2023 Illinois Renewal Bundle

Course Highlights

  • In this implicit bias training course, we will cover the implications and long-term outcomes of unaddressed subconscious biases in healthcare and why it is important for providers to recognize and remove any biases that could impact their ability to offer equitable care.
  • You’ll also learn the basics of identifying inappropriate sexual behaviors in the workplace, as required by the Illinois Board of Nursing.
  • You’ll leave this course with a broader understanding of Alzheimer’s and other types of dementia.


Contact Hours Awarded: 20

Course By:
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The following course content

This 2023 Illinois License Renewal Bundle meets all renewal requirements for Illinois LPNs and RNs.

This course includes multiple interesting topics in one easy course, including the Implicit Bias, Sexual Harassment Training, and Alzheimer’s and Dementia courses that are required by the IL BON. Upon completion of this course, you will receive a single certificate of completion for 20 contact hours.

Course Outline

  1. Implicit Bias Training (Meets Illinois BON Requirement)
  2. Sexual Harassment Training (Meets Illinois BON Requirement)
  3. Alzheimer’s and Dementia Training (Meets Illinois BON Requirement)
  4. Effective Communication in Nursing
  5. Ensuring Patient Confidentiality in Nursing
  6. Nursing Documentation 101
  7. Nursing Ethics
  8. Infection Control and Barrier Precautions
  9. PTSD in Nurses
  10. End of Life Process
  11. Following a DNR: An Ethical Dilemma in Nursing
  12. Screening for Suicide Risk Factors in Pediatrics

Implicit Bias Training


Health equity is a rising area of focus in the healthcare field, as renewed attention is being given to ongoing data covering discrepancies and gaps in the accessibility, expanse, and quality of healthcare delivered across racial, gender, cultural, and other groups. Yes, there are some differences in healthcare outcomes purely based on biological differences between people of different genders or races, but more evidence points to the vast majority of healthcare gaps stemming from individual and systemic biases.  

Policy change and restructuring are happening at institutional levels across the country, but this will only get us so far. In order for real change to occur and the gaps in healthcare to close, there must also be awareness and change on an individual level. Implicit, or subconscious, bias has the potential to change the way healthcare professionals deliver care in subtle but meaningful ways and must be addressed to modernize healthcare and reach true equity. 

This implicit bias training meets the “Implicit Bias Training for Healthcare Workers” requirement needed for Illinois nursing license renewal.  

What is Implicit Bias?

So what is implicit bias and how is it affecting the way healthcare is delivered? Simply put, implicit bias is a subconscious attitude or opinion about a person or group of people that has the potential to influence the actions and decisions taken when providing care. This differs from explicit bias, which is a conscious and controllable attitude (using racial slurs, making sexist comments, etc.). Implicit bias is something that everyone has to some capacity, whether we are fully aware of it or not and it can influence our understanding of and actions towards others. The way we are raised, our unique life experiences, and individual efforts to understand our own biases all affect the opinions and attitudes we have towards other people or groups (6). 

Of course, this can be both a positive or a negative thing. For example, if a patient’s loved one tells you that they are a nurse, you may immediately feel more connected to them and go above and beyond the expected care as a “professional courtesy.” This does not mean that you dislike your other patients or their loved ones, it just means that you feel more at ease in the presence of another healthcare professional and this shapes your thoughts and behaviors in a positive manner.  

However, this is a rare case. Oftentimes, implicit biases have a negative connotation and can lead to care that is not as empathetic, holistic, or high quality as it should be. Common examples of implicit bias in healthcare include:  

  • Thinking elderly patients have lower cognitive or physical abilities 
  • Thinking women exaggerate their pain or have too many complaints 
  • Assuming patients who state they are sexually active are heterosexual  
  • Thinking Black patients delay seeking preventative or acute care because they are passive about their health 
  • Assuming a chatty college student is asking for ADHD evaluation because she is lazy and wants medication to make things easier 

On a larger, more institutional and societal level, the effects of bias create barriers such as: 

  • Underrepresentation of minority races as providers: in 2018, 56.2% of physicians were white, while only 5% were Black and 5.8% Hispanic (2). 
  • Crowded living conditions and food deserts for minority patients due to outdated zoning laws created during times of segregation (15). 
  • Difficulty obtaining health insurance for minority or LGBTQ clients, decreasing access to healthcare (3). 
  • Lack of support and acceptance for LGBTQ populations in the home, workplace, or school as well as a lack of community resources can lead to negative social and mental health outcomes. 
  • Due to variations in the way disabilities are assessed, the reported prevalence of disabilities ranges from 12% to 30% of the general population (13). 
Quiz Questions

Self Quiz

Ask yourself...

Before introducing the implications and long-term outcomes of unaddressed implicit biases in healthcare, reflect on your practice and the clients you work with. This will help as we progress through this implicit bias training course.

  1. Are there certain types of people you assume things about just based on the way they look, their gender, or their skin color? 
  2. In what ways do you think these assumptions might affect the way you care for your clients, even if you keep these opinions internal?  
  3. How do you think you could try and re-frame some of these assumptions?  
  4. Do you think being more aware of your internal opinions will change your actions the next time you work?  


Once you have an understanding of what implicit bias in healthcare is, you may be wondering what it looks like on a larger scale and what it means in terms of healthcare discrepancies. In order to address ways that those in healthcare can identify, address, and overcome implicit biases later in this implicit bias training, we must first cover its implications and outcomes. Listed below are just a few examples of outcomes stemming from subconscious biases in healthcare:

  • Medical training and textbooks are mostly commonly centered around white patients, even though many rashes and conditions may look very different in patients with darker skin or different hair textures. This can lead to missed or delayed diagnoses and treatment for patients of color (8).  
  • A 2018 survey of LGBTQ youth revealed that 80% reported that their provider assumed they were straight or did not ask otherwise (11).  
  • In 2014, a post-physician appointment survey showcased that over half of gay men (56%) respondents reported that they had never been recommended for HIV screening, despite their increased risk for contraction (9).  
  • A 2010 study found that women were more verbose in their encounters with physicians and felt unable to fit all of their complaints into the designated appointment time, leading to a less accurate understanding of their symptoms by their doctor (4). For centuries, any symptoms or behaviors that women displayed (largely related to mental health) that male doctors could not diagnose fell under the umbrella of “hysteria,” a condition that was not removed from the DSM-III until 1980 (18).  
  • When treating elderly patients, providers may dismiss a treatable condition as part of aging, skip preventative screenings due to old age, or over-treat natural parts of aging as though they are a disease. Providers may be less patient, responsive, and empathetic to a patient’s concerns because they believe them to be cognitively impaired (16).  

Although these are only a few examples, there are obvious and substantial consequences of these biases; which is why it is vital that we address them in this implicit bias training course.  

Below, are just a few more examples of what the long-term effects of what implicit biases in healthcare can lead to if both institutional and personal behaviors are not addressed:  

  • A 2020 study found that Black individuals over the age of 56 experience decline in memory, executive function, and global cognition at a rate much faster than white individuals. Data in this study attributes this difference to the cumulative effects of chronic high blood pressure more likely to be experienced and under-treated for Black Americans (14). 
  • Lack of health insurance keeps many minority patients from seeking care at all. 25% of Hispanic people, 14% of Black people 8.5% of white people are uninsured in the U.S. This leads to a lack of preventative care and screenings, a lack of management of chronic conditions, delayed or no treatment for acute conditions, and a later diagnosis with poorer outcomes of life threatening conditions (3). 
  • A 2010 study reported men and women over age 65 were equally likely to have visits with a primary care provider, but women were less likely to receive preventative care such as flu vaccines (75.4%) and cholesterol screening (87.3%) compared to men (77.3% and 88.8%, respectively) (4).  
  • About 12.9% of school aged boys are diagnosed and treated for ADHD, compared to 5.6% of girls, though the actual rate of girls with the disorder is believed to be much higher (5).  
  • Teenagers and young adults who are part of the LGBTQ community are 4.5 times more likely to attempt suicide than straight, cis-gender peers (10).  
Quiz Questions

Self Quiz

Ask yourself...

For the purpose of this implicit bias training, put yourself in a patient's perspective and reflect on the following:

  1. Have you ever been a patient and had a healthcare professional assume something about you without asking or getting the whole story? How did that make you feel? 
  2. How do you think it might affect you over time if every healthcare encounter you had went the same way?  

Exploring Areas of Bias


Cultural competence is an essential topic to cover as healthcare professional. There are many training and informational programs that cover how various religions, ethnicities, or beliefs can be integrated into medical practices. Students and staff members are often reminded that the highest quality of care must also meet the cultural needs a client may have no matter if these beliefs or needs differ from the provider’s.  An awareness of the potential variances in care, such as dietary needs, desire for prayer or clergy members, rituals around birth or death, beliefs surrounding and even refusal for certain types of treatments, are all certainly very important for the culturally sensitive healthcare professional to have (and the distinctions far too many for the scope of this course); however, there is also a fine line between being aware of cultural similarities and stereotyping. Since this course is an implicit bias training, it is essential that this topic is covered. 

Clinicians should ensure that they understand that people hold different identities, beliefs, and practices across racial, ethnic, and religious groups. Remember that just because someone looks a certain way, or identifies with a certain group, does not mean all people within that group are the same. Holding assumptions about clients of a particular race or religion, without getting to know the individual needs of a client, is a form of implicit bias and may cause a client to become uncomfortable or offended.  

