Ohio Renewal Bundle

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The following course content

This 2023 Ohio License Renewal Bundle meets all renewal requirements for Ohio LPNs and RNs. Upon completion of this course, you will receive a certificate of completion for 24 contact hours.

This course includes multiple interesting topics in one easy course, including the Category A Ohio Nurse Practice Act course. Per the Ohio Board of Nursing’s continuing education requirements, all Ohio nurses are required to pass a test with a score of 80% or higher to receive their certificate.

Course Outline

1. Ohio Nurse Practice Act – Category A (Meets Ohio BON Requirement)
2. Key Concepts of Critical Thinking in Nursing
3. Effective Communication in Nursing
4. Ensuring Patient Confidentiality in Nursing
5. Nursing Documentation 101
6. End of Life Process
7. Sexual Harassment Prevention
8. Following a DNR: An Ethical Dilemma in Nursing
9. Screening for Suicide Risk Factors in Pediatrics
10. Human Trafficking
11. Pain Management in Nursing
12. Drains: Everything you need to know
13. Administration of Blood Products
14. A Nurse’s Guide: How to Deal with Difficult Patients

Ohio Nurse Practice Act – Category A

This fulfills the continuing education requirement of 1.5 contact hours relating the Ohio Nurse Practice Act for the state of Ohio.  

Modern nursing has been standardized nationwide in the way that nurses are educated and the standards they are held to when performing their jobs. While the minimum proficiency exam, the National Council Licensure Exam (NCLEX), is used to determine who qualifies to be a nurse, each state has its own Nurse Practice Act that oversees the nurses of that state and sets ensures the standards for safe and skilled care are being followed (1). This course will cover Ohio Nurse Practice Act in detail to best prepare Ohio nurses to provide the best care possible. 

Introduction and Objectives 

Nursing as a trained profession has been around for over 200 years in the United States, with the first courses on caring for maternity patients taught by Dr. Valentine Seaman in 1798 in New York. Over the next 100 years, nursing education became more standardized and widespread, following the overseas lead of Florence Nightingale and rising to meet the need for skilled health professionals with the outbreak of the Civil War. In 1873, there were three schools for nursing education in the United States; by 1900, there were more than 400 schools (8)! Fast forward another 120 years, and there are now 3.8 million nurses caring for the citizens of this country, and the demand for more is expected to grow as the Baby Boomer population ages (1).  

Modern nursing has been standardized nationwide in the way that nurses are educated and the standards they are held to when performing their jobs. While the minimum proficiency exam, the National Council Licensure Exam (NCLEX), is used to determine who qualifies to be a nurse, each state has its own Nurse Practice Act that oversees the nurses of that state and sets ensures the standards for safe and skilled care are being followed (1). Upon completion of this course, the learner should have increased knowledge of the standards outlined by the Ohio Nurse Practice Act and demonstrate an understanding of:  

1. The definition and roles of the Ohio Board of Nursing, and the Ohio Administrative Code, and Revised Code. 
2. Differences between scopes of practice and nursing process for RNs and LPNs. 
3. Basic concepts included in Standards of Competency for nurses. 
4. Standards of care required to maximize patient safety. 

Ohio Administrative Code, Revised Code, and Board of Nursing

The Ohio Administrative Code (OAC) delineates the rules and regulations of various licensed professions, and Section 4723 of the Ohio Revised Code (ORC, 2022) is specific to nursing practice. This section of the ORC (based on the Ohio Nurse Practice Act) outlines specifics in ensuring proper safety, delegation, competency standards, applying the nursing process, and disciplinary action for nurses with an Ohio license.  

While the ORC (2022) sets the standards and scope of practice of nurses in the state, there needs to be a governing body to enforce the rules and regulations. This is where the Ohio Board of Nursing (OBN) comes in. The ORC Section 4723-01 (2022) dictates that the OBN be composed of thirteen members; at least eight of which should be registered nurses (RNs), at least two licensed practical nurses (LPNs), two advanced practice registered nurses (APRNs), and one consumer representative. All licensed members of the board should have an active, unencumbered license and at least five recent years of experience in the workforce (3). 

The board is legally authorized to enforce the rules put forth by the Ohio Nurse Practice Act’s OAC and must review each rule at least once every five years. Among other duties, they are also responsible for reviewing and granting approval to nursing education programs, issuing and renewing nursing licenses, and regulating the substance abuse monitoring program for nursing professionals. The funding for the OBN comes from licensure fees for nurses practicing in the state of Ohio (4). 

Scopes of Practice and Application of Nursing Process

The scopes of practice within the Ohio Nurse Practice Act encompass a list of duties, services, and tasks that Ohio nurses are qualified and permitted to perform under their license. The scope of practice varies by level of licensure (LPN, RN, APRN) and allows nurses to effectively carry out their roles while maintaining maximum patient safety.  

RN Scope of Practice

Section 4723.04 of the ORC (2019) specifies that RNs can utilize the specialized training and multifaceted, holistic knowledge gained from an accredited nursing education program to provide nursing care to individuals or groups. Tasks considered "nursing care" include: 

1. Identifying patterns in human response to actual or potential health issues that could be altered by preventative, restorative, or health-promotion "nursing regimens." 
2. Delivering nursing regimens/interventions utilizing the nursing process (outlined below). 
3. Using interviews, observation, and physical exam techniques to assess a patient's health status to provide appropriate nursing care.  
4. Providing patients with health-related counseling and teaching. 
5. Administering medications, treatments, and other interventions as specified in orders given by a qualified and licensed professional. 
6. Teaching, supervising, delegating, and evaluating the practice of nursing (2).
   

RN Application of Nursing Process

The Nursing Process is a standard sequence of steps used to guide patients' holistic, safe, and effective care. The five steps always include Assessment, Diagnosis, Planning, Implementation, and Evaluation. Further review of each of these steps, as supported by the ORC, is below:

1. Assessment- Collect data from patients via history, observations, and physical exam. This can also include data reported to the nurse from a patient's family or an LPN.
2. Diagnosis- Establish or modify the nursing diagnosis.
3. Planning- Analyze collected data to form a plan for nursing interventions
4. Implementation- Communicate and carry out the plan of care within the scope of practice.
5. Evaluation- Assess patient response to plan and modify as needed (7). 

LPN Scope of Practice

The Ohio Revised Code Section 4723.4.04 (2019) also specifies the LPN scope of practice, which is similar to the RN scope but it has less autonomy and requires more collaboration. Tasks within the LPN scope of practice include:  

1. Observation, focused assessments, care, and patient teaching in a variety of settings. 
2. Contributing to the planning, implementation, and evaluation of nursing care. 
3. Administration of medication and treatments as ordered by a qualified
   professional and after documented completion of a medication proficiency
   course.
4. The LPN may delegate to unlicensed assistive personnel such as CNAs.
5. Teaching nursing tasks to other LPNs or unlicensed assistive personnel (2).  

 Of note, tasks prohibited for LPNs include:  

1. Engaging in nursing practice without direction from an RN or qualified licensed professional. 
2. Administering IV push medications. 
3. Teaching the practice of nursing. 
4. Supervising or evaluating the nursing practice. 
5. Performing comprehensive assessments to provide nursing care (2). 

LPN Application of Nursing Process

The Nursing Process varies for the LPN in that these professionals mostly contribute to the process rather than initiating or carrying it out. Specifics of this process, as outlined by the Ohio Nurse Practice Act’s ORC Section 4723.01 (2023), include: 

1. Collecting objective and subjective data about the patient's condition as part of
   the health status assessment. 
2. Contributing to the planning, implementation, and evaluation of nursing care.
3. Documentation of patient response to care. 
4. Communicating with members of the healthcare team to contribute to the evaluation and revision of the nursing plan of care (2). 

Case Study

The charge nurse is making patient assignments for a med- surg unit that currently has six patients. The oncoming shift has one RN and one LPN with a CNA to assist with the entire unit. The charge nurse assigns four patients to the RN and two patients to the LPN.  

1. Which factors of the patients' care will need to be considered when making assignments?
2. What responsibilities will the RN have in regards to the LPN's patients? 
3. Are both licensed nurses able to delegate tasks to the CNA on the unit? 

Standards of Competency

Standards of competency within the Ohio Nurse Practice Act’s ORC Sections 4732.4.04 (2019) outline the qualifications a nurse must have to operate within their scope of practice. If the scope of practice details what nurses can do, then standards of competency outline how they must do it. These standards include:  

1. Understanding and operating within the scope of practice appropriate for licensure level. 
2. Maintaining current knowledge of duties, responsibilities, and accountabilities for safe practice. 
3. Demonstrating consistent practices of care and recognizing when to consult with colleagues or refer care. 
4. Providing care beyond basic nursing education only when additional education and training has been obtained and documented, appropriate skills demonstrated, and the tasks within the laws of that state
5. Implementing provider orders within a reasonable time frame unless an order is determined to be invalid. 
6. Demonstrating the ability to identify invalid, harmful, or unauthorized orders and consulting with the ordering provider to rectify the situation by either obtaining a corrected order or maintaining patient safety by deciding not to follow an order
7. Collaborating with and referring to other members of the nursing team when appropriate. 
8. Maintaining patient confidentiality within the realm of legal and safety considerations. 
9. Keeping identifiable patient information (name, birth date, etc.) confidential to the greatest extent possible. 
10. Using standards of care that promote patient safety (5). 

In addition to the above standards, RNs must also consider competency standards when directing tasks to an LPN or unlicensed assistive personnel (CNA, patient care technician, etc.). Ultimately, Section 4723-13.05 of the Ohio Revised Code (2022) outlines that the care of a patient falls on the nurse, and delegation to unlicensed personnel is safe and appropriate only when the below criteria have been met:  

1. The condition and stability of the patient are appropriate for CNA care. 
2. The type of care or tasks required are within the CNA scope of practice. 
3. The complexity and frequency of said tasks are within the capabilities of the CNA. 
4. The training and skill level of the CNA will allow them to complete the delegated task competently. 
5. Resources needed to complete the task are readily available and accessible (5). 

Standards for Promoting Patient Safety 

Proper understanding of the Ohio Nurse Practice Act’s Scope of Practice, Nursing Process, and Standards of Competency should lead a nurse to provide care in such a way that promotes the best outcomes for patients, including maintaining patient safety. In case there are any situations where it is unclear what is most safe, the ORC Section 4723-4.06 of the ORC (2021) has outlined some standards. They are: 

1. Nursing professionals will wear proper identification with their name and title, visible to patients at all times when providing care. 
2. Nurses must delegate tasks and medication administration only within the scope of the professional being delegated to. 
3. Nurses must document assessments, care, patient responses to care, and any errors in a timely manner. 
4. Nurses must not falsify or alter documentation of nursing care in any manner. 
5. Nurses must maintain professional boundaries, ensure privacy, and a safe environment for patients. 
6. Nurses must not engage in any physically, verbally, or emotionally abusive behavior when caring for patients. 
7. Nurses must not misappropriate patient property in any way, accept or seek monetary gain at a patient's expense, or become involved in patients' personal or financial matters. 
8. Nurses must not engage in sexual conduct with patients or sexually harass or exploit patients. 
9. Nurses in administrative roles are responsible for ensuring their staff have valid and appropriate licensure, education, and training to provide safe care for patients. 
10. Nurses must not make false claims to the OBN, law enforcement, or hospital administration. 
11. Nurses may not use texting, email, or social media to communicate patient information for purposes other than carrying out the responsibilities of their job.

Conclusion 

There are many more subsections to the OAC that detail more specifics about licensure, disciplinary action, and APRNs but it is beyond the knowledge needed for basic competency as a nurse practicing in the state of Ohio. While most nurses will find the scope of practice, safety guidelines, and minimum competency standards as outlined in the Ohio Nurse Practice Act to be similar from state-to-state, there is the potential for differences across state lines. Having familiarity with the state in which you practice is always a good idea. Depending on your workplace setting, understanding the relationship between the RN and LPN scopes of practice and nursing processes may be of particular importance. The OAC is public domain and can be easily accessed to clarify any questions, and the OBN can be contacted for guidance on any gray areas. 

Key Concepts of Critical Thinking in Nursing

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

What is Critical Thinking? 

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

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

Information Gathering 

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

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

Investigating 

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

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

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

Evaluation 

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

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

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

Problem Solving 

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

Why is Critical Thinking Important? 

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

Patient Outcomes 

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

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

Staff Satisfaction 

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

Efficiency 

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

Healthcare Complexity 

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

Critical Thinking Education 

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

Educator Influence 

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

Environment 

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

Education System 

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

Individual Factors 

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

Strategies to Promote Critical Thinking 

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

Targeted Questioning 

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

Case Studies 

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

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

Simulation 

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

Critical Thinking Exercises 

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

Concept Mapping 

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

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

Reflective Writing 

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

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

Conclusion 

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

Effective Communication in Nursing

Introduction   

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

Types of Communication

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

Non-Verbal

This form of communication relies solely on body language, including body and facial mannerisms, and lacks spoken words or sounds (2, 3). 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 initially target that area because they have communicated (non-verbally) that this is where they are experiencing discomfort. Smiling when the next shift nurse walks in the door communicates to them that you are happy to see them and that it's about time to go home!

Since we perform non-verbal communication so often, it can become a potent or extremely damaging tool. This form of communication in nursing can be used positively to show our patients and co-workers that we have compassion and 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 (2).

Verbal

Verbal communication occurs when we use words or sounds to discuss concepts with others (2). This form of communication in nursing has the conception to be a very easy notion, but it can create unfavorable consequences when used ineffectively. In order to produce clear verbal messages, we should always speak concisely and confidently. As healthcare professionals, we have our language and understanding of when to incorporate medical jargon into conversations versus when not, which is crucial in providing care (4). When communicating among co-workers, our medical knowledge can display professionalism, and they can follow along. However, when speaking with patients and their families, this may only sometimes be the case, and we must be able to effectively gauge our audience and ensure that they clearly understand what we are teaching or explaining; this is a precious tool.

