcare setting. Fomites are materials, surfaces or objects which are capable of harboring or transmitting pathogens. These can be bedside tables, scrubs, gowns, bedding, faucets, and any other number of items that are in contact with patients and healthcare providers (7). 

    Equipment is also a common means of spreading infection, especially portable medical equipment that can come into contact with numerous patients in a day. This can include vitals machines, IV pumps, wheelchairs, and computers on wheels, among numerous other care items frequently used. Care must be taken to ensure cleaning in between each patient use. For patient’s in isolation, dedicated equipment for that patient should remain in the room for the duration of stay. 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. How can you limit the outcome of exposures as a medical professional?

    Methods to Prevent the Spread of Pathogenic Organisms in Healthcare Settings

    Standard Precautions

    Standard precautions are the minimal amount of caution and procedure applied to typical patient care. According to the CDC, standard precautions are to be used in all patient care areas with critical thinking applied to “. . . common sense practices and personal protective equipment use” (5).  The primary of these is proper hand hygiene to be exercised by healthcare providers, patients, and visitors. They will be covered in further detail in this course. 

    Standard precautions provide guidelines for respiratory hygiene and cough etiquette. The CDC recommends that the mouth and nose be covered with a tissue when coughing or sneezing, with appropriate disposal of the tissue in the nearest waste station. Hand hygiene is to be performed after any contact with any respiratory secretions or contact with potentially contaminated items (5). 

    As mentioned, healthcare workers are at a higher risk for bloodborne infections due to handling of sharps. Approximately 385,000 needle sticks and sharps injuries are reported by healthcare workers in hospital settings each year (5). Standard precautions can be applied to ensure safe injection practices and will be further covered in Element III. 

    Certain spinal procedures that access the epidural or subdural space provide a means of transmission for infection such as bacterial meningitis. The CDC states (all from 6): 

    • Face masks should always be used when injecting material or inserting a catheter into the epidural or subdural space. 
    • Aseptic technique and other safe injection practices (e.g., using a single-dose vial of medication or contrast solution for only one patient) should always be followed for all spinal injection procedures. 
    For Patients Infected with Organisms other than Bloodborne Pathogens 

    Special considerations must be given to patient populations that are infected with organisms other than bloodborne pathogens. During triage of a patient entering a facility, a thorough history should be obtained. This would include exposure to infectious agents, travel to certain countries in the world, and previous infections that are resistant to antibiotics (i.e., MRSA, VRE, or carbapenem-resistant Enterobacteriaceae). Patients that are identified with risk may be placed on the appropriate precautions in an isolation room. Infection prevention and the attending physician should be consulted immediately for further orders and treatment. 

    Control of Routes of Transmission 

    Controlling the routes of transmission is a key factor in preventing infection spread. Hand hygiene has been established as providing the primary prevention method. Care must be taken to follow guidelines for proper hand washing including: 

    • Use antibacterial soap and water when hands are visibly soiled or when a Clostridium difficile infection is known or suspected. 
    • Hands should be lathered ensuring all surfaces, between fingers, and under nails is covered and scrubbing should last at least 20 seconds. 
    • Thoroughly rinse soap from hands with running water, pat dry with paper towel, and use paper towel to turn off faucet.
    • Hand sanitizer that is at least 60% alcohol based may be used in between soap and water use. 
    • A dime sized amount of hand sanitizer should be rubbed over surface of hands and fingers, then allowed to air dry. 

    Barriers to proper hand hygiene include knowledge gaps and availability of appropriate supplies. Training programs to educate healthcare providers on proper hand washing should be accompanied with ongoing assessment and feedback to ensure that compliance is met. Incorporating hand hygiene into the professional development plan of each nurse is also recommended (7). Healthcare facilities should be diligent in ensuring that hand washing stations are located in convenient areas and that hand cleaning product is frequently monitored and refilled (7,8). Signage and educational materials may be posted in high traffic areas and at hand washing stations to encourage use by healthcare providers, patients, and visitors (7). 

    Nurses and healthcare personnel must be aware of the potential of hand hygiene materials as being a possible source of contamination or cross-contamination. Hand hygiene dispensers are touched frequently with contaminated hands and must be frequently cleaned. Follow manufacturers recommendations for cleaning. 

    Hand hygiene systems that allow product to be refilled pose a risk of contaminating the contents. If refilling is a requirement, this should be accomplished using aseptic technique as much as possible. Facilities should avoid purchasing this type of product and move to pre-filled dispensing units, if possible (10). 

    Use of Appropriate Barriers

    Appropriate barriers are essential in keeping patients and healthcare providers safe from transmitting or contracting pathogens. The type of PPE chosen depends on certain variables such as the patient care being provided, standard precautions, and transmission-based precautions. The minimal amount of PPE recommended are as follows: 

    • Contact precautions require gloves and gowns. If bodily secretions may be contacted, a mask and eye protection are required. 
    • Droplet precautions require a surgical mask. 
    • Airborne precautions require the wearing of gloves and a gown as well as an approved N95 respirator mask that has been fit tested for the individual wearing. Negative pressure rooms that are able to filter 6 to 12 air exchanges per hour are also recommended (1). 

    Be mindful that these are the minimal recommendations based solely on the identified transmission status of the patient. Selection of PPE should be made using critical thinking to identify potential risks depending on type of patient care being performed, procedure, behavioral considerations, and other factors that may deviate from the standard. 

    The following are current recommendations from the CDC for donning and doffing (all from 11).

    How to Put On (Don) PPE Gear

    More than one donning method may be acceptable. Training and practice using your healthcare facility’s procedure is critical. Below is one example of donning. 

    1. Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on training). 
    2. Perform hand hygiene using hand sanitizer. 
    3. Put on isolation gown. Tie all the ties on the gown. Assistance may be needed by other healthcare personnel. 

    Put on NIOSH-approved N95 filtering face-piece respirator or higher (use a facemask if a respirator is not available).

    If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients. 

    -Respirator: Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator.

    -Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears.

          5. Put on face shield or goggles.

    When wearing an N95 respirator or half face-piece elastomeric respirator, select the proper eye protection to ensure that the respirator does not interfere with the correct positioning of the eye protection, and the eye protection does not affect the fit or seal of the respirator. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common. 

       6. Put on gloves. Gloves should cover the cuff (wrist) of gown. 

       7. Healthcare personnel may now enter patient room. 

    How to Take Off (Doff) PPE Gear

    More than one doffing method may be acceptable. Training and practice using your healthcare facility’s procedure is critical. Below is one example of doffing. 

    1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak). 
    2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle. 
    3. Healthcare personnel may now exit patient room. 
    4. Perform hand hygiene. 
    5. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles.
    6. Remove and discard respirator (or face mask if used instead of respirator). Do not touch the front of the respirator or face mask. 
      -Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator.
      -Face mask: Carefully untie (or unhook from the ears) and pull away from face without touching the front.
    7. The final step is to perform hand hygiene after removing the respirator/face mask and before putting it on again if your workplace is practicing reuse.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. How have barriers changed in your local area since the outbreak of COVID-19?

    Appropriate Isolation/Cohorting of Patients with Communicable Diseases

    Cohorting patients is a common practice within facilities, especially with limited rooms and an increasing number of patients with MDROs (12). In order to combat these issues, placing patients with the same type of pathogen in one room, when single rooms are not available is an option. The minimal standard for all patients is standard precautions. 

    The CDC offers guidance for appropriately isolating or cohorting patients based on the type of precaution. 

    Contact: Patients with a known or suspected pathogen that is transmitted via contact should be placed in a private room, if available. Cohorting can be achieved if the cohorted patients share the same type of pathogen (13). 

    Droplet: Unless a single patient room is not available, patients in droplet precautions should only be cohorted if neither have an excessive cough or sputum production. The cohorts should be tested to ensure they are infected with the same type of pathogen. Immunocompromised patients are at an increased risk and should not be cohorted. Patients are to be separated at least three feet apart and a privacy curtain should remain drawn between their respective areas. Care providers must don and doff new PPE in between providing care to each respective patient (13). 

    Airborne: An airborne infection isolation room (AIIR) with negative air pressure that exchanges air at least 6 to 12 changes per hour is required. The door must remain closed except for entry and exit. Cohorting of patients is not recommended except in the case of outbreak or large number of exposed patients (13). In these instances, the CDC recommends the following (13):  

    • Consult infection control professionals before patient placement to determine the safety of alternative rooms that do not meet engineering requirements for AIIR. 
    • Place together (cohort) patients who are presumed to have the same infection (based on clinical presentation and diagnosis when known) in areas of the facility that are away from other patients, especially patients who are at increased risk for infection (e.g., immunocompromised patients). 
    • Use temporary portable solutions (e.g., exhaust fan) to create a negative pressure environment in the converted area of the facility. Discharge air directly to the outside, away from people and air intakes, or direct all the air through HEPA filters before it is introduced to other air spaces. 

    Host Support and Protection

    Vaccinations to preventable disease are highly recommended by numerous health organizations such as the CDC, World Healthcare Organization, and the Office of Disease Prevention and Health Promotion. As state by Healthy People 2020, “. . . infectious diseases remain a major cause of illness, disability, and death. Immunization recommendations in the United States currently target 17 vaccine-preventable diseases across the lifespan” (14). As healthcare providers, nurses are in a position to review the patient’s history for gaps in appropriate vaccination coverage and offer education to the patient. Additionally, healthcare providers hold an ethical responsibility to stay current on vaccinations and prevent transmitting known communicable diseases by receiving an influenza vaccination each year. 

    Pre- and/or post-prophylaxis may be recommended during certain types of exposures or for patients at an increased risk for infection. This is commonly used for emergent or planned procedures and surgeries that access areas that are at higher risk for becoming a portal of entry, such as the respiratory, gastrointestinal, and genitourinary tracts. Antibiotics may be ordered when it is known that the sterile field has been broken during a procedure or there has been a concern of contamination of a wound or incision site. 

    In cases of exposure to an infectious pathogen, the decision to treat includes factors such as the type of exposure, patient’s symptoms, time frame since exposure, the health status of the individual exposed, as well of the risks and benefits of the treatment. Pre-prophylaxis may be considered in the prevention of HIV for high-risk individuals. 

    Typically, after an exposure, the host’s blood is drawn to determine pathogen risk regardless if there is a known pathogen. Post-exposure prophylactics are given within a short time frame from the exposure based on results. The individual that is exposed will have baseline testing for HIV, hepatitis B virus, and hepatitis C viral antibodies. Follow-up testing occurs six weeks, three months, and six months after initial exposure. 

    Maintaining skin and immune system integrity is of the upmost importance to prevent the transmission of infectious pathogens. Nursing interventions to promote skin and immune system integrity are:  

    • Perform a thorough skin assessment every shift and with changes in condition 
    • Accurately document any wounds or incisions 
    • Use gentle cleansers on skin and pat dry 
    • Use moisturizers and barrier creams on dry or tender skin 
    • Prevent pressure ulcer development by turning and repositioning patient every 2 hours 
    • Maintain aseptic technique during wound care, dressing changes, IV manipulation or blood draws, and catheter care 
    • Use neutropenic guidelines when providing care to immunocompromised patients 
    • Encourage adequate nutritional and intake  

    Environmental Control Measures

    The cleaning, disinfection and sterilization of patient care equipment should be performed per the recommendations of the manufacturer. Cleaning should be performed between multiple patient use. For equipment that has been used in an isolation room, a terminal clean must be performed prior to being used in any other patient care. Additional information on this topic will be covered within Element V. 