Simply asking clients if they have any cultural, dietary, or spiritual needs throughout the course of their care is often the best way to learn their needs without making assumptions or stereotyping. Overall, it should be thought of as extending care beyond cultural competence and working on partnership and advocacy for a client’s unique needs.  

Quiz Questions

Self Quiz

Ask yourself...

  1. Have you ever cared for a client that you made an assumption about based on appearances and it turned out not to be true?  
  2. Did your behavior or attitude towards that client change at all once you gained new information about them? 
  3. Upon completing this section of your implicit bias training, think about ways you could incorporate cultural questions into your plan of care and how it could improve your understanding of client needs.  

Maternal Health

One of the more obvious places that implicit bias has tainted the healthcare industry is in maternal health. Repeatedly, statistics show that Black women experience twice the infant mortality rate and nearly four times the maternal mortality rate of non-Hispanic white women during childbirth. Due to this severe prevalence, it is vital that we cover maternal health in this implicit bias training course.

Pregnancy and childbirth are natural processes, but they do come with inherent risks for both the mother and baby; but in a modern society, women should feel comfortable and confident in their care, not scared they won’t be treated properly or not survive. Home births among Black women are on the rise as they seek to avoid the biases of the hospital setting and maintain control over their own experiences (17).  

A few examples that showcase the hesitance a Black woman might have with birthing in a hospital setting might include a lack of health insurance leading to poorer general health before pregnancy, a lack of prenatal care, or a lack of care in the weeks following pregnancy. However, the discrepancies still exist at an alarmingly high rate even when looking at minority women with advanced education and high income, indicating that a more insidious culprit, such as implicit bias, is hugely responsible (17). In order for true change to come, this topic must be addressed in this implicit bias training. A few notes that indicate the prevalence of implicit bias in healthcare throughout history are listed below:  

  1. Biological differences between white and black women date back to slavery, including the belief that Black women have fewer nerve endings, thicker skin, and thicker bones and therefore do not feel pain as intensely. This is an entirely false belief. Unfortunately, Black and Hispanic women statistically have their perceived pain rated lower by healthcare professionals and are offered appropriate pain management interventions less often than white peers.  
  2. Complaints from minority patients that may indicate red flags for conditions such as preeclampsia or hypertension are often downplayed or ignored by healthcare professionals.  
  3. Studies show healthcare professionals may believe minority patients are less capable of adhering to or understanding treatment plans and may explain their care in a condescending tone of voice not used with other patients. For example, one in five Black and Hispanic women report poor treatment during pregnancy and childbirth by healthcare staff. These patients are less likely to feel respected or like a partner in their care and may be non-compliant in treatment recommendations due to feeling this way, however, this just perpetuates the attitudes held by the healthcare providers (17).
Quiz Questions

Self Quiz

Ask yourself...

  1. Think about how a provider’s perception of a maternity client’s pain could snowball throughout the labor and delivery process. How do you think it might affect the rate of c-sections or other birth interventions if clients have not had their pain properly managed throughout labor?  
  2. Pregnancy is a very vulnerable time. For the purpose of this implicit bias training, put yourself into the perspective of a pregnant woman. Think about how you would feel if you were experiencing a pregnancy and had fears or concerns but your provider did not seem to validate or respect you. Would you feel comfortable going into birth? How might added fears or stress impact the experience?  

Reproductive Rights

Branching off of maternal health, is reproductive justice. Biases surrounding the reproductive decisions of women may negatively impact the care they receive when seeking care for contraception or during pregnancy. While some of these inequities may be more profound for women of color, women of all races can be and are affected by biases surrounding reproduction, which is why it is being covered in this implicit bias training course. Examples of ways implicit bias may affect care include:  

Some healthcare professionals may believe there is a “right” time or way to become pregnant and feel pregnancy outside of those qualifiers is undesirable; this can stem from personal or religious beliefs. While healthcare staff are certainly entitled to hold these beliefs in their personal lives, if the resulting implicit biases are left unchecked, they can lead to attitudes and actions that are less compassionate when caring for their clients. Clients may feel shamed or judged during their experiences instead of having their needs addressed (7). Variables that may be perceived as unacceptable or less desirable include: 

  • Age during pregnancy. Clinicians may feel differently about pregnant clients who are very young (teenagers) or even those who are in their 40s or 50s (7).  
  • Marital status during pregnancy. Healthcare professionals may have beliefs that clients should be married when having children and may have bias against unmarried or single clients (7).  
  • Number or spacing of pregnancies. Professionals may hold beliefs about how many pregnancies are acceptable or how far apart they should be and may hold judgment against clients with a large number of children or pregnancies occurring soon after childbirth.  
  • Low income and minority women are more likely to report being counseled to limit the number of children they have, as opposed to their white peers (12).  
  • Method of conception. Some healthcare professionals may have personal beliefs about how children should be conceived and may have negative opinions about pregnancies resulting from fertility treatments such as IVF or surrogacy (7).  

Personal or religious beliefs about contraception may also cause healthcare professionals to provide less than optimal care to clients seeking methods of birth control. 

  • Providers may believe young or unmarried clients should not be given access to contraception  because they do not believe they should be engaging in sexual activity (7). 
  • Providers, or even some institutions such as Catholic hospitals, may withhold contraception from clients as they believe it to be immoral to prevent pregnancy. 
  • Providers may push certain types or usage of contraception onto clients that they feel should limit the number of children they have, even if this does not align with the desires of the client. This includes the use of permanent contraception such as tubal ligation (12).  
  • Providers may provide biased information about types of contraception available, minimizing side effects or pushing for easier, more effective types of contraception (such as IUDs), despite a client’s questions, concerns, or contraindications (12). One study showed Black and Hispanic women felt pressured to accept a certain type of contraception based on effectiveness alone, with little concern to their individual needs or reproductive goals (12).  

Personal or religious beliefs about pregnancy termination may impact the care provided and counsel given to pregnant clients who may wish to consider termination. Providers who disagree with abortion on a personal level may find it difficult to provide clear and unbiased information about all options available to pregnant women or may have a judgmental or uncompassionate attitude when caring for clients who desire or have had an abortion (7).

Case Study

Alexandria is a 22 year old Hispanic woman who has always wanted a big family of 3-5 children. She met her current boyfriend in college when she was 19 and became pregnant shortly afterwards. It was an uneventful pregnancy, and Alexandria had a vaginal delivery to a healthy baby girl at 39 weeks. When that child turned 2, Alexandria and her partner decided they would like to have another baby. At 38 weeks' gestation, Alexandria was at a prenatal appointment when her provider brought up her plans for contraception after the birth. The provider suggested an IUD and stated it could be placed immediately after birth, could be left in for 5 years, and would be 99% effective at preventing pregnancy. Alexandria stated she had an IUD when she was 17 and did not like some of the side effects, mostly abdominal cramping, and that she also might like to have another baby before the 5-year mark. Her doctor stated, “all birth control has side effects, and this one is the most effective. You are so young, do you really want 3 children by age 25 anyway?” 

Quiz Questions

Self Quiz

Ask yourself...

  1. What implicit biases does this healthcare professional hold about reproductive rights?  
  2. How do you think those opinions are likely to affect Alexandria? Do you think she will change her mind or her future plans? Or do you think she will be more likely to disregard this provider’s advice and opinions moving forward?  
  3. What are some potential negative consequences for Alexandria’s pregnancy prevention plans after this exchange with her doctor?  

Where Change is Needed

In order for change to occur, there is a broad spectrum of transitions in individual thought and policy that must occur. This implicit bias training will cover both individual and institutional level focuses. 

On the individual level, efforts must focus on:  

  • Identifying and exploring one’s own implicit biases. Everyone has them, and we all need to reflect upon them. This goes beyond basic cultural competence and includes a deeper understanding of how one’s own experiences or environment may differ from someone else, and how these experiences might have developed specific feelings.  
  • Reflecting on how one’s biases affect actions. Once one has recognized their internal opinions, they can examine ways that those opinions might have been affecting their actions, behaviors, or attitudes toward others.  
  • Educating oneself and re-framing biases. In order to change patterns of thinking and subsequent behaviors that may negatively impact others, one can work on broadening their views on various topics. This can be done through reading about the experiences of others, watching informational videos or documentaries, or listening to the experiences of others and gaining an understanding of how their lives might be different than another. 
  • Not only understanding, but celebrating differences. Once one learns to see others for their differences, it becomes easier to consider how they can achieve the best care plan and outcomes for well-being. It creates a better, and more promising approach to providing equitable care. This includes understanding differences in experiences, perceptions, cultures, languages, and realities for people different from the provider, recognizing when disparities are occurring, and advocating for change and equity.  

When enough people have recognized and addressed their own implicit biases, advocacy can extend beyond individual care of clients and reach the institutional level where change is more easily seen (though no more important than the small individual changes). One of the most effective ways to make institutional-level changes is through representation of minority groups in positions of power and decision-making.  

Simply keeping structures as they are and dictating change without any evolution from leadership is not likely to be effective in the long term. Including minority professionals in positions of leadership or on decision making panels has the most potential to make true and meaningful change for hospitals and healthcare facilities. Examples of institutional-level changes include:  

Medical school admission committees could adopt a more inclusive approach during the admission process. For example, paying more attention to the background and perspectives of their applicants and the circumstances/scenarios in which they came from as opposed to their involvement in extracurricular activities (or lack of) and former education. Incentivizing minority students to choose careers in healthcare as well as investing in their retention and success should become a priority in the admissions process (8). 