Written

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

Receiving Communication 

The most common communication perception is usually directed at producing communication through non-verbal, verbal, or written forms. While the production of communication is essential, the reception of it 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...

• I was taking notes in class or during a shift.
• When a preceptor or instructor educates you on a new skill or equipment.
• You teach your patient, family, or student about a new diagnosis.
• You are watching your patient breathe for rate, depth, and effort.

We must successfully provide and receive communication in nursing through verbal, non-verbal, or written forms. If communication fails, we will experience highly adverse effects throughout our nursing system (2).

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 voiced. Hearing all these sounds is heavily dependent on how they are used. We must also listen to these sounds and words to successfully implement these sounds. 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.

Active listening is when the listener understands the information discussed and provides feedback (5). Ways to ensure active listening are having the patient repeat the information in their own words and paraphrasing it. Active listening patients may also ask questions relevant to the topic discussed. Some additional tips to ensure active listening and participation are providing the environment is free from distractions or biases, making eye contact, and allowing the speaker to fully respond before interrupting (5).

Communication Transmission Threads

Communication in nursing occurs multiple times a day between a wide range of communication threads. The type of communication through non-verbal, verbal, and written communication produced and received must be effectively performed (4). Success and implementation depend heavily 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 we pass our documentation on to another nurse for review or vice versa, there is a consistent, communicative flow of all variants (non-verbal, verbal, and written) between the team to provide patient care. Another way to effectively communicate patient information is to use a structured communication framework, such as the situation, background, assessment, and recommendation (SBAR) format.

Nurse - Ancillary Staff

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

Charge Nurse - Team

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

Nurse - Patient

The nurse-to-patient communication thread is one of the ultimate and most essential exchanges in the nursing profession (4). Patients need us, so we must maintain consistent and effective communication with them because any assessment, report, or medication administration is contingent upon it. Additionally, bedside patient reports during shift change are valuable to ensure effective nurse-patient communication.

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. It could serve as your sole historian for patient information if the patient cannot communicate at the time of data collection. Ensuring that the family is aware of and understands discharge instructions can help them recognize any potential signs or symptoms that could result in calling a physician or visiting the emergency room.

Barriers & Improvements to Communication in Nursing

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

Environmental-related barriers

When providing patient education, the surrounding environment can negatively impact effective communication. Alarms, noisy surroundings, lack of privacy, and lighting can all be distractions when fostering a positive learning environment (6). As nurses, we must try to teach patients in an optimal environment conducive to listening and learning as much as possible.

Cultural differences

Identifying cultural differences during admission and cultural awareness will allow effective communication management throughout each culture you are presented with (6). Nurses must acknowledge their personal and cultural beliefs and differences. Additionally, they should respect patients’ cultural differences and refrain from judgment.

Healthcare Institutional BarriersPatient acuity, low staffing levels, and time constraints can contribute to communication barriers (6). Nurses can improve these barriers by utilizing staff huddles and working with the administration to overcome high-acuity patient assignments and some time constraints. Nurses may utilize a patient-centered approach and prioritize patient communication over routine tasks to improve communication.

Emergent situations

Emergent situations during your shift can be relieved through adequate knowledge of the policies and procedures and by performing debriefs after the problem is resolved. Debriefings hold valuable insight into reflections on 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 receive information, we must ensure we understand, investigate, and act according to the communication presented. Utilizing various communication platforms, including emails, boards, and group messaging apps, can help to ensure education is received.

Benefits of Effective Communication in Nursing 

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

Ensuring Patient Confidentiality in Nursing

Introduction

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

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

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

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). 

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). 

Professional Statements  

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

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

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

Disclosure  

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

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

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

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

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

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

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

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).  

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).  

Best Practices of Patient Confidentiality 

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

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

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

Summary  

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

Nursing Documentation 101

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

Introduction to Nursing Documentation

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

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

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

Who

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

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

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

What

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

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

When

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

Where

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

Why

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

How

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

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

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.

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.

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

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.

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.

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.

Conclusion

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

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

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

End of Life Process

Introduction   

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. 

Transitioning 

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. 

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 lasts only two to three days and showcases 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 discomfort, nonverbal 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 briefs as often. Urine may also appear darker, similar to 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 their 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 they will not likely experience any discomfort. 

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. 

Conclusion 

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. 

Sexual Harassment Prevention

Introduction   

Sexual harassment is a serious issue within the healthcare workplace. One systematic review research study found that sexual harassment rates against female nurses was as high as approximately 43% (5). According to an article published in the American Journal of Critical Care in 2021, recent studies estimate around 60% of female nurses and 30% of male nurses have reported sexual harassment (3).  

For both student and registered nurses, patients were the most likely perpetrators. However, this varies, and some research suggests that physicians and patient relatives were also at an increased likelihood of being perpetrators of sexual harassment toward registered nurses (8). 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. 

The impacts of sexual harassment affect nurses in many negative ways. There are obvious psychological consequences, but there is also evidence to suggest that work performance and productivity can also be negatively affected (12). Many states have recognized the significant impact of this issue and have taken measures to empower nurses to prevent and/or address 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 (13). 

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 adult 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 (4, 13) 

The U.S. Equal Employment Opportunity Commission defines sexual harassment as “unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature.” Sexual harassment can also include offensive remarks about an individual’s gender or sexual orientation. No matter the type or amount of harassment, it can disrupt the workplace and potentially create a hostile work environment (10,11) As you can see, the definition of sexual harassment is broad and can encompass many situations. 

Why Are Nurses Vulnerable to Sexual Harassment?

Nurses are vulnerable to sexual harassment by the very nature of their position. The role of nursing surpasses many 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 (8). 

Staff-on-staff harassment is also commonly reported by nurses (8). Nurses are potentially predisposed to this type of harassment due to their subservient position to many staff members (physicians, administration) and the subsequent power imbalance that results. 

Key Points for Sexual Harassment

Sexual misconduct vs. sexual harassment – Sexual misconduct is a type of sexual harassment. Sexual behavior can turn 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 (11). 

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 (11). 

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 (1). 

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 (1, 11). 

It doesn’t only occur in person – Sexual harassment can occur on and off the clock. It can occur physically and virtually. Unwelcome sexual conduct through email, phone calls, texts, social media postings, and other mediums may constitute sexual harassment (6). 

Two Types of Sexual Harassment

1. 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 (7).
2. 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 (7).

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 (2). If you decide to confront the perpetrator, try to remain calm and de-escalate the situation as much as possible.   
• You should be explicit in explaining the behaviors that 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, coworker, or supervisor who can accompany you or advise you on the next steps. 
• Another way is to interrupt the harasser to distract them from the situation (2) 
• Next, make sure to document the scenario. Write down all of the details that you can recall; including any witnesses. This can be helpful in the future. 
• Reporting the issue through the appropriate channels is the next step. Oftentimes, this involves speaking with your supervisor and someone in human resources. While discussing the situation, do not make excuses for the perpetrator or try to “shrug it off.” 

How or whether you report sexual harassment is a personal choice, and you are not limited. However, you should strongly consider reporting the incident because it could escalate further in the future. The perpetrator may also be sexually harassing others. Every workplace should be free from sexual harassment and many states have laws protecting nurses against workplace sexual harassment, including harassment received from patients and family members. There are several options for reporting sexual harassment, and there are several nuances with jurisdiction and handling of complaints. However, you should not be discouraged from reporting through the appropriate avenues. 

 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 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. Law enforcement.

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

3. Office of Executive Inspector General (state government employees).

State employees may file a report directly with the OEG. To initiate a report, it is best to contact your ethics officer for guidance. 

4. U.S. Equal Employment Opportunity Commission (EOCC).

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 from the date of the incident. 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. This law may be extended up to 300 days depending in the state laws surrounding sexual harassment (10). 

Whistleblower Protections

Retaliation for reporting sexual harassment is illegal under both federal and state statutes. The U.S. Equal Employment Opportunity Commission prohibits retaliation aimed at employees who assert their rights to be free of harassment (9). 

Concluding Points

• Sexual harassment can take place in many venues and formats. It is broadly defined as any unwanted or unwelcome sexual behavior or advances. 
• Sexual harassment is experienced frequently by nursing professionals due to the nature of their positions. 
• You have a right per federal and state laws 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 provide a thorough report of the incident. 
• You have a right to report sexual harassment without retaliation per federal laws. 

Following a DNR: An Ethical Dilemma in Nursing

Introduction   

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.   

DNR 

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. 

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 they 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, they discover that the patient has a DNR order. They refuse to place the G-tube due to the DNR order and claim 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 their healthcare team and family, has decided to enact a DNR order. They have been gravely ill for a long time and want "nature to take its course." After the DNR order was placed, one of their family members arrive from out of town; they do not agree with the DNR order and want it to be revoked. The patient refuses, and the DNR is left in place. The next day, the patient becomes unresponsive while the family member is in the room. They insist that the nurse begin CPR and threatens legal action if the code blue is not started immediately. The nurse becomes intimidated by them, as they do not fully understand the DNR order, and commences the code blue. 

The patient is revived and is transferred to the ICU. They voice their anger to the healthcare team about their wishes not being followed; CPR was not to have been administered. Three days later, they become unresponsive and expired; 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 family member sought to go against the patient's explicit wishes to cancel the DNR. When they would not, as soon as the patient became unresponsive, they demanded that the staff perform CPR. The nurse should have refused, as the family member was not the legal decision-maker, and the patient's expressed wishes were known prior to them falling unresponsive; instead, the nurse breached the DNR and performed life-saving measures. 

Conclusion 

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

Introduction

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). 

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  

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  

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; they must remain supervised in the clinical setting until safety is evaluated. At the same time, the environment is freed of harmful objects, and their 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 their 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 their assigned physician is also notified in this case (3). Essentially, the patient's safety is a priority. 

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). 

Case Study

A 12-year-old child is brought to the ED via emergency transport after being found lethargic on the floor of their bathroom with an empty bottle of hydrocodone located close by their hand. It is assumed that they ingested an indefinite amount of hydrocodone tabs. Their 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, they gave their reason for the suicide attempt, which revolved around them being bullied by peers on almost a daily basis for the last couple of months. The patient excels academically and was a member of the middle school basketball team, which helped them cope until the season recently ended. Additionally, the patient lives with their grandparents, and 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 their head in their hands. You consider the appropriate next steps with the patient's safety of utmost importance.

Recommendations

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 their likelihood of engaging in suicidal behavior but rather serves as a vital means for intervening as opposed to neglecting to address the situation.

Human Trafficking

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

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

Prevalence and Definition

The Polaris Project estimates that collectively there are over 25 million victims of human trafficking worldwide. These are individuals that have been forced into sexual or labor servitude. Of those, approximately 48,326 were related to individual trafficking contacts in the United States (7).   These numbers exemplify the number of potential victims that are not reaching out for help.

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

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

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

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

Risk Factors

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

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

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

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

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

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

Mandatory Reporting

Mandatory reporting of human trafficking by health care professionals is incorporated into the law in a growing number of locations in the United States. Health care professionals are already mandated reporters through previous existing laws that require reporting of child abuse, domestic violence, as well as knife and gunshot wounds (11)

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

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

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

Recruitment Techniques

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

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

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

Federal Laws

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

A specific U.S. Federal law addressing trafficking crimes was first enacted with the Trafficking Victims Protection Act of 2000. The bill has since been revised several times; however, the fundamental of it is to provide guidance and authorization for their “three-pronged approach that includes prevention, protection, and prosecution” and covers both sex and labor trafficking (12).

Preventing Sex Trafficking and Strengthening Families Act of 2014 and The Justice for Victims of Trafficking Act of 2015 are both aimed at providing victims increased protection for exploitation and increased resources specifically aimed at prevention and support for child and youth sex trafficking crimes (12).

The Customs and Facilitations and Trade Enforcement Reauthorization Act of 2009 is aimed towards prohibiting the importation of goods made by victims of human trafficking (12).

Recognizing Signs of Human Trafficking

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

Signs and Symptoms

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

Physical

• Unexplained or implausible injuries
• Bruising
• Wounds and Cuts
• Missing or broken teeth
• Closed head injuries
• Blunt force trauma

Neurological

• Headaches
• Migraines
• Memory loss or difficulty concentrating
• Vertigo
• Insomnia
• Brain trauma

Gastrointestinal

• Diarrhea
• Constipation

Dietary

• Malnutrition
• Anorexia
• Severe weight loss

Cardiovascular and Respiratory

• Tachyarrhythmias
• Hypertension
• Respiratory distress

Reproductive System

• Sexually transmitted disease
• Vaginal and/or anal fissures
• Previous Abortions

Psychological

• Depression
• Suicidal Ideation
• Anxiety
• Self-harm including cutting or branding
• Drug and alcohol abuse
• PTSD symptoms
• Regression
• Anger
• Dissociative and depersonalization tendencies

Red Flags and Indicators

There are several characteristics that should be kept in mind as red flags during the interview and assessment that may indicate potential trafficking. These include, but are not limited to (all derived from 9, 15, 16):

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

Interview Tools and Techniques

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

Gaining trust can be difficult and conducting assessments and interviews should be completed in a non-threatening environment with an unbiased and non-judgmental tone. Creating a space that is quiet and will not be interrupted is important. This will ensure that the potential victim feels safe communicating and is not concerned that they will be overheard. Present your demeanor in a non-threatening manner, at eye level, and focus on being attentive with observant listening. Maintain respectful eye contact to convey interest and reflective listening. If taking notes during the interview is required, explain to the patient what will be documented and what it will be utilized for (17).