    Environmental cleaning personnel must be educated on the appropriate cleaning for all precaution patient environments. The Material Safety Data Sheets for all chemicals are to be available to all healthcare personnel for reference as to the proper use and storage. These should be referred to in order to ensure that the correct cleaning product is effective to terminally clean isolation rooms based on pathogen. 

    Ventilation should be thoroughly managed and maintained by the environmental operations team. Negative pressure rooms should be consistently monitored, and alarms investigated to ensure proper air exchange. Concerns from nursing regarding ventilation issues should be directed to the environmental team for follow-up. 

    Regulated medical waste (RMW) within the healthcare system that must follow state guidelines for disposal includes: 

    • Human pathological waste 
    • Human blood and blood products 
    • Needles and syringes (sharps) 
    • Microbiological materials (cultures and stocks) 
    • Other infection waste (16) 

    According to the CDC, “To ensure containment, RMW (except medical waste sharps) is required to be placed in plastic bags and then packaged in single use (e.g., corrugated boxes) or reusable rigid (e.g., plastic) or semi-rigid, leak proof containers before transport. Once packaged, RMW is either transported to a designated secure storage or collection area within the facility for third party pick-up, or to a generator’s on-site treatment facility (15). 

    Bodily fluid (urine, vomit, and feces) may be safely disposed of in any utility sink, drain, toilet, or hopper that drains into a septic tank or sanitary sewer system. Healthcare personnel must don appropriate PPE during disposal.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What are some ways vehicles for infectious matter can be contained?

    Element III

    Use of engineering and work practice controls to reduce the opportunity for patient and healthcare worker exposure to potentially infectious material in all healthcare settings.

     

    Element III Objectives

    Upon completion of course work or training on this element, the learner will be able to: 

    • Define healthcare-associated disease transmission, engineering controls, safe injection practices, and work practice controls 
    • Describe specific high-risk practices and procedures that increase the opportunity for healthcare worker and patient exposure to potentially infectious material 
    • Describe specific measures to prevent transmission of blood-borne pathogens from patient to patient, healthcare worker to patient, and patient to healthcare worker via contaminated injection equipment 
    • Identify work practice controls designed to eliminate the transmission of blood-borne pathogens during use of sharp instruments (e.g., scalpel blades and their holders (if not disposable), lancets, lancet platforms/pens, puncture devices, needles, syringes, injections) 
    • Identify where engineering or work practice controls can be utilized to prevent patient exposure to blood-borne pathogens 

    Definitions

    Healthcare-associated infections (HAIs): Infections associated with healthcare delivery in any setting (e.g., hospitals, long-term care facilities, ambulatory settings, home care). 

    Engineering Controls: Controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the blood-borne pathogens hazard from the workplace. 

    Injection safety (or safe injection practices): A set of measures taken to perform injections in an optimally safe manner for patients, healthcare personnel, and others. A safe injection does not harm the recipient, does not expose the provider to any avoidable risks and does not result in waste that is dangerous for the community. Injection safety includes practices intended to prevent transmission of blood-borne pathogens between one patient and another, or between a healthcare worker and a patient, and to prevent harms such as needlestick injuries. 

    Single-use medication vial: A bottle of liquid medication that is given to a patient through a needle and syringe. Single-use vials contain only one dose of medication and should only be used once for one patient, using a new sterile needle and new sterile syringe. 

    Multi-dose medication vial: bottle of liquid medication that contains more than one dose of medication and is often used by diabetic patients or for vaccinations. 

    Work Practice Controls: Controls that reduce the likelihood of exposure to blood-borne pathogens by altering the way a task is performed (e.g., prohibiting recapping of needles by a two-handed technique). 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Do you know the measures for injection safety?

    High-Risk Practices and Procedures Capable of Causing Healthcare Acquired Infection with Blood-borne Pathogens

    Percutaneous exposures are a work hazard within the healthcare industry. There are approximately 5.6 million healthcare workers at risk, with nurses ranking number one. Studies have shown that needlestick injuries occur most frequently within a patient room or the operating room (1). 

    Exposures can occur through not following safe practices. The following practices in handling contaminated needles and other sharp objects, including blades, can increase the risk for a percutaneous exposure and should be avoided.

    • Manipulating contaminated needles and other sharp objects by hand (e.g., removing scalpel blades from holders, removing needles from syringes) 
    • Delaying or improperly disposing (e.g., leaving contaminated needles or sharp objects on counters/workspaces or disposing in non-puncture-resistant receptacles) 
    • Recapping contaminated needles and other sharp objects using a two-handed technique 
    • Performing procedures where there is poor visualization, such as: 
      1. Blind suturing 
      2. Non-dominant hand opposing or next to a sharp 
      3. Performing procedures where bone spicules or metal fragments are produced

    Mucous membrane/non-intact skin exposures occur with direct blood or body fluids contact with the eyes, nose, mouth, or other mucous membranes via the following.

    • Contact with contaminated hands 
    • Contact with open skin lesions/dermatitis 
    • Splashes or sprays of blood or body fluids (e.g., during irrigation or suctioning)

    Parenteral exposure is the subcutaneous, intramuscular, or intravenous contact with blood or other body fluid. Injection with infectious material may occur during the following scenerios.

    • Administration of parenteral medication 
    • Sharing of blood monitoring devices (e.g., glucometers, hemoglobinometers, lancets, lancet platforms/pens) 
    • Infusion of contaminated blood products or fluids 
    • Safe injection practices and procedures designed to prevent disease transmission from patient to patient and healthcare worker to patient

    According to the CDC, unsafe injection practices have resulted in more than 50 outbreaks of infectious disease transmission since 2001.  As well, since that time over 150,000 patients were potentially exposed to HIV, hepatitis B virus, and hepatitis C virus solely due to unsafe practice (2). These deviations from best practice have resulted in one or more of the following consequences.

    • Transmission of blood-borne viruses, including hepatitis B and C viruses to patients 
    • Notification of thousands of patients of possible exposure to blood-borne pathogens and recommendation that they be tested for hepatitis C virus, hepatitis B virus, and human immunodeficiency virus (HIV) 
    • Referral of providers to licensing boards for disciplinary action 
    • Malpractice suits filed by patients

    Pathogens including HCV, HBV, and human immunodeficiency virus (HIV) can be present in sufficient quantities to produce infection in the absence of visible blood. 

    • Bacteria and other microbes can be present without clouding or other visible evidence of contamination. 
    • The absence of visible blood or signs of contamination in a used syringe, IV tubing, multi- or single-dose medication vial, or blood glucose monitoring device does NOT mean the item is free from potentially infectious agents. 
    • All used injection supplies and materials are potentially contaminated and should be discarded.

    Proper infection control technique requires that healthcare providers must follow best practice to prevent injury and pathogen transfer. At all times, aseptic technique is to be used to prepare and administer an injection. The following are best practice guidelines.

    • Medications should be drawn up in a designated “clean” medication area that is not adjacent to areas where potentially contaminated items are placed. 
    • Use a new sterile syringe and needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. 
    • Ensure proper hand hygiene (i.e., hand sanitizing or hand washing if hands are visibly soiled) before handling medications. 
    • If a medication vial has already been opened, the rubber septum should be disinfected with alcohol prior to piercing it. 
    • Never leave a needle or other device (e.g., “spikes”) inserted into a medication vial septum or IV bag/bottle for multiple uses. This provides a direct route for microorganisms to enter the vial and contaminate the fluid. 
    • Medication vials should be discarded upon expiration or any time there are concerns regarding the sterility of the medication.

    Never administer medications from the same syringe to more than one patient, even if the needle is changed. 

    Never use the same syringe or needle to administer IV medications to more than one patient, even if the medication is administered into the IV tubing, regardless of the distance from the IV insertion site. 

    • All the infusion components from the infusate to the patient’s catheter are a single interconnected unit. 
    • All the components are directly or indirectly exposed to the patient’s blood and cannot be used for another patient. 
    • Syringes and needles that intersect through any port in the IV system also become contaminated and cannot be used for another patient or used to re-enter a non-patient specific multidose medication vial. 
    • Separation from the patient’s IV by distance, gravity and/or positive infusion pressure does not ensure that small amounts of blood are not present in these items. 
    • Never enter a vial with a syringe or needle that has been used for a patient if the same medication vial might be used for another patient. 

    Dedicate vials of medication to a single patient, whenever possible. 

    • Medications packaged as single use must never be used for more than one patient: 
    • Never combine leftover contents for later use 
    • Medications packaged as multi-use should be assigned to a single patient whenever possible 
    • Never use bags or bottles of intravenous solution as a common source of supply for more than one patient 
    • Never use peripheral capillary blood monitoring devices packaged as single-patient use on more than one patient 
    • Restrict use of peripheral capillary blood sampling devices to individual patients 
    • Never reuse lancets. Use single-use lancets that permanently retract upon puncture whenever possible 

    Safe injection practices and procedures designed to prevent disease transmission from patient to healthcare worker. Fact sheet from OHSA can be found at https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Think back to specific events. What are some high risk practices you've seen take place in your workplace?

    Evaluation or Surveillance of Exposure Incidents

    A plan to evaluate and follow-up on exposure incidents should be put into place at every facility. At a minimum, this plan should include the following elements: 

    1. Identification of who is at risk for exposure
    2. Identification of what devices cause exposure 
    3. Education for all healthcare employees that use sharps. This would include that ALL sharp devices can cause injury and disease transmission if not used and disposed properly. Specific focus would include the devices that are more likely to cause injury such as:  
    • Devices with higher disease transmission risk (hollow bore)
    • Devices with higher injury rates (“butterfly”-type IV catheters, devices with recoil action)
    • Blood glucose monitoring devices (lancet platforms/pens)
    1. Identification of areas/settings where exposures occur
    2. Circumstances in which exposures occur
    3. Post exposure management - See Element VI
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Is there a plan in place for an exposure response in your workplace?