Properly training and integrating professionals like midwives and doulas into routine antenatal care and investing in practices like group visits and home births will give power back to minority women while still giving them safe choices during pregnancy (1). 

Universal health insurance, basic housing regulations, access to grocery stores, and many other sociopolitical changes could also work towards closing the gaps in accessibility to quality healthcare and may vary by geographic location. (3).  

Community programs should be available to create safe spaces for connection and acceptance. Laws and school policies can focus on how to prevent and react to bullying and violence against LGBTQ individuals (11). 

Cultural competence training in medical professions needs to include LGBTQ issues and data collection regarding this population needs to increase and be recognized as a medical necessity (11). 

Medical professionals must be trained in the history of inequality among women, particularly in regards to mental health, and proper, modern diagnostics must be used. The differences in communication styles of men and women should be taught as well (18).  

Medical facilities should emphasize respect of a client’s views on controversial topics such as pregnancy/birth, death, and acceptance or declining of treatments even if it conflicts with a staff members’ own beliefs (12).  

Healthcare facilities can adopt practices that are standardized regardless of age and include anti-ageism and geriatric focused training, including training about elder abuse (16). 


Obviously each geographic area will have differing demographics depending on the populations they serve. What works at one facility may not work at another. Hearing from the community is beneficial for keeping things individualized and allows facilities to gain perspective from the local groups they serve.  

Town hall-style meetings, keeping hospital board members and employees local rather than outsourcing from travel companies (when possible), and encouraging community involvement from staff members are all great ways to keep a community-centered facility transparent and welcoming for clients who may be having a different experience than their neighbor.  

There are many things that will need to be done in order for equitable, bias-free healthcare to become a norm nationwide. However, taking the time to learn from this implicit bias training, apply it to current practices, and continue to learn about others and their respective beliefs and cultures is just the beginning. 

Quiz Questions

Self Quiz

Ask yourself...

  1. In what ways will your approach be different the next time you care for a client unlike yourself?  
  2. Can you think of a policy or practice that your facility could change in order to provide more equitable care to the clients you serve?  

Sexual Harassment Training for Nurses

In this Illinois sexual harassment training for nurses, we will discuss sexual harassment in the nursing profession.  This course will cover topics required by the Illinois Department of Financial and Professional Regulation (IDFPR) and the Illinois Board of Nursing.


Sexual harassment is a serious issue within the healthcare workplace. In one study, more than 70% of female staff nurses reported having been harassed by male coworkers or male patients (1). In another study, 35% of student nurses reported having experienced sexual harassment in the previous year.

The most likely perpetrators for both student nurses and registered nurses were patients. However, physicians and male staff were most likely to be perpetrators of sexual harassment toward registered nurses (2). It is important to remember that sexual harassment is not limited to female registered nurses; male nurses are also at risk of experiencing sexual harassment in the workplace. Our Illinois sexual harassment training for nurses will help prepare you for any unfortunate potential experiences you may have with sexual harassment in your workplace.

The impacts of sexual harassment affect nurses in many negative ways. In this course, Illinois Sexual Harassment training will be obtained to help you avoid these negative outcomes. There are obvious psychological consequences, but there is also evidence to suggest that work performance can also be affected (3). Many states, including Illinois, have recognized the significant impact of this issue and have taken measures to empower nurses to prevent and/or address sexual harassment.

Quiz Questions

Self Quiz

Ask yourself...

  1. Have you or a co-worker ever experienced sexual harassment in the workplace?
  2. Why do you suppose this Illinois sexual harassment training for nurses might be necessary?

Why are Nurses Vulnerable to Sexual Harassment?

Not everyone has undergone training, such as with the valuable preparation you are getting through this Illinois Sexual Harassment training.  Even so, nurses are vulnerable to sexual harassment by the very nature of their position. The role of nursing transgresses societal norms regarding physical contact and involves intimate care of patients both physically and emotionally. This role is often exploited by perpetrators – they may take advantage of a nurse’s position and caring demeanor as a means to harass them (3).

Staff-on-staff harassment is also commonly reported by nurses (1). Nurses are pre-disposed to this type of harassment due to their subservient position to many staff members (physicians, administration) and the subsequent power imbalance that results.

Quiz Questions

Self Quiz

Ask yourself...

  1. Why do you feel nurses are vulnerable to sexual harassment, and how do you think an individual is likely to respond without the Illinois sexual harassment training?
  2. What workplace environmental factors can lead to nurses experiencing sexual harassment?

What is Sexual Harassment?

Sexual harassment is commonly thought to be unwelcome contact. However, sexual harassment takes many forms. It can be defined as unwelcome sexual behaviors or actions which may be verbal, physical, mental or visual (4).

Listed below are some common examples of potential sexual harassment:

  • Actual or attempted rape or sexual assault.
  • Pressure for sexual favors.
  • Deliberate touching, leaning over, or cornering.
  • Sexual looks or gestures.
  • Letters, telephone calls, personal e-mails, texts, or other materials of a sexual nature.
  • Pressure for dates.
  • Sexual teasing, jokes, remarks, or questions.
  • Referring to an adults as “girl,” “hunk,” “doll.” “babe,” “honey,” or other similar terms.
  • Whistling at someone.
  • Turning work discussions to sexual topics.
  • Asking about sexual fantasies, preferences, or history.
  • Sexual comments, innuendos, or sexual stories.
  • Sexual comments about a person’s clothing, anatomy, or looks.
  • Kissing sounds, howling and smacking lips.
  • Telling lies or spreading rumors about a person’s sex life.
  • Neck and/or shoulder massage.
  • Touching an employee’s clothing, hair, or body (6).

Here is how sexual harassment is defined in the Illinois Ethics act, which governs state officials and employees:

“…Any unwelcome sexual advances, requests for sexual favors, or any conduct of sexual nature when:

  1. Submission to such conduct is made either explicitly or implicitly a term of condition of an individuals’ employment.
  2. Submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting such individual or
  3. Such conduct has the purpose of effect of substantially interfering with an individuals’ work performance or creating an intimidating, hostile or offensive working environment.

For the purposes of this definition, the phrase “working environment” is not limited to a physical location an employee is assigned to perform his or her duties and does not require an employment relationship (5).”

As you can see, the definition of sexual harassment, according to this Illinois sexual harassment training, is broad and can encompass many situations. Though the Illinois Ethics Act primarily relates to employee-employer sexual harassment, there are many other scenarios, such as sexual harassment by patients.

Quiz Questions

Self Quiz

Ask yourself...

  1. Many nurses do not know that the definition of sexual harassment is broad. Without essential preparation from courses like this Illinois sexual harassment training, they might not know how to respond.
  2. Knowing this, are there any situations you would consider sexual harassment, where you previously would not have?

Key Points for Sexual Harassment

Sexual conduct vs. sexual harassment – Sexual behavior turns into sexual harassment when the recipient receives the behavior in an unwelcome manner. The term “unwelcome” refers to unsolicited or uninvited behavior and undesirable or offensive behavior.

Females and males can both be victims – Any unwelcome sexual behavior may be considered sexual harassment, regardless of the gender of the perpetrator and recipient. Male-on-male, female-on-female, female-on-male, and male-on-female types of harassment may occur.

Sexual harassment can affect witnesses – Anyone who is affected by the sexually offensive conduct may be a victim. This may include a person witnessing or overhearing sexually harassing behavior (6).

It can occur outside the working environment – The “working environment” is not limited to the physical location of work. A “working environment” may be extended to any location where work occurs, such as remote locations, off-site locations, and temporary working locations (6).

It doesn’t only occur in person – Sexual harassment can occur on and off the clock. It can occur physically and electronically. Unwelcome sexual conduct through email, phone calls, texts, social media postings and other mediums may constitute sexual harassment.


Two Types of Sexual Harassment


Quid pro Quo

Quid pro quo means “A favor for a favor.” In this sense, it refers to an authority figure (manager or supervisor) requesting a sexual favor in exchange for preferential treatment. This could be in the form of a promotion, raise, preferred assignment or any other job benefit which they may affect (6).

Hostile Work Environment

Another method by which an individual may coerce sexual favors is through the threat or actuality of a hostile work environment. This refers to creating or threatening to create an intimidating, hostile, or offensive work environment in order to influence sexual favors or behavior

Quiz Questions

Self Quiz

Ask yourself...

  1. What would be an example of quid pro quo?
  2. How is this type of harassment different than hostile work environment?

What Should Nurses Do If They Experience Sexual Harassment?

If you feel you have been the victim of unwelcome sexual behavior (sexual harassment) there are avenues available to you for support and to report the behavior.

While it may not be an easy thing to do (or even possible), try to make it known that the sexual behavior is unwelcome and unwanted. It is your right to inform the person of your stance and to demand the behavior cease. Though this can be difficult and uncomfortable, it is often the most effective method (7).

You should be explicit in explaining the behaviors which are unwelcome so that the perpetrator can fully understand his/her actions. If you are uncomfortable confronting the perpetrator, consider confiding in a close friend or supervisor who can accompany you or advise you on next steps.

Next, document the scenario. Write down all details you can recall including any witnesses. This can be helpful in the future.

Reporting the issue is the next step.

How or whether you report the sexual harassment is a personal choice and you are not limited. Remember that according to Illinois law you are entitled to a workplace free of sexual harassment. There are several options for reporting sexual harassment, and there are several nuances with jurisdiction and handling of complaints.