The National Human Trafficking Resource Center (NHTRC) offers a plethora of resources and scripted questions. The following are general questions on assessing if the individual is being forced into a situation and can be applied to any of the specific types of human trafficking (all from 17):

“Did someone control, supervise or monitor your work/your actions?”

“Was your communication ever restricted or monitored?”

“Were you able to access medical care?”

“Were you ever allowed to leave the place that you were living/working? Under what conditions?”

“Was your movement outside of your residence/workplace ever monitored or controlled?”

“What did you think would have happened if you left the situation? Was there ever a time when you wanted to leave, but felt that you couldn’t? What do you think would have happened if you left without telling anyone?”

“Did you feel that it was your only option to stay in the situation?”

“Did anyone ever force you to do something physically or sexually that you didn’t feel comfortable doing?”

“Were you ever physically abused (shoved, slapped, hit, kicked, scratched, punched, burned, etc.) by anyone?”

“Were you ever sexually abused (sexual assault/unwanted touching, rape, sexual exploitation, etc.) by anyone?”

“Did anyone ever introduce you to drugs, medications as a method of control?”

While screening tools provide a base for asking difficult questions, the NHTRC advises “Before screening, users should also be prepared to draw upon the expertise of local legal and medical staff and to refer identified trafficking victims to appropriate housing, health, and social services in their area . . . the tool is a complement to, not a substitute for, specialized training in human trafficking, good professional practice and victim-centered service” (17).

The NHTRC also provides a 24-hour national hotline that is able to guide health professionals through completing assessments and determining the next best steps to intervene or offer the victim assistance. This is a very beneficial resource; however, it must be understood that calling NHTRC does not fulfill the mandatory reporting requirement for certain states and the Centralized Intake (CI) at the Department of Health and Human Services is the only means of legally fulfilling the reporting obligation.

Interventions and Collaboration

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

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

For patients that seek healthcare related to sexual abuse, a SANE assessment and rape kit should be obtained per facility protocol. With permission, patients should be tested for sexually transmitted infections including HIV, gonorrhea, UTIs, syphilis, and pubic lice, as well as a pregnancy test for females. Forced and coerced abortions are frequent among minor females in the sex industry (18).

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

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

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

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

If a competent adult does disclose that they are a trafficking victim, determine if the patient is in immediate, life-threatening danger. If so, follow facility protocol and encourage and support the patient in reporting to a law enforcement agency. If there is no immediate danger, supportive care and assistance should be provided. The patient should be informed of the options available for social services, reporting, and resources. Creation of a safety plan is highly recommended (15).

Prevention

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

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

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

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

Resources

National Human Trafficking Resource Center

Phone: 1-888-373-7888

SMS Text: 233733 (Befree) – Text “HELP” OR “INFO”

Online chat: https://humantraffickinghotline.org/chat

This network provides healthcare facilities and individuals with information and connections to over 3,200 referral contacts that will assist human trafficking victims. These contacts include low or no-cost legal services, law enforcement agencies, social services, and anti-trafficking organizations. Communication is enhanced as dialect is available in English, Spanish, and 200 other languages.

HEAL (Health, Education, Advocacy, Linkage) Trafficking

Website: www.Healtrafficking.org  

The HEAL Trafficking Direct Service Committee works to improve the clinical care for trafficked persons by providing opportunities for service providers to connect, access support, share information and promising practices, identify best practices, and expand the referral network.

National Center for Missing & Exploited Children

Address:

333 John Carlyle Suite 125

Alexandria, VA   22314-3175

Phone: 1-800-THE LOST (1-800-843-5678) 24-Hour Call Center

Website: http://www.missingkids.org/theissues/trafficking

Provides specialized technical assistance, analysis, and recovery services on cases involving child sex trafficking.

Pain Management in Nursing

Pain is a subjective, complicated symptom that afflicts every human at some point in their lives. Pain management in nursing within healthcare settings is a challenge and must take into consideration patient-centered preferences, treatment goals, as well as guidelines and laws from governing bodies. For many years, opioids were the first line of defense against acute and chronic pain conditions. With the opioid crisis, this mindset has been required to change.  

The Epidemiology of Pain

Pain is a subjective, complicated symptom that afflicts every human at some point in their lives. Managing pain within healthcare settings is a challenge and must take into consideration patient-centered preferences, treatment goals, as well as guidelines and laws from governing bodies. For many years, opioids were the first line of defense against acute and chronic pain conditions. With the opioid crisis, this mindset has been required to change.  

Due to an overabundance of prescribing opioids, the opioid related death toll has continued to rise. Not only has this fatal epidemic resulted in untimely deaths for many, it is estimated that "For every 1 prescription opioid death, there are 20 specialty substance abuse treatment admissions, 45 emergency department visits for nonmedical use and adverse events, 156 people with substance use disorder and dependence, and 533 people using the drugs nonmedically overall" (1).

This public health crisis has resulted in the conviction of pharmaceutical companies that were behind the political stronghold monopoly on pain management in America. As a result, the Federal government has collaborated with The Institute of Medicine (IOM) and the Centers for Disease Control (CDC), among many other experts in the field, to develop a plan that protects the American public from unintended opioid use and promotes a multi-disciplined, multi-modal approach to combating pain in America.  

Statistics to Consider on Pain Management in Nursing

Pain is a widespread public health concern that reaches every corner within America. In a 2011 report titled, Relieving Pain in America: A Blueprint for Transforming, Care, Education, and Research, the IOM revealed that pain affects nearly 100 million Americans and nationally costs upwards of 635 billion U.S. dollars each year (2). Of these numbers, over 25 million American adults report that they suffer from pain daily, while 23.4 million state a significant amount of pain (3).  

Researchers gathered data from 8,781 American adult participants regarding individual perceptions of their overall health, underlying illnesses, and pain experiences within the previous three months. This study ranked pain on a scale of categories from one through four, with one being the least amount of pain, and four being the highest level of pain.

From this data, it is estimated that almost 40 million individuals ranked themselves as living with pain at a category three or four. Individuals in these categories were also found more likely to have an accompanying disability, access healthcare on a more frequent basis, and have an overall worse quality of health and life (4). 

What is Pain and Why Does it Occur?

Merriam-Webster defines pain as "a localized or generalized unpleasant bodily sensation or complex of sensations that causes mild to severe physical discomfort and emotional distress and typically results from bodily disorder (such as injury or disease) (5)".  

Pain is the body's defense to achieve a response against further damage from a perceived threatening stimulus. The brain perceives pain via specific pathways. Four stages of pain transmission occur: transduction, transmission, perception and modulation (6).

Receptors within afferent fibers are activated when a potential threatening stimulus occurs. This initiates three stages of pain perception. Initially, pain sensitivity is triggered. From there, signals follow a network of peripheral neural pathways towards the spinal cord. Within the spinal cord is the dorsal horn, which contains neurons that translate and relay information about the painful or irritating peripheral stimulus to the thalamus and cortex in order to elicit a protective response (6,7). 

Pain can be further distinguished within two frameworks, chronic and acute, and by pain related conditions, such as inflammatory responses, nociceptive, and physiological dysfunctions.  

Identifying Types of Pain for Pain Management in Nursing

Pain is classified by three distinct types: nociceptive, inflammatory, and neuropathic. The following are general descriptions of the types of pain; however, it must be noted that these pains can overlay each other and be occurring simultaneously.  

Nociceptive Pain

Nociceptive pain is due to nerve impairment or injury and is the most common type of pain that occurs. It is sometimes noted as being central pain that is caused by repeated or harmful stimuli. The nociceptors activated in this type of pain are spread throughout the body within internal organs, bones, joints, and the integumentary system (6).

Nociceptive pain is generally described as radicular, somatic, or visceral depending on the nerve involvement. Examples of nociceptive pain include the sensation from touching a hot object, a broken arm, or a paper cut at the initial time of injury. It may also describe pain caused by cancer, arthritic changes, and ischemic pain that  does not originate from nerve injury. 

Inflammatory Pain

Inflammatory pain is part of the cascade of sequelae that makes up the immunological defense to damage caused by heat, toxins, trauma, foreign substances, or infection. Neutrophils, along with prostaglandins, histamine, and other chemical mediators flood the location of injured tissues as a part of the bodies normal, inflammatory response. Classic signs include erythema, edema, and heat at the site of injury (6). Inflammatory pain can be seen in cases of an ankle sprain, cellulitis, and allergic reactions.  

Neuropathic Pain

Neuropathic pain is also often associated with a phenomenon called allodynia. Allodynia is the sensation of pain from an activity or event that is typically not associated with causing pain. Rather than being the result of a physiological event, neuropathic pain is pathologic in nature.

According to Yam, Loh, Tan, Adam, Manan, and Basir (2018), "This condition can be described as "pathologic" pain, because neuropathic pain actually serves no purpose in terms of defense system for our body, and the pain could be in the form of continuous sensation or episodic incidents" (6). It is thought to be caused by disorders affecting the peripheral or central nervous system and is linked to diseases that cause nerve damage such as trauma, toxins, diabetes, as well as certain viral infections, such as herpes zoster.

Chronic Pain vs. Acute Pain

Acute pain is that which is short-term and self-limiting. Generally, the timeframe of acute pain is based on the expected healing process of the injurious event and may be up to six months.

Chronic pain lasts beyond the expected period of healing or is recurrent. Acute pain can usually be attributed by a defined contributing factor or event, such as appendicitis or a broken bone. Chronic pain can be related to a myriad of causes or the etiology may be unknown (6).  

In clinical settings, pain lasting more than three months is typically used to define the transition from acute to chronic. As such, chronic pain must be treated and managed differently than acute pain. 

Risk Factors

Several risk factors have been identified that make it more likely for an individual to experience chronic pain. In general, age influences the prevalence of chronic pain by population, with those age 18 to 39 having an increased prevalence of chronic pain. This may be due to other age groups under-reporting.

Those over 80 were found to report acute pain more often but were less likely to acknowledge chronic pain when asked. As well, cognitive decline, dementia and other age-related diseases must be considered as factors when collecting data. Chronic pain after surgery is reported at a higher rate amongst adolescents (7).  

Chronic pain is more likely to be experienced and reported by females over males. However, studies have shown that women experience pain differently than males at a lower threshold. Women have been found to be more likely to seek treatment for pain (7,8). 

Certain co-morbidities have been identified that are linked to an increase of chronic pain. 

Almost 90% of patients reporting chronic pain have significant co-morbidities. Co-morbidities with the highest link to chronic pain are cardiovascular and respiratory diseases and depression. The link between chronic pain also affects mortality rates. In those reporting severe chronic pain, the 10-year survival rate decreases significantly. At ten years, those reporting severe chronic pain are twice as likely to have died from ischemic heart disease or respiratory disease than those with little to no pain (7). 

Depression and anxiety are reported at a rate four times higher in individuals with chronic pain than those living without pain (7). Specific conditions that have a higher rate of being linked to mental health disorders include (all from 8): 

• Arthritis 
• Fibromyalgia 
• Back/Neck pain 
• Chronic migraines 
• Menstrual-related pain
  

Other factors that have been found to influence the prevalence of reported chronic pain include (7,8): 

• Poverty 
• Self-identify as minority 
• Obesity 
• Manual labor occupations 
• Unemployed 
• Smoker 
• Alcohol use 
• Lack of physical activity 
• Poor nutrition 
• Low levels of Vitamin D 
• Post-surgical and medical interventions 
• Sleep Disorders 

Physical and Psychological Elements of Pain

Pain elicits a response from the sympathetic nervous system (SNS) leading to signs and symptoms affecting all systems of the body. The following are some of the physical effects that pain may cause within each individual system. 

With the sensation of pain, the cardiovascular system anticipates an event that is threatening. The SNS produces a rush of adrenaline and cortisol that results in tachycardia, hypertension, and increased oxygen demand.

The respiratory response includes elevated breathing that is shallow. The cortisol levels have an effect on the endocrine system, resulting in a surge of glucose by triggering a release of glucagon from the liver that will keep up with the demands needed for the fight or flight response.

In contrast, with chronic pain, continued elevated cortisol levels may lead chronic hyperglycemia. The gastrointestinal system slows gastric motility which may lead to nausea, vomiting, and constipation.

Chronic pain may lead to an increase in gastrointestinal discomfort, including irritable bowel syndrome. The urinary tract reacts to stress with oversensitivity leading to an increased urgency to urinate, and possibly incontinence (7).  

Physical indications of pain from the musculoskeletal system are displayed as pilo-erection, tremors, and muscle tension and rigidity. The nervous system reconfigures with the processing of pain and attempts to adapt to the additional stresses. Repeated episodes of acute pain can increase the risk of an individual developing chronic pain.

Cumulatively, the stresses and changes that occur on these systems have a negative effect on the immune system. The immune system is unable to keep up with the demands and becomes desensitized to repeated inflammation culminating in a lowered immune response. The lowered immune response then poses an increased risk of infection for the individual (5). 

Psychological Responses

Pain can cause a wide array of psychological symptoms that are subjective and may be difficult to quantify. These include anxiety and fear, poor concentration, and  inhibitory or promotory effects on pain (7). When pain is experienced, the activation of certain parts of the brain induce a heightened awareness and fear as a defense mechanism. Part of this process also provides a certain level of natural analgesia.

With long-term pain this results in continued activation of this system, leading to increased risk for depression, anxiety, and abnormal sleep patterns (7). As stated by Swift (2018), "A high threat level induces strong emotions such as fear or intense anxiety, leading to a state of high arousal, awareness and/or vigilance, which in turn reduces sensitivity to pain. A low or moderate threat level causes a less intense response, such as low-level anxiety or depression, which induces a low-to-moderate state of arousal in which pain is more easily felt" (7). 

Pain Management in Nursing

As guidelines have changed due to the opioid crisis, new evidence published by the CDC suggests that opioid dependency can occur in as little as a ten-day course of treatment.