    Engineer Controls

    Engineer controls are implemented in order to provide healthcare workers with the safest equipment to complete their jobs. Safer devices should be identified and integrated into safety protocols whenever possible. When selecting engineer controls to be aimed at preventing sharps injuries the following should be considered: 

    1. Evaluate and select safer devices 
    2. Passive vs. active safety features 
    3. Mechanisms that provide continuous protection immediately 
    4. Integrated safety equipment vs. accessory devices:  
    • Properly educate and train all staff on safer devices 
    • Consider eliminating traditional or non-safety alternatives whenever possible 
    • Explore engineering controls available for specific areas/settings

        5. Use puncture-resistant containers for the disposal and transport of needles and other sharp objects:  

    • Refer to published guidelines for the selection, evaluation, and use (e.g., placement) of sharps disposal containers 
    • National Institute for Occupational Safety and Health (NIOSH) guidelines –
      This is available at: http://www.cdc.gov/niosh/topics/bbp/#prevent  
    • Use splatter shields on medical equipment associated with risk prone procedures (e.g., locking centrifuge lids) 

    Work Practice Controls

    General Practices
    • Hand hygiene including the appropriate circumstances in which alcohol– based hand sanitizers and soap and water hand washing should be used (see Element II). 
    • Proper procedures for cleaning of blood and body fluid spills: 
    • Initial removal of bulk material followed by disinfection with an appropriate disinfectant. 
    • Proper handling/disposal of blood and body fluids, including contaminated patient care items. 
    • Proper selection, donning, doffing, and disposal of personal protective equipment (PPE) as trained [see Element IV]. 
    • Proper protection of work surfaces in direct proximity to patient procedure treatment area with appropriate barriers to prevent instruments from becoming contaminated with blood-borne pathogens. 
    Preventing Percutaneous Exposures
    1. Avoid unnecessary use of needles and other sharp objects. 
    2. Use care in the handling and disposing of needles and other sharp objects:  
    • Avoid recapping unless absolutely medically necessary. 
    • When recapping, use only a one-hand technique or safety device. 
    • Pass sharp instruments by use of designated “safe zones.” 
    • Disassemble sharp equipment by use of forceps or other devices. 
    • Discard used sharps into a puncture-resistant sharps container immediately after use. 
    Modify Procedures to Avoid Injury
    1. Use forceps, suture holders, or other instruments for suturing
    2. Avoid holding tissue with fingers when suturing or cutting
    3. Avoid leaving exposed sharps of any kind on patient procedure/treatment work surfaces
    4. Appropriately use safety devices whenever available:  
    • Always activate safety features. 
    • Never circumvent safety features. 
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What do you think are the most important procedural factors of Engineer control?

    Element IV

    Creation and maintenance of a safe environment for patient care in all healthcare settings through application of infection control principles and practices for cleaning, disinfecting, and sterilization.

    Element IV Objectives

    Upon completion of course work or training on this element, the learner will be able to: 

    • Describe the circumstances that require the use of barriers and personal protective equipment to prevent patient or healthcare worker contact with potentially infectious material
    • Identify specific barriers or personal protective equipment for patient and healthcare worker protection from exposure to potentially infectious material

    Definitions

    Personal protective equipment (PPE): Specialized clothing or equipment worn by an employee for protection against a hazard. 

    Barriers: Equipment such as gloves, gowns, aprons, masks, or protective eye wear, which when worn, can reduce the risk of exposure of the health care worker’s skin or mucous membranes to potentially infective materials.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What tools do you use on a daily basis that require proper sterilization?

    Types of PPE or Barriers and Criteria for Selection

    Per OSHA guidelines, employers must provide employees with appropriate PPE that provides protection from any potential infectious pathogen exposure (1). PPE includes gloves, cover garb, masks, face shields and eye protection. All PPE is intended to provide a barrier between the healthcare worker and potential contamination, whether from a patient, object, or surface. 

    Gloves are intended to provide coverage and protection for hands. There are several types of gloves to choose from and the type of patient care or activity should guide choice. 

    • Sterile – to be utilized when performing sterile procedures and aseptic technique 
    • Non-sterile – medical grade, non-sterile gloves may be used for general patient care and clean procedures (such as NG tube insertion) 
    • Utility – not medical grade and should not be used in patient care

    Choice in material for gloves is often is dictated by cost and facility preference. When given a choice, considerations should be made as to the types of material being handled. 

    • Natural rubber latex – rarely used in facilities due to allergen risk 
    • Vinyl – made from PVC, lower in cost, provides protection in non-hazardous and low-infection environments 
    • Nitrile – more durable, able to withstand chemical and bio-medical exposure (2) 

    An appropriately sized glove fits securely over the fingertips and palm without tightness or extra room. If a glove develops a tear or is heavily soiled, it should be replaced immediately. 

    Cover garb is a protective layer to wear over scrubs or clothes to protect garments and skin. These include laboratory coats, gowns, and aprons. As with gloves, consideration should be given to size, sterility, type of patient care involved, and material characteristics of the gown. 

    • Fluid impervious – does not allow passage of fluids 
    • Fluid resistant – resists penetration of fluids, but fluid may seep with pressure 
    • Permeable – does not offer protection against fluids 

    Masks are intended to provide protection to the wearers mouth and nose, with respirators providing an extra layer of protection to the respiratory tract against airborne infection pathogens (1).

    Goggles are designed to protect the eyes from splashes and droplet exposure, while face shields offer additional protection to the entire face. It is important to note that face shields are not designed to be a replacement for masks. 

    The choice of PPE is based on the factors that are reasonably anticipated to occur during the patient care encounter. Potential contact with blood or other potentially infectious material can occur via splashes, respiratory droplets, and/or airborne pathogens. The type of PPE chosen will be based on standard or transmission-based precaution recommendations. Follow your facility policy and procedures for guidance on appropriate choice. The nurse will also need to anticipate whether fluid will be encountered, such as emptying a drain or foley collection device. In situations where a large amount of fluid is likely to be encountered, it would be wise to choose a higher level of protection, such as an impermeable gown, if available, and to wear eye protection to ward off splashes. 

    Choosing Barriers or PPE Based on Intended Need 

    Barriers and PPE is aimed at keeping patients and healthcare providers safe. There are certain circumstances where specific PPE is selected based on patient care or circumstances. 

    Patient Safety 

    Barriers, PPE, and hand hygiene is aimed at keeping patients and healthcare providers safe. There are certain circumstances where specific PPE is selected based on patient care or circumstances. This includes, but is not limited to: 

    Sterile Barriers for Invasive Procedures

    During invasive procedures, such as inserting a central line or during a surgery, staff directly involved performing the procedure or surgery must maintain sterility. Appropriate sterile PPE will be selected based on the type of procedure and the patient will be draped in sterile fashion according to recommended guidelines.  

    Both the patient and caregiver should wear a mask during central line changes, with the caregiver adhering to aseptic technique (1). Specific policies of the organization should be referred to on the selection and donning and doffing of sterile protective equipment during surgical procedures.   

    Masks for Prevention of Exposure of Droplet Contamination

    Patients in droplet precautions pose a significant risk to healthcare workers and visitors. The patient, as well as anyone inside the patient's room, should wear a mask for the most effective prevention of transmission (1). The patient and patient's family must be educated on the importance of adhering to these guidelines while visitation is appropriate. During transport of a patient under droplet precautions, the patient should wear a mask, placed over the top of any oxygen delivery device, if needed.  

    Employee Safety

    Employees must ensure that they are evaluating the types of exposure that is likely to occur during patient care. Selection of PPE and appropriate barriers should consider the following: 

    Barriers for Prevention of Contamination

    Per the CDC, "use of PPE is recommended based on the anticipated exposure to blood, body fluids, secretions, or excretions" (3). The following are CDC guidelines based on the expected type of exposure or precaution; however, clinical judgement should be used based on the situation (all from 5): 

    Standard precautions are to be used with any potential exposure to blood, mucous membranes, compromised skin, contaminated equipment or surfaces, and body fluids. Barriers may include gloves, gown, and eye and face protection. 

    Employees must be judicious in identifying any precautions that are placed on a patient (ie. Contact, droplet, airborne) and following recommended PPE guidelines for protecting themselves and other patients.  

    PPE should be donned prior to going into a patient room and doffed upon exit. PPE must never be worn in the halls or when going from one patient room to the next. All gloves must be changed in between use and hands washed or sanitized upon removal of gloves. 

    Additionally, whenever possible, social distancing of 6 feet should occur within the work environment. When not possible, adherence to mask guidelines is sufficient.  

    Masks for Prevention of Exposure to Communicable Disease

    With the onset of Covid-19 across the globe, masks are an essential tool in preventing the transmission of communicable disease. At a minimum, medical masks should be donned during all patient care. During procedures or surgery, surgical masks are to be utilized.  

    N-95 masks are reserved for patient care with known or suspected Covid-19, if airborne precautions are ordered, or during procedures that may aerosolize (such as during intubations and certain endoscopy procedures). The CDC recommends reserving surgical N-95 masks for healthcare providers "who are working in a sterile field or who may be exposed to high velocity splashes, sprays, or splatters of blood or body fluids".  Standard N95 respirators are recommended for all other care involving confirmed or suspected Covid-19 patients (5).

    Guidance on Proper Utilization of PPE or Barriers

    Proper fit is required for PPE to be effective. Gowns and gloves chosen should fit well, allow movement, and neither be too baggy or too tight. For particulate respirators, the CDC recommends the following regarding proper fit and use of particulate respirators: 

    All workers who are required to wear tight-fitting respirators (e.g., N95 respirators, Elastomerics) must have a medical evaluation to determine the worker’s ability to wear a respirator, and if medically cleared, a respirator fit test needs to be performed using the same model available in the workplace (3, 4). 

    Prior to donning PPE, it should be inspected for any anomalies, tears, or vulnerable spots. PPE that is compromised should be disposed of and a new garment selected. Nurses must give careful consideration to the selection of PPE to ensure that it is the correct type for the job and anticipate any circumstances where splashes or saturation of fabric is likely to occur. 

    The PPE provided by the employer may be single use or re-usable. Always verify with manufacturer guidelines and facility policy on the correct usage and processing of worn garments. It is the facilities responsibility to ensure that re-usable gowns are laundered according to State guidelines. 

    In order to prevent cross contamination, OSHA offers the following guidelines: 

    • Personal protective equipment must be removed prior to leaving a work area 
    • Garment penetrated by blood or other potentially infectious material must be removed immediately or as soon as possible 
    • PPE must be discarded in “. . . an appropriately designated area or container for storage, washing, decontamination, or disposal” 
    • Employers must ensure that proper hand washing is taking place after the removal of PPE

    Healthcare facilities have a legal duty to protect their workers. Per OSHA, “One way the employer can protect workers against exposure to blood-borne pathogens, such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), the virus that causes AIDS, is by providing and ensuring they use personal protective equipment, or PPE. Wearing appropriate PPE can significantly reduce risk, since it acts as a barrier against exposure. Employers are required to provide, clean, repair, and replace this equipment as needed, and at no cost to workers” (5). 

    Employers and healthcare workers must understand the balance of cost versus benefit ratio in PPE selection and use. While it is important to be good stewards with resources, always erring on the side of caution and choosing PPE based on anticipated exposure risk is the most effective way to protect yourself and your patients. 

    For selection, donning, doffing, and disposal refer back to Element II.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Can you name some appropriate barriers for invasive procedures?

    Element V

    Creation and maintenance of a safe environment for patient care in all healthcare settings through application of infection control principles and practices for cleaning, disinfecting, and sterilization.

     

    Element V Objectives

    At the conclusion of course work or training on this element, the learner will be able to: 

    • Define cleaning, disinfection, and sterilization 
    • Differentiate between noncritical, semi critical, and critical medical devices 
    • Describe the three levels of disinfection (i.e., low, intermediate, and high) 
    • Recognize the importance of the correct application of reprocessing methods for assuring the safety and integrity of patient care equipment in preventing transmission of blood-borne pathogens 
    • Recognize the professional’s responsibility for maintaining a safe patient care environment in all healthcare settings 
    • Recognize strategies for, and importance of, effective and appropriate pre-cleaning, chemical disinfection, and sterilization of instruments and medical devices aimed at preventing transmission of blood-borne pathogens.

    Definitions

    Contamination: The presence of microorganisms on an item or surface. 