1. Within Your Organization

You may contact your supervisor or human resources representative to report an incident. This is often a more comfortable route for nurses as they may be familiar with these individuals. Your organization should have policies and procedures for handling sexual harassment reports which may include escalation to other organizations, such as IDHR and law enforcement as necessary. This is often the fastest method for reporting. Remember that reporting to your supervisor, ethics officer, or human resources official does not preclude you from reporting to other agencies as appropriate. If you wish to remain anonymous, check with your organization to see if they have a policy that gives you that option.

2. Illinois Department of Human Rights

The IDHR is responsible for administering the Illinois Human Right Act. The IDHR views and sexual harassment as a civil rights violation. The IDHR will investigate complaints and determine if “substantial evidence” for harassment exists, which may provide relief for the complainant and punishment for the accused. Nurses can report to the IDHR by going to and filing the requisite information, or by calling 1-800-662-3942 (8). Note: complaints must be made within 300 days of the incident.

The State of Illinois has an agreement with the Chicago Lighthouse Call Center, which operates a 24/7 helpline for victims of sexual harassment and discrimination. By calling, nurses can learn their options for reporting incidents, can file an anonymous report, and can be referred to appropriate agencies. Any information given during the call is confidential.

3. Law Enforcement

Criminal incidents of sexual harassment may be reported to law enforcement as appropriate. Often times your supervisor or human resource officer can assist in determining if this is necessary. If you ever feel that your physical safety is threatened, do not hesitate to contact law enforcement.

4. Office of Executive Inspector General (State Government Employees)

State employees or anyone under the jurisdiction of the OEIG may file a report directly with the OEIG. To initiate a report, it is best to contact your ethics officer for guidance.

5. U.S. Equal Employment Opportunity Commission

Sexual harassment is a violation of section 703 VII. The EOCC is charged with administering this statute and provides another option of relief for those who have experienced sexual harassment. The statute for reporting an offense to the EOCC is 180 days. Of note, the EOCC may hold employers responsible for taking all steps to create an environment free of sexual harassment and can offer an additional avenue for support (9).

Quiz Questions

Self Quiz

Ask yourself...

  1. How would you handle sexual harassment differently knowing your rights and reporting avenues?
  2. Are there any previous situation you would have handled differently?

Illinois Sexual Harassment Training for Nurses - Whistleblower Protections

Retaliation for reporting sexual harassment is illegal under both federal and state statutes. The Illinois Human Rights Act explicitly prohibits retaliation for reporting sexual harassment. Retaliation is defined as “conduct intended to deter or dissuade a person from making a complaint or filing a report of sexual harassment, or participating in an investigation conducted by the Illinois Department of Human Right or other similar agency” (Illinois Department of Human Right, reference #10). Additionally, the U.S. Equal Employment Opportunity Commission prohibits retaliation aimed at employees who assert their rights to be free of harassment (11).


Sexual harassment can take place in many venues and formats. It is broadly defined as any unwanted or unwelcome sexual behaviors.  Sexual harassment is experienced frequently by nursing professionals due to the nature of their positions.  You have a right per the state of Illinois and Federal law to be free of sexual harassment in the workplace.

If you experience sexual harassment, you should tell the harasser to stop and report the incident in one of the various methods listed above. Do not forget to document the incident and any reporting thoroughly.

You have a right to report sexual harassment without retaliation, per both Illinois law and Federal laws.  This Illinois sexual harassment training has adequately prepared you to do so in the event a situation arises.

Alzheimer’s and Dementia Training

This Illinois Alzheimer's and Dementia Training course is required for nurses who provide healthcare services and have direct patient interaction with indivuduals age 26 and older, as mandated by Public Act 102-0399, 20 ILCS 2105/2105-365.

Many times, individuals, family members, and healthcare workers misinterpret symptoms as they are related to dementia because it can be rather difficult to differentiate what is normal age-related memory loss versus early signs of dementia.  Many of us tend to become more forgetful as we age, and may need a bit longer to remember things, become distracted more easily, or have issues with multi-tasking.  Even though these changes are normal and typically occur during middle age, they can very well become a nuisance and even frustrating at times.  But, how can one know that these are normal and are not an early symptom and determinant of dementia?  For most individuals, these changes are a normal result of aging, but it is important to understand the differences so diagnosis can be accurate and efficient in treating these individuals who are dealing with dementia.  


We should be investing our efforts on observing and reporting any potential signs of underlying dementia.  The state of Illinois aims to improve early diagnosis and management and has implemented this Illinois Alzheimer's and Dementia Training for those caring for patients who are 26 and older. Early diagnosis of dementia leads to more effective treatment options and advanced decision making for interventions needed.  Accurate diagnosis of dementia is the ultimate key to proper treatment and both health care providers and caregivers need to provide empathy in caring with these individuals.  As part of reaching these goals, it will be necessary for all those caring for individuals with dementia to become more knowledgeable about dementia, proper care aspects, and the most effective approaches that need to be used with this vulnerable population.  In doing so, these practices will provide both the support and care needed to successfully care for those with dementia.  

Quiz Questions

Self Quiz

Ask yourself...

  1. Why do you think the state of Illinois has erquired an Illinois Alzheimer's and Dementia training for nurses who care for patients age 26 and older?

What is Dementia versus Age-Related Memory Loss?

At one point or another in our lives, we have misplaced a set of keys, totally blanked on remembering someone’s name, forgot a phone number, or walked into a room to do or get something and forgot and then began wondering what you went in there for.  Even though memory lapses can be frustrating, most likely they are not cause for concern.  However, age-related memory changes are not the same issue as dementia.   

As one grows older, there are various physiological changes that can cause variations in brain functions that one typically doesn’t even think about.  A few examples of these are the process of the longer duration to both learn and to recall information, one is not as quick as he/she used to be, and it can sometimes take longer to recall events to mind.  Memory lapses typically have little impact on one’s daily activities and one’s ability to do what he/she wants to do.   

Dementia is marked by a persistent and often disabling decline in two or more intellectual abilities such a memory, judgment, language, and abstract thinking.  The chart below compares the normal age-related memory changes to those that may indicate dementia (5): 

Normal Age-Related Memory Changes Symptoms That May Indicate Dementia
Ability to function independently and pursue normal activities of daily living  Difficulty conducting simple tasks (paying bills, dressing appropriately, self-grooming, etc) and forgetting how to do things that one has done many times 
Ability to recall and describe periods of forgetfulness  Unable to recall or describe specific situations where memory loss was present 
May hesitate or pause to remember directions, but does not get lost in places that are familiar  Gets lost or disoriented in familiar places and unable to follow directions 
Occasional problems finding the right words, but no problem holding a conversation  Words are often forgotten, garbled, misused, and misunderstood.  Phrases and stories are repeated several times within the same conversation 
Judgment and decision-making ability are the same  Difficulty making choices.  Poor judgment or behavior may be conducted socially inappropriately 

Treatment and Care of Alzheimer's Disease


A goal of the Illinois Alzheimer's and Dementia Training is to educate nurses on treatment options for both Alzheimer's Disease and other types of dementia.

Pharmacological Interventions

Even though there is no cure for dementia or any disease-modifying agents that can fully combat Alzheimer’s disease and the related dementias, there are some medications that can assist with slowing down the progression of cognitive loss.  These medications are classified as anti-dementia drugs and can only be prescribed by a medical doctor.  Medications prescribed are given based on the type of dementia characterized by the individual.  It is important to note that the individual may experience side effects as with any medication and the medications used for dementia are typically expensive (4). 

Non-Pharmacological Interventions

There are various therapies used to support those diagnosed with dementia and to aid is assisting the nurses and/or family caregivers who are caring for these individuals.  Not all therapies work for each individual experiencing dementia, and it is important to work together as a team with both medical providers and family members to provide and offer the best individualized solution.  The types of non-pharmacological interventions are as follows (4): 

  • Cognitive Stimulation  Therapy (CST) 
  • Reminiscence Therapy 
  • Validation Therapy 
  • Reality Orientation 
  • Physical Exercise 
  • Multisensory Stimulation: Snoezelen Rooms 
  • Aromatherapy 
Cognitive Stimulation Therapy (CST) 

Cognitive Stimulation Therapy is used for those individuals with mild to moderate dementia and the individual is invited to partake in therapeutic sessions with a trained practitioner that specializes in skills related specifically to individuals with dementia.  A session consists of themed activities that are designed to stimulate and engage the individual with dementia.  Some of the themes used may include topics such as money, current affairs, food, and clothing.  The sessions are typically held twice a week, beginning with 14 sessions followed by 24 maintenance sessions.  The key aspects focused on are person-centeredness, involvement, respect, inclusion, fun, choices, the use of reminiscence, and strengthening relationships (4). 


Reminiscence Therapy 

Reminiscence therapy allows a person with dementia to tap into his/her long-term memory and experience past memories that were pleasurable.  With this type of therapy, it has been considered one of the most popular and can be enjoyed by the individual with dementia, health service professionals, and relatives.  The therapy can be completed in several formats using life story work, simple or general reminiscence, and specific or special reminiscence (4).  


Validation Therapy 

Validation therapy attempts to use a practitioner to communicate with the person with dementia by showing empathy with his or her feelings and special meaning is displayed behind the person’s speech and behavior assisting the individual.  Validation therapy aims to validate the individual’s emotions by acknowledging one’s feelings and the aim to make the person with dementia as happy as possible, even though there may be misconceptions and misinterpretations.  It is important to keep in mind that if a demented individual is experiencing delusions or false beliefs which can cause added distress, validation therapy is not the best source of therapy (4).   