In addition, the American Pain Society and the American Society of Anesthesiologists have released guidelines that stress a multi-modal approach to pain management in the operative and recovery setting. Of the recommendations, the following were released as having high-quality evidence and strongly recommended (as cited in 8): 

". . . that clinicians offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in children and adults" 

". . . that clinicians provide adults and children with acetaminophen and/or non-steroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia for management of postoperative pain in patients without contraindications" 

". . . that clinicians offer neuraxial analgesia for major thoracic and abdominal procedures, particularly in patients at risk for cardiac complications, pulmonary complications, or prolonged ileus" 

". . . that clinicians consider surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures with evidence indicating efficacy". 

The shift has moved from starting patients on opioids after surgeries or other pain inducing procedures, to treating pain using the multi-modal approach which stresses using alternatives to opioids as the first line of defense. The CDC further recommends and advises (8): 

"Nonopioid medications are not generally associated with development of substance use disorder. The number of fatal overdoses associated with nonopioid medications is a fraction of those associated with opioid medications. Nonopioid medications are also associated with certain risks, particularly in older patients, pregnant patients, and patients.

With certain comorbidities such as cardiovascular, renal, gastrointestinal, and liver disease. Nonpharmacological treatments can reduce pain and improve function in patients with chronic pain. These treatments can also encourage active patient participation in the care plan, address the effects of pain in the patient's life, and can result in sustained improvement in pain and function with minimal risks. If opioids are used, they should be combined with nonopioid medication and nonpharmacological treatments, as appropriate." 

Pharmacological Pain Treatments (Adapted From )

Opioids may be used for moderate to severe acute or chronic lower back pain, osteoarthritis, and neuropathic pain. Studies showing long-term efficacy are extremely limited. Opioids are suggested only after other non-opioid and non-pharmacological therapies have failed to provide relief. This class should be used with caution as it may induce sedation, respiratory depression, nausea and vomiting, and constipation.  

Short Acting

• Codeine 
• Hydrocodone/acetaminophen or ibuprofen 
• Oxycodone/acetaminophen or ibuprofen 
• Hydromorphone 
• Morphine 
• tramadol 

Long Acting

• Fentanyl 
• Hydrocodone 
• Methadone 
• Morphine 
• Oxycodone 
• Oxymorphone 
• Tapentadol 

Anticonvulsants may be used for fibromyalgia, diabetic and other neuropathies, and neuralgias. Use with caution as significant drug-drug reactions have occurred. Dosing should be adjusted for renal impairment. May cause sedation, dizziness, dry mouth, weight gain, and edema. 

• Gabapentin 
• Pregabalin 
• Carbamazepine 
• Valproic acid 

Antidepressants are commonly prescribed for fibromyalgia, low back pain with radiculopathy, migraines, neuropathies and neuralgias, and chronic musculoskeletal pain. Patient must be monitored for mood changes and is at an increased risk for suicide.

Other side effects may include sedation, urinary retention, dry mouth, weight gain, and blurry vision. Cardiac patients must be monitored for arrythmias and blood pressure changes. 

Tricyclic Antidepressants 

• Amitriptyline 
• Desipramine 
• Nortriptyline 

Serotonin-Norepinephrine Reuptake Inhibitors 

• Duloxetine 
• Milnacipran 
• Venlafaxine 

Muscle Relaxers are effective for acute lower back pain and fibromyalgia. May cause sedation and dizziness. Caution must be used when operating a car or machinery. 

• Carisoprodol 
• Cyclobenzaprine 
• Metaxalone 
• Methocarbamol 
• Tizanidine 

Topical agents are particularly helpful for osteoarthritic and rheumatoid arthritic pain as well as neuropathies. May be used for relief of sprains, strains, and back pain.  

• Capsaicin 
• Diclofenac Topical Gel 
• Lidocaine 5% patches 
• Menthol/Salicylate 

Non-Steroidal Anti-Inflammatory Drugs may be used to treat backache, joint pain and inflammation, headache, arthritic pain, muscle aches, strains, and menstrual cramps.

Caution should be used in patients with liver or kidney disease and alcohol misuse. May cause gastrointestinal discomfort or bleeding. Use with caution if patient is on anticoagulation therapy. 

• Ibuprofen 
• Diclofenac 
• Indomethacin 
• Meloxicam 
• Naproxen 
• Celecoxib 
• Aspirin 

Acetaminophen remains one of the most commonly prescribed pain relievers for headache, backache, muscle ache, and joint pain. Caution must be used with liver disease and alcohol misuse. Dosage must not exceed 3,000-4,000 mg/day. 

Interventional Treatments include epidural or intraarticular glucocorticoid injections and arthrocentesis. The CDC recommends these for short-term treatment of inflammatory diseases such as rheumatoid arthritis, osteoarthritis, rotator cuff disease and other radiculopathies.

Non-Pharmacological Treatment

The CDC provides many strategies for healthcare providers to manage the challenges of patient pain control in a manner that lessens the need for opioid use and provides alternative options. Primarily, a patient-centered approach to treatment is now the gold standard and should include patient engagement.  

Suggestions and strategies to incorporate patient cooperation and engagement with their pain management plan include (all from 9): 

• Use reflective listening by maintaining eye contact, empathizing, and confirming understanding 
• Set agreed upon, reasonable and achievable goals 
• Discuss treatment options using a multi-modal treatment plan
  

As part of a multimodal therapy in treating pain, the CDC highly recommends incorporating exercise along with other psychologically based approaches into care. The following are non-medicinal forms of pain management: 

• Physical and occupational therapy includes exercise such as swimming, yoga, walking, free weights, and other strength training. This can improve strength and posture, which may provide relieve from lower back, hip, and osteoarthritic pain, improve fibromyalgia symptoms, and has been shown effective in preventing migraines (9). 
• Cognitive behavior therapy (CBT) is a psychosocial training technique that addresses modifiable situation factors and cognitive processes that may affect the experience of pain. CBT aims to provide coping techniques, relaxation methods, and may include self-help instruction, professional counseling, or support group attendance (9).  

• Heat Therapy 
• Cryotherapy 
• Massage 
• Ultrasound 
• Transcutaneous Electric Nerve Stimulation (TENS) units  
• Acupuncture 
• Hypnosis 
• Stress Management 
• Chiropractic Manipulation 
• Herbal Preparations 
• Aromatherapy

Federal Laws on Opioid Prescribing and Use

In 2016, the CDC reported that over 40 Americans were dying each day due to prescription opioid overdoses. The opioid crisis has been attributed to the over prescribing of opioids for pain and non-pain conditions with a lack of oversight leading to a 400% increase in opioid prescribing and sales since 1999 (10).

In response, the federal government implemented an initiative to combat the issue with improved education, guidelines, and treatment management. In October of 2018, the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, a 660-page bill was signed into law.

This comprehensive, bi-partisan legislation aimed to provide funding and expand access in order to increase treatment availability through Medicaid and Medicare, expand alternative non-opioid pain management treatment, set guidelines for improved patient education, and identify best practices (11).  

Prescription-drug monitoring program and the use of electronic prescribing for Schedule II and III medications is supported by the Federal government and allows individual states to have primary control over authorization and enforcement.  

Drug Classification and Schedules In the United States

As determined by 21 USC 802(21)(A) and 21 USC 813, state and federal agencies monitor certain drugs based on their risk of addiction, dependance, and abuse characteristics.

These controlled substances are categorized based on a system of Schedules I through V. There are three criteria that determines the drugs category: acceptable medical use, potential for abuse, and the predictive value of dependance if it is abused (12, 13). The schedules are as follows: 

Schedule I  drugs are considered to have no appropriate medical use and have an extremely high potential for abuse. Examples of Schedule I drugs include: 

• LSD 
• Heroin 
• Bath Salts 
• Quaaludes
  

Schedule II drugs have a high potential for abuse and may lead to psychological or physical dependance. Examples of Schedule II drugs include: 

• Fentanyl 
• Demerol 
• OxyContin 
• Morphine 
• Codeine 
• Marijuana
  

Schedule III drugs have a high potential for abuse and may lead to psychological or physical dependence. Examples of Schedule III drugs include: 

• Acetaminophen with Codeine 
• Vicodin 
• Suboxone 
• Ketamine 
• Anabolic Steroids
  

Schedule IV drugs have a low to moderate potential for psychological or physical dependence but have a lower risk for abuse. Examples of Schedule IV drugs include:

• Ativan 
• Xanax 
• Valium 
• Soma 
• Klonopin
  

Schedule V drugs are a low potential for physical or psychological dependence or abuse. Examples of Schedule V drugs include: 

• Gabapentin 
• Robitussin 
• Ezogabine 
• Phenergan with Codeine

CDC Guidelines and Recommendations on Prescribing and Use

The CDC continues to promote guidelines initiated in 2016 to support the U.S. government's initiative to curb the increasingly troubling deaths related to opioid overdose. These guidelines were aimed at assisting primary healthcare providers in effectively managing and treating patient's pain while addressing health and safety concerns. In relation to opioid use, the guidelines revolved around three main principles (all from 8):  

• Nonopioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care. 
• When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose. 
• Providers should always exercise caution when prescribing opioids and monitor all patients closely. 

Drug Diversion Within the Healthcare System

According to the Drug Enforcement Administration, the most commonly abused drugs are among five classes and are frequently used in the treatment of pain. These include opioids, depressants, stimulants, hallucinogenic, and anabolic steroids. Of these, the opioid fentanyl is the number one drug that is found to be involved in drug diversion cases (14).  

When used outside of medical purposes, fentanyl has an extremely high rate of fatality. Far from being just a public problem, the diversion of drugs is a significant problem for healthcare organizations and abusers can be found at all levels, from the C-suite to frontline staff.

There are several signs of drug diversion, including poor appearance, failing job performance, uncharacteristic behaviors for the individual, and accessing medication that is not required for their job (17).  

The Joint Commission offers these guidelines for monitoring to identify potential trends and patterns that may indicate the occurrence of drug diversion in the clinical setting (all from 14): 

• Schedule II - V substances are removed: 
• • Without provider orders 
  • Under patients not assigned to the nurse 
  • Under patients that have been discharged or transferred 
  • Excessively by one individual 
• Substitute drug is removed and administered while controlled substance is diverted'.
• Verbal order for controlled substances is created but not verified by prescriber 
• Prescription pads are diverted and used to forge prescriptions for controlled substances 
• Provider self-prescribes controlled substances 
• Patient alters written prescription 
• Unadministered medication that is documented as given to patient  
• Wastes are not completed according to policy and procedures 
• Multiple discrepancies or overrides are noted  
• Patient's report unrelieved pain, despite increasing documented pain medication administration 
• Assistance is frequently offered to administer medications for other nursing staff 
• Expired controlled substances go missing or are diverted from medication dispensing systems 

Individual policy and procedure should be followed when drug diversion is recognized in a clinical setting with consideration to the safety of the patients and offender both addressed. The drug diversion should be reported to an immediate supervisor or manager. Nursing management should contact Quality Control and initiate a thorough root-cause analysis.  

Risks of drug diversion include transmission of blood borne pathogens, patient safety compromised due to impaired healthcare provider, uncontrolled patient pain, and potential for healthcare provider overdose. 

The Joint Commission advocates for a "see something, say something" approach to combatting healthcare provider drug diversion. A plan to prevent drug diversion within the health care organizations should include three approaches: prevention, detection, and response. 

Additionally, they state "Detection of drug diversion is challenging, and even the best efforts have not yet achieved complete eradication of diversion. Patient and workplace safety require effective reliable safeguards to maintain the integrity of safe medication practices to protect against diversion. Diversion prevention requires continuous prioritization and active management to guard against complacency" (15). 

Risks of Opioid Use and Misuse

Opioids target mu receptors in the brain and spinal cord. Through inhibition of GABA, dopamine is released. Opioid's increased risk for addiction is due to the increase of circulating dopamine which is associated with increased pleasure responses.

Opioid use has been clinically linked to an increase in addiction as well as substance use disorder. Substance use disorder has been defined by the American Psychiatric Association (APA) as ". . . a problematic pattern of use of an intoxicating substance, leading to clinically significant impairment or distress" (16).

Per the APA, this is calculated by at least two of the following characteristics (all from 16): 

•  The substance is often taken in larger amounts or over a longer period than it was intended 
• There is persistent desire or unsuccessful effort to cut down or control use of the substance 
• A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects 
• Craving or a strong desire or urge to use the substance 
• Recurrent use of the substance, resulting in a failure to fulfill key role obligations at work, school, or home 
• Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use 
• Important social, occupational, or recreation activities are given up or reduced because of use of the substance 
• Recurrent use of the substance in situations in which it is physically hazardous 
• Use of the substance is continued despite having knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance 
• Tolerance: a need for markedly increased amounts of the substance to achieve intoxication or desired effect OR a markedly diminished effect with continued use of the same amount of the substance 
• Withdrawal: characteristic withdrawal syndrome for that substance OR the substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms
  

A comparison study was performed based on information garnered in a 2016-2017 study group that focused on the use and misuse of opioids among individuals medicating with opioids inappropriately. This group was split into four categories and compared medical prescription opioid users with prescriptions with the following: misusers without prescriptions, misusers of own prescriptions, and misusers with both types of misuse (14). 

Individual misusers without a prescription were typically younger, male, and unmarried versus misusers with prescriptions, whether using medically or misusing. It was found that misusers also had an alcohol disorder, used marijuana, and misused benzos and stimulants. As well, noted was that misusers were more likely to be nicotine dependent and to use cocaine and/or heroin (14). 

Prescription users were more likely to concurrently use prescribed benzodiazepines and stimulants. Depression among all misusers was higher compared with the medical users. The misuser also more commonly had received treatment from an inpatient mental health treatment center as well as had been prescribed a medication for a mental health condition. Overall, this group was not more likely to have a physical health condition (14). 