    Cleaning: The process of removing all foreign material (i.e., dirt, body fluids, lubricants) from objects by using water and detergents or soaps and washing or scrubbing the object 

    Critical device: An item that enters sterile tissue or the vascular system (e.g., intravenous catheters, needles for injections). These must be sterile prior to contact with tissue. 

    Decontamination: The use of physical or chemical means to remove, inactivate, or destroy blood-borne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles. 

    Disinfection: The use of a chemical procedure that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial endospores) on inanimate objects. 

    High level disinfection: Disinfection that kills all organisms, except high levels of bacterial spores, and is affected with a chemical germicide cleared for marketing as a sterilant by the U.S. Food and Drug Administration (FDA). 

    Intermediate level disinfection: Disinfection that kills mycobacteria, most viruses, and bacteria with a chemical germicide registered as a “tuberculocide” by the U.S. Environmental Protection Agency (EPA). 

    Low level disinfection: Disinfection that kills some viruses and bacteria with a chemical germicide registered as a hospital disinfectant by the EPA. 

    Noncritical device: An item that contacts intact skin but not mucous membranes (e.g., blood pressure cuffs, oximeters). It requires low level disinfection. 

    Semi critical device: An item that comes in contact with mucous membranes or non-intact skin and minimally requires high level disinfection (e.g., oral thermometers, vaginal specula). 

    Sterilization: The use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores. 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What is the professional’s responsibility for maintaining a safe patient care environment in all healthcare settings?

    Universal Principles

    Instruments, medical devices, and equipment should be managed and reprocessed according to the recommended and appropriate methods regardless of a patient’s diagnosis, except for cases of suspected prion disease. 

    Due to the infective nature and steam resistant properties of prion diseases, special procedures are required for handling brain, spinal, or nerve tissue from patients with known or suspected prion disease (e.g., Creutzfeldt-Jakob disease [CJD] or Bovine spongiform encephalopathy [BSE]). Consultation with infection control experts prior to performing procedures on such patients is warranted. 

    Industry guidelines as well as equipment and chemical manufacturer recommendations should be used to develop and update reprocessing policies and procedures. Written instructions must be made available for each instrument, medical device, and equipment reprocessed. The CDC recommends that critical medical and surgical devices and instruments that would be expected to enter a system through body fluids, blood, or tissue be sterilized prior to use on each patient. (1).  

    Potential for Contamination

    The type of instrument, medical device, equipment, or environmental surface creates variables that are more likely to be a source of contamination. External contamination may be caused by the presence of hinges, crevices, or multiple interconnecting pieces. If able, these devices should be disassembled. Endoscopes provide a particular challenge for both internal and external contamination, due to their lumens as well as the crevices and joints present. The disinfectant must reach all surfaces and assurance that there are no air pockets or bubbles to impede penetration (2). These devices may be made of material that is not heat resistant, preventing sterilization. In these instances, chemicals must be utilized to provide disinfection. 

    Once rendered sterile, there are multiple opportunities for potential contamination due to the frequency of hand contact with the device or surface. Packaging may be over handled and breached, or the item may come into contact with potential contaminants via poor storage, improper opening, or environmental factors. 

    The efficacy of sterilization and disinfection is dependent upon the number and type of microorganisms present. There are several types of pathogens that carry an innate resistance, making successful decontamination more challenging (2). Most infections are caused by bacteria, followed by viruses, fungi, protozoa, and prions (3).  Due to the nature of their outer membranes, spores and gram-negative bacteria have a natural barrier that prevents the absorption of disinfectants. Bacterial spores are especially resistant against chemical germicides, as are the following pathogenic organism types (all from 2): 

    • Coccidia – i.e., Cryptosporidium 
    • Mycobacteria – i.e., M. tuberculosis 
    • Nonlipid or small viruses – i.e., poliovirus, coxsackievirus 
    • Fungi – i.e., Aspergillus, Candida 
    • Vegetative bacteria – i.e., Staphylococcus, Pseudomonas 
    • Lipid or medium-size viruses – i.e., herpes, HIV 

    The number of microorganisms that are present on a medical instrument, device or surface affects the time that must be factored into disinfection and sterilization efficacy. As stated by the CDC, “Reducing the number of microorganisms that must be inactivated through meticulous cleaning, increases the margin of safety when the germicide is used according to the labeling and shortens the exposure time required to kill the entire microbial load” (2) 

    In general, used medical devices are contaminated with a relatively low bioburden of organisms. Inconsistencies or incorrect methods of reprocessing can easily lead to the potential for cross-contamination (1). 

    Steps of Reprocessing

    Reprocessing medical instruments and equipment is completed sequentially dependent upon the instrument and the process chosen. 

    Pre-cleaning is the process of removing soil, debris, lubricants from internal and external surfaces through mopping, wiping, or soaking. It must be done as soon as possible after use to lower the number of microorganisms present on the object. 

    Cleaning may be accomplished manually or mechanically. Manual cleaning relies upon friction and fluidics (fluids under pressure) to remove debris and soil from inner and outer surfaces of the instrument. There are several different machines used in mechanical cleaning including ultrasonic cleaners, washer-disinfectors, washer-sterilizers, and washer-decontaminators. Studies have shown that automated cleaning is more effective than manual; however, the frequency of fluid changes must follow manufacturer guidelines to eliminate the risk of contaminating debris (1). 

    Disinfection involves the use of disinfectants, either alone or in combination, to reduce microbial count to near insignificant. Common disinfectants used in the healthcare setting include chlorine and chlorine compounds, hydrogen peroxide, alcohols, iodophors, and quaternary ammonium compounds, among others. These products are formulated and then approved by the Environmental Protection Agency and Food and Drug Administration for specific uses. 

    Sterilization is used on most medical and surgical devices that are utilized in healthcare facilities. This requires sufficient exposure time to heat, chemicals, or gases to ensure that all microorganisms are destroyed.  

    Choice/Level of Reprocessing Sequence

    The choice or level of reprocessing is based on intended use: 

    • Critical instruments and medical devices require sterilization 
    • Semi critical instruments and medical devices minimally require high level disinfection 
    • Noncritical instruments and medical devices minimally require cleaning and low-level disinfection.

    Manufacturer recommendations must always be consulted to ensure that appropriate methods, actions, and solutions are used. There is a wide variability of compatibility among equipment components, materials, and chemicals used. Rigorous training is required to appropriately to understand equipment heat and pressure tolerance as well as the time and temperature requirements for reprocessing. Failure to follow manufacturer recommendations may lead to equipment damage, elevated microbial counts on instruments after reprocessing, increase risk for infections, and possibly patient death.  

    Effectiveness of Reprocessing Instruments, Medical Devices, and Equipment

    Pre-cleaning and cleaning prior to disinfection is one of the most effective ways to reduce the microbial count. This is only effective when completed prior to disinfection. Disinfection relies upon the action of products to eliminate microbial count. Depending on the medical instrument or device design, the product may only be required to cover the surface. However, due to the lumens of scopes, crevices, or hinges on certain instruments, immersion products and dwell times may be required (4). 

    The presence of organic matter, such as blood, serum, exudate, lubricant, or fecal material can drastically reduce the efficacy of a disinfectant. This may occur due to the presence of a barrier or the organic material acting as a barrier.  It may also occur from a chemical reaction between the organic material and the disinfectant being utilized. 

    Biofilms pose a particular challenge and offer protection from the action of disinfectants. Biofilms are composed of microbes that build adhesive layers onto the inner and outer surfaces of objects, including instruments and medical devices, rendering certain disinfectants ineffective. Chlorine and Monochloramines remain effective against inactivating biofilm bacteria (1). 

    Per the CDC, “. . . a given product is designed for a specific purpose and is to be used in a certain manner. Therefore, users should read labels carefully to ensure the correct product is selected for the intended use and applied efficiently” (1). The label will indicate the sufficient contact time with chemical solution to achieve adequate disinfection. 

    After disinfection, staff and management must adopt a system of record keeping and tracking of instrument usage and reprocessing. Reprocessing equipment must be on a schedule to be maintained and regularly cleaned, according to manufacturer guidelines. 

    There are several methods of sterilization used such as steam sterilization (autoclaves), flash sterilization, and more recently, low-temperature sterilization techniques created for medical devices that are heat sensitive. Selection depends upon the type of instrument, material, ability to withstand heat or humidity, and targeted microbes. 

    There are several methods of ensuring that sterilized instruments are processed and tracked appropriately. Indicators or monitors are test systems that provide a way of verifying that the sterilization methods were sufficient to eradicate the regulated number of microbes during the process. These safeguards include: 

    • Biologic monitors 
    • Process monitors (tape, indicator strips, etc.) 
    • Physical monitors (pressure, temperature gauges) 
    • Record keeping and recall/ tracking system for each sterilization processing batch/item 

    Studies have shown that the best-practice of handling and storage of reprocessed medical equipment and instruments uses a system of event-related shelf life, rather than time-related. The rationale for this lies in the theory that the sterile items are remaining sterile as long as the packaging is not compromised (2). Factors that are considered event-related include internal or external contamination such as damage to packaging, humidity, insects, vermin, open shelving, temperature fluctuations, flooding, location, and the composition of packaging material 

    Standards for handling must also focus on protection of workers from health issues.  

    Recognizing Potential Sources of Cross-Contamination in the Healthcare Environment

    • Surfaces or equipment which require cleaning between patient procedures/treatments 
    • Practices that contribute to hand contamination and the potential for cross-contamination 
    • Consequences of reuse of single use/disposable instruments, medical devices, or equipment  

    Factors that Have Contributed to Contamination in Reported Cases of Disease Transmission

    At any point in reprocessing or handling, breaks in infection control practices can compromise the integrity of instruments, medical devices, or equipment. Specific factors include: 

    • Failure to reprocess or dispose of items between patients 
    • Inadequate cleaning 
    • Inadequate disinfection or sterilization 
    • Contamination of disinfectant or rinse solutions 
    • Improper packaging, storage, and handling 
    • Inadequate/inaccurate record keeping of reprocessing requirements  

    Expectations of Health Professionals Based on Setting and Scope of Practice

    Professionals who practice in settings where handling, cleaning, and reprocessing equipment, instruments, or medical devices is performed elsewhere (e.g., in a dedicated Sterile Processing Department) are responsible of understanding these core concepts and principles: 

    • Standard and Universal Precautions (e.g., wearing of personal protective equipment) 
    • Cleaning, disinfection, and sterilization (Sections III and IV above) 
    • Appropriate application of safe practices for handling instruments, medical devices, and equipment in professional practice 
    • Designation and physical separation of patient care areas from cleaning and reprocessing areas is strongly recommended 
    • Verify with those responsible for reprocessing what steps are necessary prior to submission of pre-cleaning and soaking

    Professionals who have primary or supervisory responsibilities for equipment, instruments, or medical device reprocessing (e.g., Sterile Processing Department staff or clinics and physician practices where medical equipment is reprocessed on-site) are responsible for understanding these core concepts and principles: 

    • Standard and Universal Precaution 
    • Cleaning, disinfection, and sterilization described in Sections III and IV above 
    • Appropriate application of safe practices for handling instruments, medical devices, and equipment in professional practice 
    • Designation and physical separation of patient care areas from cleaning and reprocessing areas is strongly recommended

    Facilities must be fastidious in developing appropriate reprocessing practices that follow regulatory guidelines. When selecting appropriate methods, consideration must be given to the antimicrobial efficacy, time constraints and requirement of these methods, as well as compatibility.  Compatibility among equipment/materials includes the corrosiveness, penetrability, leaching, disintegration, heat tolerance, and moisture sensitivity. 