Reality Orientation 

With this type of therapy, it helps the individual with dementia by reminding him/her about the present.  Self-identity is reinforced and recognition about one’s surrounding environment is also emphasized.  The different forms used with reality orientation are calendars, reminder boards, and cueing and typically take place in groups or individually.  It is important to be mindful of the fact that the individual may have difficulty remembering current or recent events due to his/her cognitive impairment (4).   

Physical Exercise 

The act of exercising has been shown to benefit people with and without a cognitive impairment and has been found to be extremely beneficial to those who once led a very active life.  It is important to encourage individuals with dementia to participate in some form of physical activity and to make adaptations as needed once dementia progresses.  In formulation exercise programs for these individuals, attention should be given to the individual’s abilities, preferences, interests, and safety needs.  Physical activity has also been recognized for its effects on reducing depressive symptoms and behavioral disturbances such as aggression and agitation (4). 


Multisensory Stimulation: Snoezelen Rooms 

Multisensory stimulation are increasingly being used in long term residential care settings to help individuals with dementia who may be agitated or restless.  A Snoezelen room incorporates multiple sources of stimulation such as light, water color, fiber optics, contrasting textures, quiet music, and soft furnishings.  All of these features are meant to help relax the individual with dementia and can also enhance communication between the individual and his/her caregiver (4).  



Aromatherapy is often used with individuals with dementia and the use of smells, massage, and bathing can stimulate pleasurable emotions for the individual with dementia.  Two of the most commonly used essential oils are lavender and a special type of balm.  Aromatherapy has proven in many trials to produce a decrease in agitation among these individuals with dementia (4). 

Common Types of Dementia


Alzheimer’s Disease  

The individual presents with symptoms such as memory loss and difficulty planning and performing routine tasks.  The symptoms are mild at first but progressively worsen.  Other symptoms noted may be confusion about person, place, and time, difficulty speaking and/or writing, losing things and unable to find them, showing poor judgment, and mood and personality changes (1). 

Vascular Dementia  

Individuals with this type of dementia have typically had a stroke and symptoms depend on which part of the brain is affected by the stroke.  The first signs noted with vascular dementia is poor judgment or difficulty planning, organizing, and making decisions.  Other noted symptoms are memory problems that disrupt the individual’s daily life, difficulty speaking and understanding speech, difficulty recognizing sights and sounds that used to be familiar, becoming confused or agitated easily, changes in mood and personality, and difficulty walking with increased falls (1).   

Dementia with Lewy Bodies (DLB) 

Lewy bodies consist of tiny microscopic deposits of a protein that form in some individual’s brains.  The deposits of the protein develop and form in the part of the brain called the cortex and the symptoms include difficulty thinking clearly, making decisions, or paying attention.  The individual also has problems with memory, experiencing hallucinations, unusual sleepiness during the day, periods of “blanking out” or staring, difficulty with movement including slowness, trouble walking, and the individual may have dreams where he/she acts out physically such as walking, talking, and kicking (1).   

Parkinson’s Disease Dementia 

Studies have shown that individuals with nervous system disorders experience this type of dementia an estimated 50-80% of the time.  Typically, the symptoms of dementia develop approximately ten years after a person is first diagnosed with Parkinson’s (1).   

Frontotemporal Dementia (FTD)  

Individuals with this type of dementia have developed cell damage in areas of the brain that control judgement, planning, emotions, movement, and speech.  These individuals may also experience behavior and personality changes, sudden lack of inhibition in social and personal situations, problems thinking of the correct words when speaking, and movement problems such as shakiness, muscle spasms, and balance problems (1).   

Huntington’s Disease 

In this disease, it is caused by a genetic defect that is typically passed from one family member to another.  The individual may have the gene for this disease at birth, but typically the symptoms do not usually start until the ages of 30-50.  The individual typically has difficulty with thinking and reasoning, memory, judgment, organizing, planning, and concentrating (1). 


Creutzfeldt-Jakob Disease  

In this type of dementia, a protein called prions cause normal proteins in the brain to begin developing into abnormal shapes.  This disease is a rare condition that leads to dementia symptoms that occur suddenly and quickly becomes worse.  The individual may experience memory and concentration problems, poor judgment, mood swings, confusion, sleep problems, depression, trouble walking, and twitching or jerking muscles (1).   

Normal Pressure Hydrocephalus  

A buildup of fluid in the brain is noted in this type of dementia and includes difficulty walking, concentrating, personality, and behavior changes.  In some cases, the extra fluid can be drained from the brain into the abdomen through a long, thin tube called a shunt (1).   

Wernicke-Korsakoff Syndrome 

A severe shortage of thiamin (vitamin B-1) is noted in this type of dementia and is noted most commonly in individuals who are long-term heavy drinkers.  The most common symptom noted is problems with memory, but typically one’s problem-solving and thinking skills are not affected (1).   


Assessment is a crucial factor in determining if dementia is present or if the signs and symptoms are an indicator of normal age-related memory loss.  Assessment is also the first identification to obtain the needed treatment for the individual and to offer services and support to the family members or caregivers.  The Illinois Alzheimer's and Dementia Training was enacted to prepare nurses for the management and care plans for both Alzeheimer's Diseae and the many types of dementia. To be adaquetly prepared, it is important to understand the different types, diagnosies, and care plans of each before implementing treatment.

Health systems are working to improve this area and to recognize the burden that is presented to caregivers caring for those with dementia.  There is a gap between the need for treatment, the active provisions for treatment, and educating families regarding the options that are available for treatment.  Many families seem to feel the burden is too great to care for his/her loved one with dementia independently.  Due to this reason, it is imperative that both physical and emotional support be offered.  Many times, families are not aware of the resources available for this population of individuals and they need assistance and education to evaluate the available options.  All of these factors should encourage the importance of increased support, health, and awareness among this vulnerable population.  

Quiz Questions

Self Quiz

Ask yourself...

  1. Are we doing a sufficient job at ensuring that the population of individuals with dementia and their caregivers are receiving the proper health and support they need? 

Effective Communication and Management of Care

As part of the Illinois Alzheimer's and Dementia Training, communication strategies are emphasized in order to provide an optimal care plan for patients and their caregivers in order to have the best possible outcomes.

When dealing with Alzheimer’s patients, it is imperative to offer simple, step-by-step instructions, repeat instructions and allow more time for a response, do not talk about the individual as if he/she isn’t there, and do not use “baby talk” or a “baby voice”.  Families and caregivers need to also know that management of care for a loved one with Alzheimer’s will be assisted by a support person such as a nurse, social worker, or other healthcare professional.  It is important that these resources are offered for families/caregivers caring for a loved one with Alzheimer’s.   

Quiz Questions

Self Quiz

Ask yourself...

  1. What kinds of resources are available to give families and caregivers caring for someone with Alzheimer’s at your workplace?   

Case Study

Dorothy's Story

Dorothy is living with dementia, and has been receiving live-in care support since 2013. Before considering home care, Dorothy’s family was naturally worried about having a stranger in her home.  Their concerns soon lifted after meeting with their local care specialist and talking about what Dorothy needed, such as what food she liked and how having dementia affected her a day-to-day.  This helped us to find Magda, who has fit perfectly into Dorothy’s life. 

Dorothy says, “There really is no place like home, and with Magda’s support I am able to keep in touch with all of my friends and neighbors.  We visit church every week for the Sunday morning service, I can visit the shops and I also take part in a local knitting group. This really is one of the greatest joys of staying in my own home around people I know.” 

By helping her to do the activities that mean most, Magda has made such a difference in Dorothy’s life.  An experienced caregiver with plenty of care knowledge is present and what matters most to Magda is that Dorothy is happy. 

Dorothy says, “Live-in care means friendship, a sense of security and feeling comfortable in my own home. Having previously spent a brief but unhappy period of time in a care home, I am able to recognize how perfect my situation is now. I feel very lucky and comfortable; I have a true friend. Magda is going nowhere! I want this to continue forever” (2). 

Moving Forward: The Future for Individuals with Dementia

With increased awareness among this vulnerable population and the number of individuals diagnosed with dementia, the future for those caring for these individuals proves that advanced care and education needs which have both been a recent focal point have proven successful.  The information below details some highlights for the future that are seemingly optimistic (3):  

  • Recent study from 1988 – 2015 has shown a 13 percent decreased per decade in the incidence of dementia in the United States and Europe 
  • If trends continue, there could be 15 million fewer people living with dementia in high-income countries by 2040 
  • Change is likely linked to increased heath education along with a better understanding of modifiable risk factors, such as diet and exercise 
  • Experts stress the need for doctors, health care members, individuals, family members, and caregivers to develop healthy habits to lower one’s risk for developing dementia

Both small and large actions can be taken as a client care health advocate in order for positive results to be obtained.  First, volunteer or assist in a facility that offers services to these individuals, educate yourself and your immediate circle on the facts surrounding dementia, serve as a mentor, and receive the necessary education and training to pursue legislative advocacy.  Throughout the entire process of advocacy, these elements need to remain – confidentiality, purpose, equality, diversity, empowerment, and most importantly treating the individual with dementia with empathy, compassion, and respect.    

The care and treatment for those with dementia and the ones caring for these individuals certainly have the capability of improving if healthcare workers, family members, and caregivers are trained and educated on the symptoms, treatment options, and available resources to assist those caring for these individuals.   