Perceived Barriers to Pain Management in Nursing

As another consequence of the opioid crisis, a stigma has been cast upon individuals with chronic pain whether they are taking opioids or not. Healthcare professionals should be cautioned against projecting biases onto sufferers of pain as seeking pain medications for misuse reasons.

As previously detailed, many patients experiencing pain have co-morbidities and are at a higher risk of having mental health issues in addition to pain.  

Barriers to non-opioid and non-pharmacological pain control may include insufficient medication regimen ordered to address patient's pain, inadequate training, nursing workload, and a lack of collaborative approach by the healthcare team (17).

Barriers to the use of non-pharmacological pain relief methods have been cited as (all from 17): 

• Inadequate training of personnel in how to examine pain and non-pharmacological control methods 
• Patients' lack of cooperation in the use of non-pharmacological methods to relieve pain 
• Insufficient knowledge about non-pharmaceutical pain relief methods 
• Time-consuming methods of nonpharmaceutical pain relief 
• Nurse's reluctance to use non-pharmaceutical pain relief methods 
• Failure to use non-pharmacological methods by the physician
  

The study found that with improved education, communication, and collaboration, improved pain management can be achieved by patients.  

Nursing Considerations and Interventions

Nursing care plans focused on pain management may be categorized by acute or chronic pain; however, the management and interventions are similar for each. The outcomes should be specific to the patient presentation, disease process, and preferences (18).  

Pain Assessment and Screening Tools

Screening tools are one of the easiest and most effective ways to evaluate for pain. Some of the most commonly used in clinical care include (6, 18, 19): 

• Wong-Baker FACES Scale - may be used for children over the age of 3 and adults 
• FLACC and CRIES - used for infants 
• COMFORT Scale - May be used in children and cognitively impaired or sedated adults 
• Visual Analog Scale 
• Numerical Rating Scale
  

Pain should be also assessed by the patient reported characteristics using pain standardization scales such the McGill Pain Questionnaire. Some of the verbiage used to describe pain include (6): 

• Aching 
• Burning 
• Shooting 
• Stabbing 
• Throbbing 
• Tender 

In addition to screening tools, the nursing assessment should include visualization of signs of pain that can include guarding or protecting certain areas of the body, facial changes such as grimacing or furrowing of brows, and other manifestations of pain such as restlessness, moaning, or crying (5). 

Conclusion -  Nursing Interventions Related to Pain Management in Nursing (All from 18)

• Provide therapeutic communication and patient-centered care, taking into consideration patient preference.
• Assess and document patient baseline of vital signs, complete head-to-toe assessment, and review medications.
• Assess and document patient pain through use of a pain scale, and responses to interventions.
• Establish an agreed upon pain level that is acceptable to the patient, providing education that no pain at all is not a reasonable goal.
• Administer pain medications per physician orders.
• Regularly assess for sedation in patients who are receiving pain medication.
• Administer naloxone for patients presenting with clinical signs of over-sedation with opioid use.
• Provide education on and integrate alternative pain t per patient preference and provider orders. 

As nurses, being able to have a firm concept of the different types of pain, the contributing factors that lead to pain and the various modes of treatment will allow you to provide better care for your patients, while simultaneously allowing you to relate to them on a more specific level and formulate a more individualized plan of care.  

Drains: Everything you Need to Know

Drains are often placed in patients to allow for drainage of a site. The most common indications for drains is to evacuate abscesses, infections, and/or excess fluids . Nurses caring for patients with drains are often intimidated and overwhelmed. In this CE course you will learn about drain management and how care for patients with drains.

Introduction   

Picture this: you walk into your hospital unit, fresh off a good night’s sleep. You find your patient assignment and head over to get report. Then the outgoing nurse says something that makes your heart skip a beat. “This patient has an abscess drain. You need to flush it every X hours, record the output every X hours, call the doctor if __ happens…” Before long, your head is spinning, and then you realize you’ve been spelling ‘abscess’ incorrectly for who knows how long! You think to yourself “I really need to know more about the nursing care of drains!”

Drains can be intimidating, especially with little to no prior experience in drain management. They often come with a specific set of instructions that can be somewhat confusing. What’s worse, a patient may suffer a serious delay in recovery if something goes wrong. Nobody wants to be the one to make that call to the doctor about a malfunctioning drain. Fortunately, like anything else, managing drains becomes much easier with experience and a little education.

Types of Drains

A patient may require drain placement for various reasons. Often, they are placed at the end of a surgery or percutaneously to help eliminate any fluid that may accumulate within the wound. A common type of surgical drain is the Jackson-Pratt ® . Certain organs may require a drain to assist with the removal of their contents, such as foley catheters or nasogastric tubes. Drains may also be placed to help remove fluid or air from body cavities. A chest tube is a good example of this type of drain. Finally, if a patient develops an abscess, a drain is often required to help remove the infected fluid more quickly.

Drains serve a very important purpose (other than driving the patient and his/her nurses crazy). The accumulation of fluid in the wrong place can have a detrimental effect on the patient’s health and healing (1). Excess fluid in the surgical site can cause significant pain as well as injury to surrounding tissues and organs (1). It can also increase the chance of infection (1).

Medical drains can be divided into multiple categories.

Drains are often described as being active or passive. Passive drainage allows for gravity to help remove excess fluid, without the use of pressure (2). An example of passive drainage would be placing a foley catheter to gravity or using a penrose drain. A penrose drain is a relatively flat, ribbon-like tube that creates a passage from a wound to the open air, which allows any excess fluid to simply flow outward (2). The area surrounding the opening is often lightly covered with gauze to collect fluid as it drains and must be changed when saturated (2).

The following image is an example of a penrose drain (3).

Active drains use actual pressure, typically negative pressure, to help remove excess fluid from the body.

An example of an active drainage system would be a Jackson-Pratt (JP) ® drain or hemovac ®. With both types of drains, the pressure is created by compressing the collection container, which creates a low pressure vacuum that pulls the fluid out of the body (2). The following images are examples of hemovac (12) and JP ® drains (3).

Open vs. Closed Drains

Drains can also be described as open or closed. An open system simply means that it is open to air. An example of an open system would be a penrose drain, as described above. A closed drain, on the other hand, is not open to the environment. Rather, the draining fluid is contained within the system, and the collection bulb or bag is simply emptied from time to time, as needed. A JP ® drain is an example of a closed drain.

Surgical vs. Percutaneous Drains

While not a technical classification, it is interesting to note how the drain is placed. Surgical drains are usually positioned in the operating room or, more rarely, at the bedside by the physician. The JP ® is an example of a surgical drain.

Drains may also be placed percutaneously:

Percutaneous: (adjective) effected or performed through the skin (4)

Percutaneous drains are placed without surgical intervention. Rather, Interventional Radiologists use imaging, such as CT, ultrasound, or fluoroscopy to guide a needle into a fluid collection (5). This technique is generally less invasive (6). Before surgical or percutaneous insertion of a drain, the patients coagulation status and hemostasis risk must be evaluated (13). 

Infections 101: A Brief History of Drains

Before the advent of antibiotics, the development of an abscess or postoperative infection was often a death sentence (7). Thanks to advances in modern medicine, suffering patients now stand a chance. In certain situations, infections can be treated simply with a course of antibiotics. However, if there is any concern for the development of sepsis, further intervention is needed (6).

Until the 1970s, the most effective (and only) way to treat infection and abscess was surgical intervention (7). Surgeons would attempt to remove the infected material while striving for “directness, simplicity, and above all, avoidance of unnecessary contamination of uninvolved areas” (7). Unfortunately for these patients, this meant that a second surgery was required to heal them from complications of their first surgery. Even with the addition of antibiotics, these situations were associated with significant morbidity and mortality (6).

Luckily, rapid advances in technology allowed for the development of a less invasive solution. The advent of fluoroscopy, ultrasound, and especially CT provided physicians with a tool to see inside the body without having to cut someone open. The first studies involving the use of medical imaging for percutaneous drain placement were published in the late 1970s (7). Over the next several years, multiple studies reported success rates ranging from 60-80% using these new techniques (8).

Doctors are now able to drain up to 3 separate abscess/infection sites percutaneously (8). Recent studies report technical success of up to 90% with percutaneous drain placement, and it can offer immediate improvement in sepsis, with return to hemodynamic stability within 1-2 days (9). CT is considered the imaging modality of choice because of its ability to fully visualize the infection and surrounding structures as well as provide a pathway from the skin to the destination (9).

Patient Considerations for Percutaneous Drain Placement

Not every infection or fluid collection requires percutaneous drain placement or even surgery. Thus, it is important for physicians to work together to determine the appropriate treatment for each patient individually. When a patient is found to have an abscess, multiple doctors may get involved, usually either a surgeon or interventional radiologist (sometimes both) and a clinical pharmacist if an infection is suspected or confirmed.

It is essential that providers choose patients carefully, as ineffective or incomplete drainage of the infection can lead to significant morbidity and mortality (8). For example, percutaneous drainage is sometimes avoided in patients with chest infections, such as empyema, abscess, and pleural effusion because of the risk of pneumothorax (9). Additionally, pyogenic and fungal abscesses in the lung parenchyma often resolve with more conservative management, namely through supportive care and antibiotics (9). Pancreatic abscesses remain at high risk of treatment failure with percutaneous drain placement, thus surgery is usually still the intervention of choice (9).

Conversely, there are many types of abscesses that respond well to percutaneous drainage. Liver abscesses have a very low risk of complications with this type of drain placement, around 1-4% (9). It is also very effective in managing infections related to visceral perforation, which may result from Crohn’s disease, prior operations, diverticulitis, and appendicitis (9). Deep pelvic abscesses respond well to percutaneous drainage, although these can be more challenging and require careful planning because of the presence of nearby organs (9).

Percutaneous drainage is often considered for patients who are too ill for surgery, in the hopes that it may improve sepsis and promote increased strength/rest (8). It is also recommended for patients who have a good response to antibiotics and low risk of mortality.

Image-Guided Drainage: How Does it Work?

When first contemplating percutaneous drainage, doctors must first decide which modality to use: fluoroscopy, ultrasound, or CT. As mentioned previously, CT is most often used to guide drain placement because of its superior visualization.

The interventional radiologist will typically review any available imaging beforehand to plan the most appropriate route for drain placement. Care must be made to avoid major vessels and other important structures (6). To minimize the risk of complications, physicians are advised to use the safest, most direct route and attempt placement in the most dependent part of the fluid collection to encourage effective drainage (6).

Once the patient is properly positioned on the table, the physician will use the CT, ultrasound, or X-ray to guide the placement of a special needle, taking frequent pictures to monitor its progression from the skin through soft tissue and into the infection (6). Once the needle is in place, a wire is passed through the needle into the fluid collection and then the needle is removed, leaving only the wire in place.

Next, a drainage catheter is threaded across the wire to its final resting place. The tip of the catheter rests within the fluid collection. The drainage catheter contains holes to help fluid pass out of the body. Once the tube is in place, the wire is removed. A drainage bag is attached. Throughout the procedure, pictures are taken to ensure correct placement. Patients are often given moderate sedation to make them more comfortable, but not in every case.

Drain Management

Care for the patient with a drain can seem intimidating, but it doesn’t have to be. Often, the physician will write orders to guide nursing staff while caring for these patients. Drain management may also differ depending on what type of drain the patient has. If there are no orders it is reasonable to contact the physician who placed the drain for clarification.

Surgical Drains

Two of the more common types of surgical drains are the hemovac ® or JP ® drain. As mentioned previously, both of these drains are active, closed systems, meaning they use negative pressure to help remove excess fluid from a surgical wound, all of which is stored within the collection device.

When managing JP ® or hemovac ® drains, it is important to note the color of the drainage fluid. The fluid is typically bloody or purulent at first, but should gradually lighten to a light pink, clear, or yellow color (10). Indications for removal may vary, but in general, these drains remain in place until the daily output decreases to less than 30 ml (10).

Follow any written instructions provided by the ordering physician. Nurses will also be responsible for emptying the drain, observing the site and documenting findings. The drain should be emptied no later than when it becomes half full, as it will lose suction and become ineffective (2). Observe the insertion site for drainage and signs of infection. Be sure to keep the skin clean. These drains may also be sutured in place. The drains should be further secured with medical adhesive or pinned to the patient's gown with a safety pin to secure the drains before mobilizing and to avoid accidental removal. 

Percutaneous Drains

Percutaneous drains usually look a little bit different. The interventional radiologist uses a special type of drainage tube that is also sometimes called a ‘pigtail’. These tubes do not always have to be sutured in place, for they may contain a string that, when pulled, curls the distal end of the tube, making it a bit harder to pull out. They are then usually adhered to the skin with a dressing.

Again, it is important to note the color of the drain output. Keep in mind that percutaneous drains are often used for abscess or infection, meaning fluid will be purulent and/or bloody. Check for any specific written instructions for drain management. Monitor the drain site regularly for signs of infection or drainage. Empty the drainage bag as directed or as needed and document findings. These drains may also use a collection bag that applies suction through negative pressure.

Percutaneous abscess drains are more likely to require flushing because the purulent drainage can be thick and pose a risk for occluding the drain. They may be equipped with a three-way stopcock to allow for easy flushing.

(French pigtail catheter [Cook Inc., Bloomington, IN; C-PCS-830-LOCK]).

How to Flush a Drain Using a Three-way Stopcock

The first step is to review any written orders and become familiar with policies regarding drain flushing. You may be required to have a provider order in order to flush a drain. Then gather some supplies: gloves, an alcohol pad, “dead end” cap or clave, clean pad/towel, and saline flush syringes. Prepare by applying gloves and laying out a clean towel or pad underneath to create a workspace and catch any drainage. Flushing a drain is usually painless, but advise patients that they may feel a little discomfort.