    The toxicity of the products used can pose occupational and environmental hazards to staff and patients. Facilities must adopt policies and procedures to reduce exposure to harmful substances, monitor for harmful exposures, and train staff on reprocessing cleaning and chemicals. To reduce potential exposure to harmful substances, OSHA mandates that training for workers prior to use include (all from 5): 

    • Health and physical hazards of the cleaning chemicals 
    • Proper handling, use, and storage of all cleaning chemicals being used, including dilution procedures when a cleaning product must be diluted before use 
    • Proper procedures to follow when a spill occurs 
    • Personal protective equipment required for using the cleaning product, such as gloves, safety goggles and respirators 
    • How to obtain and use hazard information, including an explanation of labels and SDSs

    Other considerations in developing a safety plan for appropriate reprocessing practices include: 

    • Potential for patient toxicity/allergy 
    • Residual effects including antibacterial residual and patient toxicity/allergy 
    • Ease of use 
    • Stability of products, including concentration, potency, efficacy of use, and effects of organic material 
    • Odor 
    • Cost 
    • Monitoring requirements and regulations 
    • Specific labeling requirements for reprocessing single-use devices (specific information may be obtained at https://www.fda.gov/media/71405/download) 
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. List some bacterial spores that are chemically resistant.

    Element VI

    Prevention and control of infections and communicable diseases in healthcare workers.

     

    Element VI Objectives

    At the conclusion of course work or training on this element, the learner will be able to: 

    • Recognize the role of occupational health strategies in protecting healthcare workers and patients 
    • Recognize non-specific disease findings that should prompt evaluation of healthcare workers 
    • Identify occupational health strategies for preventing transmission of blood-borne pathogens and other communicable diseases in healthcare workers 
    • Identify resources for evaluation of healthcare workers infected with HIV, HBV, and/or HCV 

    Definitions

    Infectious Disease: A clinically manifest disease of humans or animals resulting from an infection. 

    Communicable Disease: An illness due to a specific infectious agent or its toxic products that arises through transmission of that agent from an infected person, animal, or inanimate source to a susceptible host. 

    Occupational Health Strategies: As applied to infection control, a set of activities intended to assess, prevent, and control infections and communicable diseases in healthcare workers.  

    Pre-Placement and Periodic Health Assessments

    Occupational health strategies are aimed at ensuring that employees are healthy and stay healthy. Upon hiring, employees should undergo an initial health screening that reviews immunization records. The CDC suggests that healthcare workers are screened when newly hired and on a periodic basis to (all from 1): 

    • Ensure sufficient immunity to vaccine-preventable diseases such as measles, mumps, rubella, varicella, hepatitis B, annual influenza and any other recommended or mandated requirements 
    • Assess for and manage underlying conditions and illness that may affect workplace safety 
    • Prevent, assess, and treat any potential infectious exposures or illness that may be acquired or transmitted within the healthcare setting 
    • Initiate and continue personalized health counseling 
    • Thorough history and physical  

    A tuberculosis screening should be completed prior to new employees providing patient care and upon possible exposure for an existing employee.  A thorough assessment should include an evaluation of the following symptoms: 

    • Fever 
    • Cough 
    • Chest pain, or pain with breathing or coughing 
    • Night sweats 
    • Chills 

    A Mantoux tuberculin skin testing (TST) must also be completed. The test is performed by injecting a small amount of tuberculin to the epidermis of the forearm. The test is then evaluated for a reaction in 48 to 72 hours. If there is no reaction, the test result is negative. If reactive, a scale is used to interpret the measurement of induration and to direct further testing or treatment (2). 

    When working in healthcare, nursing staff must be healthy to provide optimal care. This is especially true with vulnerable patients that have weakened immune symptoms. The following symptoms require immediate evaluation by a licensed medical professional: 

    • Fever 
    • Cough 
    • Rash 
    • Vesicular lesions 
    • Draining wounds 
    • Vomiting 
    • Diarrhea 

    Upon evaluation, there may be restriction from patient care activities and work clearance must be completed prior to a return.  

    Management Strategies for Potentially Communicable Conditions

    Management and the Infection Prevention department should collaborate and strategize to ensure that employees that have had an exposure or possible exposure are protected and have support in seeking treatment without fear of retaliation or job loss (3). Managerial support should prioritize: 

    • Appropriate evaluation and treatment 
    • Limiting contact with susceptible patients and staff  
    • Placement in a non-clinical setting 
    • Depending on severity of symptoms or potential transmission, a furlough until noninfectious may be necessary 

    Specific Occupational Health Strategies for Prevention and Control of Blood-borne Pathogen Transmission 

    Robust training and educational programs are essential for the prevention of healthcare worker exposure and transmission. Prevention strategies should include education, training, and availability of the following: 

    • Information on potential agents such as HBV, HCV, and HIV 
    • HBV vaccination (including safety, efficacy, components, and recommendations for use) 
    • Hand hygiene 
    • Appropriate PPE and barrier precautions (see Element II) 
    • Sharps safety (see Element III) 
    • Standard and Universal Precautions 
    • Education on the availability of confidential and anonymous testing for blood borne pathogens (4)  

    Post-Exposure Evaluation and Management

    Each facility must make a plan for post-exposure evaluation and management in the case that any employee or patient experiences a potential or actual blood borne exposure. The plan should incorporate the following: 

    1. Prompt evaluation by licensed medical professional 
    2. Risk assessment in occupational exposures 
    3. Recommendations for approaching source patient and healthcare worker evaluations 
    4. Recommendations for post-exposure prophylaxis emphasizing the most current CDC guidelines 
    5. Post-exposure management of patients or other healthcare workers when the exposure source is a healthcare worker requires that the patient be informed of the type of exposure, whether it is healthcare worker’s blood or other potentially infectious material. 

    Airborne or droplet pathogens require several special considerations. The below guidelines should be applied appropriately.  

    • Risk of exposure or illness 
    • Testing 
    • Options for and risks and benefits of post-exposure prophylaxis or treatment 
    • Need for specialty care 
    • Follow-up testing and treatment 
    • Work restrictions, if indicated 
    • Risk of transmitting infections to others and methods to prevent transmission, and 
    • Signs and symptoms of illness to report after an exposure, including side effect of prophylaxis.  

    Evaluation of Healthcare Workers Infected with HIV, HBV, HCV and/or other Blood-borne Pathogens

    The CDC provides the following recommendations based on scientific evidence-based practice in relation policies to prevent infected health care personnel-related blood-borne pathogen transmission (3). 

    • Strict adherence to Standard Precautions 
    • Voluntary testing without fear of disclosure or discrimination 
    • There is not mandatory screening of healthcare workers for blood-borne pathogens in every state. Such a program would cost millions of dollars and would not produce any appreciable gain in public safety. Negative antibody tests for HIV, HBV, and HCV do not rule out the presence of infection since it can take some time for measurable antibodies to appear. 

    Criteria must be followed when evaluating infected health care workers for risk of transmission in order to adhere to laws protecting workers from discrimination. The following outlines a general assessment to determine the risks posed: 

    1. Nature and scope of professional practice 
    2. Techniques used in performance of procedures that may pose a transmission risk to patients 
    3. Assessed compliance with infection control standards 
    4. Presence of weeping dermatitis, draining or open skin wounds 
    5. Overall health:  
    • Physical health – ability to carry out duties with Cognitive status 
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. As a healthcare worker, did you see a growing need for healthcare workers to be evaluated during the pandemic?

    Element VII

    Sepsis Awareness and Education

     

    Element VII Objectives

    At the conclusion of course work or training on this element, the learner will be able to: 

    • Describe the scope of the sepsis problem  
    • Describe persons at increased risk of developing sepsis 
    • Identify common sources of infection that may lead to sepsis 
    • Describe early signs and symptoms that may be associated with sepsis in adults and children and infants 
    • Understand the need for immediate medical evaluation and management if sepsis is suspected 
    • Educate patients and families on methods for preventing infections and illnesses that can lead to sepsis and on identifying the signs and symptoms of severe infections and when to seek medical care  

    Definitions

    Sepsis: a life-threatening condition caused by a host’s extreme response to infection. The Surviving Sepsis Campaign 2016 International Guidelines define sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. Earlier definitions defined sepsis as an inflammatory response to infection, while sepsis associated with organ dysfunction was identified as severe sepsis.

    Septic shock: a subset of sepsis that manifests with circulatory and cellular/metabolic dysfunction; it is associated with a higher mortality risk.  

    Sepsis – Scope of the Problem

    Over 1.7 million Americans are diagnosed with sepsis each year, with the incidence rising by approximately 8% annually. Sepsis is a life-threatening medical emergency that requires early recognition and intervention. Sepsis occurs when the body overcompensates in response to an infection, resulting in multiple organ dysfunction and damage. Most sepsis cases are community-acquired. Early recognition and treatment are the most effective ways to combat sepsis. 

    In 2013, New York State became the first in the U.S. to develop a state mandate that requires all hospitals to develop and adopt sepsis protocols. The mandate is dubbed “Rory’s Regulations,” after Rory Staunton, a 12-year-old boy whose death was attributed to lack of sepsis recognition. These protocols were required to adopt the following practices (all from 2): 

    1. A process for the screening and early recognition of patients with sepsis, severe sepsis, and septic shock 
    2. A process to identify and document individuals appropriate for treatment through severe sepsis protocols, including explicit criteria defining those patients who should be excluded from the protocols, such as patients with certain clinical conditions or who have elected palliative care 
    3. Guidelines for hemodynamic support with explicit physiologic and biomarker treatment goals, methodology for invasive or non-invasive hemodynamic monitoring, and time frame goals 
    4. For infants and children, guidelines for fluid resuscitation with explicit time frames for vascular access and fluid delivery consistent with current evidence-based guidelines for severe sepsis and septic shock with defined therapeutic goals for children 
    5. A procedure for identification of infection source and delivery of early antibiotics with time frame goals 
    6. Criteria for use, where appropriate, of an invasive protocol and for use of vasoactive agents 

    Medical staff also gained responsibility for the collection, use, and reporting of quality measures and mortality data to peers, including national, hospital and expert stakeholders (2).  

    Causes of Sepsis

    As stated by the Sepsis Alliance, “Sepsis is the body’s overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death” (4). Bacterial infections commonly trigger sepsis, although other microbial infections (e.g., fungal, or viral) can also trigger sepsis.  The triggering infection most commonly originates from the lungs, urinary tract, skin, and/or gastrointestinal tract.  

    Certain populations are at an increased risk of developing sepsis including: 

    • The very young (under 1 year), and individuals 65 years of age and older 
    • People with chronic conditions such as diabetes, lung disease, kidney disease, or cancer and 
    • People with impaired immune systems  

    Early Recognition of Sepsis

    1. Manifestations of sepsis vary based on the type of infection and host factors 
    2. Some people may have subtle sepsis presentations 
    3. Signs and symptoms that may be associated with sepsis in persons with confirmed or suspected infection can include: 
    • Altered mental state 
    • Shortness of breath 
    • Fever 
    • Clammy or sweaty skin 
    • Extreme pain or discomfort 
    • High heart rate 

    Signs and symptoms in children and the elderly may not present the same. In children and the elderly sepsis symptoms may present as above or any of the following: decreased temperature, pallor or bluish tone to skin, non-blanching rash, high respiratory rate, lethargy, and seizure. 