Education is the ongoing key to becoming more aware of proper care and treatment options for individuals with dementia.  Increased knowledge and expertise in this area and serving as an advocate for these individuals by listening and representing the individual’s views must be in place in order for this population to receive the necessary and adequate care they each deserve.  Questions can be asked on the individual’s behalf in order to ascertain that necessary treatment options and support services are being offered.  It is also imperative to use a holistic approach with both the individual and the health care members, caregivers, and family members to maintain open communication, empathy, and compassion while developing the best plan of action for the individual.   

Quiz Questions

Self Quiz

Ask yourself...

  1. How can one serve as an advocate for those with dementia? 

Effective Communication in Nursing


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.


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 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.  



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.
    Watching a EKG monitor.
    Performing a pain assessment.
  3. What techniques show others you are actively listening?
    a. Reading a document while being talked to.
    Making eye contact.
    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.
    Reviewing a policy.
    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


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 for 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 the that the organizations enforce 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? 


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 take education regarding patient confidentiality through 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 areas of email, personal electronic data devices, and transmission of data electronically.  
  • 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? 


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


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


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)


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.


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.


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.


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.

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...


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


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 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). 


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 her development of a formal training program, nursing was thought to be disreputable, and many persons providing care-giving services were prostitutes. 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. One must take responsibility for their 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 study4 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 addressed 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? 


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 the different personality and learning styles of everyone.  

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 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 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 through 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.


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.


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. 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.

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 he or she is responsible and intervene as necessary to assure compliance and safety. 

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.

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 provides 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 and renewal CEs 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


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, and 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 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 while within the healthcare system.  

Factors Influencing the Outcome of Exposures

The human body provides several natural defenses against acquiring 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 a pH 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. This will be covered in detail further along in the 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 potential source 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 six 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 room that do not mee engineering requiring 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 maintain current on vaccinations and can prevent transmitting known communicable disease 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, source 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 


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

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 by 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:  
  • 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


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 PPEor 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 made from glove 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 to 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 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 minimum, a medical mask is to 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 that "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 manufacturers 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 most effective way to protect yourself and your patients. 

For selection, donning, doffing, and disposal refer back to Element II.

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 made from glove 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 to 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 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 minimum, a medical mask is to 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 that "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/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 manufacturers 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 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.


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 which sterile body fluids, blood, or sterile tissue be sterilized prior to use on each patient. (1).  

Potential for Contamination

The type of instrument, medical device, equipment, or environmental surface cause 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). As well, these devices may be made of material that is not heat resistant, that prevents the ability to sterilize. 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 natures 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 manufacturers 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’s 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 the various equipment heat and pressure tolerance as well as the time and temperature requirements for reprocessing. Failure to follow manufacturer’s 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 are 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 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’s 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 to ensure understanding the 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 Understand 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 procedures and policies to reduce exposure to harmful substances, monitor for harmful exposures, and train staff using 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 
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 


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 employees are healthy and keeping them 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 periodically ongoing 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 employee 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 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 obligates the patient to be informed of the type of exposure, whether it is healthcare worker’s blood or other potentially infectious material. 

Airborne or droplet pathogen 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 and disability laws. 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  


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 collection, use, and report 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): 

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


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.  


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 his or herself. 
  • 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 traveling nursing job 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 shifts for 13 weeks. Her pay would be $5,000 per week plus a non-taxed stipend for lodging and meals.  

She accepts the job 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.  

Following, 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 red 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 because individuals 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). 


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 love and support that they think they should, or when the level support ends, they realize they are on their own.  

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 concern is 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 been 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 the causes are for 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).


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.  


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 illicit 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 all 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. 


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.  

End of Life Process


Have you ever cared for someone who was dying, known someone who was on hospice, or just wondered what happens as we die? Hospice involves caring for the terminally ill as they begin the end-of-life process and is utilized by healthcare facilities around the country. Hospice care can be a short or long journey, with many ups and downs. For some, the prognosis might be obvious, but for others, it might be filled with many questions and much uncertainty. Both caregivers and patients seek to understand just what the end-of-life process and its care entails. Hospice clinicians should spend time providing education on end-of-life process to those involved in caring for the patient. 

Oftentimes, caregivers have little to no experience in caring for a patient experiencing the end-of-life process and can easily find themselves feeling overwhelmed, confused, and burned out. Understanding what to expect during the final weeks of life is imperative in order to cope with the changes as they occur. The end-of-life process can vary from person to person. Although patients progress through the end-of-life process differently, there is usually a recognizable pattern of decline that occurs. In order to provide the best possible care and prepare both the hospice patient and their family members, it is important for the nurse and caregiver to be able to distinguish the phases of the end-of-life process: transitioning, actively dying, and final moments. 


This phase of the end-of-life process, otherwise identified as the pre-active phase, usually signals that a person is approaching the last two-to-three weeks of their life. During this time, caregivers might start to notice obvious changes; an increase in sleeping, for example. A transitioning person can sleep upwards of twenty hours per day. This significant increase is part of an overarching decrease in the patient engaging with the world and day-to-day life 

Beyond sleeping, examples of this disengagement include interacting less with friends and family, less desire to do one’s usual activities, and a lack of interest in things that were once pleasurable. Additional signs of a patient transitioning include increased weakness and decreased mobility. These changes typically include a decline in function, becoming non-ambulatory, chairbound, and ultimately, bedbound. Progressively, the patient will become more dependent on their caregivers to assist them with activities of daily living (ADL), which include bathing, eating, transferring, toileting, and continence. 

Another indicator that someone may be transitioning is a change in nutrition and intake. Eating and drinking less is an expected part of decline during this time. Many patients will report a lack of appetite, taste changes, and an overall lack of interest in food and liquids. Changes in swallowing may further complicate a person’s ability to eat and drink.

It is not uncommon to downgrade a person’s diet during the transition phase. This might include going from a regular diet, down to soft, and finally, to pureed. Liquids are usually given in small amounts and with an added thickener. These changes are necessary to prevent choking and aspiration.  

Increased agitation, anxiety, and restlessness may also arise during the transitioning phase of the end-of-life process. Terminal agitation and terminal restlessness are both unique to the last week or so of someone’s life and are often caused by physiological changes that occur during the end-of-life process but can also be a result of medication or emotional changes. Despite if the patient had lived peacefully and calm in the past, it is important to note that these symptoms may still occur.  

Signs of terminal agitation include an inability to remain still, picking at items in the surrounding environment, and increased confusion. Fortunately, there are medications that can be given at the end of life to promote comfort and stop these symptoms when they arise. Lastly, it is not uncommon for the transitioning patient to have visions of and talk to deceased friends and family – both are normal and could sometimes be interpreted as a welcoming sign from loved ones. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What would you say to someone you knew was dying?

  2. What do you know about hospice care? 

Active Dying 

Following the transition phase, most patients will then enter the final phase of the end-of-life process, the active dying period.  This phase usually last only two to three days and showcase significant signs of patient decline that differ from the previous phase, including a decrease in alertness and responsiveness. For example, a patient may go from a semi-comatose state to comatose or obtunded and minimal reaction should be expected. Their eyes may be open or shut, and there is little movement in all extremities. This period can be described as a deep sleep. 

Caregivers often describe it as a time of waiting. Cognitive changes, in combination with the previous changes in swallowing, make the intake of food, liquids, and medications unsafe. The patient is at high risk for aspiration. Mouth swabs can be used to hydrate the oral cavity and to do mouth care. Medications that are liquid or can dissolve under the tongue are safe and can be used to manage symptoms at the end of life. Hospice patients are provided a comfort kit of medications to use should symptoms arise.  

Additionally, changes in vitals are expected during this phase, and they typically do not cause the patient any discomfort. For example, temperature fluctuation is common at the end of life. It is not abnormal to have an elevated temperature during the active phase of the end-of-life process. This can be remedied with cooling measures such as a cool towel on the forehead or a fan to cool down the room. The skin may feel clammy as well.  

Following, changes in blood pressure and heart rate may also occur. Blood pressure begins to trend lower during the pre-active phase and can become very low during the last few days of life. The heart rate will usually trend upward and can be well over 100 beats per minute, however, this is just something for the hospice nurse to note and is not usually treated.  

Pain can also be an area of concern for someone who is actively dying, and of course, no one wants to see their loved one in pain during their final days of life. The body becomes very sensitive to the slightest movement or touch, which can present challenges for caregivers when considering that the patient still needs to be cleaned, changed, and repositioned. When the patient is no longer verbalizing their comfort, verbal pain cues must be assessed. These include grimacing, a furrowed brow, frowning, and possibly moaning. In some cases, repositioning can be an effective pain-relieving measure.  

Decreased urination is also common during the active phase of the end-of-life process. This is completely normal and expected. Caregivers may find that they do not need to change diapers as often. Urine may also appear darker in color, appearing a deep amber color due to more concentrated urine. 

Excessive secretions can lead to something commonly known as the “death rattle.” This term is almost synonymous with the last days of life. It can be described as a moist sound that is audible when someone breathes and is a good indicator that death is near. The secretions collect in the throat due to a lack of coughing and the inability to clear them out. Turning the patient on his or her side may help the secretions drain, and there are medications that can be administered to help dry them out. It is important to note that not everyone will experience this, and by the time it occurs, there is a disconnect within the patient, and he or she is not likely to experience any discomfort. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is a caregiver likely to feel while experiencing these changes? 