Take a look at the figure below (11). It is an example of a three-way stopcock. It has three different ports and an “off switch” that swivels. Whichever direction the off switch is pointing closes that port so fluid cannot flow. In the example provided, the switch is closed to the patient, meaning that fluid cannot pass into the bag.

Step 1. Find the Flush Port

To flush the drain, find the flush port located on the stopcock. It should be pretty easy to spot, as it is usually the only port that is free (since one end of the stopcock is connected to the actual drain tube, the other to the drain bag). The flush port should be capped with either a “dead end” cap or a clave. If there is a dead end cap, it will have to be removed, since saline cannot be flushed through. If a clave is present, the saline syringe can be screwed in directly.

Step 2. Prepare the Flush Port

Next, turn the off switch so it is pointing toward the flush port, if it isn’t already. This will close the flush port or “turn it off” so that drainage cannot leak out. If a dead end cap is present, remove it. Wipe the flush port with an alcohol pad and attach a new, sterile clave, if available. Claves make future flushing much easier because the flush syringe can be attached directly. If a clave is already present, wipe it thoroughly with an alcohol pad.

Step 3. Prepare the Saline

Attach a saline syringe to the flush port. 5-8 ml is usually plenty. If the ordering physician wrote specific instructions on how much saline to infuse, follow the directions closely. The off switch will have to be turned before flushing is possible. At this point, the switch is facing the flush port, which prevents fluid from exiting or entering. The attached saline simply will not flush, no matter how hard the plunger is pushed.

Step 4. Flush the Drain

Saline can be flushed either into the drain or into the bag, depending on which way the off switch is turned. To flush the drain itself, a nurse would have to direct the saline toward the patient. This means the off switch needs to be turned toward the bag. The bag is now “off” and won’t get any flow, allowing saline to travel through the flush port and up the drain into the patient. Once the saline is flushed, turn the off switch back to the flush port. This will reopen flow into the bag. The saline that was just infused should now travel freely through the drainage tube and into the bag. Observing this allows the nurse to know that the tube is draining correctly.

Sometimes the contents of the abscess can be thick or contain particles that can clog the tube leading to the bag. Thus, the drain bag may also need to be flushed. Simply follow the same steps listed above, only, instead of turning the off switch to the bag, it should be turned to the patient. This will prevent flow from entering the drainage tube, leaving a pathway from the flush port into the drain bag. The nurse should be able to see the saline traveling into the bag. Once the bag is flushed, return the off switch to face the flush port. This allows for an open pathway from the drain into the bag.

Step 5. Assess the Drain

After flushing, it is important to note any patient discomfort, as well as document how much saline was flushed.

Before leaving the bedside, and always when assessing a patient’s drain, ensure that the off switch on the stopcock is turned toward the flush port. This will allow drainage to flow seamlessly from the patient into the bag.

Note that not all drains are meant to be flushed, especially those that do not contain a flush port and/or three-way stopcock. Never flush a drain without a provider’s order. Do not attempt to flush a drain if you suspect it has been pulled away from its original position.

Properties of a Well-Functioning Drain

Since humans lack x-ray vision, the inner workings of a drain can seem a little mysterious. What is going on in there? How can a nurse know if it is doing what it is supposed to do? Repeat imaging (CT, ultrasound, etc.) is the best way to visualize how infections and abscesses change over time. However, it is costly and unnecessary to expose patients to extra radiation as a matter of curiosity.

To get some idea of how a drain is functioning, one has to look at the drain itself. Even though drains may look different, they function in similar ways, thus these considerations can be applied to both surgical and percutaneous drains.

Output

The hallmark of a well-functioning drain is output. The purpose of a drain is to get fluid out of the body. Therefore, if the collection bag/bulb is capturing drainage fluid, this is a good indication that it is working correctly. Remember that the fluid is often bloody at first, but should lighten over time. The drainage from an abscess may also be bloody at first before appearing purulent.

Skin Site Clean/Dry

The skin at the site of a drain should be kept clean and dry (2). Minimal amounts of fluid may leak around the tube, causing crusting on the skin or a small amount of visible drainage. This can be gently wiped away with clean gauze soaked with normal saline or warm, soapy water (10). Apply a fresh clean gauze at the site to protect the skin from breakdown (10). If a large amount of drainage is leaking from the skin and around the tube, this is not normal and should be addressed.

Stopcock in the Proper Position

Ensuring that the three-way stopcock (if present) is in the proper position is essential for proper function. The off switch should be pointing to the flush port at all times, unless the nurse is preparing to flush the drain. Turning the off switch to the flush port prevents fluid from draining outside the system and creates an open pathway from the drain into the drain bag.

Active Suction

All active drains should be monitored closely to ensure that the bulb or accordion is adequately compressed (2). Constant negative pressure must be maintained in order for the drain to work. To compress a JP, use the "side-in method" where the nurse compresses the JP bulb at its largest diameter (in the middle) with fingers and thumb to compress the bulb (14). The drain should be emptied when it is approximately 25 percent full to maintain the pressure within the bulb (14). 

These drains may require frequent assessment and emptying, especially at first. Examples of active drains include JP®, hemovac®, and most percutaneous drains.

Is this Normal? Drain Troubleshooting

Unfortunately, drains can develop complications. It is essential to know what to look for so that potential problems can be identified early. As mentioned previously, a delay in reporting or discovering a drain malfunction may cause delays in patient healing. Luckily, the problems are fairly easy to spot if you know what to look for.

Bleeding

Some bleeding is normal. The act of placing a drain may cause bleeding from nearby small vessels (9). This is usually self-limiting, which is why the nurse may note bleeding in the early hours after placement. The drainage should gradually lighten. Prolonged bleeding or the development of new bleeding warrants a prompt call to the physician.

Leaking

A leaky drain can be a messy business. If the source of the leak is not immediately known, the nurse should evaluate the drain. Assess the tubing for cracks or holes. Ensure all connections are tight. Sometimes the drainage bag/bulb may be punctured. If so, it is often easily replaced.

Leaking may also occur because the drain is occluded or kinked (2). Assess the tubing carefully for signs of obstruction. Flushing the drain can help dislodge occlusions. Again, never flush a drain without orders from the physician.

A drain may also leak at the skin. Minimal amounts of leakage can be expected because the drain creates a track for small amounts of fluid to escape. Moderate to severe leakage can cause skin breakdown and is not normal. It suggests that the drain is malfunctioning in some way, often due to an occlusion or displacement of the drain. Fluid travels the path of least resistance. If it can’t pass easily through the tube, it will find another way out. Notify the physician, who may order follow up imaging, like a CT scan. If a percutaneous drain is leaking, the patient may have to be sent down to interventional radiology for assessment and possible replacement.

No Output

Drain output may cease for two reasons: there is no more fluid or the fluid can’t get out. It is easy to assume the former. Yet, when faced with a drain without drainage, It is important to use critical thinking and common sense. Drainage usually tapers off, meaning it will drain a little less over time. An abrupt cessation of fluid could indicate a problem. Assess the drain for kinks or obstructions. If the drain is occluded, fluid may begin to leak around the tube at the skin. Carefully document drain output as dictated by the physician or facility protocol. Any time there is a concern, the physician should be notified.

Infection

Infection may occur with both surgical and percutaneous drains. It usually forms one of two ways: during initial drain placement or as a result of continued catheter presence (9). Infection may form during initial placement if the needle punctures a non-target area (such as the colon) or from prolonged dilation, which is why the procedure should be completed in a timely manner (9). Infections may also form at the skin if a drain is present for a long time (9).

The nurse should assess the drain site frequently. Signs of skin infection include redness, increased pain, swelling, fever, and purulent drainage (10). Additionally, sepsis is always a concern for the patient with an abscess (9). A patient with sepsis will sicken very quickly, with rapid increase in fever, chills, and rigors (9). Vital sign monitoring is essential. If the nurse suspects a new infection of any kind or deterioration, notify the physician immediately.

Displacement

Living with a drain takes some getting used to. It can be easy for patients to forget it’s there. Sometimes the tubing can become tangled up in the bed sheets or left behind when a patient stands up. Although drains come equipped with reinforcements, such as a suture or dressing to help keep the tubing in place, it is possible to pull the drain at least partially or sometimes completely out of the body.

If a drain is pulled out entirely, the nurse should cover the site with some gauze to catch any drainage. When drains are placed, they form a pathway from the abscess or infection to the skin. The tube’s job is to provide a conduit for the fluid to escape. If the tube is removed abruptly, that pathway still exists temporarily, so fluid will continue to leak out of the body in the absence of the tube. Do not attempt to put the tube back in, as it is no longer sterile. Notify the physician.

If the drain is only partially removed, reinforce the dressing as best as possible to maintain its current position and call the physician. Again, do not attempt to push the tubing back inside the patient. The physician may order imaging to assess the drain’s location (2). Removal and/or replacement may be necessary.

Summary

This course is designed to help readers become more familiar with drains. They come with all sorts of indications: to facilitate healing after surgery or infection, to assist with draining contents from affected organs, or remove fluids that have accumulated in body cavities.

Drains are classified based on their function: open or closed, passive or active. Familiarity with the different types of drains gives the nurse a basic understanding of how they work- which is important because they can look very different, depending on the manufacturer.

In the old days, surgery and antibiotics were the only way to treat intra-abdominal infections. Significant advances in technology have allowed interventional radiologists to specialize in using medical imaging (CT, ultrasound, X-ray, and MRI) to place drains without making an incision. However, patient selection is still very important, and physicians must know which patients are good candidates for percutaneous drain placement and which are better off heading to the OR.

This course is also designed to provide a basic understanding of drain management and troubleshooting. It is important for nursing staff to understand how a drain is supposed to behave when it is functioning normally so that potential problems are easier to spot. When in doubt, consult the physician. Always be aware of any written orders or policies that dictate drain management, as practices may vary from place to place.

As with anything else, the best way to become more comfortable with drains is to be around them!

Administration of Blood Products

Administration of blood products is one of the many responsibilities we have as nurses. Almost 21 million blood components are transfused each year in the U.S (1), each with the potential for harm. Unfortunately, many preventable transfusion errors occur each year. Staying up to date on blood administration is the best way for nurses to avoid potentially deadly consequences of transfusion errors.  

Introduction

Administration of blood products is one of our many responsibilities as nurses. Around 14 million blood components are transfused annually in the U.S. [6], each with potential harm. Unfortunately, many preventable transfusion errors occur each year. Staying current on procedures for administering blood products is the best way for nurses to avoid the potentially deadly consequences of transfusion errors.  

You float to an oncology unit and are assigned three patients who receive blood. Does this scenario increase your heart rate? Some nurses administer blood and blood products daily, while others are less familiar and may need a reminder of the administration basics.  

The goal of the course is to teach safe administration of blood products. 

Administering blood can be daunting, but if you remember the basics, you and your patient will be safe. Before diving in, let's look at some exciting blood facts by the Red Cross [1,2] 

• Approximately 29,000 units of red blood cells are needed daily in the U.S. 
• Around 16 million blood components are transfused each year in the U.S. 
• The average red blood cell transfusion is about three units. 
• The blood type O is the most often requested by hospitals.  
• A victim from a single car may require as many as 100 units of blood. 
• An estimated 6.8 million people in the U.S. donate blood annually. 
• About 45% of Americans. have Group O (positive or negative) blood; 57% of Hispanics and 51% of African Americans also have Type O 
• 7% of the U.S. population has type O negative blood, which is always in high demand since it can be given to patients of all blood types.  
• Type AB plasma can be transfused to patients of all blood types, and only 4% of people in the U.S. have A.B. blood. 

Pre-Infusion / Pre-Administration of Blood Products

There are many steps before the infusion starts; the most important is to verify, verify, verify [3,4,6,7].  

Verify the physician's order.  

No order? No blood – it's that simple.  

Standard blood orders include whole blood, red blood cells, and leukocyte-reduced RBC. 

Whole blood is the simplest, most common type of blood donation. It's also the most flexible because it can be transfused in its original form or separated into specific components such as red cells, plasma, and platelets. Whole blood treats patients needing blood components, such as those with significant blood loss from trauma or surgery.  

Red blood cells (RBCs) are prepared from whole blood by removing the plasma. RBCs treat anemia without increasing the patient's blood volume too much. Patients who benefit most from transfusion of red blood cells include those with kidney failure or gastrointestinal bleeding and trauma.  

Leukocyte-reduced RBCs are prepared by removing leukocytes (white blood cells) by filtration after donation before the RBCs are stored. This is done because, over time, the leukocytes can deteriorate, triggering adverse reactions in the patient who receives them.  

Verify the patient has signed a blood consent.  

The only time you can transfuse blood without written consent is for emergency treatment. In this rare situation, the physician may verbally order to infuse blood emergently without a concrete written order. 

Pre-Infusion Checklist

• Check if premedication is required. 

• Premedication such as acetaminophen and or diphenhydramine may be required for patients who have acquired antibodies from multiple transfusions in the past. An example of this is sickle cell patients.  

• Check for special requirements (such as CMV negative).  

• Special requirements may be needed for patients who have acquired antibodies from prior reactions or illnesses like cancer. 

• Verify if the patient has had a history of blood transfusion reactions.  

• If they have had a history, find out their reaction and ensure this information is shared with the ordering physician. 

• Discuss the order with the patient and explain the process to the patient.  

• Even though they signed a consent, this is a new part of their treatment plan and must be included. Include teaching about signs and symptoms of transfusion reaction. More discussion on this topic is below. 

• Verify the patient has an active type and cross.  

• Blood can only be distributed with this information if in an emergent situation. Type and cross screens are typically valid for three days. 

• Review the patient's morning laboratory reports.  

• Pivotal labs to monitor include potassium, as it may rise with transfusion; BUN/Cr to ensure kidney function; hemoglobin and hematocrit for the severity of the anemia; PT/PTT/INR/Platelets to evaluate the coagulation status of your patient. 