    Sepsis can progress to more severe forms of sepsis, including septic shock. When septic shock occurs, the body’s inflammatory response causes extensive vasodilation throughout the body. This results in a sudden drop in blood pressure that can quickly lead to organ failure and damage (5). 

    If a person presents with suspected or confirmed infection, healthcare professionals should assess for signs of, and risk factors for sepsis following facility sepsis protocols. 

    Principles of Sepsis Treatment

    Sepsis treatment starts with a prompt recognition and diagnosis. The diagnosis of sepsis starts with the assessment of a patient with a known or suspected infection. For adults, sepsis is defined as having two or more symptoms of systemic inflammatory response syndrome, which includes (all from 6): 

    • Temperature (>38 o C or <36 o C) 
    • Elevated heart rate > 90 bpm 
    • WBC (<4×109/L or >12×109/L) 
    • Respiratory rate (>20 breaths/min, PACO2<32 mm Hg 

    Severe sepsis has traditionally been defined as having sepsis plus organ failure, while septic shock involved sepsis along with refractory hypotension after fluid resuscitation or requiring vasopressors to maintain hemodynamics (6). The standard changed in 2016 with the elimination of severe sepsis; however, most facilities still adhere to the above criteria. Follow sepsis protocol and bundles per facility. 

    With recognition of sepsis and/or septic shock, previously state law mandated that one- and three-hour care bundles be created. While these may vary slightly per facility, Surviving Sepsis promotes a one-hour bundle that incorporates all the recommendations of the other bundles; yet, decreases the time to treat (all from 7):  

    One Hour Bundle

    1. Obtain lactate level. Reorder if initial lactate is > 2 mmol/L 
    2. Obtain blood cultures prior to administering antibiotics 
    3. Administer broad-spectrum antibiotics 
    4. Rapidly infuse crystalloids at a rate of 30 mL/kg for hypotension or lactate ≥ 4 mmol/L 
    5. If hypotensive post fluid resuscitation, administer vasopressors to maintain a mean arterial pressure ≥ 65 mmHg

    In addition to blood cultures, type and screens may be ordered for urine, wound exudate, or respiratory secretions depending upon where the suspected infection is originating from. Blood tests may also include a complete blood count and basic metabolic panel to assess for any damage to the kidneys or liver. Other diagnostic imaging may include chest x-ray, CT, ultrasound, and MRI (8). 

    Fluid resuscitation and vasopressors, if needed, will continue until the patient is hemodynamically stable. Physicians should be notified when blood cultures result in order to ensure that the ordered antibiotic is effective against the identified organism (8). 

    Patient Education and Prevention

    Patient education should strive to provide memorable and simple ways to stay free of infection. The number one method of preventing infection is adequate hand hygiene. The CDC also suggests that patients keep wounds and cuts clean and covered until healed. 

    Patients at higher risk should be notified of their risk factors, including (all from 9): 

    • Adults 65 or older 
    • People with chronic medical conditions, such as diabetes, lung disease, cancer, and kidney disease 
    • People with weakened immune systems 
    • Sepsis survivors 
    • Children younger than one

    Patients should be educated on warning signs and symptoms of sepsis that are easy to remember. The Sepsis Alliance suggests the following acronym and verbiage for seeking immediate care (all from 4): 

    T - Temperature

    I - Infection

    M - Mental Decline

    E - Extremely Ill

    Patients should be encouraged to give relevant history and information to clinicians, including if they have had a recent infection, sepsis in the past, or are immunocompromised. 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. What are the lead causes of sepsis?
    2. How can sepsis be treated?
    3. How can sepsis be prevented?

    PTSD in Nurses

    Introduction

    Nursing can be highly stressful, demanding, and unpredictable. In some cases, nurses are exposed to potential physical, psychological, and mental hazards for upwards of 12-16 hours a day. Each person reacts and responds to extreme stress and trauma in various ways, and because there are so many variables to consider, it has been challenging to diagnose PTSD in nursing 

    It is natural for individuals to experience fear, heightened senses, and avoidance after experiencing a traumatic event. Nurses are aware of our body’s natural defense to danger or fear, commonly identified as the "fight or flight" response. There are many scenarios that define a traumatic event, and not everyone identifies them the same. For example, some may say losing a loved one is traumatic for them, whereas others may define life-threatening situations or witnessing one as being traumatic for them – all of which are valid.  

    The question now stands, “when do these traumatic events turn into PTSD?  

    In order to fully answer this, we must first define PTSD.  

    Definition 

    Post-traumatic stress disorder is defined as a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event (1). 

    The DSM-5 diagnostic criteria for PTSD include: 

    A. Stressor (one required):  

    • Personally experiencing trauma or watching someone endure it. 
    • Learning that a traumatic event(s) may have occurred to a close family member or friend. 
    • In cases of life-threatening instances, or the death of a family member/friend, the event(s) must have been violent or accidental.  
    • Experiencing repeated excessive exposure to adverse effects of a traumatic event (e.g. nurses working in critical care units, caring for COVID-19 patients, etc.) (2). 

    B. Intrusion symptom (one or more required):  

    • Recurrent and distressing memories or dreams of the trauma experienced. 
    • A dissociative reaction in which the person is completely unaware of their surroundings.  
    • Intense, prolonged psychological exposure to internal or external cues that may resemble the traumatic event.  
    • Distinct physiological reactions of internal or external reminders that may represent any aspect of the traumatic event (2). 

    C. Avoidance (one or both required): Avoiding any memories, thoughts, or feelings related to the traumatic event on a continuous basis.  

    • Avoidance or efforts to avoid instances or items that resemble or remind the person of the traumatic event. Examples include (2): 
    • People 
    • Places 
    • Activities 
    • Conversations 
    • Familial objects 

    D. Negative alteration in cognition and mood (two required):  

    • Inability to remember specifics of the traumatic event due to dissociative symptoms.  
    • Persistent and over-exaggerated negative belief about oneself, others, or the world (e.g. the world is completely dangerous or my whole nervous system is shot).  
    • Persistent negative emotional state (e.g. fear, anger, guilt, or shame).  
    • Persistent distorted perception about the cause of the traumatic event leads an individual to blame themselves. 
    • Distinctive or diminished interest or participation in any significant activities. Feelings of detachment from others. Continuous inability to experience positive emotions (2). 

    E. Alterations in arousal and reactivity (two or more): 

    • Angry outbursts and irritable behavior without provocation, leading to physical aggression toward people or objects.  
    • Self-destructive reckless behavior. 
    • Hypervigilance. 
    • Exaggerated startle response. 
    • Problems with concentrating. 
    • Sleep disturbance (2). 

    F. Duration of the disturbance (criteria B, C, D, and E required):  

    • More than a month. 

    G. Functional Significance (required): 

    • Clinically significant distress caused by the traumatic event(s) or impairment in social, occupational, or other areas of functioning.  
    • The functional disturbance is not attributable to the psychological effects of a substance or any other medical condition (2). 

    Case Study 

    Laura is a 26-year-old nurse of five years who has decided to take a travel nursing assignment to help with the overwhelming demand to care for COVID-19 patients. She is given a wonderful opportunity to make a difference. The staffing agency offered Laura a critical care staff nurse position, where she is expected to care for two patients and work 36 hours weekly on night shift for 13 weeks. Her pay would be $5,000 per week plus a non-taxed stipend for lodging and meals.  

    She accepts the assignment and immediately takes leave from her full-time position in Tennessee. She packs her belongings, says goodbye to her family, and begins her venture to California.  

    Upon her arrival to the hospital, Laura reports to the critical care department to meet with the nurse manager. Following, she is told by her superior that her contracted assignment has changed and that she will now be taking care of at least seven COVID-19 patients due to short-staffing. Laura is confused and feels as though she cannot say no due to her being under contract, so she attempts to reach out to her agency; no one is available to take her call. She leaves a message in hopes that someone will get back to her as soon as possible, however, she is expected to start her first shift that same evening.  

    Laura's first night is horrific; she is caring for seven COVID-19 patients that are all on ventilators, and she has no resources available to her if she has any questions. The environment is overwhelming; patients are lined against the wall, people are crying, a code blue is being called every 10-to-15 minutes, and most of the time, the patient dies. The morgue is overflowing, and some of the deceased patients are placed in body bags and lined against the wall or piled into a single room.  

    After only three shifts, Laura decides she cannot fulfill this contract because she has no support, is experiencing nightmares, feels extremely agitated, anxious, and seems to be crying all the time. As a result, she reaches out to her agency and informs them of her decision to end the contract. 

    The agency tells her that she will be reported to both the Tennessee (her home state) and California Board of Nursing for job abandonment, meaning she cannot practice if she breaks her contract.  

    Upon receiving this ultimatum, Laura decides to stay to fulfill the contract.  

    Over the next few weeks, Laura notices that some of her co-workers are manifesting a change in behavior. They have become increasingly sad, detached from others, displaying anger toward other staff members, and anxious. Laura feels as though her work environment is toxic, and she wishes she were anywhere else in the world but there, however, she cannot leave. 

    This is a prime example of PTSD in nurses.  

    Refer to this case study to answer some of the learner exercise questions throughout the course.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Have you experienced perceived trauma that can be categorized as PTSD in nurses? 

    2. Can a person experience PTSD without having a clinical diagnosis?

    3. When you are having a stressful day, what do you think your colleagues are feeling or thinking? 

    4. How are Laura's colleagues relating to her actions? 

    Sign and Symptoms of PTSD in Nurses 

    There are many signs and symptoms of PTSD in nurses. Symptoms may develop immediately, or within three months of the traumatic event(s). On some occasions, a person can suppress their feelings for up to a year before remembering a traumatic event. Many of the signs and symptoms are grouped into four categories: intrusive memories, avoidance, negative changes in mood and thinking, and negative changes in physical and emotional reactions (3).  

    Intrusive memories include: 

    • Recurrent distressing memories of the traumatic event 
    • Flashbacks 
    • Nightmares 
    • Severe emotional distress 
    • A physical reaction to something that reminds the person of the traumatic event 

    Avoidance: includes any memories, thoughts, or feelings related to the traumatic event on a continuous basis. For examples, see The DSM-5 diagnostic criteria for PTSD include section above.  

    Negative changes in mood and thinking includes:

    • Feelings of hopelessness about the future 
    • Not remembering certain aspects of the traumatic event 
    • Difficulty in maintaining close relationships 
    • Feeling of detachment 
    • Lack of interest in activities once enjoyed 
    • Difficulty experiencing positive emotions 
    • Feeling emotionally numb 
    • Alcohol or drug abuse 
    • Having negative thoughts about yourself, other people, or the world (3)   

    Changes in physical and emotional reactions include: 

    • Heightened senses, fight or flight 
    • Insomnia, trouble concentrating 
    • Overwhelming feelings of guilt or shame 
    • Increased irritability, aggressive behavior, outbursts with no provocation 
    • Chronic illnesses, gastrointestinal problems, sweating/shaking 
    • Angina 
    • Self-destructive behavior, depression, hallucinations, anxiety, and feelings of constant sorrow (3)
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Take a mental moment. Do you feel like you are experiencing any of these symptoms or have experienced them in the past?