  2. What does comfort mean to you? 

Final Moments 

It can be hard to imagine the final moments of someone’s life. This is especially true for caregivers and families who have witnessed steady decline throughout both phases of the end-of-life process. It is the role of the hospice clinician to provide education regarding what to expect during this time. There are likely to be signs that death is possible at any moment. A patient can be expected to be comatose with little to no response when death is imminent. 

In addition to changes in vitals described previously, changes in respirations usually occur. Patterns can vary from shallow and fast to deep and slow. Periods of apnea are also normal. Cheyne-stokes breathing may also be present. Skin changes are also expected; pallor, cyanosis, and mottling are signs that death is near. The body may begin to feel cool, especially in the hands and feet. Comfort medications can still safely be used up until death occurs. As mentioned before, foods and liquids should not be given at this point. Caregivers should continue to talk to the patient, as their hearing will remain until the end. 

Quiz Questions

Self Quiz

Ask yourself...

  1. Have you been present when someone died?

  2. How did it make you feel to witness this? 


Hopefully, this has been an informative piece on what to expect for end-of-life care. Hospice can be a great resource for both the patient and caregiver. Most people do not have experience in caring for a dying person and need education and assistance throughout the journey. Not everyone who is dying will experience all the symptoms mentioned in this course, and it is important to note that everyone experiences the end-of-life process in their own way and own pace. 

Following a DNR: An Ethical Dilemma in Nursing


End-of-life issues are often full of emotion and difficult to deal with for all involved. Do-not-resuscitate (DNR) orders can present many moral and ethical dilemmas in nursing. It takes the entire healthcare team, including the patient and their family, to ensure that all final wishes for the patient are followed. In order to understand this ethical dilemma in nursing, we must first define what ethical dilemmas are and what a DNR order is. 

What is an Ethical Dilemma in Nursing? 

Ethics are a system of moral principles or rules of conduct recognized by a particular group; however, the American Nurses Association (ANA) has developed its own code of ethics (1). The ANA Code of Ethics with Interpretive Statements includes nine provisions that direct a nurse’s moral and ethical practice, it reads:  

Provision 1

The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.  

Provision 2

The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population.  

Provision 3

The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.  

Provision 4

The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care.  

Provision 5

The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.  

Provision 6

The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.  

Provision 7

The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.  

Provision 8

The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.  

Provision 9

The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy (2). 


An ethical dilemma in nursing arises when decisions are made that go against the ANA Code of Ethics with Interpretive Statements.  

It is important to note that the nurse's main duty is to be an advocate for their patient, meaning that all actions should be in the patient’s best interest. Adhering to this principle will ensure a clear moral path where any ethical dilemma in nursing can be avoided.   

Quiz Questions

Self Quiz

Ask yourself...

  1. What is an ethical dilemma in nursing? 
  2. Thinking of your own practice, have you ever had to make choices that compromised your personal ethics or breached the ANA code of ethics? 
  3. Can ethical issues be completely avoided? 


A DNR is an order written by a physician that is usually given to those who are critically or terminally ill. The order states that in the event of cardiopulmonary arrest, should the patient's heart stop or should they stop breathing, cardiopulmonary resuscitation (CPR) will not be administered. The decision for a DNR order is always discussed with the patient if they are conscious and have the capacity to make informed decisions. Should the patient be incapacitated, their power of attorney (POA), health care agent, or family member may be allowed to make the decision for a DNR. If a patient is known to be gravely ill, they may already have an existing DNR order, or an advanced directive/living will. Once this document is produced for the institution, the order will go into effect. If a DNR order has been put in place by the patient and physician, the family should not have the power to lift the order once the patient deteriorates and can no longer make decisions (3). 

There was a time in the history of healthcare when there were different tiers of a DNR order. For example, there used to be a medication only/chemical code where medication could continue to be administered, but no compressions or artificial respirations could be performed by the healthcare team; in the end, this proved to be a wasted effort as the medication would be circulated and provide no effect. Many institutions have gotten away from the tires of DNR; what I mean by this is, either there is a DNR order in place for a patient, or there is not. 

Quiz Questions

Self Quiz

Ask yourself...

  1.  Have you ever initiated a DNR order? 
  2. Have you ever been in a situation where a patient's family or healthcare team did not agree with the DNR? 
  3. What is a DNR order? 

Ethical Dilemma in Nursing: DNR 

If a DNR order is put in place by the physician in conjunction with the patient, how could there possibly be any ethical dilemmas in nursing? There should be no problems associated with a DNR order; however, ethical dilemmas arise when the team (patient, physician, healthcare workers, and family) are not all on the same page regarding the DNR. One of the main problems is that different healthcare workers have different interpretations of what a DNR means. It must be understood that a DNR means “do not resuscitate,” and does not mean “do not treat.” To better explore the ethical dilemmas in nursing associated with a DNR order, we will look at scenarios that I have come across over my 25 years of nursing: 

Scenario 1 

A patient is sent from a telemetry unit to radiology for a CT scan. The patient has severe cardiomyopathy and requests a DNR upon admission. The order is noted on the patient’s chart. When they are sent to radiology for the scan, the floor nurse neglects to place the code status on the patient hand-off form. During the scan, the patient becomes unresponsive, and a code blue is called; CPR is initiated, and the patient is intubated.   

During the resuscitation, it is discovered that the patient has a DNR order. The physician running the code continues with CPR, rationalizing that he could ‘not just stop’ the life-saving measures that they had already begun. The patient is revived and transferred to the ICU. Later, during the admission, the family withdraws life support, and the patient expires.  

In this first scenario, we can see that a communication error led to the DNR order not being followed. Once discovered, the physician in charge refused to comply with the order.  Ultimately, the patient passed after a few days on life support.   

This ethical dilemma came to play once the code team realized that the patient had a DNR. The code could have been stopped at this point, and the lead physician could have spoken with the patient's family to explain what had occurred. Many facilities do have policies in place where if a patient goes for a procedure/surgery, the DNR order may be on hold during the time that they are in the procedure; this does not generally include diagnostic scans.   

Scenario 2

A G-tube is ordered for a terminally ill cancer patient. The patient is unable to eat and needs a G-tube for nutrition and medication administration. When the gastroenterologist comes in to do the consult, he discovers that the patient has a DNR order. He refuses to place the G-tube due to the DNR order and claims that the G-tube is a ‘life-saving’ measure. The patient is sent back up to their room without having the G-tube placed. After two days, a second consult is placed, and a different doctor approves and places the G-tube. 

The ethical dilemma in this scenario is that the provider refuses to provide treatment based on a poor understanding of what a DNR really means. Again, DNR does not mean “do not treat.”  There are many procedures that can and should be performed regardless of a patient's code status. Though a G-tube can prolong someone's life, it also serves as a means to keep them comfortable through both nutrition and the administration of needed medications, including analgesics. A G-tube insertion can ultimately assist the patient to die with dignity by allowing them to receive alimentation and medicines. It is not solely the provider's responsibility to decide what measures are heroic and which are not. The entire multidisciplinary healthcare team should be involved in the care of the patient, especially when questions could arise as to if a certain procedure is ethical.   

This scenario led to a peer review of the provider's actions.   

Scenario 3

A patient, along with his healthcare team and family, has decided to enact a DNR order. He has been gravely ill for a long time and wants "nature to take its course." After the DNR order was placed, one of his daughters arrives from out of town; she does agree with the DNR order and wants it to be revoked. The patient refuses, and the DNR is left in place. The next day, the patient becomes unresponsive while the daughter is in the room. She insists that the nurse begin CPR and threatens legal action if the code blue is not started immediately. The nurse becomes intimidated by the daughter, as she does not fully understand the DNR order, and commences the code blue. 

The patient is revived and is transferred to the ICU. He voices his anger to the healthcare team that his wishes were not followed; CPR was not to have been administered. Three days later, he becomes unresponsive and expires; however, this time CPR was not administered, and the DNR was followed. 

Once again, the ethical issue occurred due to misunderstandings and a lack of knowledge from both the patient’s family and the healthcare team. The patient's daughter sought to go against her father’s explicit wishes to cancel the DNR. When he would not, as soon as he became unresponsive, she demanded that the staff perform CPR. The nurse should have refused, as this daughter was not the legal decision-maker, and the patient's expressed wishes were known prior to him falling unresponsive; instead, the nurse breached the DNR and performed life-saving measures. 

Quiz Questions

Self Quiz

Ask yourself...

  1. In your nursing practice, have you ever come across an ethical issue involving a DNR order? 
  2. In the three scenarios, what was the cause of the ethical issues? 
  3. Could these ethical issues have been avoided? 


A DNR order is put in place when a patient does not want life-saving measures to be performed. The healthcare team and family are involved in the decision-making process, but the decision ultimately belongs to the patient. A patient with a DNR order still needs to be treated for their medical problems and, like any other patient, needs to be treated with dignity and respect. It is important that the healthcare team understands what the DNR encompasses and who can make decisions for the patient should they deteriorate. The nurse must always do what is best for the patient and follow the ANA Code of Ethics with Interpretive Statements. 

Screening for Suicide Risk Factors in Pediatrics


Our youth are our future, and their welfare (physical as well as psychological) is a public health concern. In the youth population, suicide is attributed as the 2nd leading cause of death (3). Moreover, suicidal ideations and attempts are even more common than suicidal deaths (3). Our youth's mental health must be addressed when conducting routine or urgent health screenings to deal with this global public health problem. Consequently, screenings for suicide risk factors in pediatrics have proven beneficial in suicide prevention, and most clinical practices have incorporated them into clinical pathways (3). Ultimately, screenings for suicide risk factors are vital tools that can be utilized to detect behaviors relevant to suicide. The results of those tools can serve as guides for warranted intervention. 