Assess Your Patient

Why is your patient getting blood? It would help if you documented this to understand the clinical picture. As the nurse, this is important so you can develop a baseline to know if anything changes with your patient during the infusion process. 

It is essential to understand how to perform the following critical assessments in addition to baseline vitals.  

• Neurological Assessment – Alert and oriented to what? Is the patient at their baseline neurological status? Any changes?
• Pulmonary Assessment – What are their breath sounds like? Any crackles? How are their respirations at rest? What did the morning chest x-ray look like? Are they on oxygen? How much? What is the pulse oximetry reading? Any weight gain overnight? Pedal edema? 

Any patient at risk for fluid volume overload needs to be identified (such as patients with heart failure or renal disease). If you are concerned that your patient is experiencing fluid volume overload while administering blood products, discuss this with the healthcare provider who ordered it. Options may include slow administration of the blood product or premedicating with furosemide [7,8].  

Baseline Vital Signs (1, 3, 5) 

• Temperature – The patient should be afebrile. If they are febrile, do not order or administer blood unless the physician orders to transfuse despite their knowledge of fever. 
• Heart Rate – Rate, rhythm, and pulse quality should be documented. 
• Respirations – Rate and rhythm should be documented. 
• Blood Pressure – Baseline blood pressure should be documented for the patient. Is it "normal" for the patient? What is the trend? 

Determine IV Access 

The IV gauge for routine blood infusions should be 20 gauge or larger in adults, and for rapid transfusions, nurses may use a 16 to 18-gauge IV [7]. The larger the IV, the quicker blood can be administered. The IV line should be used for blood only. Nothing else can be transfused with blood [7]. 

Blood tubing must always be primed with 0.9% normal saline. Normal Saline is the only fluid in which blood products should be infused. Blood tubing, called Y tubing, has a 170-260 micron filter. Blood tubing must be replaced with every unit of blood or every 4 hours, whichever comes first and depends on hospital protocols [7]. Depending on your institution, blood warmers and pumps may be optional or mandatory. 

Infusion / Administration of Blood Products

Once the blood is removed from the blood bank, it should be infused within 20 to 30 minutes, or returned blood must be infused within 4 hours [7,8] 

Now that you have the blood in hand and a patient with a grand IV, grab your nearest Registered Nurse (RN), Medical Doctor (MD), or appropriate second verifier (Determined by your institution) and verify, verify, verify ([5,6,7]. 

Typical Blood Verification Checks include: 

• Patient name 
• Medical record number 
• Date of birth 
• Patient blood type 
• Donor blood type 
• Unit/pool/lot number 
• Product type 
• Special preparations (i.e.; Leuko-reduced)
  
• Rh factor 
• Expiration date and time of blood 
• Visually inspect bag for damage 
• Visually inspect blood for color difference or clots 

*Remember: This is a suggestion of the main points of a blood infusion checklist. Your institutional policy determines the definitive checklist by which you should administer blood. *

Before administration, two licensed personnel should verify the correct blood product and match it with the patient. This should be done at the patient's bedside using the identifying band on the patient for verification as well as the patient themselves (if possible) [5,6,7]. 

The Importance of Two-Step Verification  

Did you know that the most frequent error leading to transfusion of ABO-incompatible Blood occurs during patient identification at the bedside? As a result, although the blood is labeled appropriately, it is transfused to someone other than the correct recipient [4]. 

The problem with transfusion errors and accurate patient identification led to one of the 2024 National Patient Safety Goals to "use at least two patient identifiers when providing care, treatment, and services” [10]. To prevent this from occurring, The Joint Commission requires (before initiating a blood or blood component transfusion):  

• Match the blood or blood component to the order of the physician or provider.  
• Match the patient to the blood product.  
• Use a two-person verification process [9].
  

When using a two-person verification process, one individual conducting the identification verification is the qualified transfusionist who will administer the blood or blood component to the patient [9]. When using a two-person verification process, the second individual conducting the identification verification is qualified to participate, as determined by the hospital [9]. 

Now that you have verified blood and are infusing the product, it is not the time to go to lunch. Stay with the patient during the first 15 minutes of transfusion to monitor for any immediate reaction and start the infusion slowly. Vital signs should be repeated 15 minutes after the beginning of the transfusion, during the procedure per facility policy, at the conclusion, and one hour after the transfusion [7,8]. 

The rate of the actual infusion should be based on a) if a rate was ordered, b) ensuring the infusion is complete within the allotted 2-4 hour time frame, and c) nursing judgment related to the patient's hemodynamic and pulmonary status [7]. 

Reassessment of Vital Signs 

• Neurological Assessment – Changes in baseline neurological assessment, including lethargy, confusion, or any decrease in Glasgow Coma Scale, may indicate a transfusion reaction. 
• Pulmonary Assessment – Any changes from baseline? Oxygen requirement changes? Saturation changes? Signs of increased pulmonary secretions or pulmonary edema? These are signs of fluid overload and may indicate a transfusion reaction.  
• Temperature – An increase is often a sign of a transfusion reaction. 
• Heart Rate – Tachycardia or arrhythmias may signify a transfusion reaction. 
• Respiration – An increase in respiration may be a sign of a transfusion reaction or fluid volume overload. 
• Blood Pressure – An increase in B.P. may be a sign of fluid overload, but a significant decrease is a sign of a transfusion reaction. 
• IV Access – Still patent? Infusing without difficulty? At the prescribed rate? [8]. 

Blood Transfusion Reactions

Why must you stay in the room and reassess everything in 15 minutes? 

If the patient is going to experience an acute blood transfusion reaction, it usually takes place within the first few minutes of infusion.  

There are many signs and symptoms of blood transfusion reactions for hemolytic and non-hemolytic reactions  [6,7,8]. 

If a reaction is suspected, the transfusion should be immediately stopped, blood products and tubing removed, and the intravenous line kept open with normal Saline. The provider should be notified immediately, and the patient should be monitored. The remaining blood products and tubing should be taken to the laboratory [5,7,8]. Refer to facility policy and procedure for documentation and other requirements. Labs must be drawn as part of a suspected transfusion reaction workup. 

If all goes well, continue to monitor the patient according to your facility’s protocol during the remainder of the infusion. If there are no changes after 15 minutes in assessments or vital signs, vital signs should be repeated at least every hour and at the conclusion [7,8]. Again, refer to your facility policy, as this can vary. 

Post-Infusion / Post-Administration of Blood Products

Once the administration of blood products is complete, obtain a set of vital signs. Compare to baseline and 15-minute vital signs. If you haven’t already done so, complete documentation: 

• Start/Stop time 
• Pre, 15-minute, and post-infusion vital signs 
• Blood volume infused 
• 0.9% Normal Saline volume infused 
• Signs & Symptoms of transfusion reaction, if any 
• Reason for transfusion 
• Answer "yes" or "no" to suspected transfusion reaction 
• Document in the notes how the patient tolerated the infusion 
• Properly dispose of blood and blood tubing in a red waste container 
• Flush the IV access with Saline
  

Now, wait – you aren't done yet! Remember that non-acute blood transfusion reactions can occur hours after the infusion, so continue to monitor and assess your patient closely. Remember to document the one-hour post-infusion vital signs and complete any post-infusion labs that may have been ordered [7,8].  

Knowledge about any skill improves your confidence and results in safe patient care. Hopefully, this has improved your understanding of the administration of blood products and increased your confidence in performing this procedure! 

Institutional Policies on the Administration of Blood Products 

All organizations have different policies, it is important to review your institutional policy regarding the administration of blood products. It is your responsibility to learn your institution’s policies regarding the administration of blood products and to follow them appropriately. Documentation is per institutional policy and should include the reason for the infusion as well. Every institution has a procedure for releasing blood products. Follow the institutional policy to obtain the blood to have it to infuse in a timely manner.

A Nurse’s Guide: How to Deal with Difficult Patients

Introduction

Being in the business of caring for people when they are at their worst means we often come face-to-face with patients amid emotional outbursts of anger. We can improve patient outcomes and our work-life satisfaction by understanding why anger occurs, learning to become aware of what goes on in others' brains when they are upset, and adopting optimal techniques for handling these tough situations. Learning how to deal with difficult patients and being able to resolve conflict in a positive manner is one of the most valuable skills a nurse can possess. 

Consider Anger  

We all have our own personal opinions when it comes to understanding and tolerating anger in ourselves and others. Generally, it doesn't feel good to experience it, nor is it pleasant to be around others who are feeling this way. Experiencing anger is part of being human, it's normal, and as healthcare professionals, we must learn more about it so we are aware of how to deal with difficult patients. Perhaps approaching this from a philosophical standpoint will further help us to see beyond our patient’s immediate anger and we can work to develop a plan to resolve the conflict. 

Anger as a Motivator  

First off, anger can be motivating. Oftentimes, when we perceive that there is a problem that is causing harm or injustice - whether it is affecting ourselves, a patient, the barista at the corner coffee shop, the planet, whatever - it is often anger that pushes us to act. As a very basic (and optimistic) example, a patient might be angry about being stuck in the hospital. Optimally, the experience will bother them enough to want to follow all of the steps their physician provides them so that they do not have to be readmitted. 

Catharsis 

For some, the act of being angry can be cathartic. For example, when we feel angry and begin to shout or slam a door, it is actually a way of releasing that built up, negative energy. Some people achieve catharsis and release their anger in productive ways, such as exercising, talking with a friend or therapist, journaling, or cleaning. Once you have completed the action and released the anger that you had, you slowly begin to calm down (1).  

If we don't release this energy over long periods of time, it can unfortunately cause physical harm. Anger increases heart rate, blood pressure (think MI or CVA), blood sugar, and intraocular pressure; it can lower our immune function and increase our risk of developing cancer; it also affects the digestive system; decreases bone density, and can also cause headaches and migraines. Being angry also negatively impacts our short-term memory, as well as the ability to make rational decisions (2). Applying therapeutic techniques can be a beneficial method of how to deal with difficult patients, as this can provide the opportunity to help them release some of the pent-up emotions they have before they cause physical harm.  

Control 

When learning how to deal with difficult patients, we must consider the relationship anger has with control. When a person is in our care, there is undoubtedly at least one major thing going on with them that they cannot control; otherwise, they would be at home. Being in a hospital setting removes all of the controlled variables that the patient has been accustomed to from their daily life (i.e. foods, who they come in contact with and at what time, etc.) and a common response to this change is anger in an attempt to regain control of the situation (1).  

Stress & Trauma 

There is a strong correlation between people who carry a lot of anger inside of them and stressful life events, particularly childhood trauma such as neglect and physical abuse. There's also an association between anger and psychiatric disorders such as bipolar disorder and borderline personality disorder. This is not surprising since many people with these and other psychiatric disorders experienced extreme stress and trauma in their youth (3).  

I find that keeping these tidbits of information about anger in mind helps me with how to deal with difficult patients and allows me to maintain my own composure. 

Explore Your Thoughts/Feelings/Opinions/Triggers 

Self-awareness is extremely important when learning how to deal with difficult patients. Allowing ourselves to be aware of our own experiences, feelings, and triggers, understanding that they can influence how we respond to others in heated situations. For example, suppose you are someone who grew up in a household where you frequently experienced violence -- in that case, you might respond in an unexpected, unhelpful, and unprofessional way when exposed to angry behavior from others, such as shouting back. On the flip side, perhaps you grew up in a household where there was little to no conflict and you are unsure of how to properly respond when someone behaves angrily towards you. Maybe you have been judged harshly for your feelings and/or resulting actions, and consequently, judge others the same in turn. 

Oftentimes we aren't aware of our own tendencies until we step back and intentionally evaluate them. Considering your own experiences, thoughts, judgments, and things that trigger you can help you to become aware of why you react to situations the way that you do. You'll then be more prepared to respond in a deliberate way when you next find yourself in a scenario with a disgruntled patient.  

Common Practice 

"Calm down!" and, "It's not okay to yell!" yelled the nurse. We've all heard the countless ways healthcare professionals respond when figuring out how to deal with difficult patients who are angry. Maybe we have even found ourselves yelling similar statements as well, and that’s okay – we are all human, and being yelled at can be very triggering, Don't be too hard on yourself, evaluate how you should respond next time and prepare for it as best as you can because dealing with difficult patients is inevitable. 

Often, clinicians become triggered - in other words, we get angry or irritated with ourselves when confronted with an angry patient. If we aren't mindful of our own tendencies and subsequently give in to that trigger, we inadvertently make what's going on with the patient about ourselves when the patient is the one who needs our care. How is it helpful if we become upset as well? When learning how to deal with difficult patients, keep in mind that by responding with anger or with words that are seeking to control, the patient will miss an opportunity to release their pent-up, intense energy which can result in physical harm. 

I am reminded of a time when my daughter was an infant. She always had a terrible time facing backward in her car seat. We were riding with a friend of mine and her six-year-old son when my daughter began to cry. The young boy covered his ears, saying, "Why does she have to be so loud?" My friend's golden response was, "I know, honey, it's no fun, but think how much worse it must be for her."  

Even though this scenario is quite different from a healthcare environment, I think those same words whenever I hear one of my patients yelling or are upset about something. All I want to do is cover my ears, but by thinking of how much worse it must be for them, I'm able to avoid making it about me. 

Distraction 

Another common approach to dealing with difficult patients during an angry episode is to utilize distraction. There are times when this application is going to be the best choice, particularly, when dealing with patients who are cognitively impaired (4). However, there are other instances where this technique may come off as insulting with otherwise oriented people and could exacerbate the issue. 

An example of an appropriate time to utilize this technique would be when dealing with a patient who has dementia and gets increasingly (and repeatedly) worked up over their belief that a loved one - who hasn't seen the patient in recent history - is stealing from them. In this case, distraction might be the only way to calm them down. 