    2. As a nurse, can you identify any of these symptoms in your co-workers? Does Laura or her co-workers display any of these symptoms? 

    3. How many times have you brushed off any of these symptoms as just isolated events? 

    Types of PTSD 

    Since we know that the American Psychiatric Association describes PTSD as a psychological disorder, we know there are different types and severity levels of PTSD. As previously mentioned, everyone can experience the various types, however, we are going to focus on the commonly diagnosed types of PTSD in nurses.  

    Overall, there are five types of PTSD, which include: normal stress response, acute stress disorder, uncomplicated PTSD, complex PTSD, and comorbid PTSD (4). 

    Normal Stress Response 

    The normal stress response, the "fight or flight," is the precursor to PTSD in nurses, and it does not always lead to full-blown PTSD. Any event that causes our natural stress response, such as surgery, an injury or pending thoughts of danger, all initiate a normal stress response; the problem occurs when this response is not alleviated within a short amount of time. 

    Acute Stress Disorder 

    A life-threatening event such as job loss, illness, natural disaster, or death of a loved one can initiate this early form of PTSD in nurses. While the individual may experience this type of disorder, they will typically overcome the initial stressor. If it becomes prolonged and untreated, it can lead to full-blown PTSD. 

    Uncomplicated PTSD 

    This type of PTSD in nurses is associated with one major event, making it the easiest form of PTSD to treat. The individual will want to avoid everything that could remind them of the event. 

    Complex PTSD 

    Complex PTSD is just as the name implies. This type of PTSD in nurses is associated with multiple traumatic events and is usually associated with various types of abuse, violence, war, and traumatic losses. The unfortunate problem with diagnosing this type of PTSD is that some professionals confuse it with a borderline or antisocial personality disorder or dissociative disorders (4). 

    Comorbid PTSD 

    This type of PTSD in nurses is associated with a person with more than one mental health concern and substance or narcotic abuse issues at the same time. This condition is extremely common because most people have more than one problem. PTSD makes this more complicated to treat. Individuals may try to self-medicate because they are in denial, but this only leads to self-loathing and self-destructive behaviors (5). 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Can you identify with any one of the types of PTSD listed?

    2. If any, which type of PTSD might Laura be experiencing? What about her co-workers?

    3. How difficult would it be to recognize the difference between the five types of PTSD within yourself or your co-worker?

    Phases of PTSD in Nurses 

    There are four phases of PTSD identified by Pyramid Health. The phases are impact (emergency), rescue, intermediate recovery, and long -term reconstruction (5). 

    Impact (Emergency) 

    The impact phase consists of the initial reaction such as anxiety, helplessness, guilt, shock, or fear. This occurs immediately after the individual experiences the traumatic event. The duration of this phase depends on the severity of the event (5). 

    Rescue

    The rescue phase involves the individual being able to come to terms with what has happened. This is closely related to the acceptance phase in grieving. The individual may experience flashbacks, confusion, anxiety, denial, or feelings of despair. 

    Intermediate Recovery

    The intermediate recovery phase is associated with the individual making the adjustment to return to everyday life. In this phase, the individual can begin to look at other issues within their life. While addressing new issues, they may have the feeling of altruism, in which they feel the love and support from others, causing them to believe that they can also help others. 

    Additionally, they may also develop the feeling of disillusionment, in which they feel overwhelmed because they are not receiving the love and support that they think they should, or they realize they are on their own when it ends.

    This phase is closely related to the acceptance phase in grieving. As with the grieving phase, the individual may go back and forth between phases. 

    Long-term Reconstruction

    The long-term reconstruction phase is characterized by the individual being able to rebuild while continuing to deal with the trauma's aftermath. Their main concerns are about their future and how they can maintain healing. 

    Causes of PTSD 

    Defining the causes of PTSD in nurses can be quite tricky because physicians have not been able to determine why some individuals may have a different response to the same traumatic event. Many nurses have experienced stressful experiences that did not cause PTSD. Some causes or increased risk for developing PTSD in nurses could include inherited mental health risk, an individual's temperament, and how our brain regulates chemicals and hormones that release stress in our bodies. 

    The hippocampus is a component of the brain that works to consolidate information from short- to long-term memory, links these memories to sensations, and enables our ability to navigate through spatial memory (6). The hippocampus is located under the cerebral cortex in the allocortex, and there are two hippocampi, one on each side of the brain that have very distinct roles.  

    PTSD is associated with abnormal hippocampal activity (6). It has been noted that PTSD is mainly associated with functional and structural changes in the amygdala, medial prefrontal cortex, and the hippocampus (6). The main role of the posterior hippocampus is in memory retrieval and spatial cognition, whereas the role of the anterior hippocampus is mainly associated with the amygdala, hypothalamic-pituitary-adrenal (HPA) axis, and limbic prefrontal circuitry (6).  

    The anterior hippocampal-amygdala connections are thought to underlie atypical memory processes in PTSD, including flashbacks, intrusive thoughts, and nightmares (6). There are current theories of PTSD that identify hippocampal dysfunction as a key contributor to hallmark symptoms of PTSD in nurses(7). 

    One common denominator for causes of PTSD is the actual stress an individual goes through when they experience or learn about a life-threatening event, serious injury, sexual assault, childhood physical abuse, being threatened with a weapon, an accident, being exposed repetitively to death, violence, or sickness. 

    The Effect on Nurses 

    The COVID-19 outbreak has had a severe impact on the healthcare industry. Professionals are working tirelessly to care for patients who are experiencing health issues caused by COVID-19, leading to a significant spike in PTSD in nurses.  

    Professionals in critical care, trauma, and emergency room departments are continuously witnessing death on top of working within a crowded, high-stress environment that often faces short-staffing. 

    Factors relating to development of PTSD in nurses: 

    • Age  
    • Work experience  
    • Previous psychiatric history  
    • Marital status  
    • Family support  
    • Coping styles  
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. From the information in the case study, what do you think is causing Laura's symptoms?  

    2. Who do you think would be more susceptible to PTSD, the senior nurse, or the junior nurse?

    Prevalence of PTSD in Nurses 

    Based on the current U.S. population (223.4 million), around 7 to 10 of every 100 people will have experienced some traumatic event in their lifetime. 20% of the population (44.7 million) suffer from PTSD. The chances of experiencing traumatic events and receiving a PTSD diagnosis within the nursing profession are very high (8).  

    In most instances, nurses are trained to put their patients’ needs over their own when they walk in the door. When their shift starts, they attempt to suppress their emotions so they can get through their shift. A nurse may experience a rush of feelings such as anger, guilt, confusion, sadness, sorrow, and grief and sometimes, in extreme cases, suicidal or homicidal ideations. To mask their emotions, they may turn to drinking, drugs, or destructive behaviors to cope with the day-to-day trauma from their job. 

    A 2009 nursing study covering depression and anxiety revealed a high prevalence of burnout syndrome and PTSD in nurses. The 810-person study revealed that 22% of participants experience symptoms of PTSD, and 18% met the diagnostic criteria for PTSD. Additionally, the results determined that while 86% met the criteria for burnout syndrome, 98% fulfilled the diagnostic criteria for PTSD and were positive for burnout syndrome. The study concluded that nurses with burnout syndrome and PTSD were significantly more likely to have difficulty in their outside life from work (13).  

    An additional study that evaluates the results of over 24 publications regarding PTSD in nurses between 1999 and 2019 determined that a majority of nurses with PTSD had the following: 

    • Leadership roles 
    • Negative outlook on patient care 
    • Lack of supportive relationships, staffing, and organizational support 
    • Internalized both short- and long-term patient suffering 

    As they continue to push through global pandemics, natural disasters, and continuous tragic events, PTSD in nurses is a prevalent issue that we must address.

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Would Laura' symptoms or actions lead you to think she was experiencing PTSD? 

    2. What about her co-workers, would their actions lead you to think they were experiencing PTSD? 

    3. Based on the statistics in the section above, does that make a difference on your assessment of Laura's symptoms? 

    Current Therapy

    PTSD will continue to worsen without treatment. The Veterans Health Administration and Department of Defense (VA/DoD) and the American Psychological Association (APA) in 2017 each established treatment guidelines for PTSD (10). Both guidelines recommend the use of prolong exposure (PE), cognitive processing therapy (CPT), trauma-focused cognitive behavioral therapy (CBT), and eye movement desensitization and reprocessing (EMDR) therapy (10).  

    Non-trauma-focused treatments include medication, relaxation therapy, and stress inoculation training (SIT).

    Trauma-focused:

    Prolong Exposure (PE)

    Prolong exposure (PE) therapy is strongly recommended by both the APA and VA/DoD as a successful treatment of PTSD. PE is based on the emotional processing theory, which stipulates that traumatic events are not emotionally processed at the time of the event. 

    PE therapy consists of two main components: in vivo and imaginal exposure (10). 

    Cognitive Processing Therapy (CPT) 

    CPT utilizes the social cognition theory and the informed emotional processing theory. Following a traumatic event, usually, a survivor attempts to make sense of what has happened and leads to distorted cognitions regarding themselves, the world, and others. The main goal of CPT is to shift an individual's unhelpful beliefs related to their trauma toward more accommodating, positive and helpful beliefs to promote new learning (10). Sessions usually take 12 weeks, and they incorporate psychoeducation about the cognitive model and exploration of the patient's conceptualization of the traumatic event (10). 

    Cognitive Behavioral Therapy (CBT)

    Trauma-focused CBT is based on behavioral and cognitive models drawn from cognitive behavior theories, including PE and CPT. This type of therapy includes modifying negative appraisals, correcting the autobiographical memory, and removing the problematic behavior and cognitive strategies. 

    It is believed that guilt-associated appraisals tend to evoke negative effects and are usually paired with images or thoughts of the trauma, thus causing a repeated and reconditioned memory of the trauma; Ultimately producing distress, leading to tendencies to suppress or avoid the trauma-related stimuli in individuals (10).  

    The techniques associated with CBT include exposure and cognitive restructuring. The exposure technique for a traumatic memory utilizes imaginal exposure, writing about the trauma, and reading the traumatic memory out loud (10). The most important aspect of cognitive restructuring is teaching the patients to identify the various dysfunctional thoughts and erroneous thinking, replace them with rational alternative thoughts, and having them reconsider their beliefs about themselves, the trauma, and the world (10). 

    Eye Movement Desensitization and Reprocessing (EMDR) Therapy

    EMDR therapy requires healthcare professionals to help a patient move their eyes back and forth while imagining or recalling their traumatic event. This technique allows the individual to reprocess the memory while addressing the past, present, and future aspects of the traumatic memory.  

    Non-trauma-focused:

    Medication Therapy

    The current medication therapy recommended by the APA for PTSD treatment is sertraline (Zoloft), paroxetine (Paxil), fluoxetine (Prozac), and venlafaxine (Effexor). Although all medications must be customized for each individual, it is important to note that Zoloft and Paxil are the only FDA-approved medications for the treatment of PTSD (11). 