The Significance of Screening Tools for Suicide Risk Factors in Pediatrics 

As previously emphasized, screening tools for suicide risk factors in pediatrics are vital when assessing the potential for suicidal intentions or behavior (5). These tools are significant because incorporating them into routine assessments can assist in prompt identification and intervention. However, it is warranted that screening tools only account for a portion of the overall assessment pertaining to the risk of suicide in the youth population; thus, those tools must not be solely relied upon (5). 

One of the most popular screening tools for suicide risk factors in the pediatric population is the Ask Suicide-Screening Questions (ASQ) Toolkit (3). The ASQ is a free toolkit approved by the Joint Commission, and it has been validated for use in all populations receiving treatment in medical settings (3). Particularly, there is a youth version of the ASQ that is developmentally appropriate for assessing suicide risk in children eight years of age and older (3). More importantly, the ASQ is available in multiple languages. Unfortunately, there are no screening tools for children less than eight years of age; therefore, a full mental health evaluation is conducted (3). Regardless of the approach selected, children are screened without their parents or guardians present for accurate results (3). Additionally, policies or plans of action must be in place if screenings or evaluations indicate positive results (3). 

Quiz Questions

Self Quiz

Ask yourself...

  1. As a clinician, how can you incorporate screening tools for suicide risk factors into your assessments? 

Suicide Risk Factors in Pediatric Populations 

There are numerous risk factors that contribute to suicidal ideations and attempts. Among those suicide risk factors are age, gender, ethnicity, genetics/history, environmental factors, and psychological/physical health factors (4). Elementary and middle schoolers are 40% more likely to attempt suicide, though the risks of suicide-associated deaths are prominent in adolescents 16 years of age and older (4). Likewise, females are 2-3 times more likely to attempt suicide, whereas males are four times more likely to complete suicide acts (4). Even more so, there are more suicide attempts and completions in American Indian, Alaskan Native, Latina/Latino youths (4).  

However, genetics and history of suicide attempts are other factors to consider. One of the strongest predictors of completed suicides with 25-50% of youth victims correlates to previous attempts (4). Even more troubling is that risk significantly increases by at least three times when there is a family history of suicide (4). Those risk factors should not be overlooked.  

As clinicians, we must maintain accountability for screening and assessing for all indicators of suicide potential. In saying that, environmental factors such as dysfunctional family dynamics, domestic violence, abuse and neglect, bullying, stressors (i.e., life-changing events or losses), and socioeconomic strains should be considered notable suicide risk factors that are highly impactful (4). Also, it is important to inquire about an individual's access to lethal methods, especially if they imply that they have a plan (4).  

Here are psychological/physical health factors highly linked to suicide (4) 

  • depression or other mental illness 
  • traumatic brain injury or concussion 
  • chronic physical condition 
  • alcohol or substance use/abuse 
  • lack of social interaction or support 
  • learning difficulties or disabilities 
  • aggressive or disruptive behavior 
  • excessive video game or internet use (more than five hours daily) 
  • in foster care or adopted  
  • sexual orientation 
  • impulsivity  
Quiz Questions

Self Quiz

Ask yourself...

  1. What are some risk factors that indicate immediate interprofessional collaboration? 

  2. How can you, as a clinician, better assess for suicide risks and identify patients who need prompt interventions? 

Signs & Symptoms of Associated with Suicide 

Oftentimes, suicide signs and symptoms are comparable to those noted in depressive situations.  

Some of the signs and symptoms linked to suicidal behavior include (4): 

  • isolation from others 
  • hopelessness 
  • ridding self of cherished possessions 
  • discussions of death 
  • irritability or agitation 
  • defiance 
  • expressions of guilt or shame 
  • violent behavior 
  • personality changes 
  • neglecting personal appearance 
  • physical complaints 
  • loss of pleasure in usual activities 
  • low self-esteem 
  • psychosis  
Quiz Questions

Self Quiz

Ask yourself...

  1. What signs and symptoms would indicate immediate intervention, even without initially using a screening tool? 

Interventions for Concerns Related to Suicide Risk Factors 

The ASQ outlines "Next Steps" to take in circumstances of positive results (3). This is based on a "Yes" response to any of the four questions, which would then prompt asking the fifth question. If the answer to question #5 is "Yes," the screening is marked as an acute positive screening, and the patient is considered at imminent risk. In that regard, the patient requires an immediate safety/full mental health evaluation; he/she must remain supervised in the clinical setting until safety is evaluated. At the same time, the environment is freed of harmful objects, and his/her physician or responsible clinician is notified (3).  

Contrarily, if the answer to question #5 is "No," the screening is noted as a non-acute positive screen that insinuates a potential risk identified. The patient must remain in the clinical setting until his/her safety is evaluated. For that matter, there is a brief suicide safety assessment conducted to establish whether a full mental health evaluation is necessary (3). The clinician responsible for the patient's care or his/her assigned physician is also notified in this case (3). Essentially, the patient's safety is a priority. 

Quiz Questions

Self Quiz

Ask yourself...

Think about your current practice. 

  1. Are there guidelines in place for dealing with patients who are suicidal?
  2. How often are those guidelines or policies reviewed to assure appropriate practices are being implemented? 

Management of the Suicidal Patient 

Assessment and management of a suicidal patient are pertinent to prognosis. Although no intervention is 100% guaranteed to stop an individual from carrying out an act, interventions have proven to be positively impactful in many cases. It has been proven that asking questions pertaining to suicide risk does not increase an individual's likelihood of committing suicide (2). Rest assured that detailed assessments and evaluations facilitate deriving the most appropriate plans of care. Therefore, the following ten steps are recommended when assessing for suicide risk in pediatric patients and managing patients who are suicidal: assess for suicidal risk factors; assess mental status, involve parents or guardians, if possible; offer psychological education; consider the need to hospitalize the patient; interprofessional collaboration or involvement of other services (e.g., psychologist or psychiatrist, counselor, or crisis assessment team/public mental health service); create a youth safety plan or make a referral to a mental health clinician with this expertise; focus on treating underlying mental health problems with psychotropic mediation (i.e. antidepressants) and/or psychotherapy (i.e. cognitive behavior therapy aka CBT); document the risk assessment, interventions, and patient status); and arrange for review (2). 

As previously mentioned, safety is a priority; hence, composing a safety plan is a key component in providing effective and efficient care for the individual. The safety plan should encompass the following components: recognizing signs of patient status worsening; identifying and listing personal coping mechanisms; utilizing family and friends as distractions from suicidal ideations; involving the family in problem-solving during a crisis; contacting mental health clinicians and restricting access to lethal means (2). Likewise, providing access to a resource such as the National Suicide Prevention Lifeline to patients and families is also a means for them to receive counseling, suicide educational materials, and referrals (1). 


Quiz Questions

Self Quiz

Ask yourself...

  1. Are you competent in assessing and intervening when faced with a patient who is at risk for suicide? 

  2. What do you believe is the best approach for making sure patients receive appropriate care and follow-up? 

Case Study

A 12-year-old boy is brought to the ED via emergency transport after being found lethargic on the floor of his bathroom with an empty bottle of hydrocodone located close by his hand. It is assumed that he ingested an indefinite amount of hydrocodone tabs. His initial vital signs are temperature, 97.9 F; heart rate, 50 beats/min; blood pressure, 85/57 mm Hg; respiratory rate, 8 breaths/min; and oxygen saturation 95% on room air.  

The patient is difficult to arouse, and Narcan is administered per protocol. Once the patient's condition is stabilized, he voiced his reason for the suicide attempt, which revolved around him being bullied by peers on almost a daily basis for the last couple of months. The patient excels academically and was a member of his middle school basketball team, which helped him cope until the season recently ended. Additionally, the patient lives with his grandparents, and he stated, "Everyone is always making fun of how I dress and the car that my granddad drives. I'm just tired of people bothering me, and I wanted it to be all over." This was the patient's first suicidal attempt. During the one-on-one evaluation, it is noted that the patient made minimal eye contact and intermittently placed his head in his hands. You consider the appropriate next steps with the patient's safety of utmost importance.


Quiz Questions

Self Quiz

Ask yourself...

  1. What next steps would you implement for managing this patient's care? 


Conduct suicide assessments and evaluations on every visit because each visit affords the opportunity to identify, educate, and intervene. Research best practices and stay cognizant regarding recommendations for effective approaches associated with suicidal patients. Involve family members, other health care providers, and support personnel for a collaborative approach to meeting the patient's needs. Remember, inquiring about a patient's suicide risk does not increase his/her likelihood of engaging in suicidal behavior but rather serves as a vital means for intervening as opposed to neglecting to address the situation.

References + Disclaimer

Illinois Implicit Bias Training
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Nursing Documentation 101
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Infection Control and Barrier Precautions
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PTSD in Nurses
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Following a DNR: An Ethical Dilemma in Nursing
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Screening for Suicide Risk Factors in Pediatrics
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  5. Patterson S. (2016). Suicide Risk Screening Tools and the Youth Population. J Child Adolesc Psychiatr Nurs, 29(3):118-26. doi: 10.1111/jcap.12148. Epub 2016 Aug 23. PMID: 27552927. Retrieved on March 12, 2021 from

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