Giving Advice 

I work in a psychiatric setting, and when I was new to my position, I learned first-hand one technique that was not effective.  

A 40-year-old, physically tall and sturdy male patient became so upset that he started punching our walls. Staff intervened and ending up having to take him down to the carpet for everyone's safety. Other than his increase in rate and depth of breathing, he was lying quietly, prone on the ground. I kept a safe distance and asked if he was alright: he didn't respond. I wasn't sure what to do or say. I was new, undoubtedly nervous, and hadn't yet learned the value of what one of our psychiatrists refers to as "therapeutic silence." I had learned in the past from my education and own personal experiences that breathing techniques were calming, so I tried saying, “it's okay, just breathe."   

Subsequently, he began yelling at me. He was saying not to tell him what to do, that he hated me, and to go away. By suggesting something to him in that intense moment, he took offense. If I'm honest with myself, if I were upset and someone had said something similar to me, it might not have gone over much better.  

Setting Limits

Although this should only be used when absolutely necessary, nurses must be able to learn and understand how to deal with difficult patients by setting limits to their behavior. Where I work, some patients simply live for the three smokes a day that they're allowed. An example of this sounds something along the lines of, "if you do not do XYZ, you're not going to get your cigarette." Please note that this approach should not be utilized all the time, but in some cases, it can seem like the only way to get through to your difficult patients.

Benefits of Learning How to Deal with Difficult Patients When They are Angry 

As caregivers, we experience increased job satisfaction when we can adequately care for people who are angry. Imagine how rewarding it is to successfully manage situations and achieve positive outcomes for our patients that could've gone badly otherwise. Not only that but, we potentially run the risk of losing our jobs if we don't learn this essential skill (see Case Study #2 below). Rapport increases when appropriately utilized techniques are applied in practice because they foster trust and show respect for what the patient has to say (8). 

For patients, these situations serve as great opportunities for them to release some of their anger. If we can be facilitators, assisting them to come to a more even-keeled place, they will undoubtedly experience better outcomes. Additionally, a situation involving a an angry patient can become dangerous quickly, so it is critical that we learn these skills for our own safety, and that of our patients. 

Anatomy Review 

The amygdalae are a couple of bunches of neurons found deep in each temporal lobe that play an important role in our emotions, including triggering the fight or flight response (5). The hypothalamus is near the base of the brain right under the thalamus, and is attached to the pituitary gland (6). Among many other things, it's responsible for controlling the secretion of hormones from the pituitary gland, which is located behind the nose (7). Finally, our adrenal glands sit on top of our kidneys and put out different kinds of hormones, particularly, stress hormones (2). 

The Hormone Cascade 

Something triggers us (i.e. we've just sat down to chart, and the call light goes off for what seems like the hundredth time, and we haven't eaten or used the bathroom all day). Our amygdalae, like canaries in a coal mine, sound the alarm by signaling the hypothalamus and release a corticotropin-releasing hormone -- causing the pituitary gland to release adrenocorticotropic hormone. This chain of hormone releases tells the adrenals to drop big stress bombs: adrenaline, noradrenaline, and cortisol (2). 

When there's too much cortisol, increased calcium is allowed to get into our neurons, which can end up leading them to die. Our prefrontal cortex (PFC) and hippocampus suffer the most from this unfortunate outcome. The function of the PFC becomes suppressed, which affects our ability to have good judgment. For example, saying something hurtful or that you do not mean to someone you care about during an argument. Following, when neurons die in the hippocampus, this is where our memories are stored. So if it's not working well, our short-term memory and ability to store new ones are affected most (2).  

The presence of too much cortisol will also result in a lack of serotonin - the happiness neurotransmitter. With less serotonin, we feel more sensitive to pain, anger, increase in aggression, and more prone to depression (2).  

Consider every time you've ever tried to reason with a person who was already upset. How did it go? Did they immediately come to see the error of their ways? I can think of several occasions where a patient was so enraged about something that fixing whatever the issue was did nothing to quell the tirade. When trying to figure out how to deal with difficult patients, understanding what is going on in their brain during these episodes of rage can help us to make sense of it all and how to plan a deliberate, appropriate, and effective way to resolve the conflict.  

Tips for Handling Patients When They are Angry 

Beyond this lesson, you will find several publications that discuss  how to manage de-escalation during potentially dangerous situations. De-escalation involves maintaining a calm demeanor and avoiding attempts to control the patient. As a result, they feel respected, and the trust between the two of you builds. Every person and situation is different, so a certain amount of intuition is also essential in order to creatively develop solutions (9). 

Safety First 

Since we now know that during escalated, angry situations, our patient’s brains are not exactly functioning at full capacity so try your best to expect the unexpected. One moment, a patient can seem like the calmest, and most collected person in the world -- then they get triggered, and who knows what could happen?  

With this in mind, the first thing we always have to consider is safety - for ourselves, the patient, and others nearby. Here are some recommendations for keeping everyone as safe as possible: 

• Be aware of what's around you and your patient. Are there things that could be thrown or used as a weapon? Do you wear necklaces or long earrings that can be pulled? 
• Always maintain a safe distance. If you don't feel safe, get to safety. It's okay to walk away from a situation if you feel that you are in danger, but never turn your back. 
• Bring a co-worker if you need to go into an angry patient's room - never go alone. 
• Observe for signs of aggression. If your patient exhibits balled fists, getting too close to you, pacing, tense shoulders, glaring, tense jaw, facial flushing, shouting, or heavy breathing, be prepared.  
• Try to keep the area clear of others who might be put in danger or exacerbate the situation. This might be a challenge when you're focused on engaging with your patient. However, it is helpful if you and your coworkers are all on the same page. Consider working with management to train everyone to be on alert for potentially dangerous situations with patients and their loved ones. 

What to Say vs. What Not to Say 

When I'm upset, the thing that helps me the most is feeling like I am being heard. For my patients, I have found that listening is one of the tactics that works best, but remember that in some instances, patients may have a hard time listening to others because they may become triggered. If that occurs, it can become difficult to maintain a calm demeanor that is necessary for de-escalating tense situations. If we can find a way to keep the focus on the other patient (who is coming to us with the issue), we can become better listeners and remain calm.  

Listening is a skill that not everyone excels in but it can make a huge difference when figuring out how to deal with difficult patients.   

Tips to improve listening skills: 

• Do not interrupt.
• Give your full attention rather than getting distracted by inner thoughts or environmental stimuli. 
• Repeat back what you've heard to affirm you got it right. 
• Ask related questions to show you're concerned and want to deepen your understanding. 
• Convey a sense of empathy by using your body language, and making brief statements like, "That's understandable." 

Since there is not a specific prescription or solution for dealing with all angry patients, we need to stay tuned and be creative to reach a mutually beneficial goal. By staying calm and truly listening, we're better able to understand what is going on so that we can attempt to remedy whatever the problem is when the time is right. After listening, affirming, and giving the patient time to calm down, we can begin to work toward a solution. For example, I might say, "I hear that you're upset about what happened, and that's totally understandable. What can I do for you right now to help?" By approaching the situation this way, it affirms that I heard the patient, respect their feelings, and genuinely want to help them. When learning how to deal with difficult patients, this is an extremely valuable tool to possess.  

Additionally, body language is extremely important - it conveys so much! Simple adjustments like squaring ourselves to whomever we're listening to and conveying accurate facial expressions depending on the situation ensures in the patient that we are giving them our full, undivided attention and that we truly care about what they’re saying.

Boundaries 

A word about maintaining boundaries; these are key! Just because I aim to listen and convey kindness actively does not mean that I am a pushover, and that my patients will get everything they want.  

For example, as nurses, we all know that we often don't have the time (or energy) to have deep, confiding conversations with each and every patient. However, being kind can be done swiftly, and without caving to demands. A simple "no" can be said in a respectful manner. For example, we can briefly say in a kind tone, "I know it's frustrating, and I get it, but unfortunately, I can't talk with you right now because I'm in the middle of passing meds. Can we talk in half an hour or so?" 

There are also times when we have to set boundaries because we can see that we can't do any good in that moment. I have a patient who shouts so loudly when they are upset that I have to cover my ears for fear of damage! Sometimes they are able to convey their feelings in a way that I can actively listen to, and these times seem to be helpful for them, but when they can't, I give them boundaries. I say, "I want to listen to you, but you're hurting my ears." If they are unable to control the volume, I gently remove myself, stating, "I hear that you're having a hard time, but I have sensitive ears, and your shouting is hurting them. Let's talk later." 

We all have to figure out where our boundaries lie. If you are someone who gets triggered by the angry behavior of others, you might do best to excuse yourself early on to catch your breath and ask someone else to help with the situation. If you are triggered, it'll be tough for you to make the best decisions when figuring out how to deal with difficult patients.  

Not Taking Things Personally 

As nurses, I am sure we have all learned early on to not take anything personally, especially when dealing with difficult patients. In most cases, an angry patient yelling in your face will not be your fault. Remember, we are not responsible for other's feelings and reactions; those are about them, not us. As we mentioned previously, we are all probably guilty of saying something that we didn’t mean when we were upset and we wish we would have given it a second thought, and in some scenarios, this could be the case. However, there are other instances where the angry behavior of a patient then results in them wanting to speak with your manager regardless of whatever the reason is being your fault or not.  

It's helpful to recognize when a behavioral response is not in proportion to what actually happened because this can be a clue into possible long-standing issues. Of course, knowing all of this doesn't mean we shouldn't always do our best, but it can help us refrain from beating ourselves up too much when our best seems to fall short. 

Attempt to be aware of the things we have reviewed here so you can effectively handle and devise a solution on how to deal with difficult patients who are angry. Bear in mind how challenging it can be not to have control, especially during situations where we are unable to make rational decisions.

What to Do if You're the One to Lose Your Cool 

As we discussed earlier, when we become triggered, our prefrontal cortexes (PFCs) don't work properly, and that is when our decision-making becomes poor. The good news is that, since we know what's going on in our brain, we can work on reactivating that precious (and potentially life-saving) PFC. At first, we might not be able to look at ourselves clearly until after an episode, but we can learn to recognize the signs of becoming triggered by examining what happened. Once we can do that in real-time, we can intentionally work toward becoming calm again.  

Take Care of Yourself 

Nurses are used to taking care of others all the time, but what about themselves? This is crucial. You must take care of and be kind to yourself. Our best is different every moment of every day, and that's all just part of being human. Some days, we might be having a tough time, struggling with any number of things, just like our patients. Our temper might be shorter, our tone may be a little more on edge, but rather than judging ourselves too harshly, we should recognize our own humanity and just do our best.

Case Studies on How to Deal with Difficult Patients

Case Study #1

A 46-year-old female patient received an IM injection in her right glute this morning. It is afternoon shift change, and she is complaining that her right hip has been hurting since receiving this injection. She has repeatedly been approaching the nurse's station about this issue. The off-going day shift nurse calls over his shoulder as he's frantically attempting to finish documenting, "I've already assessed you, and I don't see anything wrong. I talked to the doctor, and he ordered Ibuprofen which you received. I have let her know that you would like to speak with her; you'll have to wait until she rounds next."  

The patient begins yelling, stating, "None of you care about me! My doctor doesn't care about me! Otherwise, she wouldn't make me get these injections that hurt me!" The evening shift nurse arrives, sees that the patient she knew from the evening before is upset and that the off-going nurse is busy. The evening nurse steps behind the station desk so that there's a barrier between her and the patient (in case she becomes more agitated and aggressive) and turns to face the patient with a concerned expression in place. "*Fiona, I see that you're upset. How can I help?" The nurse listens, not interrupting the patient as she relays her issue. At a natural lull in the patient's speech, the nurse responds, "It sounds like you're frustrated about this situation. I get it; that's totally understandable." The patient goes on to express her feelings of not being cared for by the staff or the doctor, tearfully raising her voice. The nurse looks at the patient with concern and considers the possibility that this woman might have some history of not being cared for. She continues to listen as the patient goes on venting. Eventually, the patient shouts one last time, turns away, and stomps down the hall to her room. An hour later, she returns looking tired, a little embarrassed, but calm, and apologizes then thanks the nurse for listening. 

Case Study #2

A 70-year-old male patient rings the call bell. The nurse answers and the patient shouts loud enough to be heard without the aid of the speaker, "Get over here! You people are useless! Because of you, I'm swimming in a puddle of my own urine." The nurse responds, "Okay, but you don't have to be so rude." The nurse slams the phone down, muttering expletives to themselves. They takes their time, finishing up what they were working on, still ruminating over the patient, while he gets increasingly upset.  

They walks into the patient's room, and sees that he's standing next to his bed, naked, leaning precariously on his IV pole. The nurse says, "What are you doing? You're going to fall." The patient responds, "Well, you're not doing your job!" "I shouldn't have to deal with this," the nurse mutters under their breath as they begins to gather the soiled sheets. The nurse, whose back is turned to the patient, doesn't see that his face has gone the color of a bag of packed RBCs, his eyes are bulging, and his knuckles are white as they grip the IV pole. The patient attempts to use the pole as a weapon to hurt the nurse but ends up slipping on his urine-wet feet, striking his head against the wall, resulting in a concussion. He files an official complaint regarding the nurse, considers suing them for damages, and the nurse gets written up for the second time. Next time, they'll be out of a job. 

Conclusion 

People get angry - it's just a fact of our existence. Some, unfortunately, make poor choices when they feel anger whether it's out of frustration, stress, feelings of loss of control, or unmanaged old triggers coming to the surface. As nurses, we often have to figure out how to deal with difficult patients while being able to remain calm and composed. By understanding more about people who experience excessive anger and learning to apply the techniques discussed in this course, you will be able to form flexible and creative solutions that can result in making the best out of very challenging situations.