    In some cases, taking antidepressants in conjunction with PTSD medication treatments can serve as beneficial. Those medications include: 

    • Clonidine and Guanfacine, Risperidone for agitation 
    • Clonidine, Prazosin and Trazodone for trauma-related nightmares 
    • Beta-blockers such as Propanol are used to decrease hyperarousal symptoms but it has not been approved by the FDA (12). 
    Relaxation Therapy

    Relaxation therapy is a form of psychotherapy that utilizes breathing techniques, progressive muscle techniques, and meditation to elicit a voluntary relaxation response of the individual. Sometimes, guided imagery is utilized to have the individual focus on positive images in their mind. This technique helps lower the individual’s blood pressure, relieves tension in their muscles, and lowers their stress. 

    Progressive Muscle Relaxation has been utilized to help reduce fatigue and relieve PTSD in nurses. This technique involves sequential tensing of major muscles in the body. This form of relaxation therapy reduces feelings of tension, lowers perceived stress, and can be performed anywhere at any time. This technique has the positive effect of decreasing the pulse rates, increases the individual's oxygen saturation and is sometimes used in conjunction with other forms of psychotherapy (13). 

    Stress Inoculation Training (SIT) 

    SIT is a form of psychotherapy used for the treatment of PTSD. This training is a type of cognitive-behavioral therapy that teaches the individual coping skills and helps them find new ways to deal with their PTSD symptoms. SIT teaches individuals to react differently in stressful situations and is performed in phases (14).

    In the first phase, the individuals learn about their PTSD symptoms, and they identify the traumatic stress that they experienced. Following, the individual learns how to monitor their stress level. In the second phase, they learn new problem-solving strategies and coping skills that help them relax their bodies, control their breathing, interrupt the upsetting thoughts, and help the individual stay in the current moment. Research shows that SIT is one of the most effective forms of therapy for PTSD (14). 

    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Which therapy options do you think best suit Laura and her co-workers and why? 

    Coping Mechanisms 

    It is sometimes difficult for individuals experiencing PTSD to cope with the mountain of symptoms that they may encounter. For nurses experiencing PTSD, it is critical that they seek treatment and develop coping mechanisms. If their symptoms go untreated, their work performance and quality of patient care may decrease. 

    Nurses have resources available to help them cope with PTSD. Some workplaces have elicited the help of psychiatrists or psychologists to provide drop-in services at the worksite. Various positive coping mechanisms include 

    • Spiritual guidance in prayer 
    • Having a strong support system to lean on such as a sponsor that the individual can call when feeling overwhelmed 
    • Including their family in the healing process 
    • Performing mindful meditation or yoga  
    • Performing guided imagery to focus on positive thoughts when the stressors resurface 
    • Prescription medication  
    • Peer support at work 
    • Professional counseling 
    • Group therapy
    Quiz Questions

    Self Quiz

    Ask yourself...

    1. Think of your work environment. Do you know what resources are available to you if you experience PTSD? 

    2. How can you help your colleagues cope with the day-to-day pressures of working in a high-stress environment? 

    3. Looking back to the case study, perform a complete assessment of Laura and her work situation and develop a plan of care for her and her co-workers. 

    Conclusion 

    PTSD can be a very debilitating condition and affects millions of people every year. Nurses are on the front lines serving the public during a health crisis, and we now know that for them to do their jobs effectively, their mental health must be a priority 

    Many organizations now offer counseling, time off, peer support, and incentives for nurses to take care of themselves. With proper treatment, we can alleviate or control PTSD in nurses. Our goal for the future is to continue to make the physical, spiritual, and mental health of all health care workers a top priority so that they can continue to provide the best care to patients.  

    References + Disclaimer

    Florida Domestic Violence
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    13. Emergency Nurses Association. (2018). Intimate Partner Violence. Emergency Nurses Association (ENA). https://www.ena.org/docs/default-source/resource-library/practice-resources/position-statements/joint-statements/intimatepartnerviolence.pdf?sfvrsn=4cdd3d4d_8 
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    Florida HIV/AIDS
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    2. Hartog, J., & Robinson, G. (2013, August). Florida’s Omnibus Act: A brief legal guide for healthcare professionals. Retrieved February 25, 2021, from http://www.floridahealth.gov/diseases-and-conditions/aids/administration/_documents/Omnibus-booklet-update-2013.pdf 
    3. Hartog, J., & Robinson, G. (2013, August). Florida’s Omnibus Act: A brief legal guide for healthcare professionals. Retrieved February 25, 2021, from http://www.floridahealth.gov/diseases-and-conditions/aids/administration/_documents/Omnibus-booklet-update-2013.pdf 
    4. Centers for Disease Control. (2016). Today’s HIV/AIDS epidemic. Retrieved from: https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/todaysepidemic-508.pdf   
    5. Centers for Disease Control. (2020). Evidence of HIV treatment and viral suppression in preventing the sexual transmission of HIV. Retrieved from: https://www.cdc.gov/hiv/pdf/risk/art/cdc-hiv-art-viral-suppression.pdf 
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    8. Nursing Times. (2020). HIV: epidemiology, pathophysiology, and transmission. Retrieved from: https://www.nursingtimes.net/clinical-archive/immunology/hiv-1-epidemiology-pathophysiology-and-transmission-15-06-2020/
    Florida Laws and Regulations
    1. The Florida Senate. “Chapter 456.” Chapter 456 – 2018 Florida Statutes – The Florida Senate, www.flsenate.gov/Laws/Statutes/2018/Chapter456
    2. The Florida Senate. “Chapter 464.” Chapter 464 – 2018 Florida Statutes – The Florida Senate, www.flsenate.gov/Laws/Statutes/2018/Chapter464/All 
    3. Intervention Project for Nurses, 2016, www.ipnfl.org/ 
    4. State of Florida. Department List – Florida Administrative Rules, Law, Code, Register – FAC, FAR, ERulemaking, www.flrules.org/gateway/Division.asp?toType
    Florida Medical Errors Prevention
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    4. CMS. (2020, 11 19). Hospital CAHPS (HCAHPS). Retrieved from CMS.gov: https:www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/HCAHPS1
    5. Federico, F. (2021). Improvement Stoties. Retrieved from ihi.org: https://www.ihi.org/resources/Pages/ImprovementStories/FiveRightsofMedicationAdministration.aspx
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    12. TJC. (2020, 08 01). Official “Do Not Use” List. Retrieved from jointcommission.org: https://www.jointcommission.org/-/media/tjc/documents/fact-sheets/do-not-use-list-8-3-20.pdf?db=web&hash=2489CB1616A30CFFBDAAD1FB3F8021A5
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    Florida Recognizing Impairment in the Workplace
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    4.  Employer Information. (n.d.). Retrieved February 03, 2021, from https://www.ipnfl.org/employer-information/#sec1 
    Florida Human Trafficking
    1. https://polarisproject.org
    2. https://humantraffickinghotline.org/state/florida/
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    Key Concepts of Critical Thinking in Nursing
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    Nursing Documentation 101
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    13. Peters, P. G. (2008). Twenty Years of Evidence on the Outcomes of Malpractice Claims. Clinical Orthopaedics and Related Research, 467(2), 352-357. doi:10.1007/s11999-008-0631-7
    14. Singh, H. (2018). National Practitioner Data Bank Generated Data Analysis Tool. Retrieved March 1, 2019, from https://www.npdb.hrsa.gov/analysistool/
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    18. Reising, D. L., & Allen, P. N. (february 2007). Protecting yourself from malpractice claims. American Nurse Today,2(2). Retrieved March 1, 2019, from https://www.americannursetoday.com/protecting-yourself-from-malpractice-claims/.
    19. Reising, D. L. (2012). Make your nursing care malpractice-proof. American Nurse Today,7(1). Retrieved March 1, 2019, from https://www.americannursetoday.com/make-your-nursing-care-malpractice-proof/
    Nursing Ethics
    1. Gallup Poll finds nursing is most honest and ethical profession. (2021, January). Oakland University News,, . https://oakland.edu/oumagazine/news/nursing/2021/gallup-poll-finds-nursing-is-most-honest-ethical-profession 
    2. Rushton, C. (2017, January).  Why ethics?. John Hopkins Nursing. https://magazine.nursing.jhu.edu/2017/01/why-ethics/ 
    3. Fowler, M., “Nursing’s Code of Ethics, Social Ethics, and Social Policy,” Nurses at the Table: Nursing, Ethics, and Health Policy, special report, Hastings Center Report 46, no. 5 (2016): S9-S12. DOI: 10.1002/ h 
    4. Florence Nightingale Pledge. (2010) https://nursing.vanderbilt.edu/news/florence-nightingale-pledge/#:~:text=I%20solemnly%20pledge%20myself%20before,knowingly%20administer%20any%20harmful%20drug
    5. Rich, K., & Betts, J. (). Ethical theories and approaches. Jones & Bartlett Learning. 
    6. The ICN Code of Ethics for Nurses (2021). https://www.icn.ch/system/files/documents/2020-10/CoE_Version%20for%20Consultation_October%202020_EN.pdf 
    7. Edmonton, C. & Zelonka, C. (2019). My own worse enemy: the nurse bullying epidemic. Nursing Administration Quarterly. July – September. 43(3). 274-279. 
    8. Bell, J.A. ( 2013). Five generations in the nursing workforce.  Journal for Nurses in Professional Development 29( 4 ) https://www.sgna.org/Portals/0/Bell_FiveGenerationsInTheNursingWorkforce_2013.pdf 
    9. Should Euthanasia Or Physician Assisted Suicide Be Legal(2019). https://euthanasia.procon.org/ 
    10. Llamas, J. V. (2018, November). The moral and ethical dilemma of physician assisted suicide. Minority Nurse, (), . https://minoritynurse.com/the-moral-and-ethical-dilemma-of-physician-assisted-suicide/ 
    11. 11. Lockwood, W. (2020, April).  Jurisprudence and nursing ethics. http://file:///D:/Ethics%20in%20Nursing/Jurisprudence.pdf
    Infection Control and Barrier Precautions
    1. RETRACTED: https://www.health.ny.gov/diseases/conditions/sepsis/ 
    2. https://www.health.ny.gov/facilities/public_health_and_health_planning_council/meetings/2013-02-07/docs/13-01.pdf
    3. RETRACTED: https://health.ny.gov/press/reports/docs/2017_sepsis_care_improvement_initiative.pdf
    4. https://www.sepsis.org/sepsis-basics/what-is-sepsis/ 
    5. https://www.nhsinform.scot/illnesses-and-conditions/blood-and-lymph/septic-shock
    6. Kim, H, & Park, S. (2019). Sepsis: Early recognition and optimized treatment. Tuberculosis and Respiratory Disease, 82(1), 6-14. doi: 10.4046/trd.2018.0041 
    7. https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/Adult-Patients
    8. https://www.mayoclinic.org/diseases-conditions/sepsis/diagnosis-treatment/drc-20351219 
    9. https://www.cdc.gov/sepsis/pdfs/Consumer_fact-sheet_protect-yourself-and-your-family-P.pdf
    PTSD in Nurses
    1. Torres, F. (2020, August). What is Post-traumatic Stress Disorder. Retrieved February 17, 2021, from https://www.psychiatry.org/ 
    2. DSM-5 Diagnostic Criteria for PTSD Trauma-Informed Care in Behavioral Health Sciences NCBI. (n.d.). Retrieved February 17, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK207191/box/part_ch3box16/ 
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